Chapter 4. The Psychiatric Interview

Human behavior is complex. When it becomes dysfunctional because of environmental stress or brain disease it can mystify the inexperienced clinician. This is especially true of neurobehavioral disorders, which involve neuropsychiatric changes in cognition and emotion that overlap the boundary of psychiatry and neurology. The clinician must appreciate and assess the signs and symptoms of neurobehavioral disorder with the same discernment as in physical syndromes such as myocardial infarction or infectious disease.

This chapter describes the psychiatric history and mental status examination (MSE), in the conduct of an effective psychiatric interview. The steps of the interview process are described along with the techniques the clinician must master in order to elicit information relevant to a diagnostic formulation in an orderly, reliable, and comprehensive manner. The components of the psychiatric history and the MSE are described in accordance with the stages of the interview during which they would usually be obtained.

What can be achieved at the initial psychiatric interview? The outcome depends on the situation in which it is conducted and what the physician and the patient are seeking. For example, a brisk, focused interview in an emergency room contrasts with the more extensive survey appropriate to an outpatient clinic. Both types of interview differ from what is possible at the bedside of a patient who is severely ill in a medical or surgical ward. Despite these observations, fundamental issues can be addressed to varying degree in any clinical situation, as illustrated in Table 4–1. We return to these issues in our discussion of the elements of the psychiatric history.

[Some of this material also appears in Nurcombe B, Gallagher RM: The Clinical Process in Psychiatry: Diagnosis and Management Planning. Cambridge University Press, 1986. Reprinted with the permission of Cambridge University Press.]

Inception

If the interviewer works in a clinic, at the opening of the psychiatric interview he or she goes to the waiting room, introduces himself or herself to the patient, accompanies the patient to the interview room, and shows him or her to a seat. After taking identifying data from the patient, the interviewer can tell the patient what he or she already knows. This approach avoids unnecessary mysteries and clears the way for action. Consider the following example:

Psychiatrist: Your parents came to see me yesterday. They told me they’re worried because your schoolwork has fallen off, although you’ve always been a good student; you’ve dropped most of your friends; and you seem to have become depressed. Last week they found one of your assignments in which you spoke about suicide. They think you may need help for an emotional problem.

Patient (a 16-year-old boy): So?

Psychiatrist: So they asked you to see a psychiatrist. I get the impression you’re not too happy about that.

Patient: No.

Psychiatrist: Maybe we can start by you telling me how you feel about it.

Interviews are not always conducted in an office; they may be transacted beside a patient's bed, or between pieces of equipment in the examination room of an emergency clinic, or even while driving a car. Wherever they occur they include a pattern to the beginning, a certain formality. The interviewer introduces himself or herself, says why he or she is there, and invites the patient to respond by telling his or her story. If the patient does not want to do so, the interviewer helps the patient to explain why.

Reconnaissance

The interviewer helps the patient tell his or her story as spontaneously as possible. He or she listens and does not interrupt any more than is necessary to keep the story flowing. The interviewer does not rush the reconnaissance nor try to direct it prematurely. If all the interviewer does is ask direct questions, all he or she will get is answers. Open-ended probes should be used as much as possible. The more leading the probe, the less valid the response, unless the issue in question is a simple, unequivocal one. The facilitating techniques we describe later in this chapter are particularly appropriate for the reconnaissance stage.

Detailed Inquiry

After the patient has finished his or her story, the interviewer seeks further information about the present illness, past illness, medical history, early environment, education, and other relevant matters from the psychiatric history. A full detailed inquiry will take several interviews, but a scanning of the features most important for a provisional diagnosis can be accomplished within an hour.

Table 4–2 lists the content of the psychiatric history. The order suggested in the table should not be followed blindly. The interviewer should be prepared to deal with topics in whatever sequence is natural. In accordance with the case, some areas will be emphasized and others pursued in less detail.

Detailed inquiry involves questioning, but the questions are kept as open ended as possible at the outset, moving from general to specific as more detail is required. Compare the following questions:

• How are things in your marriage?
• How are things between you and your wife?
• How do you and your wife get on?
• Is your marriage a happy one?
• Do you love your wife?

This approach is similar to the way a surgeon approaches a guarded section of a painful abdomen: from the outside in. Direct questions provoke circumscribed responses and are most appropriate to issues of fact (e.g., What year were you married?).

Some issues are left to a later time after a therapeutic alliance has developed. Unless the patient presents his or her sexual life as a problem at the outset, an exploration of this area is usually postponed.

Transitions

The interviewer never moves abruptly from one topic to another. Change should be signaled. For example, the psychiatrist could say, “Okay. I’d like to go on from there to something else. Could you tell me about the jobs you’ve had? What did you do after you left school?”

Standard versus Discretionary Inquiry

Part of the detailed inquiry is standardized, including questions obligatory for patients of a given age, in a specific clinical situation, or as part of a minimum database. The components of a standard inquiry should be defined for each clinical setting. The rest of the detailed inquiry is largely discretionary and involves the eliciting of evidence supporting or refuting the diagnostic hypotheses generated after reconnaissance.

We now discuss the components of the psychiatric history, which are shown in Table 4–1. Each issue addressed in Table 4–1 must be addressed and the information related to one of the categories shown in Table 4–2.

The Present Illness

An accurate psychiatric history is the guide to diagnosis, intervention, and treatment. To this end, it is useful to define the present episode with its precipitants and then determine whether the present episode constitutes a discrete psychiatric illness or an episode in a chronic psychiatric illness that can be documented chronologically.

Some patients present a variety of subjective concerns. Others have a more focused complaint and can identify particular issues as problematic. Whatever the problem(s) for which the patient or his or her associates seek help, the clinician attempts to delineate them; to understand how the patient experiences them; and to ascertain their duration, onset, development, and persistence.

Precipitation of Illness & Relevant Stressors

If the problems had an onset, the interviewer attempts to determine whether the patient experienced physical or psychosocial stress at that time. The mere coincidence of stress and onset does not substantiate a causal association; indeed, causation remains speculative in some cases. Causation is supported, however, if the patient previously had a breakdown when exposed to a similar stress or if the patient's account of the stress indicates its personal significance.

Some stressors have universal impact. Others are highly idiosyncratic, and painstaking work may be required before they can be unraveled in psychotherapy. In some cases it is an open question whether an event was a true precipitant, or secondary to a disorder in its early stages, or mere coincidence.

Previous Psychiatric Illness & Behavioral Problems

The interviewer considers the following questions in evaluating the patient for previous psychiatric illness and behavioral problems: Has the patient had any problems of a similar nature in the past? What precipitated them, if anything? Has the patient had any other emotional disorders or physical symptoms related to tension? Has the patient had, or does he or she have, physical or neurologic disease that could contribute to the present problem? Does the patient have, or has he or she had, personal habits (e.g., substance abuse) that could cause, precipitate, or complicate the present problem?

Previous Psychiatric Treatment & Mental Health Intervention

The interviewer should be aware of any therapeutic interventions prior to the current evaluation, including formal psychiatric treatment (or treatment by another mental health professional), emergency evaluations, hospitalizations, or mental health treatment rendered by a primary care physician. The clinician who carried out the treatment and the treating facility should be identified, as should the approximate date(s) and duration of treatment. The patient's response to each pharmacologic agent and associated side effects should be documented. The type, duration, and results of psychotherapy should be identified. The interviewer will usually verify and amplify this information by requesting records from previous treating professionals and facilities, with appropriate written consent from the patient.

Predisposition & Potentials

The interviewer considers the following questions in evaluating the patient for predisposition to and family history of psychiatric illness: What kind of person was the patient before he or she became ill? What biopsychosocial strengths and weaknesses predisposed the patient to breakdown? These questions require a comprehensive evaluation, and it is unrealistic to expect all of this information to be elaborated in a single interview. However, important pieces of the jigsaw puzzle are usually available, if the interviewer keeps his or her eyes and ears open. The interviewer can seek information about the following additional questions: What personal and environmental strengths, resources, and liabilities are apparent at the present time? What has the patient got going for him or her now? What holds the patient back? What hurdles does he or she face? An inventory is required of the patient's physical, intellectual, emotional, and social assets and deficiencies. This inventory is crucial to the design of an individualized plan of management.

Presentation

The interviewer considers the following questions in evaluating the patient's current presentation for treatment: Why does the patient seek help now? Is the patient being seen at the onset of a disorder or later, either when a relatively defined pattern of symptoms has developed or after the patient has recovered partially but remains troubled by residual difficulties? Did the patient come of his or her own accord, or was he or she persuaded to do so? Did others bring in the patient for treatment? Why?

Insight, Judgment, & Motivation for Treatment

The interviewer considers the following questions in evaluating the patient's insight, judgment, and motivation for treatment: Does the patient think he or she is unwell? Does the patient think he or she has been referred inappropriately? The patient may be correct. If the patient recognizes his or her own disturbance, does he or she have any idea of its nature or cause? How realistic are these notions?

What kind of help does the patient seek, if any? Is this in line with what is advisable, appropriate, or feasible? Is the patient troubled by doubts concerning his or her problem and the kind of treatment he or she will receive? Fears of craziness or of exotic psychiatric treatments are likely to be inflamed by deep-seated anxieties about helplessness and victimization. These fears are often aggravated by images derived from family or cultural values, including those depicted in the media. It is better that such concerns be expressed as soon as possible and corrected when they are the result of misinformation.

Family History

The family history is an important component of the initial interview. It helps to understand the patient's family structure and the family influences that were brought to bear on the patient's growth and development. It documents the patient's genetic predisposition to psychiatric illness. This initial inquiry is the beginning of a genogram that can be developed in more detail in subsequent interviews. The initial interview should identify each family member for one or two generations and also identify individuals with psychiatric illness for at least two generations. This line of questioning is subtle because of social stigma and the natural reluctance of individuals to disclose family problems. It is desirable to inquire about the presence of psychiatric illness in several ways. The interviewer may begin with an open-ended question such as inquiring whether any family member has had emotional or behavioral problems. Follow-up questions can include whether any family member has been treated by a behavioral health provider and whether anyone in the family has been hospitalized for psychiatric illness.

Social History

The social history should be elicited in the first diagnostic interview, even if time does not permit a full exposition of this subject. This part of the initial interview informs the examiner of the social, cultural, and family structural influences that contribute to the patient's personality, values, and social integration. Open-ended questions that invite the patient to describe the structure and membership of the nuclear and extended family is a good start. Often the description will be colored by feelings and attitudes toward each person that can be explored in depth in a subsequent interview. Marriages, children, divorces, major illnesses, and deaths within the immediate family should be documented as part of the social history. This part of the interview can be interwoven with the family history of illness, particularly psychiatric illness. The social history is often ignored in initial psychiatric interviews, but the absence of this information limits the diagnostic formulation.

Educational and Occupational History

The initial diagnostic interview should include a brief educational and occupational history. During this part of the interview, the diagnostician is forming a time line to register major events in the patient's life and evaluating developmental milestones. The educational history helps to give a developmental history extending through the second decade of life, as well as an indirect indication of intellectual capacity and social adjustment. Interruptions in education are often a sign of emerging psychopathology or a discrete behavioral setback or crisis. The occupational history is valuable life history information, but can also indicate periods in a person's life when an acute psychiatric illness occurred or when the gradual development of psychopathology altered a person's life, including his ability to work. Choices of educational and occupational paths may provide a window into understanding a patient's personality, motivation, identification with people who are important to the patient, and family values and influences.

A military history is important when it is relevant to the patient's life. Major psychiatric illnesses often present for the first time under the stress of military service when the individual is in his late teens and early twenties. Military health care provides substantial documentation of symptoms in an acute psychiatric illness, diagnosis, and response to treatment. If an individual has a medical discharge from the military, the documentation of the illness is very useful data for diagnostic impression, treatment response, and prognosis.

Legal History

A legal history is relevant in an initial psychiatric interview if the interviewer infers that it may be important for the diagnostic impression. To omit this inquiry because it is a difficult subject is an error if it turns out that the diagnostic formulation hinges on this aspect of the history. The content of this history can include lawsuits, divorce and custody disputes, bankruptcy, arrests, convictions, and imprisonment.

Forming Hypotheses

Throughout the initial interview, the diagnostician is working to form hypotheses about the etiology of the current problem under evaluation. This involves an acquired skill set that involves memory, a questioning technique that draws the patient out in a nonintimidating manner, a capacity to convey empathy, and an ability to make each part of the interview productive in terms of information gathering, while also building an alliance with the patient. It is reasonable to take occasional notes, but it is a poor technique to look at a written document constantly instead of the patient. Likewise, it is poor technique to follow a rigid interview outline and not follow leads that the patient offers when they occur. It is precisely this mixture of structure and completeness in acquiring clinical data, combined with spontaneity in following psychodynamic leads and continually forming hypotheses about the patient's defining life events and diagnosis, that constitutes a skill acquired gradually by the experienced clinician.

The MSE is a set of systematic observations and assessments undertaken by a diagnostician during the clinical interview. Properly conducted, the MSE provides a detailed and systematic description of the patient at that time, information essential to the consolidation of those patterns of clues and inferences that are required for the generation of diagnostic hypotheses. The MSE, guided by the hypothetico-deductive approach to diagnosis, is an essential part of the subsequent inquiry plan. In this section we offer a comprehensive description of the components of the MSE. In regard to a particular patient—and in accordance with the clinical context, background information, and psychiatric history—the interviewer will apply the MSE tactically, pursuing brief, comprehensive, or discretionary lines of inquiry, as warranted.

The Need for Standardization

Because the MSE, like the psychiatric history, should involve routine and discretionary lines of inquiry according to the context of assessment and the diagnostic hypotheses being entertained, it should not be standardized as a whole. Instead the separate observations and assessments that compose the MSE should be standardized. The techniques of eliciting data should be formalized, the phenomena in question clearly defined, and the weight to be placed on each phenomenon clarified.

Reliability

The reliability of a test refers to the likelihood (usually expressed as a correlation) that similar results will be obtained on retesting (test–retest reliability) or that similar results will be obtained by different observers (interrater reliability). Test–retest reliability applies to relatively stable characteristics such as the use of language; it is not to be expected in characteristics (e.g., mood) that are potentially changeable and often linked to a current situation.

When psychiatrists test for the patient's abstracting ability, for example, by asking the patient to explain proverbs in his or her own words, how certain can the psychiatrist be that the clinical test is a true measure of the ability in question? In other words, what is the validity of the test? Over the years, a set of informal mental state assessments has accumulated but in some instances their validity is questionable. When we describe any clinical test in this chapter, we will consider its validity along with the mental faculties required for adequate performance on the test.

Types of MSEs

Brief Screening MSE

When a patient has been referred to an ambulatory clinic for a situational or personality problem, and none of the indications for a comprehensive screening examination pertain (see next section), a brief, informal screen is sufficient. The brief screening MSE is completed during the inception, reconnaissance, and detailed inquiry stages of the psychiatric interview. In particular, the interviewer notes the patient's general appearance, motor behavior, quality of speech, relationship to the interviewer, and mood. From the patient's demeanor, conversation, and history, the interviewer makes inferences about consciousness, orientation, attention, grasp, memory, fund of information, general intellectual level, language competence, and thought process. Abnormal thought content is not investigated unless clinica1 clues indicate the need for such discretionary inquiry (e.g., into hallucinations, obsessions, depersonalization). Physiologic functions (e.g., sleep, appetite, libido, menstrual cycle, energy level) and insight should always be assessed.

Comprehensive Screening MSE

The interviewer should be alerted to the need for a comprehensive screening MSE whenever there is a reasonable possibility that the patient has psychosis or primary or secondary brain dysfunction. Table 4–3 summarizes the settings and clues that mandate a comprehensive MSE. If the clinician has any doubts, the comprehensive screen should be completed.

Components of the MSE

Table 4–4 summarizes the areas to be covered in the MSE. The following sections describe these areas in more detail:

Appearance & Behavior

From the moment the interviewer first greets the patient, he or she will be aware of the patient's appearance. The interviewer should try to describe it in detail before drawing inferences from it. What is the patient's physique and habitus? Is there evidence of weight loss or gain? Does the patient have any conspicuous marks or disfigurement? The interviewer should describe the patient's face and hair. Does the patient look ill? What is the expression of the eyes and mouth? Does the patient appear to be in touch with the surroundings? Is the patient clean and neat, or does he or she exhibit deficiencies in personal hygiene revealed by poor grooming of the skin, hair, or nails? How is the patient dressed? Is the patient's clothing neat? Is it appropriate or peculiar? After the interviewer describes these characteristics, he or she determines whether an inference may be made about the kind of “statement” the patient is attempting to make with his or her attire.

The interviewer notes general overactivity or underactivity, abnormalities of posture, gross incoordination, or impairment of large muscle function. What is the patient's gait like and how does he or she sit? The interviewer notes any abnormalities of finer movement and posture, such as tremor, tics, or fidgeting.

Stereotypies are organized, repetitive movements or speech or perseverative postures. They are usually associated with schizophrenia, particularly the catatonic type. A striking variant of postural stereotypy is waxy flexibility, in which the patient will remain indefinitely in a position into which the interviewer places him or her (e.g., standing on one leg). Other disorders of movement associated with catatonia include a stiff expressionless face; facial grimacing or contortions; stiff, awkward, or stilted body movement; and unusual mannerisms of expressive movement or speech. The latter should not be confused with the gracelessness of someone who is socially anxious. The interviewer also notes whether the patient exhibits any rituals such as a need to touch objects repetitively, as in obsessive–compulsive disorder, or any habits such as nail biting, thumb sucking, lip licking, yawning, or scratching.

The interviewer attends to the accent, pitch, tone, and tempo of the patient's speech, paying particular attention to unusually high or low pitch and abnormal tone, as in the high-pitched “squawking” monotone sometimes encountered in children with early infantile autism.

In mutism, which may occur in advanced brain disorder, severe melancholia, catatonia, or conversion disorder or in the elective mutism of negativistic children, the patient is unable or unwilling to utter anything. In conversion disorder, mutism is less common than is aphonia, in which the patient is able to speak only in a hoarse whisper.

Relationship to the Interviewer

The interviewer should infer the quality of the patient's relationship by how he or she behaves and by what he or she says. The relationship may be constant, it may vary with the topic being discussed, or it may be influenced by other factors. These factors may remain obscure if they are unexpressed (e.g., when the patient is privately amused by an auditory hallucination). The interviewer should note whether this is the case.

Affective states are difficult to assess, aside from noting whether they are inconstant or are apparently influenced by obscure factors. The interviewer draws on a number of behavioral clues to assess the quality of the patient's relationship and mood. As a rule, the more inferential the judgment, the more unreliable the conclusion. Interviewers may differ in their inferences concerning a patient's affect, especially when it is unstable, ambiguous, complex, or shielded by interpersonal caution.

The interviewer's behavior will inevitably affect the ebb and flow of the patient's feelings. The patient may be responding appropriately to the interviewer's friendly approach (or rudeness, for that matter). He or she will also be responding to highly idiosyncratic internal predispositions. For example, a patient may harbor mingled anxiety and deference for somebody he or she perceives as a threatening authority figure who must be placated.

Given the fallibility of inference, the interviewer is well advised to stick closely to observations and be able to cite them. This skill requires training. The beginner may be overly impressed by brilliant intuitive leaps; the expert heeds intuition but realizes how unreliable it is. The beginner grasps for, and holds firmly to, an inference, sometimes in spite of contrary evidence. The expert makes the inference, cites the clues on which it is based, can offer alternative explanations, and discards the inference for a better one if contrary evidence emerges.

The quality of the patient's eye contact is of great importance in gauging affective states. Negativistic patients, especially those with catatonia, may avert their gaze from the interviewer. Children with early infantile autism characteristically demonstrate eccentricities of eye contact, for example, staring “through” the interviewer or averting their gaze from him or her. A delirious patient whose sensorium is impaired may stare into space, as may a melancholic or schizophrenic patient whose thoughts are dominated by gloomy ruminations or delusional preoccupations. Intermittent staring is a feature of different forms of epilepsy. The interviewer notes whether the patient's attention can be captured, albeit briefly. If not, the interviewer should suspect an organic brain disorder.

Some patients stare at the interviewer intently. He or she should distinguish the wide eyes of awe or fear from the narrowed slits of hypervigilant suspiciousness. Other patients make hesitant eye contact, particularly when they are embarrassed about what they are saying. Not all patients with shifty gaze are liars, and some prevaricators have learned to deliver their lines without batting an eyelash.

The impact of the eyes on interpersonal relations cannot be overestimated. The configuration of supraorbital, circumorbital, and facial musculature; eyelids; palpebral fissure; gaze; depth of ocular focus; pupil size; and conjunctival moisture combine to produce a range of social signals of great significance for interpersonal dominance, competition, attraction, hostility or avoidance, the initiation and punctuation of conversation, and the feedback a person requires to know how the other person has responded to what one has said.

Eyes and face are combined with body posture and movement in a gestalt. The face provides the clues to remoteness, bewilderment, and perplexity, whereas the whole body is involved in tenseness (e.g., clenched fists, sweaty palms, stiff back, leaning forward), restlessness, preoccupation, boredom, and sadness.

The patient may be uncommunicative or, in the extreme, quite mute. In contrast, he or she may be friendly and communicative, even loquacious or garrulous. Patients convey antagonism by hectoring; by being uncooperative, impertinent, or condescending; or even by making direct threats, criticizing, or verbally abusing the interviewer. In contrast, by tone of conversation and demeanor, the patient can convey respect, deference, anxiety to please, or ingratiation. The interviewer notes and describes the following attitudes in the patient: shyness, fear, suspiciousness, cautiousness, assertiveness, indifference, passivity, clowning, interest in the interviewer, clinging, coyness, seductiveness, or invasiveness.

Affect & Mood

Affect refers to a feeling or emotion, experienced typically in response to an external event or a thought. The patient's relationship to the interviewer is a particular manifestation of affect. Affects are usually associated with feelings about the self or about others who are of personal significance to the individual. Less often, an affect is experienced alone, as though adrift from its reference point. Affect is the conscious component of a monitoring system that signals whether the individual is on track toward a personal goal; whether he or she is obstructed, frustrated, or prevented from achieving the goal; or whether he or she has already attained it. Compare, for example, the anticipatory pleasure at preparing to meet someone beloved; the anxiety and fear at seeing the beloved with a serious rival; the rage and despair of loss; and the exaltation of reunion. Similar, though more complex, affects may attend mountain climbing, solving mathematical puzzles, or giving birth. Whatever the goal, its remoteness, proximity, loss, repudiation, attainment, or inaccessibility are all accompanied by self-monitoring affect.

In contrast to an affect, which may be momentary, mood refers to an inner state that persists for some time, with a disposition to exhibit a particular emotion or affect. For example, a mood of depression may not prevent an individual from deriving momentary diversion from a joke; however, the expression of gloom, sadness, or desolation returns and prevails. Affects and mood are inferred from the patient's demeanor and spontaneous conversation. A general query such as “How are you feeling, now?” or “How have your spirits been?” can be helpful. The interviewer should try to avoid leading questions such as “Do you feel depressed?”

Demeanor and affect usually coincide, but sometimes they do not. For example, a stiff smile can mask anxiety or depression. If the interviewer suspects this to be the case, he or she can offer an indicating or clarifying interpretation to help the patient recover suppressed emotion, such as “I notice that even though you speak of sad things, you are smiling” or “It's hard to smile when you feel bad inside.”

The interviewer describes in the mental status report the general qualities of the patient's emotional expression. Particular morbid affects or moods are noted. For example, is the patient affectively flat, that is, emotionally dull, monotonous, and lacking in resonance? This presentation is characteristic of chronic schizophrenia and dementia. Is the patient emotionally constricted, with a narrow range of affect, as in obsessional or schizoid personality? Does the patient exhibit inappropriate or incongruous affect, in that it is not in keeping with the topic of conversation?

Does the patient show evidence of lability, suddenly changing from neutral to excited or from one emotional pole to the other? Lability is often associated with emotional intemperateness, an abrupt unreflective expression of heightened emotion (e.g., excited anticipation, affection, irritation).

The interviewer notes the presence of histrionic affect, the blatant but rather shallow expression of emotion often observed in those who exaggerate their feelings in order to avoid being ignored and who need to capture, or who fear to lose, the center of the interpersonal stage. Histrionic affect is often encountered in people with histrionic, narcissistic, or borderline personality disorder.

Morbid euphoria, a sense of well-being expressed in inexorable good spirits, is encountered in hypomania or mania and less commonly in schizophrenia and organic brain disorder. Frontal lobe dysfunction, characteristic of neurosyphilis, disseminated sclerosis and after traumatic brain injury, may be associated with fatuous joking and lack of foresight. Silliness is sometimes encountered in histrionic or immature people overwhelmed by the enormity of a difficult situation. Morbid silliness is also characteristic of some disorganized schizophrenic patients.

As it becomes exaggerated, euphoria merges into elation and excitement; although the manic patient commonly also exhibits irritation if obstructed or thwarted. An extreme and transcendent exaltation of mood may be observed in the ecstatic states rarely associated with acute schizophreniform or schizophrenic disorders and epilepsy.

Apathy, a pervasive lack of interest and drive (also known as anergia), may be observed in patients with preschizophrenic, schizophrenic, depressive, and organic brain disorders. The apathetic patient has little or no enthusiasm for work, social interaction, or recreation. Anergia is usually associated with a decrease in sexual activity. Anhedonia, a subjective sense that nothing is pleasurable, is commonly associated with anergia and is observed in preschizophrenic, schizophrenic, and melancholic patients. Excessive fatigue, which may be manifest as hypersomnia, is associated with many disorders such as organic brain disorder, schizophrenia, anxiety disorders, depressive disorders, and somatization disorder.

When applied to an affect or mood, depression refers to a pervasive sense of sadness. Depression is often related to a life event involving loss, rejection, defeat, or disappointment. It may be associated with tearfulness and anger about the event. In severe depression or melancholia, the patient feels emotionally deadened or empty, the world stale and unprofitable, and the future hopeless. The patient is preoccupied with dark forebodings and may be agitated by persistent self-recrimination about past misdeeds. Diminished concentration and a slowing of thinking and movement characteristically accompany depressed affect and gloomy ruminations. In some patients agitated depression is associated with psychomotor restlessness. Severe depression has important somatic features, including characteristic posture and facies, headache, irritability, precordial heaviness, gastrointestinal slowing, anorexia, weight loss, loss of sexual interest, and insomnia. Depression typically has a diurnal variation: Dysphoria, hopelessness, and agitation are worse in the morning, and the patient brightens up by evening.

The interviewer will readily recognize open anger and irritability. These feelings may be quite understandable in the context of the patient's circumstances. Morbid anger, however, is defined by its pervasiveness, frequency, disproportionate quality, impulsiveness, and uncontrollability. Morbid anger is associated with organic brain disorder, usually in the form of catastrophic reactions to frustration, especially when the patient can no longer complete a familiar or easy task. Abnormal anger is also associated with some forms of epilepsy; personality disorders of the aggressive, antisocial, borderline, or paranoid type; attention-deficit and disruptive behavior disorders of childhood; drunkenness; paranoid disorders; hypomania or mania; and intermittent or isolated explosive disorders.

Controlled hostility may be expressed as sullenness, uncooperativeness, superiority, or mockery. It can be helpful to invite the patient to express anger or resentment directly and to define its origin. This is particularly the case with adolescents. When working with adolescents, the interviewer might consider saying, “Whenever I ask you a question, you close up. Something about being here is making you pretty uptight. Can you tell me what it is?”

Anxiety and fear refer to the subjective apprehension of impending danger, together with widespread manifestations of autonomic discharge (e.g., dilated pupils; cold, sweaty palms; tachycardia; tachypnea; nausea; bowel hurry; urinary urgency). Fear has an object: the need to defend oneself against uncertain odds (e.g., a charging bull, a near accident in an automobile). Anxiety is associated with the threat to an essential value, for example, being attached to someone beloved, not being a coward, being successful, or being highly regarded. Direct action (i.e., fight or flight) can eliminate fear, whereas the adaptive solution to anxiety is likely to require planning and persistence. Anxiety and fear are biologically advantageous because they signal the need for constructive responses.

In morbid anxiety, affect is cast adrift from its moorings, either to float free or fasten on a substitute, phobic object or situation (e.g., heights, a particular animal, elevators, enclosed spaces, being fat). Morbid anxiety appears disproportionate or eccentric and is recognized as pathologic by the patient and others. Many of the disorders of thought content (described later in this chapter) can be regarded as unconsciously determined, pathologic mechanisms that detach anxiety from its object or block and divert it at its origin.

Cognition & Memory

Table 4–5 lists the cognitive functions that can be assessed in an MSE. We describe them in more detail in the following sections.

Level of Consciousness & Awareness

The psychiatrist may be asked to consult on a comatose or stuporous patient, if a nonorganic cause is hypothesized. Coma is a state of nonawareness from which the patient cannot be aroused. Diminished awareness is called semicoma or stupor, in which case the subject is temporarily rousable (e.g., by pain or noise) but reverts to stupor when the stimulus ceases. In stupor, eye movements become purposeful when the painful stimulus is applied, and wincing or pupillary constriction may occur, but the patient remains akinetic and mute. Stupor and coma occur in primary neuronal dysfunction (e.g., Alzheimer disease), secondary neuronal dysfunction (e.g., metabolic encephalopathy), supratentorial lesions (e.g., infarction, hemorrhage, tumor), subtentorial lesions (e.g., infarction, hemorrhage, tumor, abscess), and psychiatric disorder (e.g., dissociative disorder, depression, and catatonia).

Psychogenic coma is suggested by normal vital and neurologic signs, resistance to opening the eyes, normal pupillary reactions, and staring (rather than wandering) eyes. Swallowing, corneal, and gag reflexes are usually intact, and electroencephalography and oculovestibular reflexes are normal. Intravenous barbiturate may increase verbalization in psychogenic stupor. It depresses awareness further in organic conditions.

Torpor denotes a lowering of consciousness short of stupor. Awareness is narrowed and restricted, and apathy, perseveration, and psychomotor retardation are observed, but the more dramatic phenomena of delirium (i.e., illusions, hallucinations, and agitation) are lacking. Torpor is associated with severe infection and multiinfarct dementia.

In twilight or dreamy states, restricted awareness is manifested as disorientation for time and place, with reduced attention and impaired short-term memory. In addition, the patient may have the sense of being in a dream.

Delirium is a common condition in medical and surgical wards. It is caused by a diffuse cerebral dysfunction of acute or subacute onset and fluctuant or reversible course. After prodromal restlessness and insomnia, delirium typically presents with obtundation, emotional lability, and visual illusions. The clinical features tend to worsen at night (“sundowning”), with insomnia, agitation, hallucinations, and delusions. So-called quiet deliria are common, with little more to note than clouding of consciousness, mild disorientation for time and place, and reduced concentration. Restlessness, tremor, asterixis (irregular, asymmetrical jerking of the extremities), myoclonus, and disturbance of autonomic function are also common. Patients vary in their psychological reactions to delirium: depressive, paranoid, schizophreniform, anxious, and somatoform responses may be encountered. Delirious patients may be fearfully or combatively hypervigilant, or torpid and apathetic.

Visual illusions, which are characteristic of delirium, involve the patient misinterpreting moving shadows, curtains, and surrounding bedroom furniture. Physical sensations may also be misperceived. For example, the patient may mistake abdominal pain for the knives of malefactors and tinnitus for radio waves. If poorly systemized delusional beliefs arise, the patient may act on them, seeking escape or defense. Visual hallucinations are more common than auditory hallucinations in delirium. Visual hallucinations are sometimes playful (e.g., animals romping), sometimes personal (e.g., the face of a dead relative), or sometimes horrible or threatening (e.g., dismembered bodies, accidents). They are most evident at night and can be provoked when the eyes are closed, especially when the orbits are pressed. Affect is usually labile in delirium, but persistent blunting, anxiety, suspiciousness, hostility, depression, or euphoria may be encountered and is usually congruent with the prevailing illusions or hallucinations.

Delirious patients may exhibit wandering attention and concentration; their thinking may become disconnected or incoherent and their memory impaired. These patients sometimes confabulate, linking memories out of correct sequence. Subtle restriction of consciousness often occurs during acute anxiety and results in vagueness or amnesia for traumatic experiences. Rarely, the amnesia is accentuated. The patient may wander off in a daze, turning up in an emergency room unaware of his or her name or address. This is known as dissociative fugue state and should be differentiated from epilepsy or postictal conditions.

Orientation, Attention, & Concentration

Disorders of orientation are most often involved when the sensorium is clouded, as in torpor, obtundation, dreamy states, delirium, or fugue. Orientation is usually lost in the following order: time, place, and person. Disorientation for time and place usually indicates organic brain disorder. Disorientation for personal identity is rare and is associated with psychogenic or postictal fugue states, other dissociative disorders, and agnosia (loss of the ability to recognize sensory inputs). The interviewer assesses the patient's orientation by asking him or her for the information listed in Table 4–6. The reliability of the clinical assessment of orientation is high, but its predictive validity is uncertain.

Attention is involved when a patient is alerted by a significant stimulus and sustains interest in it. Concentration refers to the capacity to maintain mental effort despite distraction. An inattentive patient ignores the interviewer's questions, for example, or soon loses interest in them. The distractible patient is diverted from mental work by incidental sights, sounds, and ideas.

Table 4–7 describes simple clinical tests for attention and concentration. These tests have high reliability but little validity. Primarily they test the ability to concentrate. A patient's ability to answer arithmetic questions requires not only concentration but also intelligence and education. Errors are common and are related to psychiatric disturbance, socioeconomic status, intelligence, and the patient's ability to cope with an interview situation. The procedure helps to identify organic brain disorder but has little diagnostic specificity.

Memory

Memory has several stages. Information must first be registered and comprehended. It is then held in short-term storage. If the material is to be retained beyond immediate recall, a more durable memory trace is formed. Memory traces in long-term storage will decay, consolidate, or become simplified and schematized, partly as a result of subsequent experience. Long-term memories are retrieved or recalled from storage by tagging a pattern of sensory phenomena and matching it with long-term memory schemata.

In clinical practice, abnormal memory is manifest as amnesia (memory loss) or dysmnesia (distortion of memory). Psychogenic amnesia occurs in several forms. During and after severe anxiety, memory is likely to be defective. Some people have the ability to repress unwelcome anxiety-laden ideas; their memory is thereby rendered patchy or selective. In dissociative disorders, such as psychogenic amnesia and fugue, the patient usually loses memory for a circumscribed period of time during which profoundly disturbing events took place. Less commonly the amnesia is generalized (i.e., total) or subsequent (i.e., amnesia for everything after a particular time).

In addition to displaying generalized amnesia, patients in a psychogenic fugue state may travel a distance from home and assume a new identity. Often it is unclear in such cases whether unwitting self-deception or conscious imposture are involved.

Organic amnesia occurs in acute, subacute, and chronic forms. After acute head trauma, retrograde amnesia (loss of memory of past events) is likely to occur as a result of a disruption of short-term memory. The extent of anterograde amnesia (inability to form new memories) after head trauma is an index of the severity of brain injury. Amnesia also occurs in association with alcoholism (i.e., blackouts) and after acute intoxication, delirium, or epileptic seizures.

Subacute amnesia (the amnestic syndrome) occurs in Wernicke encephalopathy, a disease caused by thiamine deficiency and encountered most commonly after alcohol abuse. Wernicke encephalopathy is characterized by conjugate gaze ophthalmoplegia, nystagmus, ataxia, and delirium. After the delirium clears, most patients experience a residual Korsakoff syndrome with disorganized memory in an otherwise clear sensorium. Patients with Korsakoff syndrome have difficulty recalling events from before the onset of the encephalopathy. They also experience severe impairment of the ability to lay down new memories after the encephalopathy. The retrograde amnesia affects the patient's ability to remember the precise order in which events occurred. The anterograde amnesia, however, tends to be even more marked; the most severely affected patients, for example, are unable to store new information. As a consequence, these patients are often disoriented for place and time and may confabulate to fill the memory gaps. Thus, the characteristic pattern of Korsakoff syndrome is of amnesia, disorientation, confabulation, a facile lack of concern, and a tendency to get stuck in the one groove of thought (perseveration). Chronic amnesia, as in dementing illnesses, extends back for years. Recent memory is lost before remote memory.

Disorders of recognition include déjà vu, déjà vécu, and psychotic misidentification. Déjà vu and déjà vécu are common and normal, particularly in adolescents. They involve the sudden uncanny feeling that one has experienced the present situation, or heard precisely the same current conversation, on a previous occasion. These phenomena are associated with anxiety and less commonly with temporal lobe epilepsy. Psychotic misidentification may occur in schizophrenia. These patients describe familiar people as strangers or claim to recognize people they never met. Patients with Capgras syndrome regard familiar individuals (such as family members) as doubles or impersonators of themselves.

Disorders of recall include retrospective falsification and confabulation. All people indulge at times in retrospective falsification, embellishing the past to present a more appealing, tragic, or amusing impression. Histrionic people sometimes invent such an extensive and impressive past that they are drawn into imposture. Depressive individuals find sin, failure, and occasion for self-recrimination in their unexceptional lives. After recovery from psychosis, patients often repress their memories of illness and retain only bland or vague reminiscences of the acute disorder. It is inadvisable to ask them to recall their experiences in detail.

A confabulation is a false memory that the patient believes is true. Confabulations may be quite detailed, but they are often inconsistent and fanciful. Confabulations commonly fill memory gaps, especially in the amnestic syndrome. Some schizophrenic patients confabulate, spinning complicated fantasies about telekinesis, extrasensory perception, nuclear radiation, and the like. It is difficult to draw the line between confabulation and deception in the hysterical impostor or the dramatic abnormal illness behavior of the patient with Munchausen syndrome.

Table 4–8 lists the clinical tests for immediate, recent, and remote memory. These tests have good test–retest and interrater reliability. Their validity is affected by intelligence and age and by emotional states such as depression and to a lesser extent anxiety. The most useful tests for detecting organic lesions appear to be orientation, delayed recall, sentence repetition, and general information.

Information

The patient's fund of general knowledge depends on education and current interest in contemporary affairs. Table 4–9 provides a clinical test of information. Organicity is suggested if the patient makes 12 or more mistakes (ϵ = 60%) on this test. If administration is standardized, reliability is high. The test is quite useful as an estimate of organicity, although it does not assess a unitary cognitive function.

Comprehension

A patient's comprehension is evaluated by his or her grasp of the importance of the immediate situation. For example, does the patient know why he or she is where he or she is? Does the patient appreciate that he or she is ill or in need of treatment? Does the patient understand the purpose of the examination?

There are no tests for comprehension. It is evaluated as the interview proceeds. Although comprehension is often disturbed in delirium and dementia, for example, there is no evidence that this disturbance contributes anything to the diagnosis of organicity beyond what is provided by other tests of the sensorium (i.e., orientation, concentration, memory).

Conceptualization & Abstraction

Simple levels of conceptualization are assessed by testing the patient's capacity to discern the similarities and differences between sets of individual words. The patient's capacity to abstract is tested by asking the patient to discern the meaning of well-known metaphorical statements (Table 4–10). The tests listed in Table 4–10 have poor reliability and validity. They are affected by intelligence, educational level, culture, and age and have little discriminating power. The tests do not effectively detect organicity. Research has shown that clinicians using these tests could not distinguish between manic patients, schizophrenic patients, and creative writers. They are of most use when they tap unmistakable formal psychotic thought disorder. Consider the following examples:

A young man with disorganized and accelerated thinking responds thus to the proverb “People in glass houses should not throw stones”: “Oh yeah. My California uncle passed the shotgun out the windows and started firing!”

To the proverb “A rolling stone gathers no moss,” he answers, “Put a few pebbles in your mouth when you’re hiking. You’ll go a few more miles.”

Another young patient, who has the delusion that he is Christ, responds to the glass houses proverb as follows: “Those who know that it has been seen what they have done—and believe me it has all been seen—let him who is without sin cast the first stone. Okay? That's what I believe it means.”

The same patient responds to the rolling stone proverb in this way: “If you can continue to move and always move and always follow yourself and no one else, you’ll never have the evil one within yourself.”

Unfortunately the sample of thinking provoked by these tests is usually so small, and its pathology so equivocal, that these tests are of dubious virtue.

Language

Language is a system of communication that is also used as a tool of thought. Language facilitates thinking by the way semantics hierarchically organizes ideas and concepts and by the way in which syntax indicates the relationship between those ideas and concepts.

Language competence is assessed from the patient's speech during the psychiatric interview. Any history of spoken or written language difficulty, or any observation of clumsy articulation, disordered rhythm, and difficulty in the understanding or choice of words, should be noted and investigated further. Language comprehension is tested by asking the patient to point to single objects, and then to point to a number of objects in a particular sequence. The interviewer may also ask the patient to perform a series of actions in an arbitrary sequence (e.g., “Touch your nose with your right index finger, then point that finger at me, then put it behind your back.”). Language expression is evaluated by asking the patient to repeat words, phrases, and sentences and to name correctly a number of objects. Expression and comprehension are evaluated by asking the patient to read a passage aloud and to answer questions about it. Asking the patient to take dictation tests graphic language. Any errors and slowness in performance should be noted. The following sections describe some common disorders of language.

Aphasia

Aphasia is a dysfunction in the patient's ability to express himself or herself. The three most common forms of aphasia are all manifest as difficulty in repeating words or phrases. In Broca aphasia, comprehension is relatively intact but expression dysfluent, sparse, telegraphic, and full of circumlocution. In Wernicke aphasia, comprehension is affected. Expression, though fluent, rambles, lacks meaning, and is full of errors to which the patient seems oblivious. In conduction aphasia, comprehension is intact, expression is fluent but full of errors and pauses, and repetition is difficult; however, reading is relatively intact.

Muteness

Muteness is seldom found in neurologic disease, except in the acute phase, in seizure disorder, or in advanced cerebral degeneration. The aphasic patient is never mute. Muteness is much more commonly a sign of melancholia, stupor, catatonia, somatoform disorder, dissociation or negativism in children (i.e., elective mutism).

Schizophrenic Language

The psychiatrist's main diagnostic problem is to differentiate schizophrenic language from the “jargon” of Wernicke aphasia. Schizophrenic patients tend to be heedlessly bizarre in thought content; aphasic patients are more aware of their errors and are more likely to use substitutions to overcome their language defects. The confused speech of schizophrenic patients is known as word salad. It may be so chaotic as to be barely comprehensible.

Paralogia

Paralogia, or talking past the point, occurs when the patient gives answers that are erroneous but reveal knowledge of what should be the correct answer. For example, the interviewer may ask, “How many legs has a cow?” and the patient responds, “Five.” Talking past the point occurs in Ganser syndrome (also called the syndrome of approximate answers). It is most likely to be observed in individuals who regard hospitalization for insanity as preferable to incarceration for crime.

Neologisms

Neologisms are new words coined by the patient. They are often condensations of ideas that attempt to capture the ineffable. Neologisms are most common in schizophrenia; they must be distinguished from aphasic paraphasia, and circumlocution, to which the patient resorts in order to overcome expressive difficulty. Sometimes a neologism reveals that the patient has been “derailed” by the sound or sense of an associated word or idea. At other times, neologisms are a response to hallucinations or a defense (in a private code) against the intrusion by the interviewer upon the patient's privacy.

Disorders of Thought

Pathology of thought may be found in the process, in the form, or in the content of thinking. The process and form of thinking may be disordered in terms of tempo, fluency (including continuity and control), logical organization, and intent. Normal thinking is characterized by reasonable but not excessive speed, and a smooth and continuous flow from one idea to the next. Normal thinking has clear goal-direction, organization, and consensual logic in the links between, and the sequence of, its constituent ideas.

In psychological illness, particularly the turmoil associated with psychoses such as schizophrenia and mania, any or all of the above characteristics may be disorganized. Pathologic thinking can be sluggish, headlong, disconnected, meandering or halting, and prone to lose its track, wander off at tangents, or follow an illogical line.

Abnormal thinking can be experienced by the thinker as invasive, inserted, or controlled by alien forces (thought insertion). It can also be sensed as leaking, stolen, lost, or broadcast from the mind into the outside world (thought withdrawal or broadcasting). Finally, the psychotic thinker, oblivious to or unconcerned about the need to make sense, may lose contact with the audience or use language defensively as a mocking camouflage.

Abnormalities of Thought Process & Form

Tempo

Thinking is accelerated in flight of ideas, which may reach such a pitch that goal direction is lost and the connection between ideas is governed not by sense but by sound or idiosyncratic verbal or conceptual associations. Alliteration, assonance, rhyme (clang associations), and punning may determine the torrent of ideas that is distracted readily by internal or environmental stimuli. Flight of ideas is usually associated with pressured speech and may be experienced by the patient as racing thoughts. Flight of ideas is characteristic of mania, but it may occur also in excited schizophrenic patients, especially those in acute catatonia. In hypomania the flight of ideas is less marked, the tempo being accelerated but the associations less disorganized.

The tempo of thinking may be slowed in retardation of thought, especially in major depression. The patient often complains of fuzziness, woolliness, and poor concentration. Response time to questions is increased. There are long silences during which the patient may lose the thread of the conversation. In the extreme, retardation of thought becomes mutism or even stupor.

Fluency

In circumstantiality, although the goal direction of thinking is retained, associations meander into fruitless, overly detailed, or barely relevant byways. The listener may feel impelled to hurry the speaker along. Circumstantiality is said to be characteristic of some epileptic patients whose peculiar combination of pedantry, perseveration, religiosity, and cliché lend their thinking a so-called “viscous” quality.

Perseveration refers to a tendency to persist with a point or theme, even after it has been dealt with exhaustively or the listener has tried to change the subject. It is also observed, for example, when a child fixedly repeats one aspect of a drawing, leaving multiple lines or dwelling on the shading in an exaggerated manner.

Continuity

In thought blocking, the patient's speech is interrupted abruptly by silences that last less than a second or much longer, even a minute or more. During the pause the patient's eyes often flicker, particularly if he or she is listening to an auditory hallucination. Sometimes the patient becomes mentally blank. Blocking is often precipitated by questions or ideas that have personal significance, particularly if their import is threatening. Blocking is an uncommon but striking sign. It tends to be identified far too often, the observer mistaking the retarded thinking of a depressed or preoccupied patient for the abrupt roadblock of the true phenomenon. It is almost pathognomonic of schizophrenia but must be differentiated from the absences of petit mal epilepsy, the hesitation caused by anxiety, and the peculiar mental fixity associated with amphetamine intoxication.

During the period of blocking, intermediate associations may be lost, and the patient recommence on an apparently different track (tangential thinking). This can give rise to a phenomenon known as the knight's move in thought: The listener can sometimes intuit how the patient got from A to E and realizes that the unspoken intermediate associations (B, C, and D) were quite indirect. On other occasions, the patient's thinking appears subject to derailing (jumping the track to proceed on a different subject), particularly when a sore point has been touched on. Patients are often aware of disturbances in the continuity of their thinking and will describe how their thoughts become paralyzed, interrupted, or jumbled.

Control

Akin to the subjective phenomena described in the previous section is the patient's sense that speed, direction, form, or content of thought are out of control. Complaints such as “confused,” “racing thoughts,” “unable to concentrate,” “scatterbrained,” “jumbled,” and “going crazy” often reflect the subjective perception of pathologically accelerated, dysfluent, or discontinuous thinking.

Sometimes schizophrenic patients report that their thinking is controlled by external forces or people, for example, by means of radio waves or other transmissions. Thinking may be perceived as directed by the external agency, or particular thoughts experienced as having been implanted by it. This is known as thought insertion or thought alienation.

In thought deprivation or thought broadcasting, the patient senses that ideas are leaking out of the mind, being stolen by others, or being broadcast via radio or television. The perception that the television picks up and repeats one's thoughts may provoke a grandiose or persecutory delusional misinterpretation.

Logical Organization

Psychotic thinking may reflect a deterioration in the capacity to think formally or logically. Commonly, the schizophrenic patient uses a private logic, with overpersonalized concrete symbols. Within this logical framework, conceptual boundaries are blurred, and the thinking patterns are metaphorical and idiosyncratic, almost as if they emerged directly from a dream-state. Thus, to the observer, when such thoughts are expressed, they appear on the surface to be diffuse, bizarre, and lacking in clarity. However, it is possible to interpret their meaning in the context of the patient's personal situation, and the issues that he or she is struggling with.

Intent of Communication

The conventional purpose of discourse is to communicate, but the clinician may be misled by the intentions of a schizophrenic patient. The schizophrenic patient may attempt to remain private or to deride the clinician, subtly, by conversing in an obscure, remote, supercilious, attacking, mocking, or farcical manner.

Abnormalities of Thought Content

Several disorders are virtually defined by the presence of abnormalities of thought content. In many instances the patient will complain of these phenomena (e.g., a phobia of heights); in other cases the patient appears to have accepted an eccentric idea (e.g., the delusion of being a reincarnation of Christ) and to be acting accordingly. Abnormal thought may be divided into the following categories: abnormal perceptions, abnormal convictions, abnormal preoccupations and impulses, and abnormalities in the sense of self.

Abnormal Perceptions

Perception is physical sensation given meaning, the integration of sensory stimuli to form an image or impression, in a manner or configuration influenced by past experience. Perception may be increased or decreased in intensity. Heightened perception occurs in delirium, mania, after hallucinogens, and in the rare ecstatic states that occur as part of acute schizophrenia or “transported” hysterical trances. Dulled perception occurs in depression and organic delirium.

In derealization, the external world seems different, changed, vague, unreal, or distant. This symptom is common during adolescence, in association with depersonalization, the sense that one is distanced from the environment or a spectator of one's own actions. It is also associated with anxiety or dissociative disorders, depression, schizophrenia, organic brain disorder, and after hallucinogen use. In synesthesia, the subject perceives color in response to music, for example. It is a common psychedelic experience.

Time may be experienced as accelerated under the influence of hallucinogens, in mania, or during an epileptic aura. Time may seem slowed or stopped in depression or epilepsy. In some conditions, time seems to lack continuity and the subject feels uninvolved in the temporal stream. This is particularly likely to be encountered in depersonalization, amnestic syndromes, depression, schizophrenia, or toxic-confusional states.

An illusion is sensory stimulation given a false interpretation, that is, a false perception. Illusions are most likely to occur when the mind is under the sway of an emotionally determined ideational “set” (e.g., vigilance for an intruder), when sensory clarity is reduced (e.g., at night), or when both sets of circumstances are operating (as when a frightened elderly patient has both eyes bandaged following ophthalmic surgery). Illusions are common in delirium and may be visual (e.g., fluttering curtains seen as intruders), auditory (e.g., a slamming door interpreted as the report of a pistol), tactile (e.g., skin sensations thought to be caused by vermin), gustatory (e.g., poison detected in the taste of food), kinesthetic (e.g., flying), or visceral (e.g., abdominal pain thought to be caused by ground glass). Illusions may also occur in hysteria, depression, and schizophrenia, particularly when perception is subordinated to a delusional idea (e.g., of guilt or persecution) or an emotion of great force (e.g., abandonment or erotic yearning).

A hallucination is a false perception that occurs in the waking state in the absence of a sensory stimulus. It is not merely a sensory distortion or misinterpretation, and it carries a subjective sense of conviction. A true hallucination appears to the subject to be substantial and to occur in external objective space. In contrast, a normal mental image is insubstantial and experienced within internal subjective space. Deafness, tinnitus, or blindness, usually in association with dementia or delirium, may determine the modality of hallucinations.

Sensory deprivation experiments have produced visual and auditory hallucinosis in many subjects. Hallucinosis and delirium following cataract operation probably acts by the same mechanism, especially in association with dementia. Diencephalic and cortical disease may be associated with hallucinations (usually visual). Tumors of the olfactory or basal temporal regions may cause olfactory hallucinosis, for example, as an aura. Hallucinations, especially visual in modality (though sometimes vestibular and kinesthetic), are common in the delirium caused by toxins (e.g., drugs, hallucinogens, alcohol, toxins), fever, cerebro-vascular disease, and central degenerative disorders. Hallucinations may also be a prominent feature of the uncommon schizophrenia-like psychosis associated with epilepsy. Aside from these medical circumstances, hallucinations are common and normal, especially in some people, when falling asleep (hypnagogic) or waking (hypnopompic). Severe sleep deprivation can cause hypnagogic hallucinosis.

Hallucinations can be auditory, visual, olfactory or gustatory, tactile, or somatic. In form, they may be amorphous, elementary, or complex. They may be experienced as emanating from inner or outer space and, if from outside, from near or far. Hallucinations may be unsystematized, appearing to have no link to life circumstances, or systematized and part of a causally interconnected delusional world.

Auditory hallucinations may be inchoate (e.g., humming, rushing water, inaudible murmurs), fragmentary (e.g., words or phrases such as “fag,” “get him,” or “beastly”) or complex. Typically the schizophrenic patient locates complex hallucinations in inner or outer space, as a voice or voices speaking to or about him or her. The voice may be soothing, mocking, disparaging, or noncommittal. Sometimes the voice echoes the patient's thoughts or comments neutrally on his or her actions. Sometimes the voice orders the patient to perform actions, or puts thoughts into his or her head, a perception verging on thought insertion. The voice may be perceived as coming from the radio or television, from outside the window, or even from a distant place. In alcoholic hallucinosis, typically, a conspiracy of threatening whisperers plan to injure the patient, provoking the patient to self defense or flight.

Visual hallucinations vary from elemental flashes of light or color, as in disorders of the visual pathways and cortex, to well-formed scenes of people, animals, insects, and things. In delirium, insects or other small objects may be seen moving on the bed or in the surroundings. Lilliputian hallucinations, of little people on the bed, for example, occur in delirium and other organic brain syndromes. Complex audiovisual hallucinations may occur in temporal lobe epilepsy. In general, visual hallucinosis suggests acute brain disorder rather than functional psychosis and tends to occur in a setting of confusion or obtundation. Sometimes, however, a schizophrenic patient will report visual hallucinations (e.g., trips in flying saucers) aligned with his or her prevailing delusions. The visual hallucinations of hysteria or dissociative disorder have a pseudo-hallucinatory (i.e., “unreal”, “as though”) quality and sometimes represent the intrusive memory of a traumatic event, as when a war veteran reexperiences a battle incident.

Olfactory and gustatory hallucinations (e.g., burning rubber, steak and onions) may occur in epilepsy. Schizophrenic patients may perceive gas being pumped into their bedrooms by persecutors or may think they taste poisonous substances in their food. Melancholic patients may be conscious of the stench of corruption rising from their unworthy bodies or may complain of the changed, metallic, tasteless quality of their meals.

Tactile hallucinations are characteristic of cocaine and amphetamine intoxication, the patient being distracted by the sensation of insects crawling on the skin. Schizophrenic patients may detect the effect on the skin of radioactivity beamed at them from a hostile source.

Somatic hallucinations occur in schizophrenia, whereby genital, visceral, intracerebral, or kinesthetic sensations are often referred to the influence of persecutors or machines. The melancholic patient may have the sense of having no stomach, with food dropping from the throat into a void.

In schizophrenia, or under the influence of hallucinogens, the patient may have the uncanny sense that somebody, a presence, is behind him or her. This can occur in states of extreme fear, but it may become a central feature of schizophrenia, in the guise of the Doppelgänger or Horla, a hallucinatory double of the self who always lurks just behind the periphery of vision.

Abnormal Convictions

A delusion is a false belief not susceptible to argument and inconsistent with the subject's sociocultural background. Bordering on delusion is the overvalued idea, a notion eccentric rather than false but likely to become a governing force in the patient's life.

It is not always easy to draw the line between an eccentric individual, somebody who holds unfamiliar views that are nevertheless consistent with a different sociocultural system, and a deluded person. Indeed, some people drift across the misty boundaries between these categories. An active delusion, however, is rigid, unshakable, and self-evident. It dominates the subject's life, subordinating all other matters. It is private, idiosyncratic, ego-centered, and inconsistent with the common experience of people from the same background. A delusion, therefore, isolates the subject from others and alienates them from him or her.

Severe sensory deprivation, or exhaustion and physical privation, may lead to delusional misinterpretation, often associated with wish-fulfilling hallucinations. A delusion can act as a transcendental escape from an existential wasteland. This is the ground from which cosmic, messianic, and redemptive delusions grow.

As for the content of delusions, the commonest are of persecution, jealousy, love, grandeur, disease, poverty, and guilt. Delusions of persecution are most frequently encountered in schizophreniform disorders or schizophrenia, paranoid disorders, organic mental disorder (especially alcoholic hallucinosis, amphetamine delirium or delusional disorder, other hallucinogenic syndromes, epilepsy, and all forms of delirium) and, less commonly, in melancholia or during transitory psychotic breaks in the life-course of patients with borderline personality. The patient may perceive others as talking conspiratorially about him or her (delusions of reference) or spying on him or her. External agencies (e.g., communists, FBI, freemasons) are regarded as acting in concert and disconcerting the subject with radiation, poisonous gases, radio and television, intruders, assassins, and so on. The patient often alludes to the use of tape recorders, cameras, and other surveillance paraphernalia. Delusions of poisoning, particularly by the spouse, are sometimes encountered.

Delusions of jealousy occur in the same syndromes as delusions of persecution but are especially likely in association with alcoholism in men. In that case, delusions of marital infidelity (possibly related to alcohol-related sexual impotence) are characteristic, the patient closely scrutinizing his partner and her belongings for evidence of adultery.

Delusions of grandeur occur in mania, schizophrenia, paranoid disorders, and organic delusional syndromes (e.g., neurosyphilis). In mania and organic grandiosity, the patient's megalomania (e.g., of being God, the governor, the Virgin Mary, Napoleon) are in line with his or her general high spirits. In schizophrenia and paranoid disorders, an inflated sense of importance may be reinforced by auditory hallucinations and the grandiosity of a delusional explanation for ideas of persecution: Why else would important agencies (e.g., the FBI, the Vatican, the PLO) be persecuting the patient?

Erotic delusions (erotomania) are more common in female schizophrenic or paranoid patients. A lonely person develops a crush on another, often a celebrity or prominent citizen. Fantasies evolve into delusions, and the subject bombards the other person with telephone calls and messages. The failure of the loved one to reciprocate is put down to conspiratorial forces that stand in the way of destiny. In schizophrenia, the patient may receive erotic hallucinations from the beloved.

Somatic delusions, usually of disease or ill health, occur in many psychiatric disorders. Schizophrenic patients may have bizarre complaints, possibly in an attempt to explain somatic hallucinatory experiences, for example, of blood running backward in the head, of radiation being trained on the genitals by an outside agency, or of objects placed inside the body by malevolent forces. In melancholia, the patient may have delusions of being dead (no blood in the body), of the internal organs rotting away, or of the brain being destroyed by syphilis, in retribution for an unpardonable sin. The boundary between hypochondriasis, disease phobia, and disease conviction on the one hand and somatic delusions on the other may be difficult to define.

Melancholic patients are prone to delusions of poverty and delusions of nihilism. The future is hopeless, the present desolate, the patient destitute and abandoned to a bleak fate. Depressive patients may also complain of inordinate guilt, the most extreme punishments being meted out to them for unremarkable, ancient transgressions.

Abnormal Preoccupations & Impulses

A phobia is a morbid and irrationally exaggerated dread that focuses on a particular object, situation, or act (see Chapter 19). Phobias differ from generalized anxiety in their focused quality, although a diffuse anxiety state sometimes precedes a phobic disorder. The patient is aware of the exaggerated, irrational nature of a phobia and regards it as symptomatic. The patient often tries to avoid the phobic situation or is compelled to perform actions (such as hand washing) in order to eradicate the object of the fear, or atone for tabooed action.

An obsession is a persistent idea, desire, image, phrase, or fragment of music that cuts into the stream of conscious thinking. The patient recognizes the alien nature of the obsession and attempts to resist it, without success. The obsession often presses the subject to perform compulsive acts, to relieve anxiety. The key characteristics of obsessions are their persistent, irresistible, imperative nature; their ego-alien quality; and their repetitiousness. Obsessional symptoms have been reported after encephalitis. They occur in the premonitory phase of schizophrenia or as part of a major depression (e.g., the patient may experience persistent ruminations that old tax returns were in error and that ruin will result). Obsessive–compulsive symptoms are most characteristic of the anxiety disorder that bears the same name (see Chapter 21).

Impulsions differ from compulsions in that the former are less likely to be resisted, and they are episodic rather than repetitious, although the distinction may be blurred at times. Impulsions tend to occur in externalizing personalities, whereas compulsions are more typical of inhibited, constricted people. Impulsions cause difficulty for others and may lead to legal entanglements. Impulsive acts often spring from an emotional setting of anger, anxiety, frustration, rejection, sadness, or humiliation, particularly when the subject is disinhibited by alcohol. Common impulsions include violent assault, fast driving, excessive drinking or eating, gambling, sexual assault, sexual exhibitionism, shoplifting, stealing, and fire-setting. Sudden, episodic, if not explosive, onset is the hallmark of these phenomena. The subject does not or cannot exercise inhibition or self-control. Desire short circuits thought, leading to action without reflection.

Abnormalities of the Sense of Self

The normal person has a sense of selfhood composed of the following elements: a sense of existing and being involved in one's own body and activity; a sense of personal continuity in time between past, present, and future; a sense of personal integrity; and a sense of distinction between self and outside world. In psychiatric disorders, any or several of these phenomena may be disturbed. For example, the individual may feel uninvolved in his or her own body or actions, like a spectator looking at another person (as in depersonalization); the individual's sense of temporal continuity may be dislocated, with the past and future seeming remote and the present but a series of disconnected scenes; the individual's ego may feel as though it is falling apart, shedding, fragmented, or split in two; or the difference between the self and other persons or objects may have become blurred.

The sense of depersonalization, often associated with derealization, occurs in adolescence, epilepsy, dissociative disorders, schizophrenia, and depression. Adolescents in severe emotional turmoil sometimes develop a sense of discontinuity, disintegration, and dedifferentiation. These symptoms are very common after ingestion of hallucinogens (and may be reexperienced as flashbacks) and in reactive psychosis, schizophreniform disorder, or schizophrenic disorders.

Physiologic Function

Sleep disturbances are often encountered in psychiatric practice. Sleep deprivation may precipitate or accentuate psychiatric disorder. Sleep disturbance may be a prodrome, a symptom, or a sequel of psychiatric disorder. Many psychopharmacologic agents also affect sleep. See Chapter 27 for more on sleep disorders.

Appetite may be increased in depression (especially dysthymic personality) and after psychotropic drug medication. Eating binges (not necessarily determined by increased appetite) may occur in bulimia nervosa as a condition separate from, in alternation with, or following, anorexia nervosa (see Chapter 26).

Anorexia and weight loss can occur in almost any stress condition but are particularly likely in major depression, paranoid schizophrenia, somatoform disorders, alcoholism or drug addiction, and, of course, anorexia nervosa. A comprehensive physical screening investigation is always required when anorexia and weight loss are present.

Sexual desire may be increased in mania, in some forms of acute schizophrenia, and in narcissistic or borderline personality under stress. Sexual behavior may be disinhibited after alcohol or drug ingestion, in delirium, or in organic dementia. Sexual desire is decreased by any debilitating disorder, by anxiety, worry, tiredness, age, poor nutrition, and lack of affection for the partner. It is usually reduced by depression, schizophrenia, alcoholism, substance abuse, and by neuroleptic, antihypertensive, and antidepressant medication.

Absent, irregular, infrequent, and scanty menstrual periods may occur in psychiatric disorder, particularly in depression, anorexia nervosa, anxiety disorders, schizophrenia, and substance abuse. Any condition that reduces total body fat to below 14%, in the female, produces anovulation and amenorrhea. Dysmenorrhea, dyspareunia, vaginismus, and other pelvic complaints are common in somatoform disorders, and in abnormal illness behavior generally, but a discretionary physical screen is required before a stress-related condition is diagnosed. See Chapter 25 for a more complete discussion of sexual dysfunctions.

Any or all body systems may be accelerated in the hyperdynamic states of anxiety, delirium, mania, and catatonic excitement or slowed in the general hypomotility of depression, organic dementia, and hypothyroidism. The patient's level of energy, or fatigue, may also be affected by disorders with accelerated or sluggish mental processes. Anergia, weakness, or obscure bodily discomfort are encountered frequently in somatoform disorders.

Insight & Judgment

Insight

The patient's attitude or insight into the illness has several aspects. For example, does the patient recognize that he or she has a problem? Does he or she identify the problem as personal and psychological in nature? Does he or she understand the nature and cause of the illness? Does he or she want help and, if so, what kind of help?

The hypomanic patient has no problem. He or she feels very well (e.g., high-spirited, amusing, energetic, expansive, and optimistic). The manic or schizophrenic patient may view the problem as external (i.e., other people or agencies are stupidly obstructive or malevolent). Many patients with externalizing personality disorders (e.g., borderline, antisocial, narcissistic) blame others for their predicament.

Sophisticated patients, particularly those who have undergone previous treatment, may have considerable knowledge of the formal diagnosis and the theoretical or actual causes of their disorder. Indeed, sometimes this causes problems in treatment: Other mental health professionals who develop psychiatric illness are notoriously difficult to manage for this reason.

The patient may be aware of having a problem but want no help, or he or she may want help of a particular sort or from a particular kind of clinician. Whenever this is reasonable and feasible, it should be arranged. The patient's desires should be respected as much as possible in the negotiation phase of the clinical process.

Judgment

The interviewer can ask the patient one of the following questions to test judgment: What would you do if you found a stamped, addressed envelope in the street? Why are there laws? Why should promises be kept? Good judgment requires intact orientation, concentration, and memory. There is no evidence that a finding of poor judgment adds anything to diagnosis beyond that provided by the detection of deficits in the lower-order functions, such as accomplishing household chores, maintaining personal hygiene, or selecting appropriate attire.

Termination

A psychiatric interview may last 15 minutes or go on for much longer. The usual time is about 50 minutes: Long enough for a rapid survey but not so long as to exhaust the patient. The interviewer can signal the approach of the conclusion by saying, for example, “Our time is almost finished, and there are a few things we need to discuss.”

A concluding summary of the material points of the interview can be very helpful. It allows the patient to correct or modify misinterpretations and leads naturally into the interviewer's plan for what happens next—another interview, for example, or special investigations.

Facilitating the Interview

If an interview is to achieve its purpose (i.e., to gather information), the interviewer must develop an atmosphere favoring the expression of ideas, feelings, and attitudes. The patient must develop a sense of trust and confidence in the interviewer, in order to be as spontaneous as possible. He or she will thereby see the interview as encouraging participation and collaboration toward a therapeutic end, through free expression and self-exploration.

What can the interviewer do to promote trust, spontaneity, and free expression? The interviewer must accept the patient, without moral judgment. If he or she cannot do so, it is better to be honest about it and refer the patient to another physician. Anybody can help somebody, but nobody can help everybody. If a patient angers, repels, or frightens the interviewer, and the feeling persists, the interviewer should seek help from a colleague.

The interview is facilitated if the interviewer understands the patient and conveys this understanding by facial expression, intonation, and well-timed reflections of the content and emotion behind the patient's story. The deepest affective understanding is empathy, that is, feeling with, or sharing the feelings of, the patient. It contrasts with sympathy, which is a feeling for the patient.

The open-ended style of questioning described earlier in this chapter as being most appropriate to reconnaissance and detailed inquiry helps to convey the spirit of collaboration, free expression, and self-exploration. An atmosphere of trust is fostered if the interviewer is relaxed and receptive, not preoccupied, rushed, abrupt, or irritable. Interviewers will likely adapt to their own purposes the techniques of others that have impressed them.

Interview Setting

A skilled interviewer can be effective walking along a corridor, playing catch, or sitting by the side of a bed. Nevertheless, offices are preferable to closets, and chairs are an improvement over packing boxes. If the interviewer has the opportunity, he or she should arrange the interview room to take advantage of its size, proportions, furnishings, and design.

The fundamental principles are simple. The room should be large enough to fit the patient, a desk, chairs, and other equipment, without crowding the interviewer. It is desirable, though not always possible, to have enough room and seating to accommodate the patient and four others, particularly if the interviewer plans to see families as well as individuals. The arrangement of the desk and chairs should allow entry and egress, but the interviewer should not sit between the patient and the door. He or she should try not to interview people from across a desk. Harsh lighting should be avoided. The patient should not be blinded by glare shining directly from a window or a lamp. The chairs should be comfortable, and the interviewer should not tower over the patient. The interviewer should not leave the patient stranded in the middle of the room; people feel less exposed with something solid behind them. The interviewer should not sit too close (i.e., knee to knee) or too far away. He or she should be near enough to make arm contact by leaning forward.

Interview Techniques

The interviewer should encourage free expression during the reconnaissance and detailed inquiry stages of the psychiatric interview. He or she does so by the setting provided, the atmosphere created, and the interview techniques used. The interviewer should be at ease with these techniques, and they should be used naturally, without flamboyance or stiltedness. If a particular technique does not suit the interviewer, he or she should not use it; an alternative should be found that conveys the same spirit and has a similar purpose.

The following are examples of useful techniques: Attentive listening, subtle vocal and nonvocal encouragement, support and reassurance, the reflection of feeling, gentle indication, and judicious paraphrasing.

Having invited the patient to tell his or her story, the interviewer waits and listens. He or she does not stare but meets the patient's gaze from time to time to indicate he or she is following. The interviewer's intent but relaxed posture indicates involvement. If the interviewer takes notes, they are brief and unobtrusive.

While the flow of associations proceeds, the interviewer need do little but maintain relaxed concentration, signaled by posture, eye contact, and subtle nonvocal or vocal encouragement. A nod or an “uh-huh” or “mm-mm” at strategic points may be all that is needed. Sometimes, when the flow seems to waver or slow, it is very effective to pick up and repeat a significant phrase or the last word the patient has said. But the interviewer should not be mechanical and should not do something unless it feels natural.

The interviewer needs to be alert to the patient's reactions, particularly to changes in voice intonation and speech tempo, tensing of facial muscles, alterations of skin color, and moistening of conjunctivae, which herald a flush of anxiety or anger or a sudden feeling of sadness.

How does the interviewer handle silences? If the patient is thinking fruitfully, all the interviewer need do is wait. Similarly, if the patient has broken down in tears, it may be better to wait calmly until the patient can continue. If the silence occurs when the patient has lost track of or has confused feelings about the topic, the interviewer can facilitate associations with a subtle oral reflection, picking up a key word, phrase, or idea from the recent conversation and repeating it gently, sometimes with a questioning intonation. Oral reflection is also useful to help circumstantial patients get back on track.

The reflection of feeling is a variant of the technique of oral reflection. The interviewer picks up and echoes feelings explicit or implicit in what has been said but that have been expressed incompletely up to that point.

Transference & Countertransference

Transference refers to the unreasonable displacement of attitudes and feelings that originated in childhood to people in the here and now. This phenomenon is particularly likely to affect the doctor–patient relationship when patients are made vulnerable by fear, anxiety, guilt, despair, or hope.

Note the term “unreasonable” in the definition. The patient who is upset by overt rudeness is not displaying transference. However, if the patient is angered because the interviewer has a mustache or wears pearls, it is apparent that something is being added to an objectively neutral situation.

The patient may unconsciously regard the physician as a parent or a sibling, casting him or her in a caring or antagonistic role. Some examples of the commonest roles are of nurturing mother, demanding mother, protective father, punitive father, and rivalrous sibling. Sometimes older patients will relate to the physician as though they themselves were parents, reversing the roles.

How can the interviewer recognize transference? When the patient is exceptionally deferential, hanging onto the interviewer's opinions, singing his or her praises to others, or is easily slighted by a brief or delayed appointment, the interviewer may suspect a positive transference. When the patient is unexpectedly hostile, suspicious, or competitive, and there is no reasonable explanation for such antagonism, a negative transference is likely.

It is not difficult to imagine how a positive transference can become eroticized, the patient falling in love with an idealized parental figure. Most of these infatuations are transitory, like the crushes of adolescence. If the interviewer recognizes them and responds in a professional manner, they will go no further. Occasionally, however, unscheduled visits, notes, telephone calls, unasked for gifts or seductive dress indicate that the matter is more serious. The interviewer may need to consult a psychiatric colleague to decide how to proceed. The interviewer should not respond impulsively, out of fear or affront, lest a vulnerable patient be hurt.

Transference has its counterpart in a physician's countertransference, which occurs when a physician irrationally transfers to a patient his or her attitudes and feelings derived from childhood experiences. Psychiatric interviewers must be alert for countertransference. They should suspect it whenever they have powerful feelings of affection, protectiveness, fear, frustration, irritation, hatred, or erotic excitement toward a patient; when they very much look forward to the next appointment; or when they cannot tolerate a particular patient. If the interviewer recognizes these feelings, they will be much less likely to respond impulsively with rejection, flight, or self-indulgence. Once again, the interviewer should seek the help of a colleague or group of colleagues if he or she is unsure how to proceed in the patient's best interests.

There is no need to be embarrassed by transference or countertransference. Experienced clinicians know that these emotional displacements are ubiquitous and inescapable. They are most likely to be problematic when the interviewer is overworked, preoccupied, or rendered emotionally vulnerable by the vicissitudes of his or her personal life. The interviewer must look after himself or herself physically and emotionally and should do the best he or she can to have a fulfilling life outside of medicine itself.

There is a role for standardized rating scales and structured interviews in developing a psychiatric history and evaluating changes in psychopathology while a patient is under treatment. However, these instruments are rarely appropriate to substitute for a traditional psychiatric interview in clinical practice. Screening questionnaires are used in primary care practice or in identifying psychopathology in large populations. Examples are depressive screening instruments in primary care and posttraumatic stress disorder screening instruments in military populations.

Diagnostic rating scales are used to identify specific psychiatric disorders in epidemiological studies and large scale clinical trials. Specific training is required to administer these scales to obtain appropriate validity and reliability. The Present State Examination was developed to standardize psychiatric diagnosis in international epidemiological studies, such as those conducted by the World Health Organization. The Composite International Diagnostic Interview was developed by the World Health Organization using items from the Present State Examination. The Diagnostic Interview Schedule is an epidemiological instrument designed to be used by nonclinicians in large scale epidemiological studies to develop diagnoses found in DSM-IV, Research Diagnostic Criteria, and Feighner criteria. The Schedule for Affective Disorders and Schizophrenia was developed by Endicott and Spitzer to differentiate between affective disorders and schizophrenia in a standardized manner for clinical research. The Structured Clinical Interview for Axis I DSM-IV Disorders was developed to arrive at Axis I diagnoses according to DSM-IV. It is widely used in clinical trials and epidemiological studies.

Symptom-based scales are designed to measure change in a particular symptom or a syndrome-based group of symptoms, rather than establish a diagnosis in the framework of a particular diagnostic system. These scales can be useful in clinical practice to document, objectively and quantitatively, the change in response to a therapeutic intervention or simply change over time. They can be self-rating scales completed by the patient or rater-administered scales completed by the clinician. Obviously, the disadvantage of self-rated scales is the reliability of the measurement.

The Brief Psychiatric Rating Scale measures major psychotic and nonpsychotic symptoms in patients with a major psychiatric disorder. It is a widely used rater-administered scale for evaluating baseline psychopathology and treatment response, particularly in inpatient populations. The Hamilton Rating Scale for Depression is one of the most widely used rater-administered scales for assessing symptoms of depression and measuring their change over time. It is frequently used in clinical trials. The Beck Depression Inventory and the Zung Depression Scale are both self-rating scales that are frequently used to evaluate severity of depression in patients engaged in treatment. The Zung scale is also used as a screening instrument for depression. The Hamilton Rating Scale for Anxiety is a frequently used rater-administered scale for evaluating the severity of anxiety symptoms. There are a variety of symptom-based scales designed to be used in child psychiatric disorders, substance-abuse disorders, and geriatric psychiatric syndromes. The reader is directed to the bibliography for further details in these areas.

The purpose of the psychiatric interview is to obtain information from the patient about the presenting problem and its precipitation and about previous disorders, predisposition, biopsychosocial strengths and limitations, reason for the current presentation, insight, and desire for help. The psychiatric history covers topics that range from identifying data to coping mechanisms. The four stages of the interview—inception, reconnaissance, detailed inquiry, and termination—are adapted to different topics.

In the inception stage, the interviewer makes introductions, gets the patient or family seated, takes identifying information, and summarizes what he knows. The quality of the interview is enhanced if the interviewer creates an atmosphere of trust, spontaneity, and expressiveness by his or her acceptance, empathic understanding, open-ended style, and natural manner. The decor, lighting, furnishings, and arrangement of the room can also promote (or subvert) the desired atmosphere.

During the reconnaissance stage, the interviewer helps the patient describe the presenting problem and its precipitation and development.

During the detailed inquiry, routine and discretionary, the interviewer explores past illness; early development and environment; later educational, occupational, social, and marital history; interests, values, and aspirations; habitual coping style; family history; and mental status.

During the interview, the clinician fosters free expression and association by being attentive and by using certain techniques such as vocal and nonvocal encouragement, support and reassurance, reflection of ideas or feelings, indication of inconsistencies, and paraphrasing.

The clinician will seldom, if ever, need to turn over every stone and pebble in this chapter. What is required is a set of criteria to decide whether comprehensive or brief discretionary screening MSE is indicated.

At termination, the interviewer summarizes the interview and negotiates with the patient over what the next step should be.