Mental Status Examination

Renate H. Rosenthal and Hagop S. Akiskal

Department of Psychiatry, University of Tennessee, Memphis, TN 38163
Introduction
The Mental Status Eamination represents the most important step in
the clinical evaluation of in!ivi!uals sufferin" from or suspecte! of havin"
mental !isor!ers# The evaluation is $ase! on o$servations of a patient%s overt
an! ver$al $ehavior as &ell as on his or her su$'ective eperiences# Patients%
presentin" pro$lems !ictate $oth the types of (uestions as)e! an! the !epth of
in(uiry necessary for a coherent an! complete assessment of the mental status#
*n "eneral, the more !eviant an! severely !istur$e! the patient, the more
pro$in" the mental status eamination shoul! $e#
Some in!ivi!uals &ho present for outpatient psychotherapy or
counselin" can $e vie&e! as havin" +pro$lems of livin"#+ *n such cases, the
relevant mental status information can $e lar"ely "leane! from a &ell,
con!ucte! history,ta)in" or inta)e intervie&# -i.arre i!eation, unusual
preoccupations, memory or concentration !istur$ances, an! !istur$ances
in moo! an! perceptions, if any, can $e assesse! (uite rea!ily in this type of
interaction# *n the a$sence of such symptoms, the tas) $ecomes lar"ely a
matter of or"ani.in" the information "aine! in the intervie& into the
structure an! terminolo"y use! to report a patient%s mental status# /n the
other han!, if the patient appears to $e sufferin" from si"nificant
!istur$ance of moo!, perception, thin)in", or memory, a formal Mental Status
Eamination is in or!er 01raepelin, 12345# This almost al&ays the case &ith
psychiatric inpatients an! &ith me!ical patients &hose mental functionin" is
cause for concern# Thus, althou"h much can $e learne! a$out a patient%s
mental status from "eneral o$servations ma!e !urin" a stan!ar! intervie&,
specific pro$es are often nee!e! to "ain essential information a$out
patholo"y that "oes $eyon! pro$lems of livin"#
*n the past, psycholo"ists ten!e! to $e suspicious, if not anta"onistic, to&ar!
any activities that smac) of the +me!ical mo!el#+ Psychiatric !ia"nosis, classification
of mental illnesses, an! approaches that appeare! to sanction the conceptuali.ation of
$ehavioral !istur$ances as !iseases &ere suspect# 6o&ever, in li"ht of remar)a$le
a!vances in the fiel!s of "enetics, pharmacolo"y, neuro,en!ocrinolo"y, an! neu,
rophysiolo"y over the past !eca!e, the i!ea of un!erlyin" physical7$iochemical
!ysfunction in some psychiatric !isor!ers can no lon"er $e !ispute!# Thus, the illness
concept has $een eten!e! $eyon! the or"anic mental !isor!ers 0formerly )no&n as
or"anic $rain syn!romes5 to inclu!e ma'or +functional+ !isor!ers, nota$ly the
schi.ophrenias, the affective !isor!ers, an! some aniety an! personality !isor!ers#
8or patients suspecte! of sufferin" from these con!itions, a careful Mental Status
Eamination is man!atory#
Psycholo"ists are often front,line evaluators, particularly in mental health
centers &here many of these con!itions are seen in their mil!er forms# *t
#
is
therefore essential to )eep in min! that su$tle $ehavioral a$normalities sometimes
are the first in!icators of un!erlyin" me!ical illness# The Mental Status
Eamination can provi!e important !ata for !ifferential !ia"nosis# Psycholo"ists
are also# present in increasin" num$ers in me!ical settin"s, &here they are calle!
on to evaluate patients &ith )no&n me!ical illnesses an! to colla$orate &ith
nonpsychiatric physicians in the treatment process# Many me!ical !isor!ers are
accompanie! $y mental symptoms that may result from the !irect impact of
illness on the patient%s mental functionin" 0e#"#, in meta$olic !istur$ances5, from
the use of me!ications that affect moo! or co"nitive capacity 0e#"#, antihypertensive
!ru"s or narcotics5, or from the personally !isa$lin" psychosocial conse(uences
of the illness# 8amiliarity &ith mental status terminolo"y ena$les the psycholo"ist
to communicate more effectively &ith me!ical specialists, &ho have $een traine!
to or"ani.e their fin!in"s in this fashion# Thus, the terminolo"y applie! to
!escri$e a patient%s mental status an! the structure use! in or"ani.in" these
fin!in"s serve an important communicative function# The structure! nature of the
Mental Status Eamination also forces the eaminer to !ocument fin!in"s &ith
factual eamples an! to move from "lo$al impressions to specific o$servations#
This, in turn, permits a !ia"nosis, if in!icate!, an! there$y prepares the "roun!
for a more coherent an! focuse! treatment plan#
Areas Covered in the Mental Status Examination
9 systematic eamination of the mental status covers several ma'or areas that
are outline! in Ta$le 1 an! !iscusse! later#
Appearance and Behavior
9lthou"h appearance an! $ehavior is the first item in a Mental Status
Eamination, relevant !ata on appearance an! $ehavior are "athere!
throu"hout the intervie&# 9ttire, posture, facial epression, mannerisms, an!
level of "roomin" are !escri$e! in such a &ay that the person rea!in" or
listenin" to this narration can visuali.e the patient%s physical appearance at the
time of the eamination, much as if the clinician ha! ta)en a photo"raph# The
settin" of the intervie& is also $riefly !escri$e! in this section#
*n some cases, little &ill $e reveale! a$out the mental status $y these
o$servations, $eyon! the fact that the patient%s physical appearance &as
unremar)a$le, failin" to !istin"uish him or her from other people of the same
a"e, e!ucational level, an! socioeconomic $ac),"roun!# *n other instances, this
initial section may alrea!y "ive some important clues a$out the patient%s
personality, moo!, thou"hts, a&areness of social convention, an! a$ility to
Table I. Outline of Mental Status Examination
Date an! time of intervie&
9ppearance an! $ehavior
9ttitu!e to&ar! intervie&er
Psychomotor activity
9ffect an! moo!
Speech an! thou"ht
Perceptual !istur$ances
/rientation
9ttention, concentration, an! memory
*ntelli"ence
:elia$ility, 'u!"ment, an! insi"ht
function a!e(uately in society at the time of the evaluation# Some eamples &ill
illustrate the value of this initial para"raph of the Mental Status Eamination#
Ms#9#, a ;3,year,ol!, sin"le, &hite stu!ent, &as intervie&e! in the Stu!ent
<ounselin" <enter# She &as self,referre!# She is a petite, frail,loo)in" &oman
appearin" much youn"er than her state! a"e# She &ore no ma)eup, an! &as !resse!
in simple attire consistin" of a $lue $utton,!o&n $oy%s shirt, a pair of cutoff $lue
'eans, &oolen )nee stoc)in"s, an! penny loafers# She carrie! a )napsac) full of
$oo)s &hich she hel! closely on her lap# Throu"hout the inter,vie&, her han!s &ere
ti"htly claspe! aroun! her )napsac) so that her &hite )nuc)les sho&e!# 6er
fin"ernails &ere $itten !o&n to the (uic)#
The !escription of this patient%s appearance "ives us !ues a$out a mo!erate
level of aniety an! tension, !ues that shoul! $e pursue! !urin" the remain!er of
the eamination# The net eample illustrates a more !istur$e! patient#
Mrs# -#, a !ivorce! &hite &oman, &as $rou"ht to the mental health center $y
her !istrau"ht son an! !au"hter,in,la& $ecause she ha! $ecome increasin"ly hostile
an! com$ative at home an! &as stayin" up all ni"ht# She &as restless !urin" the
intervie&, risin" fre(uently from her chair, loo)in" at every !iploma on the &alls,
ma)in" comments a$out each of them# She loo)e! her state! age of =3, $ut her
clothes &oul! have $een appropriate only for a much youn"er person> althou"h
(uite o$ese, she &ore oran"e +hot pants+ an! a halter top &hich sho&e! a $are
mi!riff# 6er le"s ha! prominent varicose veins# She &ore ol! &oo!en $each san!als
&ith spi)e hi"h heels# 6er "eneral level of "roomin" &as very poor her short "ray
hair &as matte! on $oth si!es of an irre"ular part> her fin"ernails &ere lon" an!
yello&e! from nicotine? her toenails &ere also very lon"#
The "eneral appearance of this patient su""ests a psychotic level of !isor!er
an! raises hypotheses of a much !ifferent nature from those "enerate! $y our first
patient, necessitatin" further in(uiry alon" the lines of a manic or a schi.ophrenic
!isor!er#
The "eneral appearance of our thir! patient su""ests entirely !ifferent
!ia"nostic possi$ilities>
Mr# Smith, a ;=,year,ol! sin"le, &hite pharmacy stu!ent, &as seen in the
university health clinic# 6e &as impecca$ly !resse! in a three,piece "ray pin,stripe!
suit an! matchin" !ress shoes# 6is hair an! mustache &ere carefully "roome!#
@hen he si"ne! his name on the a!mission form, his han!s &ere visi$ly
tremulous# 6e "enerally appeare! uneasy, an! "lance! furtively a$out the room,
payin" special attention to electrical outlets, air,con!itionin" vents, an!, most
especially to the camera, althou"h he ha! $een assure! that it &as not in use# *n(uiry
alon" the lines of a !elusional illness is su""este! $y the "eneral appearance of
this patient, an! !ifferential !ia"nosis shoul! consi!er such con!itions as
amphetamine psychosis an! paranoi! schi.ophrenia#
Psychotic patients may !isplay etreme forms of inappropriate $ehavior
0e#"#, $are $reasts or "enitals5 or maintain $i.arre postures for lon" perio!s of
time 0)no&n as &ay flexibility, arisin" either spontaneously or in response
to physical manipulations $y the eaminer#5 9ll such "ross !eviations in
$ehavior shoul! $e carefully recor!e!#
Attitude toward the Interviewer
9ttitu!e to&ar! the intervie&er is availa$le $y o$servation, &ithout
specific in(uiry# The patient may relate easily, $e cooperative an! open, an!
reveal information freely# /ther patients may $e suspicious an! "uar!e!,
re(uirin" fre(uent reassurance that the content of the session is confi!ential#
Some patients are hostile, en"a"in" in one,upsmanship, an! tryin" to
em$arrass or humiliate the eaminer# This type of patient may ma)e sni!e
remar)s a$out the intervie&er%s a"e or cre!entials> +6o& ol! are you,
any&ayA+ +* &ant to tal) to a real !octor#+ *n more etreme cases, the patient
may refuse to tal) alto"ether# Some patients are manipulative an! o$se(uious,
tryin" to "et the intervie&er on their si!e, often $y emphasi.in" ho& much
$etter an! more competent an! more li)a$le the eaminer is than +all those
other !octors &ho !on%t seem to care#+
@hatever the (uality of the interaction, the eaminer must !ocument
&ith specific eamples ho& the reporte! con!usions &ere reache!# 8or
instance, the statement that a patient &as +covertly hostile+ can $e !ocumente!
$y o$servin" that after &aitin" 1= minutes to $e seen, the patient remar)e! to
the eaminer, +* thou"ht you ha! !ie! an! # # # "one to hell#+
s!chomotor Activit!
9 patient &ho !isplays psychomotor restlessness or a"itation moves
aroun! constantly, appearin" to have !ifficulty sittin" still# There may $e
han! &rin"in", foot shufflin", crossin" an! uncrossin" of )nees, pic)in" on
sca$s, scratchin", nail $itin", hair t&istin", or even hair pullin"# *n more
severe illness, the patient may "et up from the chair or $e!, &an!er aroun! the
room, an! en"a"e in $ehaviors inappropriate to the contet of the intervie&,
such as tryin" to ma)e a phone call, com$in" hair, an! the li)e# <onversely,
psychomotor retar!ation is characteri.e! $y a "eneral slo&in" of movement,
speech, an! thou"ht# The patient &ill sit (uietly, movin" very little# Speech is
soft an! slo&, accompanie! $y minimal, if any, "estures# 8acial epression can $e
immo$ile# Tal)in" seems to $e an effort, an! there are fre(uent perio!s of silence#
Buestions are ans&ere! after a prolon"e! latency# *n some !isor!ers, such as
affective psychoses, psychomotor a"itation an! retar!ation may coeist 0e#"#, the
patient may $e physically restless an! men,tally slo&e! !o&n5# Precise !escription
of psychomotor retar!ation is no& possi$le throu"h the use of a recently !evelope!
scale 0@i!l/cher, 12835# U neither psychomotor a"itation nor retar!ation is
o$serve!, the patient%s psychomotor activity is 'u!"e! as +normal#+ This &oul! $e
the case in the ma'ority of patients &ho see) counselin" for pro$lems of livin"#
9$normal psychomotor activity, o$serve! on repeate! eamination, ten!s to $e
in!icative of a ma'or psychiatric !isor!er#
Affect and Mood
Affect refers to the prevailin" emotional tone !urin" the intervie& as
o$serve! $y the clinician# 9 +normal+ patient &ill sho& a ran"e of affect, lau"hin"
&hen somethin" is funny, an! loo)in" som$er &hen sa! or painful issues are
!iscusse!# 9ffect &ill, in other &or!s, $e con"ruent &ith the content of the
conversation#
<ommonly o$serve! !istur$ances in affect inclu!e hostility 0a pre,
!ominantly ar"umentative an! anta"onistic stance to&ar! the inter,vie&er an!
others5 an! lability 0rapi! shifts from happiness to sa!ness, often accompanie! $y
"i""lin" an! lau"hin" or so$$in" an! &eepin"#5 These shifts may cover the &hole
"amut of feelin" states in the course of an intervie&#
Inappropriate affect is o$serve! &hen the patient%s feelin" state seems to $e
incon"ruent &ith the content of the conversation 0for eample, "i""lin" &hen the
!eath of a love! one is !iscusse!? &eepin" &hile tal)in" a$out events &hich, $y
o$'ective criteria, shoul! not cause ecessive sa!ness#5
The patient &ith a $lunte! affect has minimal !isplay of emotion, &ith little
variation in facial epression# Emotional flattenin" is a more severe !e"ree of
emotional impoverishment an! refers to the virtual a$sence of all emotional
reactivity#
*t is important to note that cultural varia$les play an important part in the
interaction on &hich the 'u!"ment of affect is $ase!# 9 fri"htene!, insecure patient
from a minority $ac)"roun! may "ive the false impression of emotional flatness
$ecause he or she is hyin" to "uar! a"ainst "ivin" a poor impression $y
revealin" only minimal information &ith minimal emotional involvement# *f
the eaminer suspects that his or her o$servations are colore! $y such
contetual varia$les, !efinite conclusions shoul! $e suspen!e! until there has
$een an opportunity to o$serve the patient ino$trusively interactin" &ith peers,
family mem$ers, nursin" staff, or others# 9ssessment shoul! $e carrie! out to
!eter,mine if there is an ina$ility to !isplay emo
t
ional &armth or if the patient
&as respon!in" to the social contet of a
t
hreatenin" intervie& &ith an
unfamiliar an! ina!vertently intimi!atin" professional# *nvo)in" cultural
varia$les to eplain a$normal fin!in"s re(uire a thorou"h )no&le!"e of the
culture or su$culture in (uestion#
Mood refers to the su$'ective emotion eperience! $y the patient over a
perio! of time an! therefore is $ase! on self,report# These self,reports !o not
al&ays coinci!e &ith the affect that is o$serve! !urin" the intervie&# 8or
instance, a patient may loo) !e'ecte!, $ut vi"orously !eny a !epresse! moo!?
conversely, a patient may interact &ell an! sho& a "oo! ran"e of affect $ut
report
!
eepenin" !epression over the prece!in" several &ee)s# Such
incon"ruities, &hich are commonplace in the assessment of emotion, shoul! $e
specifically recor!e! in the Mental Status Eamination# *n a!!ition to
depressed moo! 0e#"#, +1 am !o&n in the !umps, an! * !on%t seem to $e a$le to
pull myself out of it+5, &hich is pro$a$ly the most common complaint in a
clinical population, one may hear reports of elated or euphoric moo! 0+* feel as
hi"h as a )ite, as if * &ere on <lou! 2+5, irrita$ility 0+* am short fuse!,
everythin" seems to $other me? * yell at my )i!s, at my collea"ues# # #+5, an!
aniety or a sense of fore$o!in" 0+* feel )in! of scare!, li)e somethin" $a! is
a$out to happen
+
5# *n the a$sence of specific moo! !istur$ance, the su$'ect is
!escri$e! as euthymic.
Speech and Thou"ht
The patient%s speech is !escri$e! &ith re"ar! to lou!ness, spee!,
compleity, usa"e of &or!s, an! a$ility to come to the point#
6er speech &as soft an! slo&# 9t times, she &as $arely au!i$le an! ha! to $e
as)e! to repeat &hat she sai!# She spo)e only in response to specific (uestions an!
nee!e! to $e as)e! repeate!ly to ela$orate on her ans&ers# 6er voca$ulary &as
limite!, commensurate &ith her ei"hth "ra!e e!ucation# 6o&ever, her speech
&as coherent, an! her ans&ers &ere appropriate#
*t is important to !ocument any !eviations from &hat &oul! $e
consi!ere! +normal+ $y citin" relevant eamples, usin" the patient%s o&n &or!s,
if possi$le# Thus, it is not sufficient to summari.e one%s o$servations $y notin" +stilte! ver$al
$ehavior+ or +pressure of speech#+ Such conclusions must $e corro$orate! $y relevant (uotes or $y
a !escription of the $ehavior that le! the eaminer to arrive at them#
6is speech &as contrive! an! stilte!# 6e trie! har! to convey that he &as &ell,e!ucate!,
usin" lon" &or!s, often inappropriately# 8or eample, &hen tryin" to say that thin"s often "ot hectic
at his 'o$ as a telephone operator, he state! thin"s "ot +eu$erant#+
Thou"ht or thought process refers to ho& i!eas are put to"ether, an! in &hat se(uence
an! spee!# 9 patient may ehi$it no a$normality# /n the other han!, there may $e an a$sence of
coherent thought that is clear, lo"ical, an! easy to follo&# Circumstantiality is a ten!ency to
ans&er (uestions in te!ious an! unnecessary !etail an! circumlocution# This is sometimes seen in
people from a rural $ac)"roun!# <ircumstantiality is also fre(uent in people &ith etreme
o$sessional characteristics &ho &ant to ma)e sure they inclu!e all facts that mi"ht $e remotely
relevant to the point in (uestion# Severe circumstantiality in!ications often "oes han! in han! &ith
other in!ications of lo& intelli"ence an!7or or"anic mental !istur$ance# The
most severe !e"ree of circumstantiality is )no&n as tangentiality 0o$li(ue or totally irrelevant
responses5, often seen in schi.ophrenic !isor!ers#
*n pressure of speech, seen in aniety states an! a"itate! !epressions, the patient feels
compelle! to tal)# Patients &ith fli"ht of i!eas, a ma'or !ia"nostic si"n in mania, not only feel
pressure! to tal), $ut their thou"hts race ahea! of their a$ility to communicate them# The patient
&ill s)ip from one i!ea or theme to another# *n contrast to looseness of associations, the connection
$et&een !ifferent i!eas is not entirely lost, $ut may $e tenuous, consistin" of rhymes or puns
(clang associations).
6er speech &as lou! an! rapi!, intersperse! &ith lau"hter an! 'o)es# 9t times, she appeare!
to trip over her &or!s, an! her thou"hts seeme! to $e racin" ahea! of her a$ility to put them into
&or!s# @hen as)e! &ho the presi!ent &as, she replie!> +Cohnson, Cohnathan, my son, sunshine,
Einstein#+ 0This patient entertaine! the $elief that her son &as smarter than Einstein an! &oul!
$ecome the net presi!ent#5#
*n the etreme, it may $e !ifficult to !ra& the line $et&een fli"ht of i!eas an! looseness of
associations 09n!reasen, 12D2a5# *n the latter, the patient%s speech loses any meanin"ful or lo"ical
se(uence# Patients may actually invent &or!s that have meanin" only to them (neologisms).
6ere is an eample of severe loosenin" of associations, intersperse! &ith neolo"isms# *t is the
first para"raph of a &ritten statement presente! to one of us $y a patient &ho
hope! that this &oul! clarify his reasons for comin" to the hospital#
Eoo! DayF atherath. *n early times man has stru""le! for the lon" surrinel
of the human orator, the inner intestinal cavity, the lun"s# *t is )no&le!"ea$le that the
$one structure of man is !ura$le &ith tintured calcium, s)in seven epi!ural thic)
&hich replenishes it in the case endergy an! mental po&ers# 9t
times, mil! loosenin" of associations manifests itself in a "eneral va"ueness of
thin)in"# 6o&ever, althou"h not as !is'ointe! as the pre,ce!in" sample, very
little information &ill $e conveye!, even thou"h many &or!s may have $een
use!# This !istur$ance, )no&n as poverty of thou"ht content, is !ia"nostic of
schi.ophrenia &hen )no&n or"anic mental states are rule! out 09n!reasen,
12D2a5# *n
perse!eration, the patient a!heres to the same &or!s or concepts an! seems
una$le to procee! to other topics# 8or instance, a patient respon!e! to
se(uential (uestions as follo&s> +6o& many years have you $een marrie!A+
+Seven#+ +6o& many chil!ren !o you haveA+ +Seven#+ +6o& many &ee)s
have you $een out of &or)A+ +Seven#+ Echolalia is the irrelevant echoin" or
repeatin" of &or!s use! $y the intervie&er 0+<an you tell me &hat $rin"s you
here to the emer"ency roomA+ +:oom, room, room#+5 Echolalia is often
accompanie! $y echopraxia, &hich consists of repeatin" movements initiate!
$y the eaminer# These !istur$ances are often seen in catatonic an! or"anic
mental !isor!ers#
Confabulation !enotes fa$rication of information to fill in memory "aps
0seen, for instance, in the @emic)eG1orsa)off syn!rome, a complication of
chronic alcoholism5#
"hought bloc# refers to the su!!en stoppa"e of thou"ht in the mi!!le of a
sentence# Sometimes, after a momentary pause, the patient may $e"in a ne&
an! unrelate! thou"ht# 9t other times, the patient may seem perplee! an!
una$le to continue to tal)# This eperience, &hen mil!, may $e !ue to
ehaustion, aniety, or a retar!e! !epression# More severe thou"ht $loc) is
seen in schi.ophrenia, possi$ly as the o$serva$le counterpart of the su$'ective
eperience of thou"ht &ith!ra&al#
$etardation or inhibition of thought processes, characteristic of $ipolar
!epressives, consists of a slo&in" of thin)in" H su$'ectively eperience! as
poor concentration, in!ecision, or ruminative thou"hts# Such patients may
complain of +poor memory+ H &hich, to"ether &ith poor performance on
co"nitive tests, may lea! to the erroneous !ia"nosis of !ementia in el!erly
su$'ects# Such pseu!o!emente! !epressions shoul! o$viously $e !istin"uishe!
from true !ementia, as the former are eminently treata$le#
Mutism is the complete loss of speech# The patient cannot $e ma!e to tal) at
all# *t is seen in hysteria, catatonia, an! &ith those patients sufferin" from mi!line
lesions of the $rain# Patients &ho intentionally refuse to spea) to certain people
!isplay electi!e mutism.
Stupor, &hich may have its etiolo"y in hysterical, neurolo"ic, !epressive,
an! catatonic !isor!ers, consists of almost total arrest of all motor activity
0inclu!in" speech5, &ith little or no response to eternal stimuli# Thus, stupor
represents an etreme !e"ree of psychomotor retar!ation an! mutism com$ine!#
The con!ition has $een o$serve! on the $attlefront an! in civilian catastrophes as
+paralysis $y fear,+ +an! in catatonic schi.ophrenia an! stuporous !epression#
6o&ever, stupor also can $e a si"n of severe an! life,threatenin" physical illness,
an! the first or!er of $usiness is to rule out me!
i
cal !isease or !ru",in!uce! states
even if one can fin! psycholo"ically +plausi$le+ reasons to eplain the patient%s
con!ition#
Aphonia an! dysphonia, unless $ase! on laryn"eal patholo"y, are almost
al&ays !ue to hysteria# 6ere, the patient loses his or her voice an! cannot raise it
a$ove a &hisper# *n aphonia H as contraste! &ith mutism H one o$serves lip
movements or nonver$al attempts to communicate# 9phonia can $e an
+unconscious
+
compromise in an inhi$ite! in!ivi!ual &ho, for eample, feels li)e
cursin" $ut is ashame! to !o so#
@hereas thought form refers to ho& thou"hts are communicate!, thought
content refers to &hat the patient communicates# Much of this information
$ecomes apparent in the course of the intervie&, $ut some specific (uestions may
nee! to $e as)e!# The nature of in(uiry into thou"ht content a"ain !epen!s lar"ely
on the patient%s clinical picture an! presentin" pro$lem#
Every Mental Status Eamination shoul! have an eplicit statement a$out the
presence or a$sence of suicidal thought content. 9pproachin" this topic can $e
!ifficult for the $e"innin" clinician# There is a popular misconception that one
mi"ht ina!vertently +put i!eas into the patient%s hea!+ $y eplorin" this issue# *n
fact, the !an"er lies in failure to in(uire a$out suici!al i!eation, in that the
seriousness of suici!e ris) cannot $e properly assesse! an! appropriate
interventions cannot $e ma!e# 9 tactful &ay to in(uire a$out suici!al i!eas is as
follo&s> +Iou have tol! me a lot a$out the painful thin"s that have happene! in
your life# 6ave you foun! yourself thin)in" that one &ay to for"et it all is to "o to
sleep an! not &a)e upA+ *f the ans&er is affirmative, the net (uestion coul! $e,
+6ave you ha! thou"hts that you mi"ht 'ust &ant to en! it all $y ta)in" you o&n
lifeA+ 9t this point, some patients &ill vi"orously !eny that they are consi!erin"
suici!e# /thers &ill a!mit to suici!al i!eas# *t is important to fin! out &hether these
thou"hts have evolve! into a specific plan for action an! &hether there have $een
suici!e attempts in the past# Suici!al ris) is "reatly increase! if the patient feels truly
hopeless an! helpless#
%omicidal thoughts may emer"e !urin" the intervie& an! shoul! $e note!?
a"ain, !irect in(uiry may $e necessary# $eligiosity 0reli"ious pre,occupation that
ecee!s culturally accepte! stan!ar!s in the patient%s reli"ious !enomination5 &ill also
pro$a$ly emer"e in the intervie&# 6o&ever, obsessions 0repetitive an! irrational
i!eas that intru!e into consciousness an! cannot $e sha)en off5 an! phobias
(specific irrational fears5 may not emer"e spontaneously an! shoul! $e in(uire!
a$out# :elate! symptoms, &hich may or may not $e spontaneously ver$ali.e!,
inclu!e depersonali&ation 0the uncanny feelin" that one has chan"e!5 an!
dereali&ation 0the feelin" that the environment has chan"e!5# 9lthou"h these t&o
eperiences can occur in the normal as isolate! events 0as in severe ehaustion5, they
happen most commonly in a"orapho$ia, 0fa!er J Mar)s, 12D15 an!, less commonly,
in !epressive illness#
'elusions are false, unsha)ea$le $eliefs that are i!iosyncratic to the in!ivi!ual
an! cannot $e eplaine! on a cultural or su$cultural $asis# 8or eample, the $elief that
one is possesse! $y the !evil or that one is the victim of a voo!oo curse is not
necessarily !elusional# Neither are $eliefs in unusual health practices an! fol)
reme!ies# 6o&ever, the 'u!"ment that one is !ealin" &ith culturally accepte!
phenomena must $e ma!e on the $asis of thorou"h )no&le!"e of the culture# *n fact,
in cultures &here voo!oo an! &itchcraft are still part of !aily life, !elusions often
consist of patholo"ical ela$orations of these $eliefs that &oul! not $e en!orse! or
share! $y the patient%s )in or associates# The ineperience! eaminer may fail to
reco"ni.e serious patholo"y $y $ein" overly &illin" to invo)e +cultural+ phenomena#
8or this reason, it is often !esira$le to in(uire &hether other mem$ers of that culture
share the $eliefs in (uestion#
Delusions shoul! also $e !istin"uishe! from overvalue! i!eas, &hich refer to
fanatically maintaine! notions such as the superiority of one se, nation, race, or of one
school of thou"ht, philosophical approach, or artistic en!eavor over others# 8inally,
!elusions shoul! $e !ifferentiate! from pseudologia fantastica. This !isor!er,
o$serve! in hysterical psycho,paths, consists of fantastic storytellin" &here the
in!ivi!ual eventually loses trac) of &hich statements are true an! &hich are false#
Delusions are !ivi!e! into primary an! secon!ary cate"ories# (rimary
delusions cannot $e un!erstoo! in terms of other psycholo"ical processes 08ish,
12D45# They &ere !escri$e! $y Schnei!er 012=25 as Kfirst,ran) symptoms,L an!
they consist of eternally impose! influences in the spheres of thou"ht 0thou"ht
insertion5, emotion, an! somatic function 0passivity feelin"s5 as &ell as eperiences
of thou"ht $roa!castin" 0Mellor, 12D35# Primary !elusions seem to arise out of the
contet of a +!elusional moo!+ &here the patient loses his or her "rasp of reality#
8or eample, neutral percepts 0such as a $lac) car5 may ac,(uire special personal
si"nificance of !elusional proportion 0e#"#, the en! of the &orl! is imminent5# The
presence of several of these first,ran) symptoms is in!icative of schi.ophrenia,
althou"h they can also occur in amphetamine psychosis, temporal lo$e epilepsy, an!
alcoholic hallu!nosis# 8inally, they can $e#inci!ental fin!in"s in the affective
psychoses 09n!reasen J 9)is)al, 12835#
Secon!ary delusions, on the other han!, arise horn other psycholo"ical
eperiences 0Caspers, 126;5 an! are usually eplanatory ela$orations of other
psycholo"ical themes# Eamples of secon!ary !elusions inclu!e>
1# Delusions $ase! upon hallucinations, for eample, a patient &ho
hears machineli)e noises may $e convince! that he or she is $ein"
su$'ecte! to electrical surveillance#
;# Delusions $ase! on other !elusions, for eample, a patient &ho
$elieves that his or her +s)in is shrin)in"+ may ascri$e it to $ein"
slo&ly poisone! $y his or her +enemies#+ 3#
3# Delusions $ase! on mor$i! affective states, )no&n as affecti!e
!elusions 09)is)al J Pu.antian, 12D25# 8or instance, a manic patient
state! that his eperience of ecstasy, physical stren"th, an! sharpene!
thin)in" &as so over&helmin" that there &as only one eplanation,
namely that he &as chosen $y Eo! to serve as the ne& Messiah#
*n terms of content 0@in", <ooper, J Sartorius, 12D45, the most common
!elusions inclu!e !elusions of reference 0the i!ea that one is $ein" o$serve!, tal)e!
a$out, lau"he! at, etc#5? !elusions of persecution (e.g., that one is the tar"et of
malevolent or hostile action5? !elusions of misi!entification 0the $elief that, for
eample, one%s persecutors have $een !is"uise! as !octors, nurses, family mem$ers5?
!elusions of )ealousy 0false $elief in infi!elity of the spouse or lover5? !elusions of
lo!e 0also calle! erotomania, &here a pu$lic fi"ure is $elieve! to $e in love &ith the
patient5? grandiose !elusions 0$elief in unusual talents or po&ers, or $elief that the
patient has the i!entity of a famous person, livin" or historical5? an! !elusions of ill
health 0hypochon!riacal !elusions? the patient plea!s for a cure of his or her ima"inal
an! often $i.arre +!isease+5# /thers are !elusions of "uilt 0the $elief that one has
committe! an unfor"iva$le act5? nihilistic !elusions 0insistence that $o!y parts are
missin"5? an! delusions of po!erty (*I have s(uan!ere! all my money? my family
&ill starve+5#
erceptual #isturbances
A hallucination is a perception &ithout an eternal stimulus 0e#"#, hearin"
voices &hen no one is aroun!, or seein" thin"s that are not there5# 9ny
sensory mo!ality can $e involve!> hearin", vision, taste, smell, touch, an!
even the vesti$ular sense# <ertain forms of hallucinations cannot $e ascri$e!
to such !iscrete sensory mo!alities, ho&ever# 8or instance, patients
intoicate! &ith psyche!elic !ru"s may report that they can +hear colors,+
+smell music,+ an! the li)e# This is )no&n as synaesthesia.
Illusions are often !escri$e! $y the patient as +hallucinations#+ 6o&ever,
they are simply misperceptions of actual stimuli, for eample, mista)in" a
clothes tree in a !imly lit room for a person# Such eperiences may result
from ehaustion, aniety, altere! states of consciousness, !elirium, or a
functional psychosis#
Perceptual !istur$ances may occur in in!ivi!uals &ho !o not suffer from
a mental illness# Most of us have ha! times &hen, &hile &aitin" for an
important phone call, &e actually +hear+ the phone rin"? it is not uncommon to
+hear+ a voice callin" one%s name &hen no one is actually there# *n normal
in!ivi!uals these eperiences are more li)ely to occur in perio!s of hi"h
emotional arousal or epectancy an! ten! to $e isolate! an! infre(uent events#
Auditory hallucinations are classifie! as elementary 0noises5 or complete
0voices or &or!s5# -oth forms are most commonly foun! in schi.ophrenic
!isor!ers# They may also occur in or"anic mental !isor!ers an! intoications#
8or instance, alcoholic patients fre(uently hear voices 0alcoholic hallucinosis5#
Moices that are continuous, ma)e a runnin" commentary on the patient%s
$ehavior, or ar"ue a$out him or her in the thir! person are special cate"ories of
hallucinatory phenomena inclu!e! in Schnei!er%s list 012=25 of first,ran)
symptoms# 9nother Schnei!erian first,ran) hallucination consists of hearin"
one%s o&n thou"hts spo)en alou! (Echo des pensEes). Ni)e primary !elusions,
these Schnei!erian hallucinatory eperiences are characteristic of, $ut not
specific to, schi.ophrenia 09n!reasen J 9)is)al, 12835#
9u!itory hallucinations occur not only in schi.ophrenic an! or"anic
mental !isor!ers $ut also in !epressive an! manic psychoses# The term
affecti!e hallucinations is use! to !escri$e hallucinatory eperiences $ase! on, or
un!erstan!a$le in terms of, a prevailin" mor$i! affective state#
The voice may tell the patient that he or she is +a sinner+ or +a mastur$ator+
an! shoul! $e punishe! $y !eath# 9n eample of affective hallucinations in mania
follo&s 09)is)al J Pu.antian, 12D25>
9 ;8,year,ol! $lac) female hear! +motors+ an! $elieve! that this perception
represente! the noise of an"les that &ere specifically sent to transport her, her
chil!ren an! the entire househol! into heaven# 0p# 4;25#
@hen perceptual !istur$ances occur in affective illness, they ten! to $e
transient, usually occurrin" at the hei"ht of mania or the !epth of !epression, or
!urin" the unsta$le neurophysiolo"ic transition 0mie! state5# "hey can also appear
as or"anic complications secon!ary to ehaustion, !ehy!ration, or the superimpose!
!ru" or alcohol a$use that often accompany, affective illness#
+isual hallucinations are characteristic of or"anic mental !isor!ers,
specifically the acute !elirious states? they ten! to involve fi"ures or scenes less than
life,si.e 0+Nilliputian+5, may coeist &ith au!itory hallucinations, an! are often
fri"htenin" in nature# They are common co,implications of sensory !eprivation
0e#"#, cataract sur"ery5# Psyche!elic eperiences &ith !ru"s can $e pleasant or
fri"htenin" !epen!in" on mental set# Misual hallucinations are uncommon in
schi.ophrenia $ut occur in normal "rief 0visions of a !ea! relative5, in !epressive
illness 0e#"#, seein" oneself in one%s cas)et5 as &ell as in $rief reactive 0hysterical5
psychoses# /lfactory hallucinations are !ifficult to !istin"uish from illusions of
smell# 0The smile is true for hallucinations of taste#5 Some !elusional female
patients, for instance, are al&ays conscious of their va"inal o!or an! ten! to
misinterpret neutral "estures ma!e $y other people as in!icative of olfactory !is"ust#
*n temporal lo$e epilepsy, hallucinations of $urnin" paint or ru$$er present as auras#
6allucinations of touch, or haptic hallucinations, usually ta)e the form of
insects cra&lin" upon one%s s)in an! characteristically occur in cocaine intoication,
amphetamine psychosis, an! !elirium tremens# @hen they occur in a schi.ophrenic
!isor!er, they may ta)e such $i.arre forms as or"asms impose! $y an ima"inary
phallus#
+estibular hallucinations 0e#"#, those of flyin"5 are most commonly seen in
or"anic states such as !elirium tremens an! NSD psychosis# Patients &ith such
misperceptions have $een )no&n to sustain serious in'uries or even !eath $y tryin"
to fly out of &in!o&s#
*n hallucinations of presence, eperience! $y schi.ophrenic, histrionic, an!
!elirious patients, the presence of another in!ivi!ual is someho& sense!# *n etra,
ampine hallucinations, the patient visuali.es o$'ects outsi!e his or her sensory fiel!
0e#"#, seein" the !evil stan!in" $ehin! him or her &hen he or she is loo)in" strai"ht
ahea!5# *n autoscopy the patient sees himself or herself in full fi"ure &ithout the
$enefit of a mirror? this eperience that can occur in or"anic, hysterical, !epressive,
an! schi.ophrenic con!itions is also )no&n as doppelganger, or seein" one%s !ou$le# *t
is s)illfully portraye! in Dostoevs)i%s novel "he Dou$le#
/ther varieties of hallucinations inclu!e visual eperiences that occur in the
t&ili"ht state $et&een &a)efulness an! sleep (hypnagogic) or sleep an! a&a)enin"
(hypnopompic). 9lthou"h their occasional occurrence is normal, repeate!
eperiences su""est narcolepsy# Some narcoleptic su$'ects may actually have
!ifficulty !istin"uishin" vivi! !reams from reality# *t must $e )ept in min!, ho&ever,
that patients &ith histrionic personalities may also "ive flam$oyant accounts of hallu,
cinations> they may actually +perceive+ o$'ects or events that fit their fantasies, an!
they may, in a!!ition, !ramati.e the occurrence of normal hallucinatory eperiences
such as !reams in an attention,see)in" manner#
Orientation
/rientation is conceptuali.e! in four spheres> orientation to time 0!ay, &ee),
month, an! year5, place 0location of intervie&, name of city5, person 0i!entity of self
an! intervie&er5, an! situation 0intervie& as op,pose! to, for eample, in(uisition or
trial5# 9 patient &ho is oriente! in all spheres is note! to have a clear sensorium.
Patients &ith si"ns an! symptoms of psychosis may or may not $e oriente! in
all spheres# Those &ith affective an! schi.ophrenic psychoses are not typically
!isoriente!, &hereas patients sufferin" from or"anic $rain syn!romes are
characteristically !isoriente!# *n an acute $rain syn!rome? the mental status ten!s to
fluctuate? in a hospital settin", these patients often sho& remar)a$le chan"es
!epen!in" on time of !ay, &ith &orsenin" orientation at ni"ht 0)no&n as sundo,n
syndrome). The symptomatic picture of acute or"anic $rain syn!romes 0e#"#, !ru"
intoication5 often closely resem$les acute psychoses of +functional+ ori"in
0schi.ophreniform an! manic !isor!ers5# @hether the patient is !isoriente! an!
&hether his or her mental status fluctuates are therefore important !ia"nostic !ues#
8or this reason, the eaminer must state the time of !ay of his or her intervie& on the
report to permit serial assessments#
Some specific (uestions that shoul! $e as)e! are as follo&s> -rientation to
time> <an you tell me &hat !ay of the &ee) it is to!ayA Do you )no& &hat !ay of the
month it isA 9n! &hat monthA @hat year is itA -rientation to place> <an you tell me
the name of this placeA @hat is the name of our cityA @hat is the name of the stateA
-rientation to person> Tell me your name# Do you )no& &ho * amA (If the patient
cannot $e epecte! to )no& your name, let him or her loo) at your name ta"#5 <an
you tell me &hat * am !oin" hereA -rientation to situation. Tell me &hat this is
all a$out# @hy are &e tal)in" to youA @hat is the purpose of this visit to the clinicA
*f the patient is not a$le to ans&er these (uestions, the eaminer shoul!, in a
reassurin" an! supportive manner, provi!e ans&ers an! clarification# 9t a later
point, the patient can $e as)e! the same (uestions a"ain# @hether he or she is a$le
to retain this information &ill "ive important !ues re"ar!in" short,term memory#
/$viously, it is not necessary to in(uire formally a$out orientation items in
every patient# 9 stu!ent &ith the chief complaint of fear of pu$lic spea)in" nee!
not $e eamine! in !epth a$out his or her orientation? this &ill $e evi!ent from his
or her "eneral !emeanor an! life situation#
Attention$ Concentration$ and Memor!
Much can $e learne! from careful o$servation of the patient !urin" the
intervie&# 9 patient &ith !eficits in attention has trou$le achievin" the appropriate
set that &oul! permit the intervie& to procee!> he or she may fall asleep as you
tal), he or she may practically i"nore you, $ein" !istracte! $y television,
telephone, an! other irrelevant stimuli# 6e or she cannot filter relevant from
irrelevant stimuli as they pertain to the intervie& situation# <are must $e ta)en to
!istin"uish $et&een deficits in attention, &hich are involuntary, an! lac) of
cooperation or oppositional $ehavior, &hich is a purposeful attempt to o$struct the
intervie& process# 9n eample of the latter &oul! $e a patient &ho pointe!ly leafs
throu"h a ma"a.ine &hile you are tryin" to tal) to him#
9 patient &ith !eficits in concentration may $e a$le to achieve the set re(uire!
for a successful intervie&, $ut has trou$le maintainin" it# Thou"hts are easily
!istracte!, (uestions &ill have to $e repeate!, an! complaints li)e +my min! is not
&or)in"+ are common# *f the patient sho&s !eficits in attention an!7or
concentration, a more formal in(uiry into these areas is in!icate!#
Deficits in memory can $e of four types> immediate 0the patient cannot recall
thin"s he or she has 'ust $een tol!5? short term 0the patient cannot retain information
for = minutes or so5? long term 0the patient is una$le to remem$er the events of the
past months or years5? an! remote 0concernin" events many years in the past#5
*mpairment in imme!iate an! short,term memory may actually reflect
ina$ility to concentrate, a !istinction that is not al&ays easy to ma)e# The patient
&hose !eficits arise from !ifficulty concentratin" &ill appear preoccupie!, anious,
an! &ill have pro$lems follo&in" the clinician%s instructions# /n the other han!, the
patient &ith memory !eficits &ill try his or her $est an! &ill un!erstan! &hat he
or she is suppose! to !o $ut $e una$le to perform# 9niety may also $e
present, $ut this &ill $e more of a response to the patient%s reali.ation that his
or her min! is not functionin" properly# 9 supportive an! reassurin" stance on
the part of the eaminer is essential#
Sometimes the eaminer may actually !eci!e to +coach+ a patient &ith
memory !eficits> severely !epresse! patients often !isplay concentration
!istur$ances that result in poor performance on co"nitive tests (depressi!e
pseudodementia). @ith encoura"ement an! reassurance, these patients often
fin! the correct ans&ers# 6o&ever, such coachin" !oes not &or) in true
!ementia#
Some specific tas)s that can $e use! in assessin" memory an! con,
centration are as follo&s>
Street address. +No& I am "oin" to "ive you an a!!ress that * &ant you
to remem$er for me# * &ill as) you a"ain in a$out = minutes &hat this a!!ress
is, an! you tell me# The a!!ress is 16;= Poplar 9venue# <an you repeat this for
meA 0Net the patient repeat the a!!ress#5 /#1# *%ll as) you a$out it in = minutes#
No& let%s "o on an! tal) some more a$out the other thin"s &e &ere
!iscussin"#+ 9fter = minutes, most patients &ith,out or"anic impairments &ill
$e a$le to recall the a!!ress correctly, or almost correctly#
'igits for,ard and digits bac#,ard. *o, I am "oin" to as) you to
repeat some num$ers for me# * say the num$ers, an! &hen * am !one, you say
them after me# No& * start> 1,4,=# <an you repeat these for meA+ /ne then "oes
on to increasin" num$ers of !i"its# @hen the patient has reache! the maimum
num$er of !i"its he or she can recall, the process can $e repeate! &ith the
instruction to recall !i"its $ac)&ar!, startin" &ith t&o num$ers, an! "oin" on
to lon"er strin"s# Most patients &ith normal intelli"ence an! &ithout or"anic
impairment can repeat si !i"its for&ar! an! at least five in reverse# 8or this
eercise to $e useful, the clinician shoul! not try to ma)e up the num$ers $ut
shoul! rea! them off a ta$le, in an even ca!ence# Memory for three
ob)ects. +No& * am "oin" to as) you to remem$er three thin"s for me# * &ill
as) you a"ain in a$out = minutes, an! you tell me &hat they are# 6ere are the
three thin"s> The color red/ the &or! pencil, an! the num$er 1D# :epeat these
for me# /#1#, try to han" on to these three thin"s, an! *%ll as) you a"ain, in
a$out = minutes#+ Serial subtraction. This is more
specifically a test of concentration# 9s) the patient to su$tract 3 from 133,
then 3 from that num$er 0hope,fully, 2D5, then 3 a"ain, an! so forth# *f this
poses no pro$lem for a fe& roun!s, as) him or her to su$tract D from 133,
from 23, an! so forth# E!ucational level an! calculatin" a$ility must $e ta)en
into consi!eration# :ecall of recent e!ents. -y as)in" a
patient a$out verifia$le events that transpire! in the past !ays, one can assess
mental functionin" in an uno$trusive &ay# These (uestions can inclu!e &hat the
patient ate for lunch, the current issues in the TM ne&s 0if the patient reports
havin" &atche! the ne&s5, an! the li)e# *t is important that the ans&ers can $e
verifie!, $ecause patients &ith or"anic $rain !ysfunction often confabulate their
ans&ers 0e#"#, they invent plausi$le responses in or!er to avoi! the painful
reali.ation that they cannot remem$er5# *ntellectual functionin" can also $e
uno$trusively assesse! in this &ay, $y as)in" the patient a$out current events an!
his or her un!erstan!in" of their implications# $emote memory> Such
memory function is often &ell preserve!, even in patients &ho suffer from
si"nificant or"anic impairment# *t can $e chec)e! $y "ettin" patients to tal) a$out
their chil!hoo! an! a!olescence, places &here they have live!, military service,
occupations, an! 0most verifia$ly5 $y assessin" recollections of important historical
events an! their impact 0e#"#, Pearl 6ar$or, the Ereat Depression, &ho &as
presi!ent !urin" those times, etc#5 Some specific (uestions may inclu!e +@ho &as
Cohn 8# 1enne!y an! &hat happene! to himA+ +@hat is the -erlin @allA+ +@hat
&as Sputni)A+ +@hat &as @ater"ateA+
Intelli"ence
/ne can "et a "eneral estimate of a patient%s intelli"ence simply $y tal)in"
to him or her# Specifically, the patient%s voca$ulary &ill "ive !ues a$out
intelli"ence, especially if consi!ere! in vie& of e!ucational level# 9 colle"e
"ra!uate can $e epecte! to have a "oo! voca$ulary, $ut if a la$orer &ith a thir!
"ra!e e!ucation sho&s evi!ence of a rich voca$ulary, one may conclu!e that his
intelli"ence is much a$ove his level of scholastic achievement#
Abstraction a$ility is another in!icator of intellectual functionin"# Some
specific (uestions &ill help in this assessment># the +similarities+ section of the
@echsler 9!ult *ntelli"ence Scale len!s itself to use in a Mental Status
Eamination# /ne may &ish to set the sta"e for this line of (uestionin" $y "ivin" an
eample>
No& * am "oin" to as) you a fe& more (uestions# They have to !o &ith
ho& some thin"s are li)e other thin"s# 6eir is an eample# 9 hammer an!
a scre&!river are li)e each other in that they $oth are tools# No&, am you
tell me ho& an apple an! an oran"e are li)e each otherA 9 ta$le an! a chairA
9 coat an! a !ressA
<oncrete ans&ers are more li)ely to reflect lac) of e!ucation than intellectual
impairment# 6o&ever, the ans&ers to these (uestions can $e revealin" at $oth en!s
of the spectrum# 9 patient &ith minimal schoolin" &ho sho&s a hi"h level of
a$straction a$ility can $e assume! to have "oo! intelli"ence# 9 patient &ith a colle"e
!e"ree &hose ans&ers are concrete 0an apple an! an oran"e $oth have peels? a ta$le
you eat at an! a chair you sit on###5 sho&s si"nificant intellectual !eterioration#
9nother &ay to test a$straction a$ility is $y as)in" the patient to interpret
prover$s# 6o&ever, )no&le!"e of the patient%s sociocultural $ac)"roun! is essential
$ecause one cannot assume that the patient has ever hear! or un!erstoo! the prover$s
that &e ta)e for "rante!# Prover$ interpretation can $e approache! as follo&s> +No& *
am "oin" to "ive you a fe& sayin"s, an! * &ant you to tell me &hat they mean# 6ave
you ever hear! the sayin", %Don%t cry over spilt mil)%A+ *f the patient says yes, as) him
or her to interpret# *f he or she says no, interpret it for him or her# 0+*t means that there
is no use &orryin" a$out somethin" $a! that has happene! an! that can%t $e fie!#+5
+No& let%s try another one> can you tell me &hat coul! $e meant $y %a stitch in time
saves nine%A+ <oncrete interpretations shoul! $e evaluate! in the same &ay as con,
creteness in +similarities#
+

%eliabilit!$ &ud"ment$ and Insi"ht
The intervie&er must !eci!e &hether the patient can $e !eeme! to $e a relia$le
informant# This &ill lar"ely !epen! on an estimate of the patient%s intellectual
functionin" an! on the clinician%s impression a$out the patient%s honesty, attention to
!etail, an! motivation# 8or eample, a patient &ho comes to treatment un!er family
!uress may "ive a very self,servin" story that cannot $e 'u!"e! as relia$le# 9 very
histrionic patient may $elieve his or her o&n reports, $ut they may $e colore! $y
ea""eration, retrospective falsification, an! &ishful thin)in"# 9 patient &ith antisocial
traits may tell $ol!,face! lies to "et out of le"al trou$le, an! a patient &ith limite!
intelli"ence may simply ma)e up facts to avoi! em$arrassment an! to "et the !octor
+off his $ac)#+ Psychotic patients an! patients &ith or"anic mental !isor!ers are often
unrelia$le informants# @hether or not the patient is !eeme! relia$le must $e state!
eplicitly#
Unrelia$ility !ue to carelessness, poor memory, or psychosis shoul! not $e
confuse! &ith tal)in" past the point or !orbeireden. 8irst !escri$e! in prisoners
0an! la$ele! 0anser syndrome after the psychiatrist &ho o$serve! it5, it consists of
"ivin" !eli$erately &ron" ans&ers in a fashion that in!icates that the (uestion &as
un!erstoo!# Ni)e, +@ho is the presi!entA+ +Cimmy :ea"an#+ +@ho &as presi!ent
$efore himA+ +:onal! <arter#+ Such patients, typically sociopathic, are either mal,
in"erin" to appear insane or, in the case of schi.ophrenic in!ivi!uals, are simply
amuse! $y the (uestion,ans&er se(uence# -ecause in most instances the impression
"iven is one of !ementia, the con!ition is also !escri$e! as hysterical pseudodementia
08ish, 12D4#5
1udgment must $e evaluate! clinically in li"ht of the entire history# Many
patients &ho have normal intellectual functionin" suffer from notoriously poor
'u!"ment in or"ani.in" their personal lives# This information can $e "leane! from
the facts o$taine! !urin" the intervie&? evi!ence of poor 'u!"ment shoul!, a"ain,
$e !ocumente! &ith specific eamples# 8or instance, &al)in" aroun! city streets
&earin" a $i)ini is poor 'u!"ment, as are a history of repeate! suici!al "estures or
of impulsive 'o$ chan"es# Cu!"ment can, if necessary, $e assesse! more specifically
$y usin" items from the @echsler 9!ult *ntelli"ence Scale, such as the &ell,)no&n
+@hat &oul! you !o if you &ere the first one in a movie house to see smo)e an!
fireA @hat &oul! you !o if you foun! a seale! letter &hich has an a!!ress an! a
stamp on itA+
The clinician has to assess &hether the patient has a!e(uate a&areness that he or she
has a pro$lem, an! if so, of possi$le causes an! reasona$le solutions# This is )no&n
an insight an! can $e poor or a$sent 0as in a psychotic illness5, partial 0some
co"ni.ance of the emotional nature of the pro$lem5, or "oo! 0un!erstan!in" of the
emotional roots of the pro$lems5# *nsi"ht usually !epen!s on a!e(uate intellectual
fun!O honin", $ut the converse is not true, that is, many hi"hly intelli"ent people
may $e sorely lac)in" in insi"ht#
Commonl! Misused Terms and Their #ia"nostic Si"nificance
-e"innin" clinicians often fin! it !ifficult to !istin"uish $et&een apathetic,
depressed, an! flat affect 09n!reasen, 12DP5# 9pathy can some,times $e !ue to severe
physical illness &herein the patient simply feels too ill an! too &ea) to en"a"e in a
conversation# 9pathy can, ho&ever, also $e encountere! in chronic schi.ophrenia
an! or"anic mental states#
9 patient &ith depressed affect is $est !escri$e! as $ein" in a state in &hich
he or she eperiences mental an"uish, or is una$le to eperience 'oy or pleasure
Eames, 12335# 6e or she &ill not $e cheere! up $y reassurance or 'o)es? he or she
cannot ima"ine a time &hen he or she &ill not $e sufferin" the pain of !epression#
This is typically a phasic !istur$ance an! ten!s to fluctuate &ith episo!es of the
!isor!er#
/n the other han!, a patient &ith blunted or flat affect sho&s emotional
impoverishment# 6e or she not only fails to eperience 'oy $ut cannot feel sa!ness,
an"er, !esperation, or any other emotion# Such emotional impoverishment, &hich
is characteristic of schi.ophrenia, ten!s to "o han! in han! &ith formal thou"ht
!isor!er an! is often present throu"hout the course of the illness, not 'ust !urin"
flori! psychotic flare,ups 09n!reasen, 12D2$5#
9part from usin" the patient%s history, !ifferentiation of !epression an!
emotional flatness on a Mental Status Eamination can $e accomplishe! as
follo&s# The facial epression of the chronic schi.ophrenic is typically vacant? that
of the !epresse! patient is one of "loom, pain, an! !e'ection# The intervie&er
usually has !ifficulty empathi.in" &ith the schi.ophrenic 0)no&n as praeco
feeling) ecept on an intellectual level 0+6o& this person must suffer insi!er5, $ut
the !epresse! person%s !e'ection an! pain ten!s to $e communicate! to the clinician
an! elicits emotional as &ell as intellectual empathy# 9!mitte!ly, this is a su$'ec,
tive criterion, $ut it is valua$le in the han!s of eperience! clinicians#
9nother !ifficult !istinction is that $et&een a labile affect (,hich chan"es
(uic)ly, often from one etreme to the other5 an! incongruent affect 0&hich is
inappropriate to the thou"ht content or the contet5# -oth la$ile an! incon"ruent
affect shoul! $e !ifferentiate! from affecti!e incontinence, &here the patient
lau"hs or cries for eten!e! perio!s &ith little or no provocation 0i#e#, the patient
loses control over emotional epression5# Na$ility may $e encountere! in character
!isor!ers such as histrionic personalities? in mie! states of manic,!epressive
illness &here there is rapi! shift from elation to irrita$ility to !epression? an! in
acute or"anic mental !isor!ers, &here the affect can (uic)ly chan"e from aniety
to terror to panic# -y contrast, incon"ruent affect 0e#"#, lau"hin" &hile relatin" the
"ory !etails of a fatal acci!ent5 shoul! raise the suspicion of schi.ophrenia#
Emotional incontinence occurs most commonly in or"anic mental states such as
arteriosclerotic !ementia an! multiple sclerosis#
Euphoria an! elation, althou"h characteristic of manic states, can also occur
in or"anic mental !isor!ers such as those resultin" from systemic lupus
erythematosus an! multiple sclerosis# The euphoria seen in mania has &armth that
is communicate! to the o$server, althou"h, in the etreme, the manic patient can
$e irrita$le, cantan)erous, o$noious, an! alienatin"# 9 silly )in! of euphoria
occurs in chronic schi.ophrenia an! frontal lo$e lesions? this si"n is )no&n as
@it.elsucht an! consists of the patient%s relatin" patently silly 'o)es# Manic
euphoria ten!s to $e conta"ious or infectiousHthe clinician cannot help $ut en'oy
the patient an! lau"h alon" &ith him or her# This is not the case &ith the silly
euphoria foun! in schi.ophrenic an! or"anic states# 9"ain, these are not entirely
relia$le 'u!"ments $ut seem to carry !ia"nostic &ei"ht in the han!s of eperience!
clinicians#
The term paranoid refers to psychotic con!itions &here !elusions
pre!ominate 0e#"#, paranoi! schi.ophrenia an! paranoi! !isor!er5# Thus, the term
paranoi! delusion is re!un!ant an! shoul! $e replace! in the psychiatric
voca$ulary $y more precise phrases such as persecutory delusions, delusions of
reference, or delusions of )ealousy.
"hought disorder is a rather ne$ulous term an! shoul! not $e use! &ithout
(ualification# /ne shoul! al&ays !istin"uish $et&een formal thought disorder an!
disorder 4 content. Thus, the presence of !elusions is not necessarily in!icative of
formal thou"ht !isor!er# 9s alrea!y !iscusse!, !elusions can arise from affective
an! memory !istur$ances# 8urthermore, in paranoi! schi.ophrenia, !elusions can
eist in the a$sence of "ross !istur$ances in the formal aspects of thou"ht#
2ormal thought disorder is a !isor!er in associations &here$y thou"hts are
!issociate!, !isconnecte!, or ram$lin"# *t is also )no&n as derailment 0thou"hts that
are off the trac)5# *f mil!, it leaves the impression of +va"ueness+? if etremely
severe, the patient ma)es no sense at all an! is often sai! to ehi$it ,ord salad. The
phrase loose associations is use! for an interme!iate !e"ree of severity &here$y one
fin!s fra"ments of thou"hts that seem totally illo"ical# Nevertheless, such thin)in"
may have some sym$olic si"nificance H a hi"hly personali.e! meanin" that !erives
from +primary process+ or +unconscious+ associations? for that reason it is referre!
to as autistic thin)in", that is, entirely relate! to the self, the inner &orl!, an!
!ivorce! from reality 0-leuler, 12=35# 9utistic patients invent neolo"isms to convey
hi"hly personali.e! concepts or meanin"s for &hich they fin! conventional
lan"ua"e ina!e(uate# The incoherence that one o$serves in the thin)in" of or"anic
patients is (ualitatively !ifferent from formal thou"ht !isor!er in that it lac)s
sym$olism an! the autistic (uality> *t is sometimes !ifficult to assess &hether a
patient &hose ans&ers are va"ue an! ram$lin" is intellectually !ull or has trou$le
focusin" i!eas> that is, has a mil! thou"ht !isor!er# *n the a$sence of intellectual
impairment 0e#"#, if the patient has complete! colle"e5, the hypothesis of a thou"ht
!isor!er shoul! $e entertaine!# -e"innin" clinicians may $e overly ea"er to "ive
such patients the $enefit of the !ou$t, supplyin" in their intervie& accounts
connections an! lo"ical transitions that the patient has faile! to pro!uce# This is
especially li)ely &hen the patient is intelli"ent an! shares other
characteristics of the eaminer, there$y ma)in" it threatenin" for the eaminer to
reco"ni.e the patient%s patholo"y# The converse can also occur#
Some clinicians ten! to !ia"nose schi.ophrenia &ith minimal evi!ence# This is
often $ase! on prover$ interpretation# 9n!reasen%s &or) (3455) has sho&n prover$s
to $e "enerally unrelia$le in !ia"nosin" schi.ophrenia# Iet it is often erroneously
assume! that ina$ility to a$stract on prover$s or similarities 0i#e#, concrete
thin)in"5 carries ma'or !ia"nostic &ei"ht for schi.ophrenia# *f a patient !oes not
ehi$it "ross loosenin" of associations an! !isplays concreteness on prover$s, he
or she is sai! to have a subtle thin#ing disorder. There is little scientific rationale
for this type of practice, $ecause concreteness correlates $est &ith poor
intellectual en!o&ment, cultural impoverishment, an! or"anic mental !isor!ers#
9ll three fre(uently coeist &ith schi.ophrenia, an! to this etent
schi.ophrenics &ill have impaire! a$ility in a$straction# Schi.ophrenic patients
are often annoye! $y prover$s# *n our opinion, it is $est to avoi! !irect testin"
of a$stractin" a$ility, unless one suspects or"anicity or mental retar!ation# The
main value of the prover$s test in schi.ophrenia lies not in the !e"ree of
concreteness of responses 0&hich may $e !ue to lo& intelli"ence an! social
restriction5 $ut in the patient%s ten!ency to "ive $i.arre an! i!iosyncratic
responses# *n its severe manifestations, hysteria may mimic ma'or
affective illness, schi.ophrenia, an! even or"anic mental !isor!ers# The his,
trionic patient may transiently !isplay 0or report to have eperience!5 a
plethora of severe symptoms su""estive of a ma'or psychotic !isor!er# There
can $e repeate!, $i.arre, an! flori! symptoms? such symptomatolo"y is often
reporte! &ith an affect )no&n as la belle indifference, (i.e., a remar)a$le lac)
of concern for &hat to others &oul! seem heart,ren!in" pro$lems5# This attitu!e
is often mista)en for flat affect, an! the fli"hty an! !isor"ani.e! ver$al accounts
for formal thou"ht !isor!er# *n these situations, it is of the utmost importance to
see the patient more than once, prefera$ly after the emotional turmoil that
provo)e! the clinical picture has ha! a chance to a$ate#
Some Illustrative Case %eports
*n this section &e &ill provi!e samples of Mental Status Eaminations
performe! in !ifferent settin"s#
<ase 1# Ms# 9# &as a 38,year,ol! $lac) &oman, marrie!, mother of three
teena"ers# She &as referre! $y her "ynecolo"ist $ecause "ynecolo"ic
eamination ha! faile! to eluci!ate the cause of her !ecline in seual interest#
6er Mental Status Eamination &as as follo&s>
She &as a tall, slen!er &oman, impecca$ly !resse! an! "roome!# 6er hair
&as carefully style!# She &ore ma)eup, conscientiously applie!, an! epensive,
loo)in" 'e&elry# She sat at the front of her armchair, appearin" very +e!"y#+ 6er
facial epression &as one of &orry# She &as oriente! in all spheres# She en"a"e!
in consi!era$le han! &rin"in" &hen she tal)e! a$out her trou$les an! often pic)e!
nervously on her clothes, removin" tiny spec)s of lint# She &as cooperative an!
appeare! to ans&er all (uestions to the $est of her a$ility# 6er affect sho&e! a "oo!
ran"e an! &as "enerally appropriate? she also ehi$ite! several instances of
nervous lau"hter &hen relatin" painful events# She !e,scri$e! her moo! as
!ysphoric an! &orrie!, +li)e * feel somethin" $a! is "oin" to happen, an! * have no
control in the matter#+ She &ept at times $ut al&ays mana"e! to pull herself $ac)
to"ether# No history of !iscrete panic attac)s &as elicite!, nor !i! she have specific
o$sessions or compulsions# She a!mitte! to feelin"s of etreme irrita$ility an!
frustration $ecause she &as una$le to cope &ith the +teena"e pro$lems+ of her )i!s#
@hile !iscussin" these, she state! that she felt &orse in the mornin"s, &hich &as
the time her hus$an! &ante! to en"a"e in se# She sai! she coul! $e more receptive
seually at ni"ht, thou"h she &as anor"asmic then as &ell# There ha! $een no chan"e
in appetite, $ut she ha! !ifficulty fallin" asleep# 6er attention appeare! "oo!, $ut she
ha! trou$le concentrating and often had to be brought *bac# on bac#*/ she had a
tendency to "et lost in the !etails of her complicate! story# She as)e! several times
+@hat &as it &e &ere tal)in" a$outA+ 6er memory for events appeare! normal,
$ut she complaine! that she ha! +trou$le remem$erin" thin"s#+ 8or eample, she
almost ha! a fire at home last &ee) $ecause she for"ot to unplu" her iron? she often
came home from the store &ithout items she ha! inten!e! to $uy# She sai! this &as
not li)e her? she al&ays pri!e! herself in $ein" conscientious an! &ell or"ani.e!#
She state!, +* "uess * 'ust have too much on my min!#+ 6er intel li"ence &as a$ove
avera"e, commensurate &ith her e!ucation 0a Master%s !e"ree in e!ucation5# She
epresse! herself &ell an! state! the nature of her pro$lems in sophisticate!
lan"ua"e# 6er report is consi!ere! relia$le# There &as no a$normality in her thou"ht
form or content# She state! she &as &orrie! that she &as a$out to +really lose it+
&hen, a fe& !ays a"o, she hear! the !oor$ell rin", an! no$o!y &as there# She
!escri$e! no other instances of perceptual !istur$ances# She vi"orously !enie!
suici!al thou"hts, statin" her faith 0<atholic5 &oul! )eep her from even consi!erin"
such acts $ecause she feare! eternal !amnation# 9lthou"h the freely ver$ali.e! an"er
to&ar! her hus$an!, chil!ren, an! frien!s &ho ha! sometimes +let her !o&n,+ there
&as no evi!ence of homici!al i!eation# She epresse! "uilt for feelin" an"ry# 6er
'u!"ment an! insi"ht &ere "oo!, as she reali.e! the emotional nature of her
presentin" pro$lem# She felt her main pro$lem &as her ina$ility to communicate it
properly to her hus$an!#
This mental status is compati$le &ith a "enerali.e! aniety !isor!er, ma'or
!epression, or $oth, a !ifferential !ia"nosis that shoul! $e resolve! on the $asis of
present illness, past psychiatric an! me!ical history, an! family history#
Case '
Mr# -# &as a ;1,year,ol! &hite male &ho &as $rou"ht into the emer"ency
room $y the police after he ha! !isrupte! a funeral at a local cemetery#
6e &as pale an! !ishevele!# 6is clothes &ere !irty# 9lthou"h it &as
summer, he &ore t&o &oolen hats an! a lon" muffler# 6e &as oriente! to time
an! place# 6o&ever, he state! &ith a silly "rin he &as the +9ntichrist+ an! the
eaminer &as +the Mir"in Mary#+ 6e &as restless !urin" the intervie& an! often
stoo! up from his chair# 6e seeme! $e&il!ere! an! &as reluctant to tal)# @hen
as)e! &ho ha! $rou"ht him to the hospital, he state!> %The policeF *n(uisitionF
6aF 6aF 6e &as reluctantly an! superficially cooperative, as)in" repeate!ly
+Done no&A Net me "oF+ 6is affect &as silly# 6e "i""le! inappropriately, often
after sayin" +(uietF+ at &hich time he seeme! to $e listenin" to voices# @hen
as)e! a$out them, he sai! he receive! instructions from +a$ove,+ $ut refuse! to
ela$orate# 6e !enie! other Schnei!erian first,ran) symptoms# 6e state! his moo!
&as +&on!erful#+ 6is attention an! concentration &ere impaire!, possi$ly $y
!istraction from inner stimuli or thou"hts# 6e refuse! to try serial su$tractions an!
curse! at the eaminer, statin", +Don%t you ever mess &ith the 9ntichrist no more#+ +
6is intelli"ence coul! not $e assesse!# 6is e!ucational level is un)no&n# 6e
claims he has a +PhD an! an E!D an! an MD !e"ree also#+ @hen as)e! a$out
&hat it meant to $e the 9ntichrist he sai!, +*f you !on%t )no& that $y no&, you
never &ill#+ 9fter this, he refuse! to communicate any further an! stare! (uietly
into space for the remain!er of the session# 8or this reason, suici!al or homici!al
thou"hts, or specific !elusions, coul! not $e assesse!# 6is 'u!"ment an! insi"ht
are consi!ere! to $e nil# This mental status
raises !ifferential !ia"nostic possi$ilities ran"in" from schi.ophrenic to manic
an! !ru",in!uce! psychoses# 6istorical, familial, an! la$oratory 0e#"# urinary
!ru" screen5 evaluations are necessary to !ifferentiate $et&een these alternatives#
Case (
Ms# <# &as seen for consultation on the Me!icine Service &here she &as
hospitali.e! follo&in" a lar"e over!ose of !ia.epam, &hich she ha! stolen from
her mother%s me!icine ca$inet#
She sat proppe! up in her $e!, !resse! in a hospital "o&n# She loo)e!
youn"er than her state! a"e of ;4# 6er hair &as $rai!e! in corn ro&s an! sli"htly
!ishevele!, $ut she &as other&ise neat an! !ean# She state! &ith a smile that she
)ne& the eaminer thou"ht she &as a +real mental case+ $ut that she ha! ta)en the
pills follo&in" an ar"ument &ith her fiance an! ha! ha! no intention to !ie# She 'ust
thou"ht he +nee!e! to $e tau"ht a lesson#+ 6er psychomotor activity &as normal,
an! she &as oriente! in all spheres# 6er affect appeare! shallo&# She !enie!
!epression an! state! that +all is &ell no&+> the $oyfrien! ha! +come aroun!+ to
her &ay of thin)in", an! there &ere not "oin" to $e +any more pro$lems#+ @hen
as)e! ho& the future loo)e! to her, she sai! +perfect#+ 6er attention, concentration,
an! memory appeare! normal# 6er intelli"ence an! voca$ulary seeme!
commensurate &ith her e!ucational level 013th "ra!e5# 6er account of &hat le! up
to her over!ose seeme! relia$le, $ut her 'u!"ment &as immature# There &as no
evi!ence of formal thou"ht !isor!er, an! her speech &as normal in flo& an!
content# She !enie! any hallucinations, statin" +Iou really thin) *%m a nutF+ 6er
insi"ht is !eeme! to $e poor, $ut she has no suici!al or homici!al i!eas at the
present time# This mental status, &hich fails to reveal the presence
of a ma'or 9is * !isor!er, is in!icative of a personality !isor!er, the nature of
,hich shoul! $e eplore! in future sessions of in!ivi!ual or prefera$ly, "roup
therapy 0assumin", of course, that the patient is &illin" to follo& throu"h5#
Case )
Mrs# D#, a =D,year,ol! &i!o&e! former
schoolteacher, &as seen in consultation on the me!ical service# She &as
hospitali.e! for o$servation an! !ia"nostic &or),up of "astric complaints#
9ccor!in" to the referring physician, her
mental status on admission ,as *unremar)a$le#+ /n the fifth !ay in the hospital, she
$ecame visi$ly anious, an! her con!ition &orsene! !urin" the ni"ht# The ni"ht
shift reporte! she refuse! to stay in her room an! &as foun! &an!erin" the halls in
the nu!e on t&o occasions# The nurse on the mornin" shift !escri$e! the patient as
+a s&eet la!y &ho has "one $on)ers on usF% *n retrospect, the nurse recalle! that
the patient ha! complaine! of insomnia an! ni"htmares $e"innin" &ith the secon!
ni"ht of hospitali.ation# 6o&ever, her re(uest for a hypnotic ha! not $een "rante!
$y her physician# @hen Mn# D# &as seen $y the consultant the follo&in" mornin",
she &ore only her pa'ama $ottoms an! ha! a to&el t&iste! aroun! her hea! li)e a
tur$an# She mum$le! to herself an! !isplaye! consi!era$le restlessness, "ettin" up
an! &an!erin" aroun! her room, pic)in" invisi$le o$'ects off her chest an! arms#
6er han!s sho&e! a coarse, irre"ular tremor# She &as mar"inally cooperative,
a"reein" to put on her pa'ama top an! follo&in" simple !irections such as +stic) out
your ton"ue,+ +turn your hea! to the left,+ an! the li)e# 6o&ever, her attention
span appeare! very impaire!, an! she seeme! to $e !istracte! $y visual an!
au!itory hallucinations# She state!, &ith irritation, that she coul! not sleep $ecause
+these Cehovah%s @itnesses &ere sin"in" hymns in my room all ni"ht lon"#+ She
also complaine! that the nurses ha! put a half "allon of vanilla ice cream on her
ni"ht ta$le &here it &as +meltin" an! !rippin" a&ay#+ 0There ha! never $een any
ice cream#5 6er affect &as la$ile, alternatin" from pleasant cooperation to
irrita$ility# 6er orientation &as mar"inal# She state! she &as in a hospital $ut
seeme! "enuinely pu..le! a$out &hy she &as there# She )ne& her name an! home
a!!ress# She &as !isoriente! to time# There &as no "ross loosenin" of associations?
rather, she prove! to $e etremely !istracti$le an! often !rifte! off the su$'ect,
mum$lin" to herself# 9t one point, she announce! she nee!e! to "o no& $ecause
she &as tire! of hearin" +-i" Mama+ call her for a +$olo"na san!&ich#+ 6er
memory an! concentration &ere etremely poor# She &as una$le to perform any of
the relevant tas)s 0serial sevens, three o$'ects, !i"its for&ar! an! $ac)&ar!5#
There &as no evi!ence of systemati.e! !elusions# 6er insi"ht an! 'u!"ment &ere
nil# This patient eemplifies an
acute or"anic $rain syn!rome# 8urther history reveale! that she ha! $een ta)in"
various types of minor tran(uili.ers since her hus$an!%s !eath a year a"o to help her
sleep# En,force! a$stinence in the hospital ha! resulte! in !ru",&ith!ra&al !elirium,
similar to that seen in alcohol &ith!ra&al states, $ut occurrin" much later than the
t&o, to three,!ay latency from a$stinence typical for !elirium tremens# This is !ue to
the lon"er half,life of minor tran(uili.ers#
Summar!
<urrent evi!ence in!icates that, !espite overlappin" manifestations, !iscrete cate"ories of
mental !isor!ers !o eist# The !ia"nosis of these !isor!ers re(uires systematic history ta)in" an!
intervie&in"# Elicitin" the various si"ns an! symptoms !escri$e! in this chapter is not only necessary
to support !ifferential !ia"nostic !ecisions, $ut it also serves the important tas) of communication
&ith other collea"ues an! o$'ective !ocumentation of current !ifficulties for future reference#
9 carefully con!ucte! mental status is the cornerstone of "oo! clinical &or) an! research in
psychopatholo"y 08ish, 12D45# *n a!!ition to presentin" a "eneral psychopatholo"ic frame&or)
pertinent to all professionals &ho come into contact &ith the mentally ill, this chapter has emphasi.e!
situations an! concerns particularly relevant to psycholo"ists#
:eferences
9)is)al, 6# S#, J Pu.antian, M# :# 012D25# Psychotic forms of !epression an! mania# Psychiatric
<linics 6 orth 9meria, ;, 412,432#
9n!reasen, N# <# (3455). :elia$ility an! vali!ity of prover$ interpretation to assess mental status#
<omprehensive Psychiatry, 18, 46=,4D;#
9n!reasen, N# <# 012D25# The clinical assessment of thou"ht, lan"ua"e an! communication
!isor!ers# 9rchives 4 0eneral Psychiatry, 36, 131=,1333#0a5
9n!reasen, N# <# 012D25 # 9ffective flattenin" an! the criteria for schi.ophrenia# 9merican Cournal 4
Psychiatry, 136, 244,24D#0$5
9n!reasen, N# <#, J 9)is)al 6# S# 012835# The specificity of -leulerian an! Schnei!erian
symptoms> 9 critical re,evaluation# Psychiatric Clinics 6 orth 9merica, 6, 41,=4#
-leuler, E# 012=35# Dementia praeco, or the group of schi.ophrenias# U# Qin)in Trans#5 Ne&
Ior)> *nternational Universities Press#
8ish, 8# 012D45# <linical psychopatholo"y> Si"ns an! symptoms in psychiatry *n M# 6amillton
0E!#5# -ristol> Cohn @ri"ht J Sons#
Cames, @# 012335# Marieties of reli"ious eperience# Elas"o&> @illiam <ollins ti Sons, 128;#
Caspers, 1# 0126;5# Ee&ersl p ops!rolo"y 0M# @# 6amilton J C# 6oeni", "rans.) Man!mster>
Manchester University Press#
1raepelin, N 012345# Nectures an !inin
"
psychiatry# Non!on> -alliJre, Tin!all, an! <o#
8a!er, M#, J Mar)s, N M# 012D15# <is)ei amity# Ne& Ior)> Erune J Stratton#
Mellor, <# S# 012D35# 8irst ran) symptoms of schi.ophrenia# -ritish Cournal of Psy!tiatly, 11D,
1=,;3#
Schnei!er, 1# 012=25# <linic! pry ropsthoio"y 0M# @# 6amilton, Trans#5 Ne& Ior)> Enue ) Stratton#
@i!l6!ier, D# C# 012835# Psychomotor retar!ation> 0!inical, theoretical an! psychometric aspects#
Psy!
ristric <linics 4 ' North 9merica, 6, ;D,43#
@in", C# 1#, <ooper, C# E#, J Sartarius, N# 012D45# The measurement an! classification 4 psy!ustric
symptoms# <am$ri!"e> <am$ri!"e University Press#