Psychiatric Assessment: Mental Status, Interviewing, and Diagnostic Testing

Psychiatry is the medical specialty devoted to studying and treating mental disorders, including affective, behavioral, cognitive, and perceptual disorders. Johan Weyer is identified as the father of modern psychiatry. Freud was Austrian and lived from 1856 to 1939; he founded psychoanalysis and contributed free association and defense mechanisms.

The mental status examination describes the physician’s observations and impressions of the patient during the interview. Combined with the patient’s history, it is the best way to make an accurate diagnosis for most psychiatric diseases and disorders. The examination therefore records observed findings while the history supplies the patient’s account.

Open-ended questions let the patient speak in their own words as much as possible: “Can you tell me more about this?” Closed-ended questions request specific information and leave little choice in answering: “Are you feeling the pain now?” Select the form according to whether narrative or a focused fact is needed.

Intelligence tests include the Wechsler Adult Intelligence Scale–Revised, Wechsler Intelligence Scale for Children–Revised, and Wechsler Preschool and Primary Scale of Intelligence. Achievement tests include the Wide-Range Achievement Test and Peabody Individual Achievement Test. Identify the intended domain first, then match it to the named instrument.

A hallucination is a false perception without an external stimulus and is a disorder of perception. It is involuntary, is experienced as sensory perception in inner subjective space, and does not depend on the observer’s will. These features distinguish the finding by how the perception occurs.

Freud’s contributions also include libido, repression, transference, regression, sublimation, the Oedipus complex, and analysis of cocaine’s properties. The id contains drives and instincts present at birth. The ego develops after birth, follows the reality principle, and handles defense mechanisms, judgment, reality relations, and object relationships. The superego is the conscience formed during latency.

Document appearance, attitude, behavior, speech, and thought in both form and content. Distinguish mood, the emotions perceived, from affect, the emotional responses. Also assess reliability and the ability to exercise self-control. Together, these domains describe how the patient presents and communicates during the encounter.

Facilitation uses verbal or nonverbal clues to help the patient continue, as in “Yes, continue, please.” Confrontation directly points something out to the patient, as in “You look angry today. I’d like to know why.” Facilitation sustains the account; confrontation explicitly names an observed issue.

Personality tests are used to identify personality characteristics and psychopathology. The listed instruments are the Minnesota Multiphasic Personality Inventory, Rorschach Test, Sentence Completion Test, and Thematic Apperception Test. This category is distinct from tests of intelligence, achievement, or neuropsychological function.

• Auditory hallucinations are a feature of nonorganic disorders.
• Visual hallucinations are a feature of organic psychiatric disorders; formed visual hallucinations occur with a temporal lobe lesion.
• Tactile hallucinations occur in cocaine abuse.
• Hypnagogic hallucinations occur while going to sleep.
• Hypnopompic hallucinations occur while waking from sleep.

• Agnosia: inability to recognize a specific sensory stimulus.
• Apraxia: inability to perform purposive movement.
• Alexia: inability to read.
• Acalculia: inability to perform arithmetic calculation.
• Agraphia: inability to write.
• Anosmia: inability to smell.
• Prospaganosia: inability to identify a familiar face.
• Alexithymia: inability to recognize and describe feelings.

Sensorium includes alertness, level of consciousness, and orientation. Cognition includes memory, concentration, the capacity to read, write, and learn, abstract thinking, judgment, and insight. Proverb interpretation tests abstraction: a literal answer that misses nuances or metaphor demonstrates concrete thinking, defined as literal thought with impaired understanding of nuanced meaning.

Reassurance can increase compliance when it is truthful: “His conditions are serious, but we’ll do our best to treat it.” False reassurance can decrease compliance; “Don’t worry. Everything will be fine” promises an outcome that is not established. The decisive distinction is whether the reassuring statement is truthful.

Neuropsychological tests are used to detect organicity from any psychiatric disorder. One source lists Bender-Gestalt, Luria-Nebraska, and Halted-Reitan tests; the other lists the Bender Visual-Motor Gestalt Test, Luria-Nebraska Neuropsychological Battery, and Halstead-Reitan Battery.

The listed most common delusion pairings are depression with nihilistic delusion, mania with delusions of grandeur, and schizophrenia with paranoid delusions and delusions of reference. In neurotic disorders, insight is present and reality testing is intact. In psychotic disorders, insight is absent, reality testing is not intact, and delusions and hallucinations are present.

Déjà vu is a sensation of familiarity; it is described in temporal lobe epilepsy and as “normal person psychosis.” Jamais vu is a sensation of unfamiliarity. A neologism is an idiosyncratically formed new word that cannot be easily understood. These terms name discrete findings rather than broad diagnoses.

A leading question suggests the answer within the question itself. “Is the voice telling you to kill yourself?” supplies specific content rather than allowing the patient to describe the experience independently. Recognize the technique by the embedded answer, not simply by whether the question can be answered yes or no.

First-rank symptoms include hallucinations and delusional perception. Thought-alienation phenomena include thought withdrawal, thought insertion, and thought broadcasting. Passivity phenomena include made feelings, made impulses, made acts, and somatic passivity. Bleuler’s criteria are ambivalence, autism, affect disturbance, and association disturbance. Paranoid schizophrenia is commonest; hebephrenic has early onset and bad prognosis, catatonic has late onset and the best prognosis, and simple has the worst prognosis.

• Increased dopamine: schizophrenia.
• Decreased acetylcholine: dementia.
• Increased noradrenaline: mania and anxiety.
• Decreased serotonin and noradrenaline: OCD.
• Decreased GABA: epilepsy.
• Decreased serotonin: depression. A vignette with chronic aches, weakness, insomnia, appetite loss, lack of interest in work, and social withdrawal despite denied sadness selects decreased serotonin.

Flight of ideas is rapid speech with rapid changes in ideas; verbigeration is senseless repetition of the same words. Circumstantiality delays the point through excess detail but eventually reaches the original goal. Ideas of influence are delusions that another person or external force controls the individual, as illustrated by alleged remote control of blood pressure, movements, and thoughts.