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. \200\230How is the sexual side of your relationship? \200\231 Potentially embarrass- ing t opics are best approached in a professional and matter-of-fact way. It is important to enqu ire about this directly as the symptom of loss of libido can cause considerable suffering f or patient and partner and is less likely than other symptoms to be mentioned spontaneously . During treatment this symptom should again be asked about as many psychotropic drugs nega tively affect sexual performance. \200\230Do you have any worries on your mind at the moment? \200\231 Characteristic of dep ressive illness is a tendency to preferentially dwell on negative issues. \200\230Do you feel guilty about anything at the moment? \200\231 Patients with depressive illnesses often report feelings of guilt or remorse about current or historical events. In severe illnesses these feelings can become delu- sional. Aim to assess the presence and na ture of guilty thoughts. 02_Semple_Chap02.indd 51 12/7/2012 7:03:20 PM CHAPTER 2 Psychiatric assessment 52 Asking about thoughts of self-harm Completed suicide is an unfortunately common outcome in many psychi- atric conditions. Thoughts of deliberate self-harm occur commonly and should a lways be enquired about. The majority of patients with illness of any severity will have ha d thoughts of deliberate self-harm at some stage. It should be emphasized that asking about deliberate self-harm does not \200\230put the idea in their head \200\231, and indeed man y patients will welcome the opportunity to discuss such worrying thoughts. The assessment is not only of the presence of suicidal thoughts, but also their severity an d frequency and the likelihood of them being followed by suicidal action. One suggested met hod involves asking about behaviors and thoughts associated with increasing suicide risk. T his tactful enquiry can be made in addition to an estimate of risk. The aim is not to trap the patient into an unwanted disclosure but to assess the severity of suicidal intent and h ence the attendant risk of completed suicide. \200\230How do you feel about the future? \200\231 Many patients will remain opti- mistic of improvement despite current severe sympt oms. A description of hopelessness towards the future and a feeling that things will never get better is worrying. \200\230Have you ever thought that life was not worth living? \200\231 A consequence of ho pelessness is the feeling that anything, even nothingness, would be better. \200\230Have you ever wished you could go to bed and not wake up in the morning? \200\231 Passive thoughts of death are common in mental illness and can also be found in normal elde rly people towards the end of life, particularly after the deaths of spouses and peers. \200\230Have you had thoughts of ending your life? \200\231 If yes, enquire about the freq uency of these thoughts \200\224are they \202 eeting and rapidly dismissed; or more prolo nged? Are they becoming more common? \200\230Have you thought about how you would do it? \200\231 Enquire about methods of suic ide the patient has considered. Particularly worrying are violent methods that are likely t o be successful (e.g. shooting, hanging, or jumping from a height). \200\230Have you made any preparations? \200\231 Aim to establish how far the patient \200 \231s plans have progressed from ideas to action \200\224have they consid- ered a place, bo ught pills, carried out a \201 nal act (e.g. suicide note, or begun putting their affairs in order). \200\230Have you tried to take your own life? \200\231 Has there been a recent con- cealed attempt (e.g. overdose)? If so, consider whether current medical assessment is required. Self-injurious behaviors Some patients report causing harm to them- selves, sometimes repea tedly, without reporting a desire to die (e.g. lac- erate their arms, legs, or abdomen; bur n themselves with cigarettes). In these cases, enquire about the reasons for this behavior, which may be obscure even to the person concerned. In what circumstances do they harm them selves? What do they feel and think before harming them- selves? How do they feel afterward s? 02_Semple_Chap02.indd 52 12/7/2012 7:03:20 PM ASKING ABOUT ELEVATED MOOD 53 Asking about elevated mood \200\230How has your mood been lately? \200\231 As for enquiries about depressed mood, beg in with a very general question. Report the patient \200\231s descrip- tion of their mood i n their own words. Clarify what the patient means by general statements such as \200\230on top of the world \200\231. \200\230Do you \201 nd your mood is changeable at the moment? \200\231 Besides general e levation in mood, patients with mania often report lability of mood, with tearfulness and i rritability as well as elation. The pattern and type of mood variation should be noted if p resent. \200\230What is your thinking like at the moment? \200\231 Patients with mania often repor t a subjective increase in the speed and ease of thinking, with many ideas occurring to the m, each with a wider variety of associated thoughts than normal. This experience, together with the nature of their ideas, should be explored and described. \200\230Do you have any special gifts or talents? \200\231 A characteristic feature of fra nk mania is the belief that they have exceptional abilities of some kind (e.g. as great wri ters or painters), or that they have some particular insight to offer the world (e.g. the r oute to achieving world peace). These beliefs may become frankly delusional, with the patie nt believing they have special or magical powers. The nature of these beliefs and their imp lications and meaning for the patient should be described. \200\230How are you sleeping? \200\231 Manic patients describe \201 nding sleep unneces- sary or a distraction from their current plans. Enquire about the length and quality of sl eep. \200\230What is your appetite like at the moment? \200\231 Appetite is variable in manic i llnesses. Some patients describe having no time or patience for the preparation of food; ot hers eat excessively and spend excessively on food and drink. Ask about recent weight gain or loss and about a recent typical day \200\231s food intake. \200\230How is your concentration? \200\231 Typically, manic patients have impaired concen tration and may report this; in this case the complaint should be clari \201 ed by example s of impairment. Some manic patients overestimate their concentration, along with other sub jective estimates of ability. Report on objective measures of concentration (e.g. attention to inter- view questioning or ability to retain interest in newspapers or TV while on the ward). \200\230How is the sexual side of your relationship? \200\231 Again, this topic should be broached directly and straightforwardly. Manic patients sometimes report increased interest in sexual activity. Clarify the patient \200\231s estimate of his or her own sexual attrac tiveness and recent increase in sexual activity or promiscuity. 02_Semple_Chap02.indd 53 12/7/2012 7:03:20 PM CHAPTER 2 Psychiatric assessment 54 Anxiety symptoms Anxiety symptoms are the most common type of symptoms seen in patients wit h psychiatric disorders. They are the core clinical features of the ICD-10 neurotic disorde rs (which are indeed called anxiety dis- orders in DSM-IV), and are also prominent clinical features in psychotic illnesses, affective illness, organic disorders, and in drug and alc ohol use and withdrawal. Anxiety has two components: psychic anxiety \200\224an unpleasant effect in which there is subjective tension, increased arousal, and fearful appre- hension; and somatic anxiety \200 \224bodily sensations of palpitations, sweating, dyspnoea, pallor, and abdominal discomfort . The sensations of anxiety are related to autonomic arousal and cognitive appraisal of thr eat which were adaptive primitive survival reactions. Anxiety symptoms are part of normal healthy experience, particularly before novel, stressfu l, or potentially dangerous situations. Moderate amounts of anxiety can optimize performanc e (the so-called \200\230Yerkes \200\223 Dobson \200\231 curve \200\224plotting performanc e level against anxiety shows an inverse-U shape). They become pathological when they are a bnormally severe, abnormally prolonged, or if they are present at a level out of keep- ing with the real threat of the situation. Anxiety symptoms may be present at a more or less constant level \200\224 generalized anxie ty; or may occur only episodically \200\224panic attacks. Anxiety symptoms may or may not h ave an identi \201 able stimulus. Where a stimulus can be identi \201 ed it may be very s peci \201 c, as in a simple phobia (e.g. fear of cats or spiders); or may be more generali zed, as in social phobia and agoraphobia. In phobias of all kinds there is avoidance of the feared situation. Because this avoidance is followed by a reduction in unpleasant symptoms it is reinforced and is liable to be repeated. Breaking of this cycle is the basis of dese nsitization methods of treating phobias (b p. 848). The repetition of behaviors in order to achieve reduction in the experience of anxiety is a lso seen in the symptoms of obsessions and compulsions. Here, the patient regards the thoug hts (obsessions) and/ or actions (compulsions) as purposeless, but is unable to resist thin king about them or carrying them out. Resistance to their performance pro- duces rising anx iety levels, which are diminished by repeating the resisted behavior. 02_Semple_Chap02.indd 54 12/7/2012 7:03:20 PM ASKING ABOUT ANXIETY SYMPTOMS 55 Asking about anxiety symptoms In enquiring about anxiety symptoms, aside from the nature, s everity, and precipitants of the symptoms, it is important to establish in all cases the im pact they are having on the person \200\231s life. Record what particular activi- ties or s ituations are avoided because of their symptoms and, in the case of obsessional symptoms, n ote how much time the patient spends on them. \200\230Would you say you were an anxious pe rson? \200\231 There is a wide varia- tion in the normal level of arousal and anxiety. Some people are inveterate \200\230worriers \200\231, while others appear relaxed at all times . \200\230Recently, have you been feeling particularly anxious or on edge? \200\231 Ask the patient to describe when the symptoms began. Was there any particular precipitating event o r trauma? \200\230Do any particular situations make you more anxious than others? \200\231 Establish whether the symptoms are constant or \202 uctuating. If the latter, enquire about those situations that cause worsening or improvement. \200\230Have you ever had a panic attack? \200\231 Ask the patient to describe to you what they mean by this. A classical panic attack is described as sud- den in onset with gradual resolution over 30 \200\22360 min. There are physical symptoms of dyspnoea, tachycardia, s weating, chest tightness/chest pain, and paraesthesia (related to over-breathing); coupled with psychological symptoms of subjective tension and apprehension that \200\230something terrible is going to happen \200\231. \200\230Do any thoughts or worries keep coming back to your mind even though you try to pu sh them away? \200\231 \200\230Do you ever \201 nd yourself spending a lot of time doing the same thing over an d over \200\224like checking things, or cleaning \200\224even though you \200\231ve already done it well enough? \200\231 Besides identifying the type of repetitive thought or action involved it is important to establish that the thoughts or impulses are recognized as the person \200\231s own (in con- trast with thought insertion in psychotic illness) and that t hey are associ- ated with resistance (although active resistance may diminish in chronic OC D). Patients with obsessional thoughts often worry that they are \200\230los- ing their mi nd \200\231 or that they will act on a particular thought (e.g. a mother with an obsessiona l image of smothering her baby). Where the symptom is de \201 nitively that of an obsessio n the patient can be reassured that they will not carry it out. 02_Semple_Chap02.indd 55 12/7/2012 7:03:20 PM CHAPTER 2 Psychiatric assessment 56 Abnormal perceptions Abnormal perceptual experiences form part of the clinical picture of m any mental disorders. Equally, the range of normal perceptual experience is very wide. Pati ents vary in their ability to explain their subjective percep- tual experiences. The brain constantly receives large amounts of perceptual information via the \201 ve spe cial senses of vision, hearing, touch, taste, and smell; the muscle, joint, and internal or gan proprioceptors; and the vestibular appa- ratus. The majority of this information is pro cessed unconsciously and only a minority reaches conscious awareness at any one time. An ex ternal object is represented internally by a sensory percept that combines with memory and experience to produce a meaningful internal percept in the conscious mind. In health, we ca n clearly distinguish between percepts which represent real objects and those which are the result of internal imagery or fantasy, which may be vividly experienced in the mind but ar e recognized as not real. Abnormal perceptual experiences may be divided into two types: Altered perceptions \200\224 including sensory distortions and illusions \200\224in which there is a distorted internal perception of a real external object. False perceptions \200\224including hallucinations an d pseudo- hallucinations \200\224in which there is an internal perception without an extern al object. Sensory distortions are changes in the perceived intensity or quality of a real external st imulus. They are associated with organic conditions and with drug ingestion or withdrawal. Hyperacusis (experiencing sounds as abnormally loud) and micropsia (perceiving objects as s maller and further away, as if looking through the wrong end of a telescope) are examples o f sensory distortions. Illusions are altered perceptions in which a real external object is com- bined with imager y to produce a false internal percept. Both lowered attention and heightened affect will pr edispose to experiencing illusions. Affect illusions occur at times of heightened emotion (e.g. while walking through a dangero us area late at night a person may see a tree blowing in the wind as an attacker lunging at them). Completion illusions rely on our brain \200\231s tendency to \200\230 \201 ll in \200\231 presumed miss- ing parts of an object to produce a meaningful percept and are the basis fo r many types of optical illusion. Both these types of illusions resolve on closer attention . Pareidolic illusions are meaningful percepts produced when experiencing a poorly de \201 n ed stimulus (e.g. seeing faces in a \201 re or in clouds). Hallucinations A hallucination is de \201 ned as \200\230a percept without an object \200 \231 (Esquirol 1838). As symptoms of major mental disorder, hallucinations are the most sig ni \201 cant type of abnormal perception. It is important to appreciate that the subjectiv e experience of hallucination is that of expe- riencing a normal percept in that modality o f sensation. A true hallucina- tion will be perceived as being in external space, distinct from imagined images, outside conscious control, and as possessing relative permanence. 02_Semple_Chap02.indd 56 12/7/2012 7:03:21 PM ABNORMAL PERCEPTIONS 57 A pseudo-hallucination will lack one or all of these characteristics and be subjectively ex perienced as internal or \200\230in my head \200\231. The only characteris- tic of true pe rceptions which true hallucinations lack is publicness; halluci- nating patients may accept that their experiences are not shared by others around them in the same way as a normal se nsory experience. Auditory hallucinations are most frequently seen in functional psychoses. Three experiences of auditory hallucinations are \201 rst-rank symptoms in schizophrenia. These are: \200 \200 \200 Hearing a voice speak one \200\231s thoughts aloud. Hearing a voice narrating one \200\231s actions. Hearing two or more voices arguing. Visual hallucinations are associated with organic disorders of the brain and with drug and alcohol intoxication and withdrawal. They are very rarely seen in psychotic illness alone b ut are reported in association with dementias, cortical tumors, stimulant and hallucinogen ingestion, and, most commonly, in delirium tremens. The visual hallucinations seen in delir ium tremens are characteristically \200\230Lilliputian hallucinations \200\231 of mini- at ure animals or people. Olfactory and gustatory hallucinations may be dif \201 cult to distinguish and occur in a wide range of mental disorders. Olfactory hallucinations occur in epileptic auras, in depre ssive illnesses (where the smell is described as unpleasant or repulsive to others), and in schizophrenia. They may also occur in association with a persistent delusion of malodourou sness. Hypnagogic/hypnopompic hallucinations are transient false perceptions which occur on fallin g asleep (hypnagogic) or on waking (hypnopompic). They may have the characteristics of true or pseudo-hallucinations and are most commonly visual or auditory. While they are sometime s seen in narcolepsy and affective illnesses they are not indicative of ill health and are frequently reported by healthy people. Elemental hallucinations are the hallucinatory experience of simple sen- sory elements, suc h as \202 ashes of light or unstructured noises. They are associated with organic states. Extracampine hallucinations are those false perceptions where the hal- lucination is of an external object beyond the normal range of perception of the sensory organs. Functional hallucinations are hallucinations of any modality that are expe- rienced simulta neously with a normal stimulus in that modality (e.g. a patient who only experiences audito ry hallucinations when he hears the sound of the ward \200\231s air conditioning). Re \202 ex hallucinations are hallucinations in one modality of sensation experienced afte r experiencing a normal stimulus in another modality of sensation. 02_Semple_Chap02.indd 57 12/7/2012 7:03:21 PM CHAPTER 2 Psychiatric assessment 58 Asking about abnormal perceptions Asking patients about their experience of abnormal percep tions and abnormal beliefs (e.g. hallucinations and delusions) presents a number of problem s for the examiner. Unlike symptoms such as anxiety, these symptoms are not part of normal experience, and so the examiner will not have the same degree of empathic understanding. Pa tients will often fear the reaction of others to the revelation of psychotic symptoms (fear of being thought \200\230mad \200\231) and so conceal them. When such symptoms are not pr esent, patients may resent such questioning or regard it as strange or insulting. As with most potentially embarrassing topics, the best approach is frankness, lack of embar rassment, and straightforwardness. If the interview thus far has not led to report of psych otic symptoms, the examiner should begin by saying something like: \200\230Now I want to ask you about some experiences which some- times people have, but \201 nd dif \201 cult to talk about. These are questions I ask everyone. \200\231 This mak es clear that these questions are not as a result of suspicion in the examiner \200\231s mi nd or an indicator of how seriously he regards the patient \200\231s problems. \200\230Have you ever had the sensation that you were unreal \200\224or that the world had become unreal? \200\231 The symptoms of depersonalization and derealization are non-speci \201 c symptoms in a variety of affective and psychotic conditions. Many patients \201 n d them dif \201 cult or impossible to explain clearly, commonly describing the experience as \200\230like being in a play \200\231. Patients often worry about these experiences fea ring they presage \200\230going mad \200\231. They may therefore be reluctant to mention t hem spontaneously. \200\230Have you ever had the experience of hearing noises or voices when there was no-one about to explain it? \200\231 If the patient agrees, then this experience should be furthe r clari \201 ed: When did this occur? Was the patient fully awake? How often? Where did th e sound appear to come from? If a voice was heard, what did it say? Did the patient recogni ze the voice? Was there more than one? How did the voice refer to the patient (e.g. as \200\230you \200\231 or \200\230him \200\231)? Can the patient give examples of the sort o f things the voice said? \200\230Have you seen any visions? \200\231 Again, clarify when and how often the experien ce occurred. What were the circumstances? Was the vision seen with the \200\230mind \200 \231s eye \200\231 or perceived as being in external space? Was it dis- tinct from the surr oundings or seen as part of the wallpaper or curtain pattern? \200\230Do you ever notice smells or tastes that other people aren \200\231t bothered by? \200\231 Again, clarify the details surrounding any positive response. Aim to distinguish o lfactory hallucinations (where there is the experience of an abnormal odor) from a patient who has a delusion that he is malodorous. 02_Semple_Chap02.indd 58 12/7/2012 7:03:21 PM ABNORMAL BELIEFS 59 Abnormal beliefs Examination of the patient \200\231s ideas and beliefs will form an import ant part of the MSE. Abnormal or false beliefs include primary and secondary delu- sions an d over-valued ideas. More so than other symptoms of mental ill health, a patient with delus ions \201 ts the common preconceptions of \200\230mad- ness \200\231. Delusions are impo rtant symptoms in the diagnosis of the major psychoses. Delusions A delusion is a pathological belief which has the following characteristics: \200 It is held with absolute subjective certainty and cannot be rationalized away. It req uires no external proof and may be held in the face of contradictory evidence. It has perso nal signi \201 cance and importance to the individual concerned. It is not a belief which can be understood as part of the subject \200\231s cultural or religious background. Note: Although the content of the delusion is usually demonstrably false and bizarre in nat ure, this is not invariably so. A secondary delusion is one whose development can be understood in the light of another abn ormality in mental state (e.g. the development of delusions of poverty in a severely depres sed patient). A primary delusion cannot be understood in this way and must be pre- sumed as arising direc tly from the pathological process. Delusions can be categorized by their content or by the manner in which they are perceived as having arisen. Over-valued ideas An over-valued idea is a non-delusional, non-obsessional abnormal belief. Here, the patient has a belief which is in itself acceptable and compre- hensible but whic h is preoccupying and comes to dominate their thinking and behavior. The idea is not percei ved as external or senseless but will generally have great signi \201 cance to the patient . Over-valued ideas may have a variety of contents in different disorders (e.g. concern ove r physical appearance in dysmorphophobia; concern over weight and body shape in anorexia ne rvosa; concern over personal rights in paranoid personality disorder). 02_Semple_Chap02.indd 59 12/7/2012 7:03:21 PM CHAPTER 2 Psychiatric assessment 60 Asking about abnormal beliefs Both at the initial interview and during subsequent treatment , professional staff dealing with a deluded patient should avoid colluding in the delusiona l belief system. The doctor should not be drawn into arguments about the truth of the delus ion \200\224by their nature delusions cannot be argued or rationalized away and arguments o f this type will damage rapport. Nonetheless, the doctor should always make clear to the pa tient that he regards the delusional symptom as a symptom of mental ill health, albeit one which is very real and important to the patient concerned. 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.