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Box 8.6
Psychological anxiety symptoms
Anxiety patterns and discrete anxiety syndromes
Subjective feeling of worry, sometimes specific concerns
(e.g. health), often nonspecific anxieties—worrying about
worrying or that something bad (unspecified) will happen;
psychological restlessness; hypervigilant with exaggerated
startle response (e.g. to noise); poor concentration;
insomnia, especially initial insomnia—getting to sleep;
depersonalization (feelings that he is not the same person)
and derealization (feeling that the world around him is not
real).
Try to get subjective measures of stress levels: if 0/10 is
no anxiety and 10/10 is the highest possible level, how do
you rate your anxiety level now? During your panics? Worst
ever?
Somatic anxiety features (these are adrenalin- based, part of
fight or flight)
GI Dry mouth, lump in throat, swallowing
sensations, nausea, vomiting, abdominal
discomfort (especially in children as ‘hurty
tummies’), diarrhoea
CNS Headaches, feeling light- headed or faints,
perioral numbness, sweating, tremor,
muscle pains (with hypocapnia), tetany of
hands
Respiratory Fast shallow breathing, subjective
breathlessness, chest tightness
Cardiac Chest discomfort or catch, palpitations,
tachycardia
Genitourinary Urinary frequency (nocturia unusual),
failure of erection, premature ejaculation,
amenorrhoea
Circumstances of anxiety (see Table 8.2).
age? With whom? Triggers to excessive use, etc: see
Box 8.4) → transitions to work or further education
→ educational achievements and vocational history
→ current status: living circumstances, employment,
income, etc. These final areas will guide you into the
nature of this person’s home life, financial status
(income, ask about debts), social supports and key
confidante(s) and what he likes about his life, right
now. These are essential structures upon which your
formulation and treatment plans will be built. In
our experience, patients enjoy telling a version of
their ‘Life Story’ as long as they feel respected and
listened to. You will learn much from your patient
with empathetic listening and eye contact: this is one
more reason not to tap away on a keyboard during
face- to- face interviews.
Two areas, sometimes related, may manifest
at this point: past traumatic experiences and/or
addiction. Adverse childhood experiences (ACEs)
were originally described by paediatricians as a
method to identify risk factors for later obesity. It
is now becoming apparent that they have a high
predictive value across a range of psychiatric and
medical conditions, misuse of substances, accidents
and even future criminal victimhood or criminal
activity. The common ACEs are physical, emotional
and sexual abuse by another, usually a family
member. Childhood neglect is also a key ACE
and reminds us to ask in general terms about the
patient’s parents, whether they perpetrated or knew
of the abusive act(s) and what they did about it.
Trauma can also occur in older children and adults.
A useful understanding is that trauma is Event(s) →
Experienced as physically/emotionally threatening/
harmful → Effects subsequently that are physical,
emotional, social and more. Box 8.3 sets out the
principles of trauma- informed care. Sensitivity and
a ‘caring awareness’ are key to all interactions with
people who are living with past trauma. As part of
your general approach here (Box 8.3), you might
make clear that this section of the interview will be
available to a few key people (on a ‘need to know’
basis), and would not be printed in a hospital report
or letter for general practitioner (that is copied by
default to a patient’s home). Knowing about trauma
early in the interview changes how we ask about
historical details and the emphases within MSE:
mood and anxiety levels, dissociation (see later),
and belief systems (lower self- esteem, loss of trust
of others).
Asking about alcohol use can be difficult in
some people. In most countries, alcohol is legal,
inexpensive and available in multiple outlets. Its
excess consumption above recommended levels for
health of 14 units weekly is encouraged by poorly
regulated advertising, and a societal dialogue that
normalizes heavy drinking to celebrate, commiserate
and much else. Just as you list current medication
doses and allergies, recording accurate alcohol
consumed weekly is an essential part of your
assessment. Practice your form of words: ‘I need to
ask you some questions about alcohol’ and then ‘What
types of alcohol do you usually drink?’ Sometimes a
screening question helps to start the alcohol history,
for example the CAGE:
Have you ever
felt you needed to Cut down your drinking?
felt Annoyed by others criticizing your drinking?
felt Guilty about your drinking? and/or
needed an Eye- opener in the morning to steady your
nerves?
Two or more ‘Yes’ answers suggest a significant
problem, and merit full enquiry. Try to get an
indication of habits (e.g. Friday night binges, drinking
subcultures after work [hospitality industry, health
care, students and many sports]), drinking at home,
whether the person thinks it is acceptable to drink
alone. Record the age of first alcohol (young age is
a good predictor of future misuse), and whether
he drank differently to, or more than, his peers.
Most clinicians record both the units consumed in
the past week, and what the patient describes as
average weekly consumption (see Box 8.4). There
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are no safe alcohol levels, and health (physical and
psychological) is impaired when people consume
more than 14 units weekly. The essential task in
heavy drinkers is to rule out alcohol dependence, as
defined by five core features (Box 8.4), and hinted
at in the fourth CAGE question. As with selective
disclosure of suicidality (to some but not others),
when a patient identifies physical dependence, you
must share and act; for example, discuss the need
for benzodiazepine detoxification in an alcoholdependent person being admitted to any hospital,
where withdrawals are likely. Previous withdrawals
(delirium tremens, see Box 8.4) predict more severe
symptoms (seizures, for example) provoked by the
next planned or unplanned cessation of alcohol.
Some vulnerable patients who withdraw are not
eating, have poor nutrition, or vomiting; even
without cognitive changes (signs of Wernicke’s
encephalopathy come too late to reverse them), they
also will need intravenous B vitamin prescription.
If alcohol use is an extension of asking to list cur-
rent medications, consider asking about any substance use as an extension of the mandatory cigarette
smoking question. Cannabis misuse is usually coincident with tobacco smoking; a minority of people who
vape (electronic cigarettes) also inhale cannabis oils
and other substances. The key questions are which
substances, an idea of quantity (usually the weekly
spend), age at first use (young age, meaning ≤14 years,
of cannabis use predicts subsequent psychosis) and
any features of dependency. These are exactly the
same five features listed in Box 8.4. Relief of physiological withdrawals is achieved by taking the substance itself or similar drugs (nicotine replacement
for tobacco, methadone for heroin use, sedatives for
stimulant drugs, etc). The best way to achieve a full
drug history is direct questioning: ‘Have you bought
any legal or illegal compounds over the counter, online,
on the street… or got these from others?’ Even special-
ists in addictions cannot keep pace with new ‘designer’ drugs, and a host of street names for substances.
It is not unusual for drug suppliers to add other substances to popular compounds to achieve greater addiction (and higher sales). You can integrate answers
into an immediate plan (e.g. will this patient need to
receive a prescribed detoxification programme?) and
a record of possible health sequelae of inhaled or injected substances. As with alcohol misuse, detail the
social consequences (Box 8.4) of substance misuse, as
well as any criminal convictions.
The later portions of history (see Box 8.1) cover
the medical and psychiatric treatments to date
(essential for your patient’s safety and to achieve the
best future treatment for him), forensic history and
a preliminary assessment of his personality. Practice
how you introduce neutral questions about forensic
history: ‘You told me about your teenage years living in
_____ near a group of friends who ____. I wonder if you
ever deliberately missed school. Did you ever get into
trouble, or get warnings, from school or the police?’ As
with substances, you are asking if these things EVER
happened—as reliable predictors of future risk. By
necessity, these are closed questions. Patients will not
easily forget a court conviction or prison sentence: if
they deny these but other informants or documents
contradict this account, this is an important finding.
As described above and in Boxes 8.1 and 8.2, key
questions are about violence to others. Protecting
yourself, other health care staff, others living with
the patient (children, elders, pets) and beyond, starts
with these important enquiries.
As you gain more experience, you will know
which aspects of personality might be different or
exaggerated in the person you are interviewing. You
have already asked a range of (often very personal)
questions and gathered much information. An
important rule applies here: one may highlight
personality difficulties, but a personality disorder
is not diagnosed at first interview. You are seeing
someone at his low point if not actually in crisis,
and this ‘brings out the worst’ in most of us. This
section tries to answer the questions ‘What is this
person like? What are his prominent character traits?’
In practice, combine what you hear (history) and
how you interact (MSE findings) with a reliable
collaborative (parent or partner) to establish
personality difficulties and their severity (see later
and Box 8.10). In this, you might usefully identify the
patient as someone who tends to worry excessively
(trait anxiety), perhaps is overly perfectionistic
(anakastic) by nature or has difficulty starting and
maintaining friendships (interpersonal problems).
Many sudden step changes in the life history suggest
a character trait of impulsivity: multiple changes
in jobs/residences/relationships, and if comorbid
mood changes are present, there may be impulsive
self- harm acts or overdoses. Some personality
components are more common in women and men,
respectively, overdependence on others being on a
spectrum with ‘loner’ personalities, who are low on
trust of others.
Mental state examination
Box 8.5 lists the seven essential components of
MSE. General appearance and behaviour set down
a description of what you observe over the course
of your assessment. Speech records the content of
what is said, and its highlights (quote your patient’s
speech segments directly at times for positive findings) may indicate underlying psychological processes. Mood comprises the subjective (score out
of 10, as above), and your objective assessment;
note any of five biological symptoms of depression
(Box 8.5) and always record suicidal thoughts (on
a spectrum), an essential component of every MSE;
thought content will have positive findings in patients
with psychosis, but so too in people with anxiety disorders such as OCD, obsessions or somatoform disorders (overvalued ideas); abnormalities in perception
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are characteristic of psychoses, but positive findings
are common in acute confusional states (typically
visual hallucinations) and some personality disorders too; cognition is impaired in confused patients;
for example, delirium always shows abnormalities in
concentration and memory, even in patients apparently orientated by day, month and year; lastly you
need to record insight, which this gives an indication
of how the patient understands his difficulties and
symptoms.
At the beginning and end of the MSE, record
mostly factual information: in general appearance
and behaviour, ‘She was brightly dressed, sitting com-
fortably and gave details in a relaxed manner’. Into
insight comes a clinician’s perspective in evaluating answers to yes/no questions (Box 8.5): ‘While
she agreed that her insomnia, loss of pleasure, anxious
thoughts and low mood could be explained by clinical depression, she did not see any link between low
mood/increased anxiety and her recurrent abdominal
pain’. Insight is not merely a measure of agree-
ment with the attending psychiatrist; large gaps
between what doctors decide are ‘best for someone’
and what they seek will be problematic. In people
with cognitive impairment, we prioritize facts (he
knew the day, month but not the year) over interpretations. Where there are clear cognitive deficits, this section of MSE is paired later to a mental
capacity assessment: see detailed cognitive assessment. Linked to insight in addicts, we record an assessment of their motivation to quit (Box 8.5 and
referral for therapy below).
There are several challenges in examining other
aspects of MSE. Comorbidity, which is common,
may be one of many episodes of poor mental health
and there are interactions between individual
components of MSE. Mood exerts a strong influence
over how we think, and thereby a person’s speech—
how that person’s thoughts are expressed. Similarly,
very high levels of anxiety change speech (too loud,
too fast… or hesitations) via underlying thought
processes. Worry can overwhelm; patients return
to the same source of worry (‘It’s my tummy pains
doctor’), or are anxious to the point of distraction
(they cannot focus on answers). Anxiety–depression
is the most common comorbidity in psychiatry, but
try to separate these out during MSE. In general,
anxiety is about fear of the future: patients with
long ‘I have to…’ lists of activities; depression is
(literally or metaphorically) about past losses, and
we put pressure on ourselves with ‘should and
should have’ statements. By this stage, you have set
out the symptoms severity and subtype of anxiety
(Box 8.6). When you observe low mood, try to place
these symptoms in the context of past episodes:
Box 8.7 shows different patterns of low mood on
a spectrum. In describing mood, comparison with
previous episodes is the best approach. Dysthymia
is low mood that does not meet the criteria for a
depressive episode; typically, this low mood lasts
2 years or more. Discrete episodes of depression
(by definition, they must last 2 weeks or more)
can occur during dysthymia—so called ‘double
depression’. Cyclothymia is a pattern of bouts of
depression, sometimes seasonal, alternating with
elevated mood that does not meet criteria for
hypomania. Hypomania describes ‘high’ mood
episodes without psychotic features. The presence of
any psychotic features (delusions or hallucinations)
achieves a mania diagnosis. Classic mania (type 1
bipolar) frequently has a family history; these
patients achieve best outcomes from mood stabilizers
such as lithium. Type 2 bipolar is a less severe variant
in which, for example, mood becomes high in the
context of antidepressant medication (that is then
discontinued).
Psychiatry enhances each clinical interview with
its focus on content (what was said) and form (how
the belief or experience is constructed). In studying
form, we take the same phenomenological approach
as Karl Jaspers in his seminal psychopathology work
(1913) and many who followed him. To diagnose
psychosis we must examine form and content. A
man believes his thoughts and bodily functions are
being controlled from outer space. The ‘contents’
here are beliefs in extra- terrestrial life, that aliens
have taken an interest in him, and that they are
actively harming him. A scientist might rebut these
beliefs in the absence of proof for any of the three,
although clinicians might point to the third belief
as subjectively self- evident; he believes this and has
demonstrable symptoms. The ‘form’ however is
composed of a false, fixed belief, based on illogical
information (‘The idea of alien control of my body first
came to me when I was playing cards’), and it is argued
beyond the bounds of reason (put simply, he cannot
show or provide any reasoned evidence for this). For
his bodily control, the form is a delusion of somatic
passivity. When the aliens force their thoughts inside
his head, this is a delusion of thought interference,
namely thought insertion. The manifest content is
paranoid: ‘They are doing these things to ME… when
I tell doctors or the police, no one believes me because
they (aliens) have got to them too’; this is secondary
elaboration of his primary delusion. Delusions can
have many themes, such as reference (random
events even news items refer back to the patient),
persecution, surveillance, control (as with aliens
above), grandeur (special powers, special mission),
guilt (common in severe depression), infestation
(Ekbom’s syndrome), love (erotomania), jealousy
or catastrophe even nihilism, at its most extreme,
that he is a person who is already dead and rotting
from the inside (Cotard delusion). We have heard
it said ‘If you have seen one schizophrenic (note the
stigmatizing choice of language) you’ve seen them
all’. Nothing could be further from the truth.
Disorders of perception also require exploration of
form and content. An illusion is a precept that arises
from a normal stimulus, such as hearing a crying
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Box 8.7
Diagnostic criteria for depression (ICD10) and mood patterns
In typical depressive episodes of all three varieties described below (mild (F32.0), moderate (F32.1), and severe (F32.2 and
F32.3)), the individual usually suffers from depressed mood, loss of interest and enjoyment, and reduced energy leading to
increased fatiguability and diminished activity. Marked tiredness after only slight effort is common.
Other common symptoms are:
(a) Reduced concentration and attention
(b) Reduced self- esteem and self- confidence
(c) Ideas of guilt and unworthiness (even in a mild type of episode)
(d) Bleak and pessimistic views of the future
(e) Ideas or acts of self- harm or suicide
(f) Disturbed sleep
(g) Diminished appetite
Mild depressive episode (F32.0)
Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms
of depression. At least two of these, plus at least two of the other symptoms (a to g), usually should be present for a definite
diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2
weeks.
Moderate depressive episode (F32.1)
At least two of the three most typical symptoms noted for mild depressive episode (F32.0) should be present, plus at least three
(and preferably four) of the other symptoms. Several symptoms are likely to be present to a marked degree, but this is not
essential if a particularly wide variety of symptoms is present overall. Minimum duration of the whole episode is about 2 weeks.
Severe depressive episode without psychotic symptoms (F32.2)
In a severe depressive episode, the sufferer usually shows considerable distress or agitation, unless retardation is a marked
feature. Loss of self- esteem or feelings of uselessness or guilt are likely to be prominent, and suicide is a distinct danger in
particularly severe cases.
Severe depressive episode with psychotic symptoms (F32.3)
A severe depressive episode that meets the criteria given for F32.2 above and in which delusions, hallucinations or depressive
stupor are present. The delusions usually involve ideas of sin, poverty or imminent disasters, responsibility for which may be
assumed by the patient. Auditory or olfactory hallucinations are usually of defamatory or accusatory voices or of rotting filth or
decomposing flesh. Severe psychomotor retardation may progress to stupor.
The affective spectrum*
(*Source: Smith, Daniel and Blackwood, Douglas. (2004). Depression in young adults. Advances in Psychiatric Treatment. 10. 4- 12. 10.1192/
apt.10.1.4.)
Single episode of depression
Chronic episode of depressio
Atypical depression
Psychotic depression
Recurrent depressive disorder
Cyclothymia
Hypomania + depression
(bipolar II disorder in DSM-IV)
Mania + depression
(bipolar I disorder in DMS-IV)
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voice as we listen to a kettle boiling. Hallucinations
are precepts without a stimulus. A simple visual
hallucination might be a flash of light; complex
hallucinations usually involve objects or living
things. Seeing things in a confused, fearful patient
is invariably related to alcohol or other withdrawals.
Some hallucinations, for example hypnoPompic
(waking uP) and hypnoGogic (Going to sleep), in
any modality (we see or hear things that are not real)
are part of normal experience. Common in emotional
turmoil are pseudohallucinations; patients hear or
see something that is not there and perceive this as
arising from their mind (inner space) not from the
world (outside space). True auditory hallucinations
have no external stimulus, do not come from that
inner space (the mind) and are perceived as ‘real’
by the person. In active psychosis, these are voices,
usually in the mother tongue, composed of men or
women speaking. Content (what the voices say) is less
important than form. Both content and form support
a diagnosis of psychosis. In abnormal perceptions (Box
8.5), descriptive psychopathology describes content
(‘I can hear two men talking about what I am doing
24/7—even when I am on my own’) and form (thirdperson auditory hallucination, running commentary).
Variations in psychotic phenomena are probably
the hardest concepts to master in psychiatry; try to
learn them ‘from’ patients you encounter and think
through the array of findings (see Box 8.7). Secondperson auditory hallucinations (voices speaking to
the person) are common in depression and tend to be
derogatory, even abusive. A subset of these, command
hallucinations, where patients are instructed to act
(‘Stand up now and leave the room’) are well described
in schizophrenia and it is important to assess any
insight so as to evaluate whether there is a risk the
person will obey these commands. None of these
experiences are pleasant and patients usually will
share descriptions of delusions and hallucinations,
even ones that happened years ago. Additionally,
and more in observation than communication,
describe how he interacted with you as his affect
(inappropriate, flat, depressed, etc.) and think too
about other negative symptoms of schizophrenia
(Box 8.8) when completing your MSE.
For completeness, dissociation experience is
another symptom type not included in the common
seven presenting complaint headings. It is a normal
experience to ‘switch off’ at periods in the day and
become ‘lost in thought’, unaware of our surroundings,
for example during a familiar commute. Afterwards,
we do not recall specific components of the journey
as our mind activated autopilot settings. During this
‘off period’, we cycled or drove safely and did not
forget how to operate these machines or obey the
rules of the road. When pathological, dissociation can
be anxiety- provoking but is not an anxiety symptom,
nor is it a mood variant. Dissociation is a partial or
complete loss of the normal integration between past
memories, identity and immediate awareness—usually
accompanied by bodily sensations. In emotionally
unstable personality disorder, most usually during a
crisis, people may experience unreality and features
that are perceived as ‘mental breakdown’, for
example hearing voices as pseudohallucinations. In
what Freud called hysteria, a patient (who has no
obvious personality difficulties) dissociates to a severe
degree and a bodily function is suddenly lost (e.g.
paralysis of a limb, loss of voice (or weakened voice)),
an apparent stroke, seizure (nonepileptic attack),
amnesia and more. These dramatic presentations
have exercised physicians for centuries because the
symptom bearer has (crudely) broken connections
with identify- experience and current situation; his
affect may seem inappropriate. This is the so- called
belle indifference in which a patient seems unperturbed
that he can no longer walk or speak or has lost a bodily
function. Some have had a history of trauma (see
Box 8.3) although may have ‘sealed over’ the distress
generated. In some, there are current ‘unfixable’
personal dilemmas in their lives, usually relationships,
and it is conjectured that these stresses have caused
an unconscious switch into what the patient thinks
of as physical or psychiatric disorders. Perhaps this
reminds us that ‘flight or flight’ (see Box 8.6) is not the
binary choice when we face threat; some vulnerable
people respond as ‘freeze or dissociate’. For example,
we see dissociative freezing in a fugue state, with
parallels to psychogenic amnesia. Extreme fatigue
and withdrawal, neurasthenia, is currently considered
unhelpfully alongside the dissociation spectrum; many
would diagnose this as chronic fatigue syndrome,
but current International Statistical Classification of
Diseases and Related Health Problems-10 (ICD10)
criteria require the exclusion of ‘post viral fatigue’
to diagnose neurasthenia. For one final dissociation
variant, the iatrogenic and highly suggestible multiple
personality disorder, current classifications (ICD10
and Diagnostic and Statistical Manual of Mental
Disorders-5 (DSM5)) are wholly inadequate.
By the time you have moved from history to
MSE, you should have a clearer indication of where
this patient’s difficulties lie. You have allowed the
patient to talk, using open questions, and MSE is
the opportunity to list the supporting evidence for
your differential diagnosis. Drawing on the seven
diagnostic headings of page 7, you will highlight
cognition findings for confused patients, mood for
depressed patients, perception and thoughts for
psychosis, etc. When you present your MSE findings
to others, some areas are less important; ‘Cognition
was intact in this adult patient’, or ‘There were no
perception abnormalities in this depressed/anxious
patient’. That said, appearance, mood and insight are
important in every psychiatric disorder. Insight will
predict engagement with treatment; for addicts, it is
necessary to define their motivation to quit right now
(see Box 8.5, and referral for psychotherapy). Do not
see the closed questions of MSE as a checklist, but as
a structured series of exchanges on which you build
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Box 8.8
Diagnosis of schizophrenia (ICD10)
At least one clear symptom, or two or more ‘less clear’ positive symptoms, or two or more negative symptoms must be present for
at least 2 months.
Positive psychotic symptoms
‘Clear’ symptoms
Delusions that are culturally inappropriate and completely impossible (e.g. being able to control the weather)
Hallucinatory voices giving a running commentary on the patient’s actions or discussing the patient amongst themselves,
Delusions of reference: beliefs that random external events in his/her life or wider society (details from a news item, song or
Delusions of thought interference: others can hear, read, insert or steal their thoughts
Passivity phenomena: beliefs and/or perceptions that others are able to control his/her will, limb movements, bodily
Thought echo: hearing one’s own thoughts spoken aloud
Hallucinations other than the above, when accompanied by delusions or persistent overvalued ideas. In the paranoid
Thought disorder: breaks in the train of thought (thought block), over indecisive and concrete thinking, neologisms
Catatonic behaviour (p. 5)
Negative psychotic symptoms (by definition, these are ‘less clear’ symptoms)
Apathy: (disinterest) manifest as blunted affect
Flat affect: emotional withdrawal
Odd or incongruous affect (e.g. smiles when recounting sad events, and vice versa)
Lack of attention to appearance or personal hygiene
Poor rapport: reduced verbal and non- verbal communication (e.g. eye contact)
Lack of spontaneity and flow of conversation
Difficulties in abstract thinking (e.g. explaining proverbs or common sayings)
(Source: The current diagnostic criteria for schizophrenia. https://www.who.int/classifications/icd/en/GRNBOOK.pdf)
Making the diagnosis of schizophrenia with ICD10 criteria
or voices coming from another part of the body
television programme) relate in a special way to him/her
functions or feelings
subtype of schizophrenia these are the prominent symptoms
your hypotheses. Some negative findings are just as
important to record as physical observations: normal
findings for mood/psychotic features, such as blood
pressure, will be important in future assessments.
Get into the habit of good MSE documentation; a
failure to record your finding that ‘He had no suicidal
ideation or intent’ might have consequences later on,
for both you and the patient.
Physical examination and investigations
Do not let the jargon ‘routine physical’ of
psychiatric inpatient admission allow you to switch
off your brain. This is about admitting someone to
hospital and making sure he is medically safe to
stay on a psychiatric inpatient ward, where nurses
may not have trained in physical care nursing, and
psychiatry trainees and consultants have ‘forgotten
their medicine’. In broad terms, you are also looking
for physical illnesses that may have caused or are
contributing to this presentation, and to multimorbidity, including currently known, new or
neglected disease manifestations. Be guided by what
you have learned so far and direct your physical
examination accordingly. Here are some key
components of physical examination:
Five ‘routine’ observations; make these or find
where they have been documented. (1) High blood
pressure needs observation, sometimes treatment,
but low blood pressure alerts to overmedication,
blood loss or sepsis. (2) Tachycardia might
indicate pain, the anticholinergic effects of
medication, anaemia, shock or other physical
abnormalities; it could be withdrawals, mania
or ‘just anxiety’ so follow this up to make sure
pulse restores to normal. (3) Fever may indicate
infection or a rare (potentially fatal) reaction to
antipsychotic medications called neuroleptic
malignant syndrome, NMS. (4) Tachypnoea
may indicate chest or cardiac disease, anaemia or
rarely (in the absence of other features) active
anxiety variants (see Box 8.6). (5) Weight is the
single most omitted physical examination finding.
Is this patient’s weight low? Adults’ height is
measured once, and this allows calculation of
body mass index (BMI), as weight (kg) divided
by height (metres) squared. The healthy range is
18.5–25, but values below this should raise the
possibility of an eating disorder, even in ‘athletic’
types. For low weight, look for signs of weight loss
and malnutrition, and document the skin changes
of acute weight loss, noting hand signs of bulimia
(Russel’s sign of tooth marks on knuckles).
Lanugo (excess fine bodily hair) is a very late
sign in anorexia nervosa. In Western society,
two of three people are overweight; this may
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Box 8.9
Diagnostic criteria for bulimia nervosa (1–3 all required). From ICD10
Eating disorders and disordered eating
Domain Mental state examination Behaviour
1 Food Preoccupation with eating
Craving for food, typically carbohydrates
2 Solution Overvalued ideas/concerns that food
consumed is ‘fattening’ and needs to be
removed from their body
3 Belief Morbid fear of fatness: a belief, held to the
intensity of an overvalued idea, but not
delusional, that they will become fat with
regular eating
Atypical bulimia nervosa
Lack one or more MSE findings Patient is overweight (BMI 25–30) or obese (BMI
Food solution belief
BMI, body mass index; MSE, mental state examination.
(Source: https://www.who.int/classifications/icd/en/GRNBOOK.pdf)
Diagnostic criteria for anorexia nervosa (1–4 all required). From ICD10
Core symptoms and
Criteria Unusual patient groups
Episodes (binges) where large amounts of food are
consumed in short periods of time
Action to reduce food effects: self- induced vomiting;
periods of restriction of food; abuse of purgatives/
appetite suppressants/diuretics/thyroxine, etc.
Sets a carefully defined weight as target: this is usually
below healthy BMI (18.5–25). There may have been
a short history of anorexia nervosa and/or transient
amenorrhoea
above 30)
signs
1 Actual weight BMI of 17.5 or less
Weight at least 15% below expected weight
2 Self- induced weight
loss
Food restriction and one of: excessive exercise;
self- induced vomiting; purging (laxative use);
Children fail to achieve expected weight on centile
charts
Diabetic patients may use insulin to excess in an
effort to reduce body weight
appetite suppressants/diuretics
3 Disorders of thinking
(overvalued ideas)
Body image distortion (perceives self as
heavier than objective evidence shows)
Morbid fear of fatness
4 Endocrine disorder Amenorrhoea; in prepubertal patients, puberty
In men, loss of sexual interest and potency
is delayed or arrested
Laboratory findings: low levels of gonadal
hormones; elevated levels of growth, cortisol,
and thyroid hormones
Atypical anorexia nervosa Lacks one or more of 1–4 criteria
(Source: https://www.who.int/classifications/icd/en/GRNBOOK.pdf)
ARFID (avoidant or restrictive food intake disorder)
‘These include having little interest in eating and/or avoidance of multiple types of food. The avoidance of specific types of food
may be based on specific sensory properties (e.g. colour, appearance, texture, taste, temperature or smell) or on perceived adverse
consequences of eating such food (to include, e.g. feared health problems, vomiting or choking). Avoidances of this nature
typically result in acceptance of a diet that is not sufficient to provide the energy and nutrients for healthy development and
functioning.’ But without core symptoms numbers 2 and 3 from ICD-10 anorexia nervosa diagnostic criteria, as listed above.
*Al-Adawi S, Bax B, Bryant-Waugh R et al. Advances in Eating Disorders: Theory, Research and Practice, 2013: Vol. 1, 10–20.
have psychological sequelae (low self- esteem)
but look also for signs of locomotor disease and
diabetes.
For cognitive impairment, depression and anxiety
look for physical disorders as antecedents: gait/
balance problems, focal neurology, liver/renal
disease, signs of low or high thyroid, effects of
poorly controlled diabetes or immunological
disorders (rheumatoid arthritis, systemic lupus).
Patients with psychosis (schizophrenia and bipolar)
lose on average 17 years of their life expectancy,
and those final years are spent in very poor physical
health. Premature mortality is even worse for
*
people with intellectual disability, addictions and
personality disorders. Regardless of their current age
or duration of mental disorder, examine the patient
for the effects of smoking, obesity- diabetes, alcohol
and substance misuse, polypharmacy including
prescribed opioid medication and some infectious
diseases (hepatitis and HIV, both treatable). Physical
examination at these opportunities is an ideal time
to document disease progression or useful baseline
measures, such as weight and blood pressure.
Examination for the effects of alcohol and
substance misuse essentially focuses on signs
of possible liver disease, but consider how
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substances are taken (intravenous, nasal ingestion,
inhalation) too. Palpate for liver tenderness or
enlargement in alcohol excess; there may be
epigastric tenderness of pancreatitis. Advanced
alcoholic liver disease may lead to ascites, bruises
(low platelets and prolonged clotting time),
engorged superficial veins (plethoric facies, spider
naevi) and epigastric veins at the umbilicus: caput
medusae. For people who misuse substances,
skin examination might reveal plethoric facies,
excoriation around the nose (typically cocaine),
arm/leg track marks or even skin abscesses from
intravenous drugs. Novel psychoactive substances
cause bodily damage too long to list here, for
example the unstable, neuropathic bladder of
ketamine misuse.
In patients with impulsive personality difficulties
or borderline traits (see Box 8.10), there may be
old scars of self- harm (arms, thighs, abdomen,
neck) that need to be documented in case
Box 8.10
Trait domain qualifiers that contribute to the expression of personality dysfunction
ICD11 reconceptualization of personality
new circumstances lead to a return of harmful
behaviours. Tattoos are now common and, as with
body piercings, record anything out of the ordinary.
Patients rarely require a full neurological
examination. Can he stand and walk? If he
is having difficulties, observe for facies of
Parkinsonism and test for cerebellar ataxia,
suggesting demyelination but common in severe
alcohol misuse. Speech has already been covered
in MSE; you might ask patients to smile broadly
to show teeth (a test for facial asymmetry) and
to mime playing the piano with both hands
outstretched as a very broad screen for major
neurological deficit. Tremor should be noted; then
test for increased tone of Parkinson’s disease or
antipsychotic medication excess (both cause cog
wheel rigidity). Finally, and this is worth noting
as an early reversible sign of alcohol excess, record
signs of peripheral neuropathy of arms or legs, to
motivate your patient to quit.
Trait domain Core definition Specific features
Negative
affectivity
Detachment A tendency to maintain interpersonal
Dissociality Disregard for the rights and feelings
Disinhibition A tendency to act rashly based
Anankastia A narrow focus on one’s rigid
(Adapted from the ICD11 Clinical Descriptions and Diagnostic Guidelines for Personality Disorder, which include a more detailed description of the trait domain
qualifiers.)
A tendency to experience a broad
range of negative emotions with
a frequency and intensity out of
proportion to the situation
distance (social detachment) and
emotional distance (emotional
detachment)
of others, encompassing both selfcentredness and lack of empathy
on immediate external or internal
stimuli (i.e. sensations, emotions,
thoughts), without consideration of
potential negative consequences.
standard of perfection and of right
and wrong and on controlling one’s
own and others’ behaviour and
controlling situations to ensure
conformity to these standards
Anxiety, anger, worry, fear, vulnerability, hostility, shame, depression,
pessimism guilt, low self- esteem and mistrustfulness. For example, once
upset, such individuals have difficulty regaining their composure and
must rely on others or on leaving the situation to calm down.
Social detachment, inducing avoidance of social interactions, lack
of friendships and avoidance of intimacy. Emotional detachment:
inducing being reserved, aloofness and limited emotional expression and
experience.
For example, such individuals seek out employment that does not involve
interactions with others.
Self-centredness: inducing entitlement, grandiosity, expectation of others’
admiration and attention- seeking. Lack of empathy: inducing being
deceptive, manipulative exploiting, ruthless, mean, callous and physically
aggressive while sometimes taking pleasure in others’ suffering.
For example, such individuals respond with anger or denigration of
others when they are not granted admiration.
Impulsivity, distractibility, irresponsibility, recklessness and lack of
planning.
For example, such individuals may be engaged in reckless driving,
dangerous sports, substance use, gambling and unplanned sexual
activity.
Perfectionism: inducing concern with rules, norms of right and wrong,
details, hyper- scheduling, orderliness and nearness. Emotional and
behavioural constraint: including rigid control over emotional expression,
stubbornness, risk- avoidance, perseveration and deliberativeness.
For example, such individuals may stubbornly redo the work of others
because it does not meet their standards.
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Box 8.10
Borderline pattern qualifier
ICD11 reconceptualization of personality—cont’d
The borderline pattern qualifier may be applied to individuals whose pattern of personality disturbance is characterized by a
pervasive pattern of instability of interpersonal relationships, self- image and affects, and marked impulsivity, as indicated by five
(or more) of the following:
Frantic efforts to avoid real or imagined abandonment
A pattern of unstable and intense interpersonal relationships, typically characterized by alternating between extremes of
idealization and devaluation
Identity disturbance, manifested in markedly and persistently unstable self- image or sense of self
Impulsivity manifested in potentially self- damaging behaviours (e.g. risky sexual behaviour, reckless driving, excessive alcohol
or substance use, binge eating)
Recurrent episodes of self- harm (e.g. suicide attempts or gestures, self- mutilation)
Emotional instability owing to marked reactivity of mood. Fluctuations of mood may be triggered either internally (e.g. by
one’s own thoughts) or by external events. As a consequence, the individual experiences intense dysphoric mood states, which
typically last for a few hours but may last for up to several days.
Chronic feelings of emptiness
Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper (e.g. yelling or screaming,
throwing or breaking things, getting into physical fights)
Transient dissociative symptoms or psychotic- like features (e.g. brief hallucinations, paranoia) in situations of high affective
arousal.
Other manifestations of borderline pattern, not all of which may be present in a given individual at a given time, include the
following:
A view of the self as inadequate, bad, guilty, disgusting and contemptible
An experience of the self as profoundly different and isolated from other people; a painful sense of alienation and pervasive
loneliness
Proneness to rejection hypersensitivity; problems in establishing and maintaining consistent and appropriate levels of trust
in interpersonal relationships; frequent misinterpretation of social signals
Adapted from the ICD11 Clinical Descriptions and Diagnostic Guidelines for Personality Disorder.
(Source: Bach, B., First, M.B. Application of the ICD11 classification of personality disorders. BMC Psychiatry 2018;18:351. https://doi.org/10.1186/s12888- 018- 1908- 3)
Collateral history
Collateral history is all about the opportunities
you make (asking a partner to attend, based on
their availability; failing this, phone them) and
your listening skills. Whether this is a parent or
partner, friend or acquaintance, each collateral
historian will want you to give details, rather
than impart information to you. If there are areas
of the history (see Box 8.1) for which there are
gaps or inconsistencies, clarify these. Explore your
working hypothesis, for example, in an anxious
patient, is this state (collateral confirms recent
stresses, important events) or trait (the patient has
frequently been outwardly anxious, even in early
childhood). Collateral history is often about unusual
behaviours; they might be avoiding activities or
people they usually enjoy (the core depressive
feature of anhedonia), or perhaps avoiding eating
or meal times (suggestive of an eating disorder). For
psychosis and substance misuse, ‘behaving strangely’
covers a multitude; document what people mean
by this, as there may be cognitive deficits. If the
referral is from a clinician who has barely met this
patient, get in touch with the doctor who knows
the patient best—usually the family doctor. Think
through patients who (understandably) minimize
their difficulties:
Cognitive impairment: a family member will
describe a decline in executive function, such as
events forgotten, appointments missed or inability
to manage shopping.
Substance misuse without insight: ‘I don’t have
a problem with my drinking but my wife has
problems with my drinking’. Find out what is
happening.
Many patients hide or ‘mask’ their depression
with a happy face, especially men; look for
evidence of (undisclosed) suicidal behaviours, for
example completion activities. These can include
cancelling future trips, failing to book an annual
holiday, paying off debts to friends or making a
will.
Paranoid patients might include hospital staff
(you) in their delusional system. Some experience
voices instructing them to silence: ‘don’t tell the
doctors’.
Obsessive compulsive disorder has rituals that the
person recognizes as ‘silly and unnecessary’ and
therefore will make efforts to hide them from
others. Mostly, cohabitants will describe these
OCD behaviours, but a close friend or partner
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who does not reside with the patient might have
accounts of appointments agreed then missed, or
long delays in leaving home owing to rituals.
Eating disorder presents other challenges, and
experienced doctors can be distracted from
making this important diagnosis. A parent or
current cohabitating informant is essential (Box
8.9) and later.
Self- harm and crisis; some patients brought to the
Emergency Department may have a ‘flight into
health’ and insist everything is somehow better,
even though they might still be depressed and/or
returning to the same adverse social setting that
led to this crisis.
Personality disorder: although this diagnosis is
openly shared with patients, many resent it as a
diagnosis of despair. In a recent example from
our practice, it was difficult to identify diagnoses
in a plausible patient with an acute self- harm
presentation until her husband gave the collateral:
‘My wife is the life and soul of every party, but
when the party is over, it’s hard to be around her’
(Box 8.10).
Collateral history from the parent(s) or guardian(s)
who has raised the patient is invaluable for more
challenging diagnoses—right up until working age
adults. Re- take parts of the life story progression
of Pages 7–8 (Box 8.1 personal history to medical
/psychiatric history): where do the two accounts
(patient versus mother) diverge? When did things
change? Has patient overlooked some protective
factors?
Ask the parent what he thinks is going on. This
is just one opinion (about which you remain
neutral), but you will feel very silly if he knew the
diagnosis, but you struggled to join the dots.
List the fact of ACEs (what? when? who?) and
the family’s response to them.
To differentiate the onset of schizophrenia (as
opposed to schizoid personality disorder or autism
spectrum), define that normal personality was
established by late teens, but then deteriorated in
early 20s (or whenever).
Record any parental concerns with the child’s
eating habits, use of alcohol and substances, school
performance or contact with police in teenage
years.
Character descriptions (Who in the family is he
most like? And why?) and life events during life
course. Descriptions of important relationships—
peers, teachers and intimate partners. Box 8.10
summarizes a rethinking of personality disorder,
abandoning decades of pejorative terms. There
are five trail domain qualifiers and these align
to existing disorders; in addition, we describe
severity (mild, moderate or severe), based on
their impact on relationships and behaviours. A
separate borderline diagnosis is set out.
Record professional medical contacts throughout
the lifespan in persistent physical symptoms;
these can have a familial subcultural context and
reinforce health anxiety (see later). Take a note of
any parental resentment at doctors, and ‘missed’
or late diagnoses.
Formulation
At this point, resist the temptation to say ‘time’s up’
and retreat to write up the diagnosis. Endings are
important; start with two useful habits. First, no matter how long your interview and how experienced
you become, have the humility to think you might
have missed something; ‘I must have asked you
hundreds of questions. Have I left out anything (or
skipped through something) that you think is important?’ If the answer is at variance with your interview, record this verbatim. For traumatized patients
(see Box 8.3), this is what matters to them, rather
than ‘what is the matter’. Second, and an excellent
way to achieve closure of an interview, test your formulation in broad terms. You would not do this if
you were uncertain (and needed to consult) or had
an insightless patient with (say) cognitive impairment or psychosis. You are ‘road testing’ your conclusions, so invite feedback: ‘I am not the expert here
(remind the patient of your student or junior status)
but, from this discussion, I think that this is…’ In this,
we suggest you give the early portions only of the
five- part formulation. Finally, think about how this
patient made you feel and specify which exchanges/
topics drew out these feelings. Mental disorders are
not infectious, but it is normal to feel anxious if we
spend an hour in the company of someone who is
very anxious, repeatedly seeking our reassurance (to
no effect). With schizophrenia, we may feel a mercurial sense of that person—that we could not pin him
down or identify much of his personality. Patients
who are overfamiliar, perhaps even flirtatious, are
pointing to emotionally unstable traits or attachment difficulties; transference describes the feelings patients develop for professionals (at extremes,
enmeshed and unhealthy attachments) and countertransference defines our feelings for them. Discuss
with seniors if your responses are extreme in either a
positive or negative way.
Formulation is the integration of history, direct and
collateral, with MSE and interacting biopsychosocial
data to determine diagnoses, their antecedents and
the best management plan. It has five components:
1. Narrative summary is a headlined introduction
to assist others with the what? and the why
now? of this presentation: ‘Mary is a 28- yearold unemployed divorced woman, living with
her older sister, self- presenting to emergency
department with 10 days of escalating suicidal
thoughts in the context of 2 weeks’ heavy
drinking that followed her grandfather’s funeral
earlier this month’.
2. Aetiology of single cause (and many) is a
challenge in psychiatry, with the exception
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