Every psychiatric history should cover the following points: (1) complaint, from the patient's viewpoint; (2) the present illness, or the evolution of the symptoms; (3) neurovegetative signs such as libido, appetite, and sleep; (4) previous disorders and the nature and extent of their treatment; (5) the family history— important for genetic aspects and family influences; (6) the personal history—childhood development, adolescent adjustment, level of education, and adult coping patterns; (7) current life functioning, with attention to vocational, social, educational, and avocational areas; and (8) present or past use of alcohol and other drugs. It is often essential to obtain additional information from the family. Observing interactions of the patient with significant others in the context of a family interview may give important diagnostic information and may even underscore the nature of the problem and suggest a therapeutic approach.
The formal mental status examination should be particularly detailed when there is any evidence or high risk of cognitive dysfunction. The mental status examination includes the following: (1) Appearance: Note unusual modes of dress, use of makeup, etc. (2) Activity and behavior: Gait, gestures, coordination of bodily movements, etc. (3) Affect: Outward manifestation of emotions such as depression, anger, elation, fear, resentment, or lack of emotional response. (4) Mood: The patient's report of feelings and observable emotional manifestations. (5) Speech: Coherence, spontaneity, articulation, hesitancy in answering, and duration of response. (6) Content of thought: Associations, preoccupations, obsessions, depersonalization, delusions, hallucinations, paranoid ideation, anger, fear, or unusual experiences; suicidal and homicidal ideation. (7) Thought process: Loose associations, flight of ideas, thought blocking, tangentiality, circumstantiality, perseveration, racing thought. (8) Cognition: (a) orientation to person, place, time, and circumstances; (b) remote and recent memory and recall; (c) calculations, digit retention (six forward is normal), serial sevens or threes; (d) general fund of knowledge (presidents, states, distances, events); (e) abstracting ability, often tested with common proverbs or with analogies and differences (eg, “How are a lie and a mistake the same, and how are they different?”); (f) ability to identify by naming, reading, and writing specified test names and objects; (g) ideomotor function, which combines understanding and the ability to perform a task (eg, “Show me how to throw a ball”); (h) ability to reproduce geometric constructions (eg, parallelogram, intersecting squares); and (i) right-left differentiation. (9) Judgment regarding commonsense problems such as what to do when one runs out of medicine. (10) Insight into the nature and extent of the current difficulty and its ramifications in the patient's daily life. Formal cognitive screens can quantify impairments and point to the need for further evaluation. The Mini-Mental State Examination produces a numerical score with up to 30 points given for correct answers to questions (likely organic < 27 points) (Figure 25-1). Specific cognitive assessment must be performed, since many patients are able to cover a deficit in routine conversation.
Mini-Mental State Exam. (Adapted from Folstein MF et al: Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189.)