Patients with mental illness and learning disability

General approach

The distinction between symptoms and signs is less clear in psychiatry than in the rest of medicine. The psychiatric interview, which covers both, has several purposes: to obtain a history of symptoms, to assess the present mental state for signs and to establish rapport that will facilitate further management.

A comprehensive history covers a range of areas ( Box 16.1 ), but the nature of the presenting problem and/or the referral question, and the setting in which the history is being taken, will determine the degree of detail needed for each. When seeing someone in the Emergency Department with a first episode of psychosis, the focus is on symptoms, recent changes in function, family history and drug use; when interviewing someone in an outpatient clinic with a possible personality disorder, assessment concentrates instead on their personal history, which is essentially a systematised biography ( Box 16.2 ).

Sensitive topics

Some subjects require a particular skill. The common theme is reluctance to disclose, which can arise because the information is private and disclosure is potentially embarrassing (such as sexual dysfunction), distressing (major previous traumatic experiences, such as rape, childhood sexual abuse, witnessing a death) or incriminating (illicit drug misuse, other crimes, homicidal ideas). For interviews undertaken in non-clinical settings, such as police stations or prisons, or for the provision of court reports, potentially incriminating disclosures are obviously especially pertinent, and it is important to be clear with the patient about any limits to confidentiality in your interview. Some disclosures, such as those relating to sexual orientation or gender identity, may expose patients to the real or perceived risk of hostility or discrimination.

Try to develop rapport early in the interview, if possible, and to consolidate it before raising a sensitive topic, although sometimes you must cover such material without delay. It is particularly important to ask about suicidal thoughts.

While clinicians should be able to interview patients regardless of their age, gender, ethnic origin or sexual orientation, the skills required may vary because patient attitudes may differ. For example, it may be more difficult for a male patient to discuss erectile dysfunction with a female than a male interviewer, or for an adolescent patient to relate to an interviewer in their late middle age than someone closer to their own years. Clinicians need to be aware of the potential effects of demographic and other differences between themselves and their patients.

The uncooperative patient

Adapt your approach to a patient who is mute, agitated, hostile or otherwise uncooperative during the interview by relying more on observation and collateral information. The safety of the patient, other patients, staff and the wider public is paramount, so your initial assessment of an agitated or hostile patient may be only partial.

Appearance

Think of this as a written account of a still photograph, prepared for someone who cannot see it. Observe:

• general elements such as attire and signs of self-neglect

• facial expression

• tattoos and scars (especially any that suggest recent or previous self-harm)

• evidence of substance misuse (such as injection tracks from intravenous drug use; spider naevi and jaundice from alcoholic liver disease)

• possibly relevant physical disease (such as exophthalmos from thyrotoxicosis).

Behaviour

Think of this as a written account of a video recording, observing such features as:

• cooperation, rapport, eye contact

• social behaviour (such as aggression, disinhibition, fearful withdrawal)

• apparent responses to possible hallucinations or unobserved stimuli

• over-activity (agitation, pacing, compulsive hand washing)

• under-activity (stupor, motor retardation)

• abnormal activity (posturing, involuntary movements, Box 16.3 ).

  16.3

  Behaviour: definitions

  Term	Definition
  Agitation	A combination of psychic anxiety and excessive, purposeless motor activity
  Compulsion	A stereotyped action that the patient cannot resist performing repeatedly
  Disinhibition	Loss of control over normal social behaviour
  Motor retardation	Decreased motor activity, usually a combination of fewer and slower movements
  Posturing	The maintenance of bizarre gait or limb positions for no valid reason

Speech

Think of this as a written description of an audio recording. It is not a description of what the patient says (that is, content), but of how they say it (form). Assess:

• articulation (such as stammering, dysarthria)

• quantity (mutism, garrulousness)

• rate (pressured, slowed)

• volume (whispering, shouting)

• tone and quality (accent, emotionality)

• fluency (staccato, monotonous)

• abnormal language (neologisms, dysphasia, clanging, Box 16.4 ).

  16.4

  Speech: definitions

  Term	Definition
  Clang associations	Thoughts connected by their similar sound rather than by meaning
  Echolalia	Senseless repetition of the interviewer’s words
  Mutism	Absence of speech without impaired consciousness
  Neologism	An invented word, or a new meaning for an established word
  Pressure of speech	Rapid, excessive, continuous speech (due to pressure of thought)
  Word salad	A meaningless string of words, often with loss of grammatical construction

Mood

Mood is the patient’s pervasive emotional state, while affect is the observable expression of their emotions, which is more variable over time. Think of mood as the emotional climate, and affect as the weather. Both have elements of subjective experience (i.e. how the patient feels, according to their own report and your specific questions) and how the patient appears to feel, according to your objective observation. So, a depressed patient might describe feeling sad, hopeless and unable to enjoy any aspect of life, and at interview, appear downcast, withdrawn and tearful, with little brightening of mood, even when talking about their much-loved children.

Pervasive disturbance of mood is the most important feature of depression, mania and anxiety, but mood changes commonly occur in other mental disorders such as schizophrenia and dementia. You might ask patients, ‘How has your mood been lately?’, ‘Have you noticed any change in your emotions recently?’ and ‘Do you still enjoy things that normally give you pleasure?’ Abnormalities of mood include a problematic pervasive mood, an abnormal range of affect, abnormal reactivity and inappropriateness or incongruity. Some terms relating to mood are defined in Box 16.5 .

Some patients prompt affective responses in the interviewer via the process of countertransference . The elated gaiety of some hypomanic patients can be infectious, as can the hopeless gloom of some people with depression. Recognising these responses in yourself can be helpful in understanding how the patient relates to others, and vice versa.

Thought form

As with speech, this is not an assessment of what the patient is thinking about, but how they think about it. Assess it by observing how thoughts appear to be linked together and the speed and directness with which the train of thought moves, considering rate, flow, sequencing and abstraction. Some terms relating to thought form are defined in Box 16.6 .

Thinking may appear speeded up, as in hypomania, or slowed down, as in profound depression. The flow of subjects may be understandable but unusually rapid, as in the flight of ideas that characterises hypomania, or unduly ‘single track’ and perseverative, as in some cases of dementia. Sometimes thinking appears to be very circumstantial, and the patient is hard to pin down, even when asked simple questions.

More severe disruption of the train of thought is termed ‘loosening of associations’ or ‘formal thought disorder’, in which the patient moves from subject to subject via abrupt changes of direction that the interviewer cannot follow. This is a core feature of schizophrenia. Concrete thinking, in the sense of difficulty handling abstract concepts, is a common feature of dementia and can be assessed by asking the patients to explain the meaning of common proverbs.

It may help to illustrate your assessment with verbatim examples from the interview, chosen to illustrate the patient’s manner of thinking and speaking.

Thought content

Thought content refers to the main themes and subjects occupying the patient’s mind. It will become apparent when taking the history but may need to be explored further via specific enquiries. It may broadly be divided into preoccupations, ruminations and abnormal beliefs . These are defined in Boxes 16.7 and 16.8 .