Delusional ideas vary in their degree of detail and in their intensity over the course of a n illness episode. In evolving psychotic illness there will often be a perplexing sense of \200\230something not being right \200\231 and ill-formed symptoms such as a vague sense t hat they are being spied upon or perse- cuted in some way. As the delusion becomes more ful ly formed it comes to dominate the person \200\231s thinking and becomes more elaborated \200\224more detailed and with more \200\230evidence \200\231 produced to support the beli ef. With treatment the delusion will hopefully fade in importance and the person may come t o appreciate the belief as false or, despite holding to its initial truth, will regard it a s no longer important. \200\230Do you have any particular worries preying on your mind at the moment? \200\231 Be ginning with a very general question like this offers the patient an opportunity to broach a topic which may have been concerning them but which they have been putting off mentioning . \200\230Do you ever feel that people are watching you or paying atten- tion to what you ar e doing? \200\231 Ask the patient to describe this sensation and an episode of its occurren ce. Distinguish normal self-consciousness or a patient \200\231s awareness of genuinely not able abnormality from referen- tial delusions. A delusion will generally have further elabo ration of the belief \200\224there will be some \200\230reason \200\231 why the reported e vents are happen- ing. Elaboration may take the form of other beliefs about cameras, bugs, etc. \200\230When you watch the television or read the newspapers, do you ever feel that the st ories refer to you directly, or to things that you have been doing? \200\231 Invite the pat ient to elaborate further on a posi- tive response. Again, probe for further elaboration of the belief and seek examples of when it has occurred. \200\230Do you ever feel that peopl e are trying to harm you in any way? \200\231 Persecutory delusions are among the most comm on features of psychotic illness. There is potential for diagnostic confusion with paranoid personality traits, with suspicion and resentfulness towards medical and nursing staff and with genuine fears, understandable in the context of the patient \200\231s lifestyle (e.g. of retribution from drug dealers or money lenders). Explore the nature and basis of the be liefs and the supporting evidence that the patient advances for them. 02_Semple_Chap02.indd 60 12/7/2012 7:03:21 PM ASKING ABOUT ABNORMAL BELIEFS 61 \200\230Do you feel that you are to blame for anything, that you are responsible for anyth ing going wrong? \200\231 Delusions of guilt are seen in psychotic depression, in addition to the psychotic disorders. The affected individual may believe that they are responsible f or a crime, occasionally one which has been prominently reported. On occasions these indivi duals may \200\230turn themselves in \200\231 to the police rather than seeking medical he lp. \200\230Do you worry that there is anything wrong with your body or that you have a seriou s illness? \200\231 Hypochondriacal delusions show diag- nostic overlap with normal health concerns, hypochondriacal over-valued ideas, and somatization disorder. Clarify this sympto m by examining the patient \200\231s evidence for this belief and the \201 rmness with wh ich it is held. 02_Semple_Chap02.indd 61 12/7/2012 7:03:21 PM CHAPTER 2 Psychiatric assessment 62 Asking about the \201 rst-rank symptoms of schizophrenia The \201 rst-rank symptoms are a group of symptoms which have special signi \201 cance in the diagnosis of schizophrenia . There is no symptom that is pathognomic of schizophrenia. The \201 rst-rank symptoms ar e useful because they occur reasonably often in schizophrenia and more rarely in other diso rders and it is not too dif \201 cult to tell whether they are present or not. They can al l be reported in other conditions (e.g. organic psycho- ses, manic illnesses). They do not give a guide to severity or prognosis of illness (i.e. a patient with many \201 rst-rank symptoms is not \200\230worse \200\231 than one with few) and they may not occur at all in a patient who undoubtedly has schizophrenia. There are eleven \201 rst-rank symptoms, or ganized into four categories according to type. Auditory hallucinations \200 \200\230Voices heard arguing \200\231 \200 Thought echo \200 \200\230Running commentary \200\231 Delusions of thought interference \200 \200 \200 Thought insertion Thought withdrawal Thought broadcasting Delusions of control \200 Passivity of affect \200 Passivity of impulse \200 Passivit y of volitions \200 Somatic passivity Delusional perception \200 A primary delusion of any content that is reported by the patient as having arisen followin g the experience of a normal perception \200\230Do you ever hear voices commenting on what you are doing? Or discussing you betwee n themselves? Or repeating your own thoughts back to you? \200\231 For this symptom to be c onsidered \201 rst-rank, the experience must be that of a true auditory hallucination whe re the hallucinatory voice refers to the patient in the third person (i.e. as \200\230him \200\231 or \200\230her \200\231 rather than \200\230you \200\231). Distinguish these exp eriences from internal monologs. \200\230Do you ever get the feeling that someone is interfering with your thoughts \200 \224that they are putting thoughts into your head or tak- ing them away? Or that your thoug hts can be transmitted to oth- ers in some way? \200\231 It is the experience itself that r enders this symptom \201 rst-rank. The patient may describe additional delusional elabora tion (e.g. involving implanted transmitters or radio waves). The important point to clarify with the patient is that the experience is really that of thoughts being affected by an ex ternal agency and that it is not simple distraction or absent-mindedness. For thought broad casting, ensure that the patient is 02_Semple_Chap02.indd 62 12/7/2012 7:03:21 PM FIRST-RANK SYMPTOMS OF SCHIZOPHRENIA 63 not simply referring to the fact that they are \200\230easily read \200\231 or that they g ive away their emotions or thoughts by their actions. \200\230Do you ever get the feeling that you are being controlled? That your thoughts or m oods or actions are being forced on you by someone else? \200\231 Again, there may be delus ional elaboration of this symptom but it is the experience itself, of an external controlle r affecting things which are normally experienced as totally under one \200\231s own contro l, which makes this symptom \201 rst-rank. Clarify that the actions are truly perceived a s controlled by an outside agency, rather than, for example, being directed by auditory hal lucinations. 02_Semple_Chap02.indd 63 12/7/2012 7:03:21 PM CHAPTER 2 Psychiatric assessment 64 Disorders of the form of thought In describing psychopathology we draw a distinction betwee n the content and the form of thought. Content and form Content describes the meaning and experience of belief, perception, and me mory as described by patients, while form describes the structure and process of thought. I n addition to abnormalities of perception and belief, mental disorders can produce abnormal ity in the normal form of thought processes. This may be suggested by abnormalities in the form of speech, the only objective representation of the thoughts, or may be revealed by em pathic questioning designed to elicit the patient \200\231s subjective experiences. When pa tients mutter to themselves, listen closely to see if it is compre- hensible or not. The la tter is usually indicative of disorder of form of think- ing. See Box 2.2 for methods of as sessing symptoms of thought disorder. Thought disorder Among the psychiatric symptoms that are outside normal experience, thought disorder is challenging to understand and perhaps the most dif- \201 cult for the clinic ian to have empathy with. Consider a model of normal thought processes and use this to simp lify discussions of abnormalities. In this model we visualize each thought, giving rise to a constellation of associations (i.e. a series of related thoughts). One of these is pursue d, which gives rise to a further constellation and so on. This sequence may proceed towards a speci \201 c goal driven by a determining tendency (col- loquially the \200\230train o f thought \200\231) or may be undirected as in daydreaming. Disturbances in the form of tho ught may affect the rate or internal associa- tions of thought. Accelerated tempo of thought Accelerated tempo of thought is called \202 ight of ideas. I t may be re \202 ected in the speech as pressure of speech or may be described by the pati ent. The sensation is of the thoughts proceeding more rapidly than can be articulated and o f each thought giving rise to more associations than can be followed up. Flight of ideas ca n be a feature of a manic episode. In the majority of cases of \202 ight of ideas, some f orm of association of each thought can be discerned. For example, it could be a super \201 cial clang association, alliteration and punning that proceeds like the game of domi- noes where the last move determines the next move. In milder forms, called prolixity, the rate is slow and eventually reaches the goal if allowed adequate time. Decelerated tempo of thought Decelerated tempo of thought, or psychic retardation, occurs i n depressive illnesses. Here the subjective speed of thought and the range of associa- tion s are decreased. There may be decreased rate of speech and absence of spontaneous speech. I n addition, the remaining thoughts tend towards gloomy themes. In both accelerated and dece lerated thought there may 02_Semple_Chap02.indd 64 12/7/2012 7:03:22 PM DISORDERS OF THE FORM OF THOUGHT 65 be an increased tendency for the determining tendency of thought to be lost (referred to as increased distractibility). Schizophrenic thought disorder Disturbances of the associations between the thoughts are cl osely associ- ated with schizophrenia and may be referred to as schizophrenic thought dis- order. Four disturbances are classically described: snapping-off (entgleiten), fusion (vers chmelzung), muddling (faseln), and derailment (entgleisen). \200 Snapping-off or thought blocking describes the subjective experience of the sudden and unin tentional stop in a chain of thought. This may be unexplained by the patient or there may b e delusional elaboration (e.g. explained as thought withdrawal). Derailment or chain of ass ociation between the meanings of thoughts. Fusion is when two or more related ideas from a group of associations come together to form one idea. Muddling is a mixture of elements of fusion and derailment. refers to the resulting speech. In mild forms the determining tenden cy in the thoughts can be followed (increased follow-up of side associations is referred to as circumstantiality). knight \200\231s move thinking describes a total break in the Driveling Box 2.2 Assessing symptoms of thought disorder Patients will rarely directly complain of the symptoms of thought dis- order. In assessing the \201 rst-rank symptoms of schizophrenia the doctor will have enquired about delusions of the control of thought and about the passivity delusions. Both these symptom areas requ ire the patient to introspect their thought processes; however, they will more rarely be aw are of disorders which affect the form as opposed to the content of their thoughts. They ca n be asked directly about the symptoms of accel- eration and deceleration of thought and th ese symptoms may be directly observable in acceleration or deceleration of speech. Observat ion and recording of examples of abnormal speech is the method by which formal thought diso rder is assessed. Record examples of the patient \200\231s speech as verbatim quotes, parti cularly sentences where the meaning or the connection between ideas is not clear to you dur ing the inter- view. Following recovery, patients can sometimes explain the underlying mean ing behind examples of schizophrenic speech. 02_Semple_Chap02.indd 65 12/7/2012 7:03:22 PM CHAPTER 2 Psychiatric assessment 66 Abnormal cognitive function All mental disorders affect cognition as expressed in affect, b eliefs, and per- ceptions. The organic mental illnesses directly affect the higher cognitiv e functions of conscious level, clarity of thought, memory, and intelligence. Level of consciousness This can range from full alertness through to clouding of consciousn ess, sopor, and coma (pathological unconsciousness); or from full alertness through to drow siness, shallow sleep, and deep sleep (physiological unconsciousness). Confusion Milder forms of brain insult are characterized by a combina- tion of disorientati on, misinterpretation of sensory input, impairment in memory, and loss of the normal clarit y of thought \200\224together referred to as confusion. It is the main clinical feature of delirium (b p. 790) and is also present during intoxication with psychotropic substances an d occa- sionally as part of the clinical picture of acute psychotic illnesses. \200 Disorientation An unimpaired individual is aware of who he is and has a constantly updated record of where he is and when it is. With increasing impairment there is disorientation fo r time, then place, and lastly, with more severe confusion, disorientation for person. Misi nterpretation ability to perceive and attach meaning to sensory stimuli. In frank delirium there may be hallucinations, particularly visual, and secondary delusions, particularly of a persecutory nature. Memory impairment the registration of new memories (anterograde amnes ia) and recall of established memories (retrograde amnesia). Events occurring during the pe riod of confusion may be unable to be recalled, or may be recalled in a distorted fashion, indicating a failure of registration. Impaired clarity of thought The layman \200\231s \200\230confusion \200\231. A variable degree of impairment in the normal process of though t with disturbed linkages between meaning, subjective and objective slowing of thought, imp aired comprehension, and bizarre content. With confusion there is impairment of the normal With confusion there is impairment in both Memory Beyond the ephemeral contents of our minds, containing our current thoughts and curr ent sensorium, our memory contains all records of our experience and personality. \200 Working memory Synonymous with short-term memory, which is responsible for the immediate re call of small amounts of verbal (as in digit span) or visuospatial information. Used for su ch purposes as holding a telephone number while dialing it. Most people have between 5 and 9 \200\230spaces \200\231 available, with an average of 7 (the \200\230magic number \200 \231). New information will enter at the expense of the old. It has been traditionally held that storage of information in long-term memory is dependent on short-term memory. This is now no longer thought to be true; rather these two memory components are thought to functi on independently of each other. For example, patients with even severe impairment of episod ic memory (e.g. persons with Korsakoff \200\231s syndrome) can present with normal short-te rm memory. 02_Semple_Chap02.indd 66 12/7/2012 7:03:22 PM ABNORMAL COGNITIVE FUNCTION 67 Long-term memory System for storage of permanent memories with apparently unlimited capacit y. There appear to be separate storage sys- tems for different types of information: memory for events (episodic memory), learned skills (procedural memory), memory of concepts and i deas unrelated to personal experience (semantic memory), which can be differentially affect ed by disease process. Intelligence A person \200\231s intelligence refers to their ability to reason, solve probl ems, apply previous knowledge to new situations, learn new skills, think in an abstract way , and formulate solutions to problems by internal planning. It is stable through adult life unless affected by a disease process. Intelligence is measured by the intelligence quotien t (IQ), a unitary meas- ure with a population mean of 100 and a normal distribution. There is a \200\230hump \200\231 on the left-hand side of the population curve for IQ representi ng those individuals with congenital or acquired lowered IQ. No pathological process produc es heightened IQ. Acute vs. chronic brain failure Despite its great complexity the brain tends to respond to insults, whatever their source, in a variety of stereotyped ways (e.g. delirium, seizure, c oma, dementia). These present as clinically similar or identical whatever their underlying cause. Acute brain failure (delirium) and chronic brain failure (dementia) are two char- ac teristic and stereotyped responses of the brain to injury. In common with other organ failu re syndromes there is an \200\230acute on chronic \200\231 effect, where patients with est ablished chronic impairment are susceptible to developing acute impairment following an ins ult which would not cause impairment in a normal brain (e.g. the development of \202 orid delirium in a woman with mild dementia who develops a urinary tract infection [UTI]). 02_Semple_Chap02.indd 67 12/7/2012 7:03:22 PM CHAPTER 2 Psychiatric assessment 68 Assessing cognitive function 1 Assessing level of consciousness The Glasgow Coma Scale (GCS) is a rapid, clinical measure of the conscious level (see Box 2.3). In delirium both the conscious level and the level of confusion may vary rapidly on an hour-by-hour basis and may present as apparently \200 \230normal \200\231 on occa- sions. Patients with symptoms suggestive of delirium should th erefore be re-examined regularly. Assessing confusion Assess orientation by direct questioning. Some degree of uncertainty as to date and time can be expected in the hospital- ized individual who is away from their n ormal routine. Directly enquire about episodes of perceptual disturbance and their nature. Document examples of confused speech and comment on the accompanying affect. Assessing memory Working memory can be assessed by giving the patient a \201 ctitious add ress containing six components, asking them to repeat it back or by testing digit span, spe lling of WORLD backwards, etc. Clinicians traditionally used the term \200\230short-term m emory \200\231 to re \202 ect material held over a short period (e.g. 5 \200\22330 min) or some time to refer to retention over the ensuing days or week. There is no evidence, how- ever, from a neuropsychological perspective of a memory system with these characteristics, and one is better occupied in thinking of memory as de \201 ned here, and thereafter consi dering anterograde and reterograde aspects of same. Level of intelligence In most cases formal IQ testing will not be used and the IQ is assess ed clinically. Clinical assessment of IQ is by consideration of the highest level of educat ional achievement reached and by assessment of the patient \200\231s comprehension, vocabul ary, and level of understanding in the course of the clinical interview. To some extent thi s technique relies upon experience giving the doctor a suitable cohort of previous patients for comparison, and allowance should be made for apparent impairment that may be secondary to other abnormalities of the mental state. In any case, if there is signi \201 cant doub t about the presence of mental impairment more formal neuropsychological testing should be undertake n. 02_Semple_Chap02.indd 68 12/7/2012 7:03:22 PM ASSESSING COGNITIVE FUNCTION 1 69 Box 2.3 Glasgow Coma Scale (GCS) The GCS is scored between 3 and 15, 3 being the worst (you cannot score 0), and 15 the best . It is composed of three parameters: [E] Best eye response (maximum score = 4) 1. 2. 3. 4. No eye opening Eye opening to pain Eye opening to verbal command Eyes open spontaneously [V] Best verbal response (maximum score = 5) 1. 2. 3. 4. 5. No verbal response Incomprehensible sounds Inappropriate words Confused but converses Orien tated and converses [M] Best motor response (maximum score = 6) 1. 2. 3. 4. 5. 6. No motor response Extension to pain Flexion to pain Withdrawal from pain Localizing pain Ob eys commands Notes: \200 The phrase \200\230GCS of 11 \200\231 is essentially meaningless; the \201 gure should b e broken down into its components (e.g. E3 V3 M5 = GCS 11). A GCS of 13 or more correlates with a mild brain injury; 9 \200\22312 is a moderate injury; and 8 or less, a severe brain injury. Reproduced from Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 304(7872): 81 \200\2234, with kind permission from Elsevier. 02_Semple_Chap02.indd 69 12/7/2012 7:03:23 PM CHAPTER 2 Psychiatric assessment 70 Assessing cognitive function 2 A wide range of standardized instruments is available for us e in screening for cognitive impairment and for measuring severity and progression in estab lished cases of dementia. There is currently no clear consensus on the best screening instr ument, but in general, shorter screening tests are favored in primary care or general medic al settings. Bedside screening instruments Six-item Cognitive Impairment Test (6CIT) (Katzman 1983) A 6- question, abbreviated form of the older Blessed Information Memory Concentration Scale (BIM C) (1968) which examines orientation, memory and concen- tration. Its usage is increasing f ollowing its use as one component in a standardized assessment (Easycare ) recognized by T he Royal College of General Practitioners. A computerized version is also available (Kingsh ill Version 2000). It is inversely scored and weighted so that a score of 8 or more out of 28 is suggestive of signi \201 cant cognitive impairment (sensitivity 78 \200\22390%, spec i \201 city 100%). Abbreviated Mental Test (AMT) (Hodkinson 1972) A 10-item question- nair e testing orientation, memory and concentration originally developed by geriatricians as an abbreviated form of the mental test score from the BIMC. Useful for rapid screening for co gnitive impairment \200\224indicated by a score of 7 or less out of 10 (sensitivity 70 \200 \22380%, speci \201 city 71 \200\22390%). Mini Mental State Examination (MMSE) In psychiatric settings there is almost universal use of the Mini Mental State Examination (Folstein 1975). It is included in many guidelines for dementia diagnosis and there is a large body of research providing reference ranges for a variety of clinical situations and premorbid levels of functioning. Copies of the questions and scoring system are usually readily available in wards and clinics (Note: as with many psychological tests the MMSE is subject to copyright). A low sensitivity makes it less suit able as a screen- ing test in primary care, but it is often used as a relatively short test to monitor changes in cognitive function over time, particularly in response to treatment. It should be remembered that the MMSE is based almost entirely on verbal assessment of mem ory and attention. It is insensitive to frontal-executive dysfunction and visuospatial de \201 cits. A score of 23 \200\22325 or less out of 30 is considered impaired; however, note low sensitivity, and clinical experience which \201 nds not uncommonly cognitive impairm ent in individuals with scores of 30/30 (sensitivity 30 \200\22360%, speci \201 city 92 \200\223100%). Addenbrooke \200\231s Cognitive Examination \200\224Revised (ACE \200\224R) (2005) When tim e permits, or clinical presentation is more complex, the ACE-R provides a more detailed, 10 0-item, clinician-administered bedside test of cognitive function. It is a superset of the MMSE and will therefore also generate an MMSE score. Questions cover \201 ve areas of fun ction: atten- tion and orientation, memory, verbal \202 uency, language and visuospatial awareness. Detailed data is available to allow interpretation of scor- ing, and speci \201 c training on administration of the test is recommended. 02_Semple_Chap02.indd 70 12/7/2012 7:03:23 PM ASSESSING COGNITIVE FUNCTION 2 71 The ACE-R version A (2005) gives a sensitivity of 94% and a speci \201 city of 89% for dem entia with a cut-off score of 88/100. Collateral information It is always useful to have third-party information when assessing c ogni- tive function \200\224usually from a spouse, partner, family member, or carer. Third- party information can be more formally assessed using standard- ized instruments, e.g. the Informant Questionnaire on Cognitive Decline (IQCODE). Recommended further reading Hodges JR (2007) Cognitive assessment for clinicians, 2nd edn. Oxford: Oxford University Press. 02_Semple_Chap02.indd 71 12/7/2012 7:03:23 PM CHAPTER 2 Psychiatric assessment 72 Supplementary tests of cerebral functioning Where there is clinical suspicion of speci \201 c functional impairment, it is often useful to directly test the functioning of the di fferent cerebral lobes. This provides more detailed supplementary information to the MMSE ( which is essentially a screening test). More formal neuropsychological assessment may be re quired with additional, well-established psychologi- cal tests, although these will usually be administered by psychologists. Frontal lobe functioning Frontal assessment battery (FAB) A brief (10-min) test of executiv e func- tion, which essentially regroups tests often used when testing executive function a t the bedside. These tests are associated with speci \201 c areas of the frontal lobes (i. e. conceptualization with dorsolateral areas; word gen- eration with medial areas), and inh ibitory control with orbital or medial areas. The maximum score is 18 and a cut-off score o f 12 in patients with dementia has been shown to have a sensitivity of 79% for frontotempor al dementia vs. Alzheimer \200\231s disease. However, any performance below 17 may indicate frontal lobe impairment. The Wisconsin card sorting task The patient has to determine the rule for card allocation and allocate cards accordingly. When the rule changes, a patient w ith frontal lobe dysfunction is likely to make more errors (tests response inhibition and s et shifting). Digit span Short-term verbal memory is tested with progressively longer numbe r sequences, \201 rst forwards (normal maximum digit span 6 1) and, subsequently, in r everse order (normal maximum 5 1). Trail-making test A \200\230join the dots \200\231 t est of visuomotor tracing testing con- ceptualization and set shifting. Test A is a simple number sequence; Test B is of alternating numbers and letters (more sensitive for frontal l obe dysfunction). Cognitive estimate testing The patient is asked a question that requires abstract reasoning and cannot be answered by general knowledge alone (e.g. \200\230how man y camels are there in the UK? \200\231). Testing of interpretation of proverbs can be helpful in uncovering concreteness of thought \200\224e.g. \200\230People in glass house shouldn \200\231t throw stones \200\231 \200 \224asking the patient \200\230are you aware of this proverb? \200\231, \200\230can you t ell me what this means/give me a life scenario in which this would apply? \200\231 It is im portant to note that persons with more orbito-medial frontal lobe dam- age may present with completely normal neurocognitive assessment, but clinically with histories that are consis tent with frontotemporal dementia- behavioral variant. Parietal lobe functioning Tests for dominant lesions Finger agnosia Patient cannot state wh ich \201 nger is being touched with their eyes closed. Astereoagnosia Patient unable to r ecognize the feel of common objects (e.g. coin, pen) with their eyes closed. 02_Semple_Chap02.indd 72 12/7/2012 7:03:23 PM SUPPLEMENTARY TESTS OF CEREBRAL FUNCTIONING 73 Dysgraphaesthesia Inability to recognize letters or numbers written on the hand. Note: Alth ough of disputed clinical value, Gerstmann syndrome is classi- cally described as: right-le ft disorientation, \201 nger agnosia, dysgraphia, and dyscalculia; due to a lesion of the dominant (usually left) parietal lobe. Tests for non-dominant lesions Asomatognosia Patient does not recognize parts of their body (e.g. hand, \201 ngers). Constructional dyspraxia Inability to draw shapes or construct geometrical patterns. Other problem areas \200 Visual \201 elds (as optic tracts run through the parietal lobe to reach the occipital lo be). Speech \200\224alexia, receptive dysphasia (Wernicke \200\231s area); conduction aphas ia (cannot repeat a phrase, but does understand the meaning). Reading/writing (angular gyru s lesions). 02_Semple_Chap02.indd 73 12/7/2012 7:03:23 PM CHAPTER 2 Psychiatric assessment 74 Insight The question of whether the patient has insight into the nature of their symptoms t ends only to arise in psychiatric illnesses. In general, a patient with physical illness kn ows that their symptoms represent abnormality and seeks their diagnosis and appropriate tre atment. In contrast, a variety of psychiatric illnesses are associated with impairment of i nsight and the development of alternative explanations by the patient as to the cause of th eir symptoms, for example: \200 An elderly man with early dementia who is unable to recall where he leaves objects and attr ibutes this to someone stealing them. He angrily accuses his son of the \200\230crime \200 \231. An adolescent, with developing schizophrenia, who believes his auditory hallucination s and sense of being watched are caused by a neighbor who has planted cameras and loudspeak ers in his \202 at. He repeatedly calls the police and asks them to intervene. A middle-a ged woman with worsening depression who develops the delusion that she is bankrupt and is s hortly to be evicted from her home in disgrace. Impairment of insight is not speci \201 c to any one psychiatric condition and is not a ge nerally a diagnostically important symptom. It tends to occur in psychotic and organic illn esses and the more severe forms of depressive illness. Neurotic illnesses and personality d isorders are generally not asso- ciated with impairment of insight. Impairment of insight c an give a crude measure of severity of psychotic symptoms. Regaining of insight into the pa thological nature of psychotic beliefs can give a similarly crude measure of improvement wi th treatment. Insight can be de \201 ned succinctly as \200\230the correct attitude to mor- bid change in oneself \200\231 \200\231. It is a deceptively simple concept that includes a number of beliefs about the nature of the symptoms, their causation, and the most appropriate way of dealing with them. Insight is sometimes reported as an all or nothing measure \200\224as so mething an individual patient either does or does not have. In fact, insight is most useful ly inquired about and reported as a series of health beliefs: \200 Does the patient believe that their abnormal experiences are symptoms? Does the patient bel ieve their symptoms are attributable to illness? Do they believe that the illness is psychi atric? Do they believe that psychiatric treatment might bene \201 t them? Would they be wi lling to accept advice from a doctor regarding their treatment? \200 \200 \200 Beyond the simple question of whether the patient has impairment of insight or not it is vi tal to understand how the patient views their symp- toms as this will tend to in \202 uenc e their compliance and future help-seek- ing behavior. It is important to emphasize that di sagreement with the doctor as to the correct course of action does not necessarily indicate lack of insight. A patient may very well not agree to be admitted to hospital or to take a particular medication despite having full insight into the nature of their symptoms. In th ese cases the doctor should be sure to clarify that the patient has all the necessary infor mation to make a suitable decision before considering the possible need for compulsory trea tment. 02_Semple_Chap02.indd 74 12/7/2012 7:03:23 PM PHYSICAL EXAMINATION 75 Physical examination Examination of the patient \200\231s physical condition is an integral part of a com- prehensive psychiatric assessment. There are \201 ve main reasons why thi s is so: \200 Physical symptoms may be a direct result of psychiatric illness (e.g. alcohol dependency \200\224see b p. 574; eating disorders \200\224see b p. 402; physical neglect in severe dep ression, schizophrenia, etc.). Psychiatric drugs may have physical side-effects (e.g. extra -pyramidal side-effects [EPSEs] and antipsychotics, hypothyroidism and lithium, withdrawal syndromes). Physical illnesses can cause or exacerbate mental symptoms. Occult physical ill ness may be present. In the case of later development of illness (or more rarely, medico- l egal issues) it is helpful to have baseline physical \201 ndings documented. \200 \200 Physical examination is all too often deferred and then not done, or not done as thoroughly as is indicated. It may well be acceptable to defer full examination on occasions (e.g. a distressed and paranoid man seen in A&E), but a minimal investigation can be done and compl eted as the situation allows. A routine physical examination has the aim of documenting the patient \200\231s baseline ph ysical state, noting the presence or absence of abnormal signs which could be associated wi th mental or physical illness, and highlighting areas requiring further examination or inve stigation. General condition Note height and weight. Does the patient look well or unwell? Are they un derweight or are there signs of recent weight loss? Note bruising or other injuries and est imate their age. Cardiovascular Radial pulse \200\224rate, rhythm, and character. Blood pres- sure. Carotid bruits? Heart sounds. Pedal oedema. Respiratory Respiratory rate. Expansion. Percussion note. Breath sounds to auscultation. Abdominal Swelling or ascites. Masses. Bowel sounds. Hernias. Neurological Pupillary response and other cranial nerves. Wasting. Tone. Power. Sensation. Re \202 exes. Gait. Involuntary movements. 02_Semple_Chap02.indd 75 12/7/2012 7:03:23 PM CHAPTER 2 Psychiatric assessment 76 Some physical signs in psychiatric illness, and possible causes (Table 2.1) General examina tion Table 2.1 Some physical signs in psychiatric illness, and possible causes. Parkinsonian facies Antipsychotic drug treatment Psychomotor retardation (depression) Opiate use Neurosyphilis Bulimia nervosa (secondary to vomiting) Clozapine treatment Thyroid disease Borderline pers onality disorder Dissocial personality disorder IV drug use Antipsychotic drug treatment Al coholic liver disease Bulimia nervosa (secondary to inducing vomiting) Anorexia nervosa Opi ate withdrawal Anorexia nervosa Abnormal pupil size Argyll \200\223Robertson pupil Enlarged parotids ( \200\230hamster face \200\231) Hypersalivation Goiter Multiple forearm scars Multiple tattoos Needle tracks/phl ebitis Gynaecomastia Russell \200\231s sign (knuckle callus) Lanugo hair Piloerection ( \200\230goose \202 esh \200\231) Excessive thinness Cardiovascular Rapid/irregular pulse Anxiety disorder Drug/alcohol withdrawal Hyperthyroidism Hypothyroidism Slow pulse Abdominal Enlarged liver Alcoholic liver disease Hepatitis Somatization disorder Multiple surgical scars ( \200\230checkerboard \200\231 abdomen) Multiple self-in \202 ict ed scars Borderline personality disorder Neurological Resting tremor Increased sympathetic drive (anxiety, drug/ alcohol misuse) Antipsychotic drug treatment Li thium treatment Antipsychotic drug treatment Tic disorder Huntingtons \200\231s/Sydenham \200\231s chorea Antipsychotic-induced dystonia Catatonia Antipsychotic drug treatment Cere bellar disease (alcohol, lithium toxicity) Involuntary movements Abnormal posturing Festinant (shuf \202 ing) gait Broad-based gait 02_Semple_Chap02.indd 76 12/7/2012 7:03:23 PM This page intentionally left blank CHAPTER 2 Psychiatric assessment 78 Clinical investigation Clinical investigations, including blood testing, imaging techniques , and karyotyping, play a smaller role in psychiatry than in other medical special- ties. T hey are mainly carried out to exclude medical conditions which may be part of the different ial diagnosis (such as hypothyroidism as a cause of lethargy and low mood) or which may be comorbid. They should gener- ally be carried out as a result of positive \201 ndings in t he history or physical examination or in order to exclude serious and reversible occult dis orders (such as syphilis as a cause of dementia). Routine investigations may be carried out to assess general physical health, and to provide a baseline measure prior to commencing medica- tion known to have possible adverse effects , for example full blood count (FBC), liver function tests (LFTs) and antipsychotic medicat ion; urea and electrolytes (U&Es), creatinine clearance, thyroid function tests (TFTs) prio r to lithium therapy). Speci \201 c screening and monitoring tests are detailed in speci \201 c sections. It is good practice to screen new patients with some standard tests, and t he usual test battery will include: FBC (and differential), U&Es, LFTs, TFTs, glucose. Wher e there is suspicion of drug or alcohol misuse/dependency, mean cell volume (MCV), B12/fola te, and toxicology screening may be added. Other physical investigations are rarely requested (with perhaps the exception of ECG for p atients on speci \201 c or high-dose antipsychot- ics) unless clinical examination indicat es the possibility of an underlying ( undiagnosed) physical disorder. Performance of a lumb ar puncture, for example, is reserved for situations where there is clear evidence to sug- gest a neurological disorder presenting with psychiatric symptoms (e.g. sus- pected meningi tis or encephalitis; multiple sclerosis) and, more often than not, in these circumstances a referral will be made for a medical review. Use of other tools, such as EEG, CT, or MRI (and SPECT or PET where available) requires jus ti \201 cation on the grounds of diagnostic need. EEG is frequently overused by psychiatri sts, and may be dif \201 cult to interpret as psychotropic medications may \200\230muddy the waters \200\231. EEG may be useful where epilepsy is suspected (on clinical grounds), t o monitor some acute (toxic) confusional states, to assess atypical patterns of cognitive i mpair- ment, to aid diagnosis in certain dementias (e.g. HIV, variant Creutzfeldt \200\223 Jakob disease [vCJD]), to evaluate particular sleep disorders, or as the gold standard for seizure monitoring during ECT. EEG should not be used as a general screening tool. Similarly, brain imaging adds little to the diagnosis of primary psychiatric disorders, and should only be used where there is good evidence for pos- sible neurological problems (e.g . history of signi \201 cant head injury, epilepsy, multiple sclerosis, previous neurosurg ery) or where history and clinical examination indicate the possibility of a space-occupyin g lesion (e.g. local- izing neurological signs, unexplained \202 uctuating level of consc iousness, severe headache, marked and unexplained acute behavioral change). With the except ion of organic disorders (e.g. the dementias \200\224where diag- nostic imaging techniques may add useful information to inform diagnosis, 02_Semple_Chap02.indd 78 12/7/2012 7:03:24 PM CLINICAL INVESTIGATION 79