Clinical interview: psychiatric history and mental status
§general introduction
§choosing a place and meeting the patient
§applying interviewing techniques
§taking a psychiatric history
§mental status examination

General introduction
§the purpose of a diagnostic interview is to gather information that will help the examiner make a
diagnosis -  the diagnosis guides treatment §psychiatric diagnoses are based on descriptive
phenomenology: signs, symptoms, and clinical course §the psychiatric examination consists of the
two arts: a psychiatric history, and mental status examination

Choosing a place and meeting the patient
§choosing a quiet place
§new patient almost certainly will be anxious (being worried by his symptoms and apprehensive about
what your assessment will be) §shake hand and introduce yourself, use formal address (i.e. Mr.,
Ms.), invite patient to sit down §be sure your patient understands the reason for your meeting
(e.g. to evaluate the problems) §your interviewing style: helping your patient tell you what is
wrong!

Applying interviewing techniques
§allow the interview to flow freely, let patient describe the events of his live in any order he
chooses, encourage him to elaborate on thoughts and feelings §provide structure for pts. who have
trouble ordering their thoughts -specific questions §phrase your question to invite the patient to
talk (open vs. closed questions)
§avoid leading questions
§help patient to elaborate ( „Tell me more about it, please go on“)

Applying interviewing techniques
§reflect your patient‘s feeling back to him (correctly verbalise patient‘s feelings) §paraphrase
the patient‘s thought („You mean, you did not feel better?“)
§summarise what the patient has said
§additional tips : avoid jargon, use the patient‘s words, avoid asking why, identify thoughts
versus feelings, avoid premature reassurance
§

Taking a psychiatric history
§1. Identifying data: (name, age, ethnic, sex, occupation, number o children, place of residence)
§2. Referral source
§3. Chief complaint   („What brings you to see me?“)
§4. History of the present problem:
§onset of problem
§duration and course
§psychiatric symptoms
§severity of problem
§possible precipitants

Taking a psychiatric history
§5. Past psychiatric history:
§all previous episodes and symptoms
§prior treatments and response, hospitalisations
§The best predictor of future treatment
§response is past treatment response !

Taking a psychiatric history
§6. Personal  history:
§Infancy:
§birth history, developmental milestones
§Childhood:
§pre-school years,  school, academic performance
§Adolescence:
§onset of puberty, early sexual experience
§peer relationship
§Adulthood
§education, military experiences, employment
§social life, sexual history, marriage, children

Taking a psychiatric history
§7. Family history of mental illness
§8. Medical history:
§current medical condition and treatment
§major past illnesses and treatments
§medical hospitalisations
§surgical history
§9. Drug and alcohol history

Mental status examination
§1. Appearance and behaviour (dress, facial expression, eye contact, motor activity)
§2. Speech (rate, clarity)
§3. Emotions
§subjective - patient‘s description
§objective -emotion communicated through facial expression, body posture and vocal tone §
(mood-a sustained emotion, affect - the way the patient shows feelings- variability, intensity,
liability, appropriateness)

Mental status examination
§4. Thought
§a) thought form:
§the way ideas are linked (logical, goal-directed,  loose associations)
§b) thought content:
§delusions (false beliefs)
§thought insertion, thought withdrawal
§depersonalisation and derealisation (sense of  unreality or strangeness) §preoccupations,
obsessions - unwanted idea that cannot be eliminated by reasoning
§phobia- obsessive, unrealistic fear

Mental status examination
§Examples of questions (concerning thought
§disorder):
§Do you think anyone wants to hurt you?
§Do you feel that others can heat your thoughts  or read your mind?
§Additional tips:
§ When something does not appear to make sense, always ask for clarification!! §Most important
question: determining the presence  of psychosis!

Mental status examination
§5. Perception:
§misinterpreting sensory input -illusion
§perceiving sensory input in the absence of any actual external stimulus - hallucination
§(„Do you ever hear voices or see things other
§people do not hear or see?“)
§Determine to what extent the patient is driven to
§actions based on a hallucination !

Mental status examination
§6. Sensorial and intellectual functions:
§alertness (degree of wakefulness)
§orientation to person, place, time and situation
§concentration (to focus and a sustain attention)
§memory recent and remote, immediate recall (repeat 5 number forwards and backwards)
§calculation (simple arithmetic)
§fund  of knowledge
§abstraction (proverbs, similarities)
§judgement and insight

Literature
§
§Waldinger R.J.: Psychiatry for medical students, Washington, DC : American Psychaitric Press, 1997
§Kaplan HI, Sadock BJ, Grebb JA.: Kaplan and Sadock´s synopsis of psychiatry, Baltimore: Williams
and Wilkins, 1997
§
§

Diagnostic systems in psychiatry
§2 diagnostic systems:
§american (APA) – DSM V
§european (WHO)
§

General psychopathology
Adapted from Raboch et al.


Basic Terms in Psychiatry
§Psychiatry studies the causes of mental disorders, gives their description, predicts their future
course and outcome, looks for prevention of their appearance and presents the best ways of their
treatment
§Psychopathology describes symptoms of mental disorders
§Special psychiatry is devoted to individual mental diseases
§General psychiatry studies psychopathological phenomena, symptoms of abnormal states of mind:
l1. consciousness 5. mood (emotions)
l2. perception 6. intelligence
l3. thinking 7. motor
l4. memory 8. personality

Disorders of Consciousness
§Consciousness is awareness of the self and the environment
§Disorders of consciousness:
lqualitative
lquantitative
•short-term
•long-term
§
§Hypnosis – artificially incited change of consciousness
§Syncope – short-term unconsciousness

Disorders of Consciousness
§Quantitative changes of consciousness mean reduced vigility (alertness):
lsomnolence
lsopor
lcoma
§Qualitative changes of consciousness mean disturbed perception, thinking, affectivity, memory and
consequent motor disorders:
ldelirium (confusional state) – characterized by disorientation, distorted perception, enhanced
suggestibility, misinterpretations and mood disorders
lobnubilation (twilight state) – starts and ends abruptly, amnesia is complete; the patient is
disordered, his acting is aimless, sometimes aggressive, hard to understood
•stuporous
•vigilambulant
•delirious
•Ganser sy

Disturbances of Perception
§Perception is a process of becoming aware of what is presented through the sense organs
§Imagery means an experience within the mind, usually without the sense of reality that is part of
reality
§
§Pseudoillusions – distorted perception of objects which may occur when the general level of
sensory stimulation is reduced
§Illusions are psychopathological phenomena; they appear mainly in conditions of qualitative
disturbances of consciousness (missing insight)
§Hallucinations are percepts without any obvious stimulus to the sense organs; the patient is
unable to distinguish it from reality

Disturbances of Perception
§Hallucinations:
§auditory (acousma)
§visual
§olfactory
§gustatory
§tactile (or deep somatic)
§extracampine, inadequate
§intrapsychic (belong rather to disturbances of thinking)
§hypnagogic and hypnopompic (hypnexagogic)
§
§Pseudohallucinations - patient can distinguish them from reality

Disorders of Thinking
§Thinking
§
§Cognitive functions
§
§Disorders of thinking:
lquantitative
lqualitative
§

Definition
§Thinking: Goal-directed flow of ideas and
§associations initiated by a problem and leading
§toward a reality-oriented conclusion.
§Thinking is a very complex and complicated
§psychic function.
§
§The evaluations of thoughts is based on what the
§patient says

Quantitative Disorders of Thinking
§Quantitative (formal) disorders of thinking:
§poverty of thought
§thought blocking
§flight of ideas
§perseveration
§loosening of associations
§word salad - incoherent thinking
§neologisms
§verbigeration

Quantitative disturbances:
1. disturbances of speed of thinking
§a) slowed thoughts:
§slowing of the flow of associations , slowed and diminished verbal production (bradypsychism)
§ blocking of thoughts - cessation of the flow of associations ( patient stops the verbal
production without any recognisable impulse from surroundings)
§Occurrence:
§depression, schizophrenia

Quantitative disturbances:
1. disturbances of speed of thinking
§b) flight of thoughts:
§excessive rapidity of thinking manifested as extreme rapidity in speech (= logorrhoea)
§Occurrence :
§mania

Quantitative disturbances:
2. disturbance of structure of thinking
§a) perseverative thinking:
§involuntary persistence of response to some question or topic, verbigeration - a meaningless
repetition of specific word or phrase
§b) circumstantiality:
§indirect speech that is delayed in a reaching the point, characterised by an overinclusion of
details
§c) tangentiality:
§patient never gets from desired point to desired goal
§Occurrence:
§fatigue, organic mental disorders

Quantitative disturbances:
2. disturbance of structure of thinking
§d) illogical thinking:
§thinking containing erroneaous conclusions or internal contradiction §neologism: new word created
by the patient often by combining syllables or other words
§e) incoherent thinking:
§thought that is not understandable
§word salade: incohorent mixture of words and phrases
§Occurence:
§schizophrenia

Qualitative Disorders of Thinking
§Qualitative disorders of thought (content thought disorders):
§Delusions:
a)belief firmly held on inadequate grounds,
b)not affected by rational arguments
c)not a conventional belief
§Obsessions (obsessive thought) are recurrent persistent thoughts, impulses or images entering the
mind despite the person's effort to exclude them. Obsessive phenomena in acting (usual as senseless
rituals – cleaning, counting, dressing) are called compulsions.

Qualitative Disorders of Thinking
§Division of delusions:
§according to onset
a)primary (delusion mood, perception)
b)secondary (systematized)
c)shared (folie a deux)
§according to theme
a)paranoid (persecutory) - d. of reference, d. of jealousy, d. of control, d. concerning possession
of thought
b)megalomanic (grandiose, expansive) – d. of power, worth, noble origin, supernatural skills and
strength, amorous d.
c)depressive (micromanic, melancholic) – d. of guilt and worthlessness, nihilistic d.,
hypochondriacal d.
d)concerning the possession of thoughts
•thought insertion
•thought withdrawal
•thought broadcasting

Qualitative disturbances:  disturbances of content of thoughts
§a) preoccupation of thought:
§certain idea is in the centre of thinking, is coming back, usually associated with a strong
affective tone
§b) obsession:
§pathological persistence of an irresistible thought or feeling that cannot be eliminated from
consciousness by logical effort, associated with anxiety
§Occurrence:
§ obsessive-compulsive disorder, schizophrenia
§c) autistic (dereistic) thinking:
§preoccupation with inner, private world

disturbances of content of thoughts
§d) overvalued idea:
§unreasonable, sustained false belief maintained less firmly than a delusion
§e) poverty of content:
§thought that gives little information because of vagueness, empty repetitions, or obscure phrases
§f) symbolic and magical thinking:
§real objects have other, symbolic meaning, in magical thinking words, situations, action have
special power and meaning
§Occurrence:
§schizophrenia

Delusions
§Definition:
§Delusions are false beliefs based on incorrect
§inference about external reality, not consistent
§with patient‘ s intelligence and cultural
§background that cannot be corrected by reasoning
§Characteristics:
§bizarre content
§not corrected by reasoning
§influence on behaviour

Delusions - classification according to the content
§Melancholic delusions:
§delusion of self accusation (false interpretation of real past event resulting in feeling of
guilt) §hypochondriac delusion (false belief of having a fatal physical illness) §nihilistic
delusions (false feeling that self, others or the world is non-existent or ending) §delusions of
failure (false belief that one is unable to do anything useful) §delusion of poverty (false belief
that one lost all property)

Delusions - classification according to the content
§Delusions of grandeur:
§delusion of importance (exaggerated conception of one‘s importance) §delusion of power,
extrapotence (exaggerated conception of one‘s abilities/possibilities) §delusion of identity (false
belief of being the offspring of member of an important family)

Delusions - classification according to the content
§Paranoid delusions: are based on ideas of reference
§(false ideas that behaviour of others refers to a
§patient):
§delusion of persecution (false belief that one is being persecuted) §delusion of infidelity (false
belief that one‘s lover is unfaithful) §erotomanic delusion (false belief, that someone is deeply
in love with them)

Delusions - classification according to the content
§Delusion of control (false feeling that one‘s will ,
§thought or feelings are being controlled):
§thought withdrawal (false belief that  one‘s thought are being removed from one‘s mind by other
people of forces) §thought insertion (false belief that thought are being implanted in one‘s mind
by other people or force) §thought broadcasting (false belief that one‘s thought can be heard by
others) §thought control (false belief that one‘s thoughts are being controlled by other people of
forces)
§

Schizophrenia
§most devastating illness
§characterized by a broad range of mental symptoms
§1% of the population

Schizophrenia- symptoms
§Thought disorder:
§any disturbance of thinking that affects language, communication, or thought content
§ the hallmark feature of schizophrenia
§manifestations range from simple blocking and mild circumstantiality to profound loosening of
associations, incoherence, and delusions

•
•
•
•
•
•
•
•
•
•genes
•fronto-temporal
•dysfunction
•risk
•factors
•stres
•
•
•        dopamine in vesicle
•
•dopamine
•release
•antipsychotics
•
•
•
•  psychosis
•
• psychosis
•aberrant
•salience
•
•
•aberrant
•salience
•
•
•
•
•dopamine receptors
•Schizophrenia results from interactions between a genetically mediated neurobiological
vulnerability and nongenetic second hits of stressors
•Howes OD., Kapur S.,
•adapted and modified)

§hyperdopaminergia
§
§subcortical hyperdopaminergia with prefrontal hypodopaminergia
§
§increased presynaptic striatal dopaminergic  function
•
•
Etiology: dopamine hypothesis
•
•
•Howes OD. et Kapur S., 2009

Schizophrenia – symptoms
§DSM V criteria
§A. 2 ( or more) of the the following, each present
§for a significant portion of time during a 1-
§month period:
§Delusion
§Hallucinations
§Disorganized speech (derailment, incoherence)
§Disorganized or catatonic behaviour
§Negative symptoms (affecti e flattening, alogia, avolition)
§B social/occupational dysfunction)
§C Durationsigns of disturbance persis for at least 6 months

Schizophrenia – symptoms
§positive
§Vs
§Negative
§Other symptoms
§  -  affective symptoms
§  -  cognitive impairment

Cognitive dysfunction
§a stable, trait-related aspect, being present in nonpsychotic relatives as well
§a key diagnostic component
§present in the majority of pts with schizophrenia
§signif. higher occurrence in pts than in healthy controls
§more robust  compared to other psych. disorders
§average effect sizes for cognitive impairment are about twice as large as those obtained in
structured MRI studies
§predicts outcome as evaluated longitudinally
•Keefe RS et al., 2005, Saykin AJ et al., 1991

Schizophrenia – symptoms
§Thought disorders  in schizophrenia
§a) autistic (dereistic) thinking:
§preoccupation with inner, private world
§b) overvalued idea:
§unreasonable, sustained false belief maintained less firmly than a delusion
§c) poverty of content:
§thought that gives little information because of vagueness, empty repetitions, or obscure phrases
§d) symbolic and magical thinking:
§real objects have other, symbolic meaning, in magical thinking words, situations, action have
special power and meaning
§

Schizophrenia – symptoms
§Thought disorders  in schizophrenia
§e) Delusions
§Delusions are false beliefs based on incorrect
§inference about external reality, not consistent
§with patient‘ s intelligence and cultural
§background that cannot be corrected by reasoning
§Characteristics:
§bizarre content
§not corrected by reasoning
§influence on behaviour

Schizophrenia – symptoms
§Delusions - classification according to the content
§Paranoid delusions: are based on ideas of reference
§(false ideas that behaviour of others refers to a
§patient):
§delusion of persecution (false belief that one is being persecuted)
§delusion of infidelity (false belief that one‘s lover is unfaithful)
§erotomanic delusion (false belief, that someone is deeply in love with them)

Schizophrenia – symptoms
§Delusions - classification according to the content
§Delusion of control (false feeling that one‘s will ,
§thought or feelings are being controlled):
§thought withdrawal (false belief that  one‘s thought are being removed from one‘s mind by other
people of forces)
§thought insertion (false belief that thought are being implanted in one‘s mind by other people or
force)
§thought broadcasting (false belief that one‘s thought can be heard by others)
§thought control (false belief that one‘s thoughts are being controlled by other people of forces)
§

Criteria for remission of schizophrenia:
(PANSS based) PANSS = Positive and Negative Syndrome Scale
§Severity only
§Score three (mild) or less on all eight of the following PANSS items
lP1 delusions
lP2 conceptual disorganisation
lP3 hallucinatory behaviour
lG5 mannerisms and posturing
lG9 unusual thought content
lN1 blunted affect
lN4 passive/apathetic social withdrawal
lN6 lack of spontaneity and flow of conversation
§Severity x time
§As above for at least 6 months

Disorders of Memory
§Sensory stores - retains sensory information for 0.5 sec.
§Short - term memory (working memory) - for verbal and visual information, retained for 15-20 sec.,
low capacity
§Long-term memory – wide capacity and more permanent storage
ldeclarative (explicit) memory – episodic (for events) or semantic (for language and knowledge)
lprocedural memory – for motor arts
lpriming – unconscious memory
lconditioning – classic or emotional

Disorders of Memory
§Disorders of memory:
§Amnesia – inability to recall past events
§Jamais vu, déja vu
§Confabulation, amnesic disorientation, Korsakov’s syndrome
§Pseudologia phantastica
§
§Hypomnesia
§Hypermnesia

Disorders of Attention
§Concentration
§Capacity
§Tenacity
§Irritability
§Vigility
§
§Hypoprosexia (global, selective)
§Hyperprosexia
§Paraprosexia

Disorders of Mood (Emotions)
§Normal affect – brief and strong emotional response
§
§Normal mood – subjective and for a longer time lasting disposition to appear affects adequate to a
surrounding situation and matters discussed
§
§Higher emotions:
lintellectual
laesthetic
lethic
lsocial
§
l

Disorders of Mood (Emotions)
§Pathological affect – very strong, abrupt affect with a short change of consciousness on its peak
§Pathological mood – two poles:
lmanic
ldepressive
§Phobia – persistent irrational fear and wish to avoid a specific situation, object, activity:
lagoraphobia
lclaustrophobia
lsocial phobias
lhipsophobia
laichmophobia
lkeraunophobia
§Depersonalization – change of self-awareness, the person feels unreal, unable to feel emotion

Disorders of Mood (Emotions)
§Pathological mood:
lorigin – based on pathological grounds, no psychological cause
lduration – unusually long-lasting
lintensity – unusually strong, large changes in intensity
limpossibility to be changed by psychological means
l
§Pathological features of mood:
leuphoria
lexpansive
lexaltation
lexplosive
lmania
lhypomania
ldepression
lapathy (anhedonia)
lblunted, flattened affect
lemotional lability
lhelpless

Mood disorders ( affective disorders )
§Mood disorders - the critical pathology in
§those disorders is one of mood

Diagnosis: major depressive disorder
§Minim. 5 symptoms, change from functioning:
§depressed mood
§diminished interest or pleasure
§significant weight loss, or decrease or appetite
§insomnia ( or  hypersomnia)
§psychomotor agitation or retardation
§fatigue or loss of energy
§feelings of worthlessness or guilt
§diminished ability to think or concentrate,  indecisiveness
§recurrent thought of death

Diagnosis: Bipolar I, manic episode
§At least 1 week of abnormally and persistently elevated,
§expansive or irritable mood, impairment in occupational
§functioning or social activities (not due to abuse or
§medical condition), min. 3 of the following symptoms:
§grandiosity
§decreased need for sleep,
§more talkativeness
§flight  of ideas
§distractibility
§increase of goal directed activity
§excessive involvement in pleasurable activities

Diagnosis : dysthymic disorder
§Dysthymic disorder: a chronic disorder, with the
§depressed mood that lasts most of the day on most days
§Symptoms:
§depressed mood for more days than not, for at least 2 y.
§2 or more further symptoms:
§poor appetite or overeating
§insomnia or hypersomnia
§low energy or fatigue
§low self esteem
§poor concentration or  difficulty making decisions
§feelings of hopelessness

Diagnosis : Cyclothymic disorder
§a mild form of bipolar II disorder, characterised by episodes of hypomania and episodes of mild
depression §for at least 2 years,  the presence of numerous periods with hypomanic symptoms and
numerous period with depressive symptoms that do not meet criteria for a major depressive  episode

Intelligence Disorders
§Intelligence:
labstract
lpractical
lsocial
§Intelligence quotient (IQ):
§ IQ = (mental age : calendar age) x 100
§Disorders of intellect:
lmental retardation
ldementia

Motor Disorders
§quantitative:
lhypoagility
lhyperagility
lagitated behaviour
l
§qualitative:
lmannerisms
lstereotypies
lposturing
lwaxy flexibility
lechopraxia
lnegativism
lshort-circuit behaviour
lautomatism
lagitation
ltics
lcompulsions
Motor disorders occur frequently in mental disorders of all kinds, especially in catatonic
schizophrenia.

Disorders of Volition
§Disorders of volition:
lhypobulia
labulia
lhyperbulia

Disorders of Personality
§Personality means a complex of persistent mental and physical traits of a person
§
§Disturbances of personality:
ltransformation of personality
lappersonalization
lmultiple personality (alteration of personality)
lspecific personality disorder
ldeprived personality

Literature
§Kaplan HI, Sadock BJ, Grebb JA.: Kaplan and Sadock´s comprehensive textbook of psychiatry, ninth
edition
§Editors: Sadock BJ, Sadock VA, Ruiz P.
§Lippincott Williams and Wilkins, 2009
§
§
§

Literature:
§Waldinger RJ.: Psychiatry for medical students, Washington, DC : American Psychaitric Press, 1997
§Kaplan HI, Sadock BJ, Grebb JA.: Kaplan and Sadock´s synopsis of psychiatry, Baltimore: Williams
and Wilkins, 1997
§
§