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Diagnosis of Psychiatric Disorders: History & Mental Status Examination

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1. The Psychiatric Interview — Overview

• Establish a criteria-based diagnosis
• Predict the course and prognosis of the illness
• Guide treatment decisions
• Provide a biopsychosocial understanding of the disorder
• Develop a person-centered treatment plan

Settings

• Inpatient psychiatric units
• Medical/non-psychiatric inpatient units
• Emergency rooms
• Outpatient offices
• Nursing homes and residential programs
• Correctional facilities

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2. General Principles of the Psychiatric Interview

Interview Techniques

• Open-ended questions at the start — allow the patient to tell their story without interruption
• Closed-ended questions — used to clarify specific details and fill gaps
• Empathic validation — acknowledge the patient's experience
• Active listening — nodding, brief verbal affirmations, silence used appropriately
• Resistance — may manifest as intellectualization, missed appointments, or acting out; often fueled by unconscious repression

Person-Centered Approach

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3. The Psychiatric History

Comorbidity is the rule, not the exception. The clinician must be alert to signs of multiple psychiatric disorders during the interview.

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4. Mental Status Examination (MSE)

• Establishing baseline findings
• Monitoring change over time
• Distinguishing diagnoses

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Components of the MSE (Adult)

A. Appearance and Behavior

• Apparent age vs. stated age
• Dress (appropriate for context?), grooming, hygiene
• Distinguishing features: scars, tattoos, disfigurations
• Body jewelry
• Acute distress; approach to interview (cooperative, agitated, disinhibited, disinterested)

B. Motor Activity

• Normal, slowed (bradykinesia — clue to depression), or agitated (hyperkinesia — mania, anxiety)
• Gait, unusual postures, pacing, hand-wringing
• Tics, tremor, restlessness, akathisia
• Tardive dyskinesia (involuntary mouth/tongue movements — adverse effect of phenothiazines)
• Mask-like facies → Parkinson's disease

C. Speech

• Rate: pressured (mania, agitation, anxiety), slow/decreased (depression)
• Volume and tone: loud, soft, whispered
• Rhythm and fluency: dysarthria, stuttering
• Latency to respond
• Prosody: emotional expression through intonation; dysprosody → dominant lobe dysfunction
• Tearfulness and overt crying → depressive or cognitive disorder

D. Mood

• The patient's subjective internal emotional state — elicited by asking "How are you feeling?"
• Described in the patient's own words
• May be euthymic, depressed, sad, anxious, angry, euphoric, dysphoric, empty, irritable
• Suicidal ideation must always be assessed:
  • "Does the patient feel life is no longer worth living?"
  • "Does the patient think he or she would be better off dead?"

E. Affect

• The objective, observable expression of emotion — what the examiner sees
• Described by:
  • Range: full ↔ restricted ↔ blunted ↔ flat
  • Appropriateness: congruent or incongruent with thought content
  • Stability: labile, sustained
  • Intensity: normal, exaggerated, diminished
• Flat/blunted affect: depression, schizophrenia, brain dysfunction
• Euphoric or expansive affect: mania, frontal lobe dysfunction (Witzelsucht — tendency to joke and laugh)

F. Thought Process (Form)

• Normal: goal-directed, logical, coherent
• Loosening of associations (derailment): ideas shift with little connection
• Flight of ideas: rapid jumping between loosely connected thoughts (mania)
• Circumstantiality: excessive digression that eventually returns to the point
• Tangentiality: never returns to the original point
• Thought blocking: sudden interruption of thought
• Perseveration: repetitive recurrence of the same word or theme
• Echolalia: repetition of another's words
• Word salad: incomprehensible mixture of words

G. Thought Content

• Delusions — fixed, false beliefs not amenable to reasoning
  • Paranoid/persecutory, grandiose, somatic, erotomanic, nihilistic, referential
• Obsessions — recurrent, intrusive thoughts recognized as senseless but difficult to control
• Compulsions — repetitive behaviors performed to neutralize obsession
• Phobias — irrational, persistent fears
• Suicidal/Homicidal ideation, intent, and plan
• Ideas of reference: belief that random events have special personal significance

H. Perceptual Disturbances

• Hallucinations: perception without external stimulus
  • Auditory (most common in schizophrenia), visual, tactile, olfactory, gustatory
  • Note: in older adults, transient hallucinations may reflect sensory deficits rather than psychosis; confusion during hallucination → organic etiology
• Illusions: misinterpretation of real external stimulus
• Depersonalization/Derealization: feeling detached from oneself or one's surroundings
• Distorted body perceptions → possible focal brain pathology

I. Sensorium & Cognitive Functions

• Cognitive impairment (delirium, dementia) → impaired orientation, memory, calculation
• Cultural and educational factors must be considered when interpreting results
• The Mini-Mental State Examination (MMSE) is a standardized cognitive screening tool used within the MSE — but is not the same as the full MSE

J. Insight

• How they are feeling and functioning
• Potential causes of their psychiatric presentation
• Whether they are experiencing mental illness

Intact insight ≠ mild illness. A psychotic patient may have good insight: "I know there are not really little men talking to me, but I feel like I can see them."

K. Judgment

• Observation of behavior during the interview
• Hypothetical scenarios: "What would you do if you found a letter on the street?"

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5. MSE in Special Populations

Children (Table 1-27, Kaplan & Sadock)

1. Physical appearance
2. Parent–child interaction (observed before the interview in the waiting area)
3. Separation and reunion — distress or absence of affect at separation may indicate relationship problems or psychiatric disturbance
4. Orientation to time, place, person (age-appropriate)
5. Speech and language development — evaluate against developmental milestones
6. Mood
7. Affect
8. Thought process and content — compare to age-expected norms
9. Social relatedness — particularly relevant for autism spectrum disorders
10. Motor behavior
11. Cognition
12. Memory
13. Judgment and insight

Children who do not use words by 18 months or phrases by 2.5–3 years (with intact babbling/nonverbal response history) are likely developing typically — consider hearing loss before concluding pathology.

Older Adults

• Repeat MSEs may be needed due to fluctuating changes
• Motor disturbances prominent: shuffling gait, stooped posture, pill-rolling tremor, body asymmetry
• Speech may be pressured (agitated/manic states) or slowed (depression)
• Suicide risk is high: loneliness, death of spouse, physical illness, pain, alcohol abuse, living alone
• Affect may be flat, blunted, or inappropriate → depression, schizophrenia, brain dysfunction
• Functional Assessment (Activities of Daily Living) is essential for treatment planning
• Hallucinations may reflect sensory deficits or organic pathology (brain tumor, focal lesion) — requires workup

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6. Current Diagnostic Framework (DSM-5-TR)

Key Features of Modern Diagnostic Classification:

• Criteria-based: Diagnoses require a specific number of symptoms from defined lists, present for a defined duration, causing significant distress or functional impairment
• Categorical + dimensional: DSM-5 is primarily categorical but incorporates dimensional severity ratings (e.g., cross-cutting symptom measures)
• Etiologically agnostic: Grouped by symptom clusters (not by presumed cause) — reflecting that biological underpinnings of most disorders remain incompletely understood
• Specifiers: Most disorders include specifiers for severity (mild/moderate/severe), course (with/without remission), and clinical features
• Multiaxial framework abolished in DSM-5 (previously Axes I–V); all diagnoses now listed together with notation of psychosocial/contextual factors

Major Diagnostic Categories (DSM-5-TR):

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7. The Biopsychosocial Formulation

• Biological factors: Genetics, neurobiology, medical comorbidities, medications, substance use
• Psychological factors: Developmental history, trauma, personality, defenses, insight
• Social factors: Family, relationships, occupation, housing, culture, religion, legal status

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