Novel treatment approaches In the last century discovery of effective treatments led to aet iological hypotheses. In this century the hope is that understanding of the molecu- lar and chemical pathways involved in risk for illness will lead to the devel- opment of novel tre atment approaches, therapeutics becoming hypothesis driven rather than hypothesis creating. Rational drug design will be aided 01_Semple_Chap01.indd 30 12/10/2012 6:23:42 PM THE FUTURE 31 by computer modeling and screening of large numbers of potential drug molecules. There will be further investigation of stem cell therapy in neu- rodegenerative disorders. Functional and diagnostic imaging Current structural scanning methods (e.g. CT and MRI) rev eal changes across cohorts of patients with major mental disorders but do not allow objecti ve diagnosis in individuals. Many psychiatric disorders show no measurable abnormalities at all using current structural methods. In the future, functional imaging (e.g. PET, functio nal MRI), either alone or in combination with structural scanning, may allow an understandi ng of how changes in neural systems contribute to illness and possibly true diagnostic imag ing. Large-scale treatment trials In current practice, even relatively common treatment decision s are not clearly evidence-based. The current evidence base is overly reliant on small rand omized trials, uncontrolled trials and \200\230expert opinion \200\231. Now, however, psyc hiatry researchers are following their peers in cardiology and oncology and recruiting to l arge-scale treatment trials. Every generation enjoys the use of a vast hoard bequeathed to it by antiquity, and transmit s that hoard, augmented by fresh acquisitions, to future ages. Thomas Babington Macaulay I like the dreams of the future better than the history of the past. Thomas Jefferson There are \201 sh in the sea better than have ever been caught. Irish proverb 01_Semple_Chap01.indd 31 12/10/2012 6:23:42 PM This page intentionally left blank 33 Chapter 2 Psychiatric assessment The clinical interview 34 Setting the scene 36 Interviewing psychiatric patients 38 Discuss ing management 40 History 42 Mental state examination 44 Case summary 46 Observations of ap pearance and behavior 47 Speech 48 Abnormal mood 49 Asking about depressed mood 50 Asking a bout thoughts of self-harm 51 Asking about elevated mood 52 Anxiety symptoms 53 Asking abou t anxiety symptoms 54 Abnormal perceptions 56 Asking about abnormal perceptions 58 Abnormal beliefs 59 Asking about abnormal beliefs 60 Asking about the \201 rst-rank symptoms of s chizophrenia 62 Disorders of the form of thought 64 Abnormal cognitive function 66 Assessin g cognitive function 1 68 Assessing cognitive function 2 70 Supplementary tests of cerebral functioning 72 Insight 74 Physical examination 75 Some physical signs in psychiatric illne ss, and possible causes 76 Clinical investigation 78 Common assessment instruments 1 80 Common assessment instruments 2 82 02_Semple_Chap02.indd 33 12/7/2012 7:03:18 PM CHAPTER 2 Psychiatric assessment 34 The clinical interview In most branches of clinical medicine, diagnoses are made largely on the basis of the patient \200\231s history, with physical examination and investigation pl aying important but subordinate roles. In psychiatry, physical examina- tion and investigat ions are of lesser diagnostic value and diagnosis is based on the clinical interview and, t o a lesser extent, the later course of the patient \200\231s illness. Clinical interviewing is thus the central skill of the psychia- trist and development of clinical interviewing s kills is the main aim of basic psychiatric training. The clinical interview includes both history taking and mental state examination. The menta l state examination is a systematic record of the patient \200\231s current psychopathology . In addition to its role in diagnosis, the clinical interview begins the development of a therapeutic relationship and is, in many cases, the beginning of treatment. Clinical interview skills cannot be learned from a textbook. This chapter is intended as a guide to the doctor developing skills in interviewing psychi- atric patients. As a trainee psychiatrist you should also take the opportu- nity to observe experienced clinicians as th ey interview patients; to review your own videotaped consultations with a tutor; and most i mportantly, carry out many clinical interviews and present the results to your seniors. Ski lls in this area, as with all others, come with experience and practice. This chapter describes a model for the assessment of general adult and old-age psychiatry p atients on the wards or in the outpatient clinic. For special patient populations, modi \201 cations or extensions to the standard interview are described in the appropriate chapt er: alcohol and drug prob- lems (b p. 552, p. 592); forensic (b p. 692, p. 710); child and adoles- cent (b pp. 612 \200\22317); learning disability (b p. 738); and psychotherapy (b p . 822). The student or doctor coming to psychiatric interviewing for the \201 rst time is likely to be apprehensive. The symptoms which the patient describes may seem bizarre or incomprehe nsible, and the examiner may struggle for understanding and knowledge of which further ques tions to ask. Remember that the interviewer is not like a lawyer or policeman try- ing to \200\230get at the truth \200\231 but rather an aid to the patient telling the story in the ir own words. Start by listening, prompting only when necessary, and aim to feel at the end of the interview that you really understand the patient \200\231s problems and their perce ption of them. The following pages describe the standard structure for a routine his- tory, mental state e xamination, and case summary; there are then pages devoted to the different symptom areas i n adult psychiatry with suggested probe questions. These are intended as guides to the sort of questions to ask the patient (or to ask yourself about the patient) and may be rephrase d in your own words. See Box 2.1 for advice on personal safety. 02_Semple_Chap02.indd 34 12/7/2012 7:03:18 PM THE CLINICAL INTERVIEW 35 Box 2.1 Always consider your personal safety when interviewing There is a risk of aggression or violence in only a small minority of psychiatric patients. In the vast majority of patients the only risk of vio- lence is towards themselves. Howeve r, the fact that violence is rare can lead to doctors putting themselves at risk due to tho ughtlessness. To combat this it is important to think about the risk of violence before eve ry consultation with a new patient or with a familiar patient with new symptoms. Before interviewing a patient, particularly for the \201 rst time, consider: who you are interviewing, where you are interviewing, and with whom. Ensure that the nursing staff have this information. \200 If possible, review the patient \200\231s records noting previous symptomatology and episod es of previous violence (the best predictor of future violence). A number of factors will i ncrease the risk of violence, including: previous history of violence, psychotic illness, i ntoxication with alcohol or drugs, frustration, feeling of threat (which may be delusional or relate to real-world concerns). The ideal interview room has two doors, one for you and one for the patient. If this is not available sit so that the patient is not between you an d the door. Remove all potential weapons from the interview room. Familiarize yourself with the ward \200\231s panic alarm system before you \201 rst need to use it. If your hospit al organizes break-away or aggression management training courses, attend these regularly t o keep your skills up to date. 02_Semple_Chap02.indd 35 12/7/2012 7:03:18 PM CHAPTER 2 Psychiatric assessment 36 Setting the scene Introductions Observe the normal social forms when meeting someone for th e \201 rst time. Introduce yourself and any accompanying staff members by name and status . Ensure that you know the names and relationships of any people accompanying the patient ( and ask the patient if they wish these persons to be present during the interview). It is b est to introduce yourself by title and last name and refer to the patient by title and last name. Do not use the patient \200\231s Christian name except at their request. Seating The traditional consultation room, with the patient facing the doctor across a desk, is inappr opriate in psychiatry. Use two or more comfortable chairs, of the same height, orientated t o each other at an angle. This is less confrontational but allows direct eye contact as nec es- sary. A clipboard will allow you to write notes as you go along. Explanation Inform the patient of your status and specialty and explain the purpose of the interview. Explain the reasons for referral as you understand them and inform the patient of the information you have been told by the referrer. Patients often imagine you know more about them than you do . It is helpful to indicate to the patient how long the interview will last; this will allo w both of you to plan your time so as not to omit vital topics. Advise them that you may wi sh to obtain further information after the interview from other sources, and obtain their c onsent to talk to any informants accompanying them if this would add to your assessment. Do cumentation For all clinical interviewing a written account is cru- cial, both as a way of recording and communicating information and as a medico-legal record. It is best to write u p the account as you go along. This saves time afterwards and allows for a more accurate ac count of the patient \200\231s own words. The record should be legible, signed, and dated, and ordered in a standard fashion. Initially you may \201 nd it helpful to write out the standard headings on sheets of paper beforehand. Interviewing non-English speaking patients Where the doctor and the patient do not speak a common language, an interpreter is essenti al. Even in situations where the patient appears to speak some English, suf \201 cient for day-to-day conversation, an interpreter is still highly desirable because idiomatic langua ge and culturally speci \201 c interpretations of psychological phenomena may confuse unde rstanding. Where possible the interpreter should share not only a language but also a cultu ral background with the patient, as many descriptions of psychiatric symptoms are culture-s peci \201 c. Do not use members of a patient \200\231s family as interpreters except where unavoidable (e.g. in emergency situations). It is unethical to use children as interpreter s. 02_Semple_Chap02.indd 36 12/7/2012 7:03:18 PM This page intentionally left blank CHAPTER 2 Psychiatric assessment 38 Interviewing psychiatric patients Interview structure The exact internal structure of the interview will be decided by the na ture of the presenting complaint. However, the interview will generally go through a number of more or less discrete phases: Initiation Introduce yourself and explain the nature and purpose of the interview. Describe how long the interview will last and what you know about the patient already. Patient-led history Invite the patient to tell you about their presenting com- plaint. Use general opening questions and prompt for further elaboration. Let the patient do most of th e talking: your role is to help them to tell the story in their own words. During this phas e you should note down the major observations in the mental state examination (MSE). Having com- pleted the history of the present complaint and the MSE you will be able to be more f ocused when taking the other aspects of the history. Doctor-led history Clarify the details in the history thus far with appropriate questions. Clarify the nature of diagnostic symptoms (e.g. are these true hallucinations? Is there diu rnal mood variation?). Explore signi \201 cant areas not mentioned spontaneously by the pa tient. Background history Complete the history by direct enquiry. This is similar to standard medi cal history-taking, with the addition of a closer enquiry into the patient \200\231s person al history. Summing-up Recount the history as you have understood it back to the patient. Ensure there are no omissions or important areas uncovered. Indicate if you would like to obtain other t hird-party information, empha- sizing that this would add to your understanding of the pati ent \200\231s problems and help you in your diagnosis. Questioning techniques Open vs. closed questions An open question does not suggest the pos- sible answers; a closed question expects a limited range of replies (cf. \200\230can you tell me how you are feeling? \200\231 and \200\230is your mood up or down at the moment? \200\231). In general, begin the interview with open questions, turning to more closed ques tions to clarify details or factual points. Non-directive vs. leading questions A leading question directs a patient towards a suggeste d answer (e.g. \200\230is your mood usually worse in the morn- ings? \200\231 rather than \200\230is your mood better or worse at any time of day? \200\231) Just as lawyers are rep rimanded for \200\230leading a witness \200\231 we should in general avoid leading our pat ients to certain replies, as the desire to please the doctor can be a very powerful one. 02_Semple_Chap02.indd 38 12/7/2012 7:03:18 PM INTERVIEWING PSYCHIATRIC PATIENTS 39 Giving advice Aim to leave at least the last fourth of the available interview time for dis cussion of the diagnosis, your explanation to the patient of your under- standing of the na ture and cause of their symptoms, and your detailing of your plans for treatment or further investigation or referral as indicated. The patient \200\231s con \201 dence in your diag nosis will be improved by their belief that you really understand \200\230what is going on \200\231 and spending time detailing exactly what you want them to do will pay dividends i n increased compli- ance. As a junior trainee you may have to break at the end of the histo ry- taking segment in order to present the case to your senior and get advice on management . After the interview The process of assessment does not of course end with the initial clini cal interview. In psychiatry, all diagnoses are to some extent provisional. You should foll ow your initial interview by gathering information from relatives, GP, previous case record s, and clarifying symptoms observed by nursing staff. In the emergency situation a modi \201 cation of this technique, focusing mainly on the acute problem, is more appropriate, w ith re-interviewing later to \201 ll in the blanks if required. 02_Semple_Chap02.indd 39 12/7/2012 7:03:18 PM CHAPTER 2 Psychiatric assessment 40 Discussing management In psychiatry, more than any other specialty, it is essential for suc cessful management that the patient has a good understanding of their disorder and its trea tment. There is no equivalent in psychiatry of the simple frac- ture where all that is requ ired of the patient is to lie back and take the medicine. The treatment of any psychiatric disorder begins at the initial interview, where in addition to the assessment, the doctor s hould aim to establish the therapeutic alliance, effectively communicate the manage- ment p lan, instill a sense of hope in the patient, and encourage self-help strategies. Establish a therapeutic relationship \200 \200 Aim to listen more than you speak (especially initially). Show respect for the patient as a n individual (e.g. establish their preferred mode of address; ask permission for anyone els e to be present at the interview). Explicitly make your actions for the bene \201 t of the patient. Do not argue; agree to disagree if consensus cannot be reached. Accept that in so me patients trust may take time to develop. \200 \200 Communicate effectively \200 Be speci \201 c management should be. Avoid jargon you use. Avoid ambiguity Clarify precis ely what you mean and what your plans are. Be explicit in your statements to patients (e.g. say \200\230I will ask one of our nurses to visit you at home on Monday morning \200\231, rather than \200\230I \200\231ll arrange some community support for you \200\231). Explai n why you think what you do Connect the advice to the patient and what it is about the pati ent \200\231s symptoms that suggests the diagnosis to you. Use repetition and recapitulatio n your advantage. Restate the important information \201 rst and repeat it at the end. Mo st of what is said to patients in medical Break up/write down interviews is rapidly forgott en or distorted. Make the information easier to remember by breaking it up into a numbered list. Consider providing personalized written information, in addition to any advice lea \202 ets etc. that you give the patient. This is imperative if the advice is complex and sp eci \201 c (e.g. dosage regimes for medication). Explain what you think the diagnosis is and what the Use layman \200\231s language or explain specialist terms which Use the \200\230primacy/recency \200\231 effect to 02_Semple_Chap02.indd 40 12/7/2012 7:03:18 PM DISCUSSING MANAGEMENT 41 Instill hope \200 Patients with mental health problems often feel extremely isolated and cut off from others, and may feel that they are the only people ever to experience their symptoms. Reassure the m that you recognize their symptoms as part of a pattern representing a treatable illness. Convey to the patient your belief that this illness is understandable and that there are pr ospects for recovery. Counteract unrealistic beliefs (e.g. fear of \200\230losing my mind \200\231 or \200\230being locked away forever \200\231). Where cure is not possible, empha size that there is still much that can be done to manage the illness and ameliorate symptom s. Encourage self-help \200 Be clear to the patient what they can do to help themselves, for example, maintain treatmen t adherence (b p. 924), avoid exacerbating factors (e.g. drug or alcohol misuse), consider lifestyle changes (e.g. house move, relationship counseling). Provide written self-help mat erials appropriate to the current disorder (b pp. 1010 \200\22317). Where appropriate, enco urage contact/attendance at voluntary treatment organizations, self-help groups, or patient organizations (b pp. 1010 \200\22317). Develop knowledge of, and links with, local resourc es and aim to have their contact numbers and location information available at the consulta tion. 02_Semple_Chap02.indd 41 12/7/2012 7:03:19 PM CHAPTER 2 Psychiatric assessment 42 History The history should, as far as possible, be gathered in the standard order presented here. This provides structure and logical coherence to the questioning, both for the docto r and the patient, and it is less likely that items will be omitted. Basic information Name, age, and marital status. Current occupation. Route of referral. Cur rent legal status (detained under Mental Health Act?). Presenting complaints Number and brief description of presenting complaints. Which is the m ost troublesome symptom? History of presenting complaints For each individual complaint record its nature (in the pa tient \200\231s own words as far as possible); chronol- ogy; severity; associated symptoms and associated life events occurring at or about the same time. Note precipitating, aggrava ting, and relieving factors. Have these or similar symptoms occurred before? To what does t he patient attribute their symptoms? Past psychiatric and medical history Previous psychiatric diagnoses. Chronological list of episodes of psychiatric inpatient, day hospital, and outpatient care. Current medical condi tions. Chronological list of epi- sodes of medical or surgical illness. Episodes of symptom s for which no treatment was sought. Any illnesses treated by GP. Drug history List names and doses of current medication (have they been taking it?) Previou s psychiatric drug treatments. History of adverse reactions or drug allergy. Any non-prescr ibed or alternative medications taken. Family history Family tree (see Fig. 2.1) detailing names, ages, relation- ships, and illne sses of \201 rst- and second-degree relatives. Are there any familial illnesses? Personal history Childhood Were there problems during their pregnancy or delivery? Did they reach developmen t milestones normally? Was their childhood happy? In what sort of family were they raised? Education Which primary and secondary schools did they attend? If more than one of each, wh y was this? Did they attend mainstream or specialist schools? Did they enjoy school \200 \224if not, why? At what age did they leave school and with what quali \201 cations? Type of further education and quali \201 cations attained. If they left higher education before completing the course \200\224why was this? Employment Chronological list of jobs. Which job did they hold for the longest period? Whic h job did they enjoy most? If the patient has had a series of jobs \200\224why did they lea ve each? Account for periods of unem- ployment in the patient \200\231s history. Is the typ e of job undertaken consistent with the patient \200\231s level of educational attainment? 02_Semple_Chap02.indd 42 12/7/2012 7:03:19 PM HISTORY 43 Relationships Sexual orientation. Chronological account of major rela- tionships. Reasons f or relationship breakdown. Are they currently in a relationship? Do they have any children from the current or previous relationships? Who do the children live with? What relationshi p does the patient have with them? Forensic (b p. 692, p. 710) Have they been charged or co nvicted of any offenses? What sentence did they receive? Do they have outstanding charges o r convictions at the moment? Social background information Current occupation. Are they work- ing at the moment? If not, how long have they been off work and why? Current family/relationship situation. Alcohol a nd illicit drug use (b p. 552, p. 592). Main recreational activities. Premorbid personality How would they describe themselves before they became ill? How would others have described them? 56 Hypertension 58 MI 32 27 30 26 6 ?ADHD 4 9 (Twins)9 Key: 32 Age 32 years Index case Female Male Deceased Affected Fig. 2.1 A family tree diagram. 02_Semple_Chap02.indd 43 12/7/2012 7:03:19 PM CHAPTER 2 Psychiatric assessment 44 Mental state examination The mental state examination (MSE) is an ordered summary of the ex am- ining doctor \200\231s observations as to the patient \200\231s mental experiences and behavior at the time of interview. Its purpose is to suggest evidence for and against a dia gnosis of mental disorder, and if mental disorder is present, to record the current type an d severity of symptoms. The infor- mation obtained should, together with the psychiatric hi story, enable a judgment to be made regarding the presence of and severity of any men- tal disorder and the risk of harm to self or others. The required information can be obtained during the course of history taking or in a system atic fashion afterwards. The MSE should be recorded and presented in a standardized format, although the information con- tained may derive from material gained in different ways. It is helpful to record the patient \200\231s description of signi \201 cant symptoms word f or word. Appearance \200 Apparent age \200 Racial origin \200 Style of dress \200 Level of c leanliness \200 General physical condition \200 Abnormal involuntary movements includin g tics, grimaces, stereotypies, dyskinetic movements, tremors etc. Behavior \200 \200 \200 \200 \200 \200 \200 \200 Appropriateness of behavior Level of motor activity Apparent level of anxiety Eye contact R apport Abnormal movement or posture Episodes of aggression Distractibility Speech \200 \200 \200 \200 Volume, rate, and tone Quantity and \202 uency Abnormal associations, clang and punning F light of ideas Mood \200 \200 Subjective and objective assessment of mood Mood evaluation should include the quality, ran ge, depth, congruence, appropriateness and communicability of the mood state Anxiety and pa nic symptoms Obsessions and compulsions \200 Perception \200 \200 Hallucinations and pseudo-hallucinations Depersonalization and derealization. Illusions and imagery 02_Semple_Chap02.indd 44 12/7/2012 7:03:19 PM MENTAL STATE EXAMINATION 45 Thought form \200 \200 \200 \200 Linearity Goal-directedness Associational quality Formal thought disorder Thought content \200 \200 \200 \200 \200 \200 Delusions Over-valued ideas Preoccupations Obsessive thoughts, ideas, and impulses Thoughts of suicide or deliberate self-harm Thoughts of harm to others. Assess intent, lethality of intent, plan, and inimicality. Does the patient show any urge to act upon the plan? Cognition \200 \200 \200 \200 Attention and concentration Orientation to time, place and person Level of comprehension Sh ort-term memory Insight \200 \200 Does the patient feel his experiences are as the result of illness? Will he accept medical advice and treatment? 02_Semple_Chap02.indd 45 12/7/2012 7:03:19 PM CHAPTER 2 Psychiatric assessment 46 Case summary The written and oral presentation of the results of clinical interview should follow a standard format \200\224history, MSE, results of physical examination, and case su mmary. The case summary can take a variety of forms but the structure suggested here is sui table for most situations. You should include a brief synopsis of the case, a differential diagnosis with your favored working diagnosis, and a comment on aetiological factors in thi s patient. Synopsis This should be a short paragraph summarizing the salient points of the preceding i nformation and covering: \200 \200 \200 \200 \200 \200 \200 basic personal information previous psychiatric diagnosis description of presentation descr iption of current symptoms positive features on MSE suicide risk attitude to illness Differential diagnosis This will usually be a short list of two or three possibilities. In an exam situation, mention other less likely possibilities you would consider in order to e xclude. Your presentation should have directed you towards choosing one as your working dia gnosis. Formulation For general psychiatric patients the formulation should include comment on why the person has become ill and why now. You should identify the \200\230three P \200\231s \200\231 \200\224predisposing, precipitating, and perpetuat- ing factors for the current il lness. This information will be important in guiding a suitable management plan. So, for ex ample, in a patient with depressed mood following the birth of a baby: predisposing factors could be family history of depressive illness, female sex; precipitating factors could be the postnatal period, job loss, change of role, and feelings of inadequacy; and prolonging factors could be disturbed sleep, unsupportive partner. Management plan Following the presentation of history, MSE, physical examination, and formu lation you would normally go on to present or to document your initial management plan, inc luding necessary investiga- tions, initial drug treatment, instructions to nursing staff, a nd comment on potential risks and whether or not, in your opinion, the patient is currently detainable under the Mental Health Act. 02_Semple_Chap02.indd 46 12/7/2012 7:03:19 PM This page intentionally left blank CHAPTER 2 Psychiatric assessment 48 Observations of appearance and behavior The greater part of the MSE consists of empathic qu estioning about the patient \200\231s internal experiences. Nonetheless, important informat ion regard- ing mental state can be obtained from careful observation of the patient \200 \231s appearance, behavior, and manner, both during the interview and in some cases, later on the ward. This is particularly important in some situations, for example with a patient who may be concealing the presence of psychotic symptoms, or where there is reason to doubt the patient \200\231s account. Take time to observe the patient during the interview and ask yourself the following questi ons. If possible, ask nursing staff about behavior on the ward (e.g. does he have any abnor mal movements or mannerisms; how does he interact with other patients; does he appear to be respond- ing to unseen voices or commands?). What is the patient \200\231s appearance? Des cribe the patient \200\231s physical appearance and racial origin. Compare what age they ap pear with their actual age (i.e. biological vs. chronological age). What is their manner of dress? Patients with manic illnesses may dress in an excessively formal, \202 amboyant, or sexually inappropriate manner. Patients with cognitive impairment may have mismatched or wrongly buttoned clothing. What is the patient \200\231s behavior during the interview? Ar e there episodes of tearfulness? Do they attend to the interview or do they appear distract ed? Do they maintain an appropriate level of eye contact? Do you feel that you have establi shed rapport? What is the patient \200\231s level of activity during the interview? Does th e patient appear restless or \201 dgety? Do they settle to a chair or pace dur- ing inter view? Is there a normal level of gesticulation during conversation? Is there any evidence o f self-neglect? Does the patient have lower than normal standards of self-care and personal hygiene? Are they malodorous, unshaven, or disheveled? Are their clothes clean? Are there cigarette burns or food stains on their clothes? Is the patient \200\231s behavior socially inappropriate? Is there embar- rassing, overly familiar, or sexually forward behavior? All are seen in manic illness or where there is cognitive impairment. Is the patient \200\231s behavior threatening, aggressive, or violent? In manner or in speech does the patient appe ar hostile or threatening? Do you feel at risk? Is there aggressive or violent behavior on display during the interview? What prompts it? Are there any abnormal movements? Does the p atient have repeti- tive or rocking movements or bizarre posturing (stereotypies)? Do they perform voluntary, goal-directed activities in a bizarre way (mannerisms)? What is their ex planation for this? For patients on neuroleptic medication, is there evidence of side-effec ts (e.g. stiffness, rigidity, tremor, akathisia)? Is the patient distractible or appearing to be responding to hallu- cinations? Does the patient appear to be attending to a voice ot her than yours? Are they looking around the room as if for the source of a voice? Are they murmuring or mouthing soundlessly to themselves? Are there episodes of giggling, verbal out bursts, or other unexplained actions? 02_Semple_Chap02.indd 48 12/7/2012 7:03:19 PM SPEECH 49 Speech The content of the patient \200\231s speech (i.e. what they say) will be our major s ource of information for their history and mental state. The form of their speech (i.e. how they say it) is abnormal in a number of mental disorders and should be observed and commen ted upon. Is there any speech at all? A small number of patients are mute during interview. Here the doctor should aim to comment on apparent level of comprehension (does the patient appear to understand what is said, e.g. shakes or nods head appropriately), level of alternate commu nication (can they write answers down, do they point or use gestures?), and level of struct ural impairment of the organs of speech (a patient who can cough on demand is demonstrably able to oppose both vocal cords normally). What is the quantity of speech? Are answers unduly brief or monosyl- labic? Conversely, are they inappropriately prolonged? Does the speech appear pressured? (i.e. there is copious, rapid speech, which is hard to interrupt)? What is the rate of speech? There is a wide variation in normal rates of speech across even the regions of the UK. Is the patient \200\231s speech unusually slow or unusually rapid, given the expected rate? This may re \202 ect accel- eration or deceleration in the speed of thought in affective illnesses. What is the volume and quality of speech? Does the patient whis- per? Or speak inappropriat ely loudly? Is there stuttering or slurring or speech? What is the tone and rhythm of speech? Even in a non-tonal language like English, normal sp eech has a musical quality with the intonation of the voice and rhythm of the sentences con veying meaning (i.e. the rise in tone at the end of a question). Loss of this range of into nation and rhythmic pattern is seen in chronic psychotic illnesses. How appropriate is the speech? Is the content of the speech appro- priate to the situation? Does the patient answer questions appropriately? Are there inappropriate or pointless digr essions? Can the meaning of the speech always be followed? Is there abnormal use of language? Are there word- \201 nding dif \201 cul- ties, which m ay suggest an expressive dysphasia? Are there neologisms (i.e. made-up words, or normal wor ds used in an idiosyncratic manner)? 02_Semple_Chap02.indd 49 12/7/2012 7:03:20 PM CHAPTER 2 Psychiatric assessment 50 Abnormal mood In describing disorders of mood we draw a distinction between affect (the emo tional state prevailing at a given moment) and mood (the emotional state over a longer peri od). To use a meteorological analogy, affect represents the weather, where mood is the clim ate. Variations in affect, from happiness to sadness, irritability to enthusiasm are within everyone \200\231s normal experi- ence. Assessment of pathological abnormality of affect i nvolves assessing the severity, longevity, and ubiquity of the mood disturbance and its ass ociation with other pathological features suggestive of mood disorder. Depressed mood is the most common symptom of the mood disorders and in its milder forms has been experienced by most people at some point. Its experience is personal and is described in a variety of ways by different people: sometimes as a profound lowering of spirits, sub jectively different from normal unhappiness; sometimes as an unpleasant absence of emotions or emotional range; and sometimes as a more physical symptom of \200\230weight \200\231 o r \200\230blackness \200\231 weighing down on the head or chest. Increasingly, severe form s of depressed mood are indicated by the patient \200\231s rating of greater severity as co mpared with previous experience, increased pervasiveness of the low mood to all situations, and decreased reactivity of mood (i.e. decreased abil- ity of the mood to be lightened by pleasurable or encouraging events). The two central clinical features of depressive illness are (1) pervasively depressed and u nreactive mood and (2) anhedonia \200\224the loss of pleasure in previously pleasurable act ivities. The clinical picture also includes the \200\230bio- logical features of depressio n \200\231, thoughts of self-harm, and, in more severe cases, mood-congruent psychotic feat ures. The biological features include disturbance of sleep (particularly early morning waki ng and dif \201 culty getting off to sleep), reduced appetite, loss of libido, reduced ene rgy levels, and sub- jective impression of poorer concentration and memory. Many depressed patients will have thoughts of deliberate self-harm or ending their lives as a way of endin g their suffering. With increasingly severe depressed mood there are increasingly frequent and formed plans of suicide. The develop- ment of a sense of hopelessness towards the futur e is a worrying sign. Mania and depression are often thought of as two extremes of illness with normality or euth ymia in the middle. Morbid change in mood (either elevation or depression) can more accurat ely be considered as being on one side of a coin with normality on the other. Some patients display both manic and depressive features in the one episode \200\224a mixed affective st ate. Manic and depressive illnesses have, in common, increased lability (i.e. susceptibilit y to change) of mood, increased irritability, decreased sleep, and an increase in subjectiv e anxiety. The core clinical features of manic illnesses are sustained and inappro- priate elevation i n mood (often described as feeling on top of the world) and a distorted or in \202 ated es timate of one \200\231s importance and abilities. The clinical picture also includes increa sed lability of mood, increased irritabil- ity, increased activity levels, disturbed sleep pattern with a sense of dimin- ished need for sleep, and subjectively improved memory and c oncentration despite objective deterioration in these skills. With increasingly severe epi- sodes of manic illness there is loss of judgment, an increase in inappropriate and risky b ehavior, and the development of mood-congruent delusions. 02_Semple_Chap02.indd 50 12/7/2012 7:03:20 PM ASKING ABOUT DEPRESSED MOOD 51 Asking about depressed mood \200\230How has your mood been lately? \200\231 Patients vary in their ability to introspe ct and assess their mood. Beginning with general questioning allows a more unbiased account of mood problems. Report any descrip- tion of depression in the patient \200\231s own word s. Ask the patient to assess the depth of depression (e.g. \200\230on a scale of one to te n, where ten is normal and one is as depressed as you have ever felt, how would you rate yo ur mood now? \200\231). How long has the mood been as low as this? Enquire about any notabl e discrepancy between the patient \200\231s report of mood and objec- tive signs of mood di sturbance. \200\230Does your mood vary over the course of a day? \200\231 Clarify if the mood varies as the day goes on. If mood improves in the evening, does it return completely to normal? D oes anything else change as the day goes on to account for the mood change (e.g. more compa ny available in the evenings)? \200\230Can you still enjoy the things you used to enjoy? \200\231 By this point of the in terview you should have some idea about the activities the patient formerly enjoyed. Depres sed patients describe lack of interest in their previous pursuits, decreased participation in activities, and a sense of any participation being more of an effort. \200\230How are you sleeping? \200\231 Many patients will simply describe their sleep as \200\230terrible \200\231. They should be asked further about time to bed, time falling asl eep, wakefulness throughout the night, time of waking in the morning, quality of sleep (is it refreshing or not?), and any daytime napping. \200\230What is your appetite like at the moment? \200\231 Patients reporting a change in their appetite should be asked about reasons for this (loss of interest in food, loss of mo tivation to prepare food, or swallowing dif \201 cul- ties?). Has there been recent weight loss? Do their clothes still \201 t? \200\230How is your concentration? \200\231 Clarify any reported decline by ask- ing about ability to perform standard tasks. Can they read a newspaper? Watch a TV show? Ask about w ork performance. \200\230What is your memory like at the moment? \200\231 Again, clarify any reported decli ne.