Evaluation of

Psychiatric Disorders
Mark E. Schneiderhan, Leigh Anne Nelson,
and Timothy Dellenbaugh

1
KEY CONCEPTS
Patients with psychiatric conditions are treated in all
healthcare settings. All clinicians need to develop basic skills
e|CHAPTER 20
1 Patients with mental disorders are treated by clinicians from
many disciplines and in all settings of healthcare. Patients often
in psychiatric assessment to provide the best care for their receive the majority of their care from nonpsychiatrists, and there
patients. is frequently a lack of coordination of care.1 Hence, the need for
2 The Diagnostic and Statistical Manual of Mental Disorders, good psychiatric assessment skills must not be limited to mental
Fifth Edition, Text Revision (DSM-5) and the Pocket Guide health clinicians. Even public education programs are being offered
to the DSM-5 Diagnostic Exam provides clinicians with a in some communities to help the public understand and to respond
standardized approach for the initial assessment and follow to signs of mental and substance use disorders.2 Along with tradi-
up of patients with mental disorders. tional assessments used across all medical specialties (e.g., labo-
3 Clinicians should be prepared to gather both the mental ratory tests, medical history, physical examination), mental health
and physical health history from their patients. Obtaining a clinicians rely on communication skills and use validated assess-
release of information (ROI) from patients to communicate ments that are perhaps less objective in nature and less familiar to
with other healthcare providers or significant others is often nonpsychiatric practitioners. This chapter provides a basic overview
necessary when there are multiple providers. of appropriate assessment techniques used by clinicians to develop
individualized treatment plans for psychiatric patients. Readers
4 The interview should be conducted in an atmosphere that needing greater depth than the materials provided in this chapter are
ensures the comfort and safety of both the patient and the referred to other sources.3–9
clinician. The clinician’s application of open-ended questions
and listening is essential in the interview process and
therapeutic relationship. One technique used is motivational
interviewing in which clinicians can empower patients to OVERVIEW OF THE DIAGNOSTIC
achieve their goals of treatment. AND STATISTICAL MANUAL OF
If the patient is in crisis, the clinician may feel some
5
apprehension about asking certain assessment questions. MENTAL DISORDERS
Knowing what specific questions to ask can help facilitate 2 The Diagnostic and Statistical Manual of Mental Disorders
inquiry about sensitive areas, such as delusional thinking (DSM) is the most widely accepted and most important diagnostic
and suicidality. reference used in the care of individuals with mental disorders. It
6 A thorough medication history to identify all medications provides a common language for practitioners to describe and diag-
currently taken, as well as those previously taken, is a nose psychiatric disorders.7 Common language is essential because
cornerstone of effective patient management. In addition, there is considerable overlap of symptoms across many diagnoses.
it must be determined whether there was an adequate trial The Diagnostic and Statistical Manual of Mental Disorders, First
(dose and duration) of current and prior medications for Edition (DSM-I) was introduced in 1952 and was the first manual
psychiatric disorders. on mental disorders to contain a description of diagnostic catego-
7 A baseline mental status examination and psychiatric ries. In 1980, the DSM-III and subsequent editions (DSM-IV (1994)
rating scales are critical tools in monitoring the severity of and DSM-IV-TR (2000)) suggested formulating psychiatric diagno-
symptoms and response to treatments of mental disorders. ses in a multiaxial (Axis I primary psychiatric diagnosis, Axis II
personality/developmental, Axis III medical, etc.) system format
8 Although there are no diagnostic tests for mental disorders, that was widely accepted in psychiatry.9,10 eTable 20-1 provides
physical and laboratory assessment of the patient can help an example of the former multiaxial system.10 The Diagnostic and
the clinician rule out drug-induced or medical causes that Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
may produce similar or overlapping symptoms. published in May 2013, includes a greater emphasis on severity as
9 Psychiatric rating scales, cognitive testing (neuropsychiatric well as presence of symptoms.11
rating scales), and psychological testing can provide The DSM-5 takes a dimensional approach to formulating diag-
objective measures of psychiatric symptoms, adverse side noses to better account for the heterogeneity and complexities of
effects, memory, and intellectual capacity and are often used mental disorders while still retaining many of the components found
in research and clinical settings. in the former DSM-IV-TR. Of note, the DSM-5 uses the term “disor-
ders” rather than “illness” or “disease” to recognize the complexities

299
Copyright © 2014 McGraw-Hill Education. All rights reserved.
300
eTABLE 20-1 Historical example of a DSM-IV-TR The pocket guide to the DSM-5 Diagnostic Exam includes examples
Multiaxial Evaluation of screening and follow-up questions used in a diagnostic interview
for each of the mental disorder categories in DSM-5. It also discusses
Axis I 300.02 Generalized anxiety disorder
building a therapeutic patient alliance, conducting a 30-minute diag-
305.10 Nicotine dependence
303.90 Alcohol dependence nostic interview, a stepwise approach to differential diagnosis, and
Axis II 301.83 Borderline personality disorder
evaluations in special populations (i.e., cultural assessments).9
In summary, the DSM-5 and the The pocket guide to the DSM-5
Axis III 250.00 Diabetes mellitus, type II
401.90 Hypertension, essential
Diagnostic Exam provide clinicians with a systematic approach of
evaluating patients, thereby creating better treatment plans and a
SECTION

Axis IV Divorce, threat of job loss

more consistent evaluation of treatment outcome.
Axis V 43 (Current)

DSM, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,

Text Revision.
THE CLINICAL INTERVIEW
  

2 in formulating diagnoses; likewise, the term “disorder(s)” will be

The mental health clinical assessment is more than a verbal com-
munication exchange. Although the focus of the interview may be
used throughout this chapter.9 Clinicians are strongly urged to review on mental health, the clinician should be prepared to assess both
Organ-Specific Function Tests and Drug-Induced Diseases

DSM-5 to appreciate the full scope of changes from the previous the mental and physical health conditions of their patients. Clini-
DSM-IV-TR. Some of the significant changes in the DSM-5 include cians need to be aware that patients with mental disorders often
modifying the diagnostic criteria of certain disorders (e.g., age crite- have a lack coordination of their healthcare.1 These patients often
ria in attention-deficit/hyperactivity disorder [ADHD]), reclassifying have multiple medication prescribers, resulting in polypharmacy.
and/or renaming certain diagnoses (e.g., certain childhood disorders Communication exchanges between psychiatry and primary care
such as mental retardation, autistic disorder, and ADHD are now all services are often fragmented even if they are co-located because of
classified under neurodevelopmental disorders and include intellec- underdeveloped shared care practices.12,13 Moreover, patients with
tual disability, autism spectrum disorder, and ADHD, respectively; severe and persistent mental illness (SPMI) have a shortened life
dementia is now classified as a major neurocognitive disorder). span and are less likely to receive the same level of primary medical
Secondly, the International Classification of Diseases (i.e., ICD-10) care compared with patients without mental disorders.14–18 Barriers
system is the current standard to improve global consistency in the to medical care include patient paranoia, ambivalence, and disorga-
coding of all mental disorder diagnoses. Thirdly, the former multi- nization, accounting for missed appointments; stigma toward mental
axial system (Axis I–III) was combined into a single diagnosis or a disorders; and poor communication among primary care and psy-
list of diagnoses (nonaxial assessment system) that describe over- chiatric clinicians.19,20 For example, a significant number of patients
lapping mental, developmental, and personality disorders, etiolo- who take antipsychotics are not adequately monitored for diabetes
gies, and contributing neurological or medical illnesses (e.g., major and dyslipidemia.21–24 Therefore, the interviewer should be aware of
depressive disorder and hypothyroidism).9,11 During the adoption of the significant health disparity in this population because best prac-
DSM-5, mental health clinicians must still remain cognizant of the tices for medical monitoring become the standard of care.18,22,25–27
former multiaxial assessments (i.e., DSM-IV-TR) that will still be
found in patients’ current and past psychiatric histories. The DSM-5
will continue to distinguish primary diagnoses from “psychosocial Clinical Controversy. . .
and environmental problems” (formerly Axis IV) and functional sta-
tus (formerly Axis V), but will use already established ICD codes to Stigma and discrimination often negatively affect the lives
classify psychosocial conditions needing clinical attention (i.e., low (e.g., employment prospects) of individuals labeled mentally
income, homelessness, uncomplicated bereavement). In addition, ill. Consumer advocating organizations such as the National
the Global Assessment of Function (GAF) rating scale (formerly Alliance on Mental Illness (www.nami.org) are committed to
Axis V) is now replaced with the World Health Organization Dis- help increase awareness about the issues and perceptions
ability Assessment Schedule 2.0 (WHODAS 2.0), which is thought surrounding mental illness.
to provide a clearer and more comprehensive measure of disabil-
ity. For a complete listing of all changes, please refer to the DSM-5
hardcopy or online at “http://www.psychiatry.org/dsm5” (changes
from DSM-IV-TR to DSM-5). Release of Information
More emphasis is placed in DSM-5 on objective diagnostic and 3 Because coordination of care is often lacking, permission from
follow-up assessments, utilization of severity rating scales, screen- the patient to obtain “collateral information,” such as psychiatric
ing tools, and cultural assessments. A complete list of the suggested and medical diagnoses, laboratory test results, medication lists,
patient assessment measures is available for clinical use and can be and other verbal or written records, should be obtained before the
found in Section III of the DSM-5 entitled “Emerging Measures and interview is completed. Collateral information can be obtained by
Models” or online at “http://www.psychiatry.org/dsm5” (Online asking the patient to sign a release of information (ROI), which is
Assessment Measures). Other important rating scales are discussed mandatory in order to contact significant others, family members,
in the section below on Psychiatric Rating Scales. and clinicians.28
The DSM-5 provides general information on all mental disor- In summary, the clinician should be prepared to assess the
ders recognized by the American Psychiatric Association (APA) and mental and physical health of the patient, which is discussed in more
includes age of onset, clinical course, complications, predisposing detail in the Mental Status Examination and Physical Examination
factors, prevalence, and differential diagnoses. The specific diagnos- and Laboratory Assessment sections later in this chapter.
tic criteria for each mental disorder, dimensional assessment tools
(i.e., rating scales), and the number of symptoms required to estab-
lish a diagnosis are also listed. Interview Techniques
Additional information besides the DSM-5 diagnosis is required 4 The interview should be conducted in a quiet, nonstimulating,
before a comprehensive treatment plan can be developed. For instance and comfortable area where the patient and the interviewer feel at
Copyright © 2014 McGraw-Hill Education. All rights reserved.
 301
ease.8 The setting should be appropriate to the patient’s level of acuity eTABLE 20-2 Examples of Interview Questions for
and the potential for risk to the patient and clinician. The interviewer Assessing Patients with Mental Disordersa
should introduce him- or herself and explain what is about to happen
Mania
in order to establish a trusting relationship (therapeutic alliance).
1. Tell me what your typical day is like.
Generally, open-ended questions come first followed by questions 2. Do your thoughts go faster than you can say them?
focused on more specific or personal data. Open-ended questions 3. Have you noticed a change in the amount of sleep that you require?
allow the patient to provide descriptions and other information in his 4. Have you spent a lot of money lately, and what did you spend it on?

e|CHAPTER  
or her own words. Even though more specific questions may then 5. Do you have a lot of extra energy?
(To assess hallucinations and delusions, see Schizophrenia section below.)
be necessary to fill in the gaps, beginning in this manner minimizes
Depression
the risk of “leading” the patient. Patients can respond to specific
1. How do you spend your time?
questions and “yes” or “no” questions with answers they think the 2. Do you cry without any reason?
interviewer wants to hear. The interviewer must listen carefully and 3. Do you still enjoy the same hobbies or activities that you once did?
remain nonjudgmental about the information offered by the patient 4. Has your weight changed recently?
to develop trust and rapport and to ensure completeness and accu- 5. Have you had changes in your energy level recently?

20
6. Do you have any guilty feelings?
racy of the information. Motivational interviewing (MI) is another 7. Do you find it difficult to remember phone numbers, names of friends,
technique that can be useful for engaging the patient if conflicting appointments, and so on?
issues arise such as discussions around tobacco, drugs, or alcohol (To assess sleep and suicidal potential, see Sleep and Suicide sections

Evaluation of Psychiatric Disorders

use.29 The MI approach to patient interactions is described by the below.)
acronym OARS (open-ended questions, affirmations, reflective lis- Schizophrenia
Delusions
tening, and summary).29–31 More comprehensive descriptions and
1. How do people treat you?
training opportunities for MI are available in other sources.29,31,32 2. Do you feel that people plot against you?
Whether a clinician takes notes or just listens during the inter- 3. Do you ever feel that you are watched or spied on?
view is an individual decision; the primary considerations are accu- 4. Do you have any special abilities?
rately recalling the details of the examination and assuring that the 5. Does anyone ever try to mess with you or bother you?
6. Do others read your thoughts?
patient is comfortable with the note taking. eTable 20-2 provides Hallucinations
examples of questions useful for gathering mental health informa- 1. Does the TV or radio ever tell you things?
tion toward the completion of the clinical interview. Before any con- 2. Do you hear voices that other people don’t hear?
clusions are made during a patient interview, the impact of culture 3. What do they say? How many voices?
4. How often do they bother you?
on the patient’s presentation should be considered. Something that
5. Do the voices ever tell you to kill yourself or someone else?
sounds delusional in one culture can be the norm in another culture. 6. Have you ever heard your name called when there is no one there?
If a clinician is unclear whether culture of origin accounts for some 7. Have you ever seen anything strange that you can’t explain?
of the patient’s symptoms, he or she should obtain an ROI to consult 8. Do you ever see things that bother you and no one else?
with a family member or someone else familiar with the patient’s 9. Do you want to act on what the voices say?
Thought Broadcasting or Insertion
culture of origin. The Cultural Formulation Interview (CFI) found 1. If I stood by you, could I hear your thoughts?
in the assessment tools of DSM-5 can also be used to assist the 2. Does your head ever act like a radio?
clinician who suspects that cultural influences may be affecting 3. Do you feel that others can put thoughts in your head?
the diagnostic assessment.9,11 Insight
1. What reasons did your family give you for coming here?
2. What brought you here?
The Challenging Patient 3. Do you consider yourself in need of help?
4. What does your medication do for you?
5 Patient assessments can be challenging when symptoms of the
Sleep
condition prevent effective engagement with the clinician. Whereas 1. Tell me about your sleep.
excited patients may exhibit speech that is rapid and unorganized, 2. How many hours do you sleep each night at present?
depressed patients may respond with few words. Patients in the 3. How many hours do you usually sleep at night?
manic phases of bipolar disorder may not pause as they speak (pres- 4. Do you sleep all through the night?
5. Is there a reason for your waking up?
sured speech), making it difficult for the interviewer to interject. In 6. Do you have trouble falling asleep?
all cases, the interviewer can regain control by politely redirecting 7. How do you feel when you wake up?
the patient back toward the question. Suicide Potential
The interviewer should always be prepared to adjust his or 1. Do you feel your life is not worth living?
her communication approach based on the responses or reactions 2. Do you ever think of killing yourself? How often?
of the patient. Often, as in the disease of schizophrenia, a patient 3. Do you see things improving in the future?
4. Do you think you will try to kill yourself now?
may demonstrate poor insight and judgment. It can be common for 5. How would you do it?
the clinician to react negatively with anger if the patient seems to 6. Do you have the means to hurt yourself?
be manipulating and not adherent with treatment. Instead of react-
For all of these example questions, try to get the patient to expand on their answers.
a
ing negatively, one principle in MI is to “roll with resistance” in
which the clinician accepts the patient’s perspective and encourages
the patient to explore his or her own solutions.29 In another situa-
tion, patients with psychosis may be paranoid and appear guarded in a loud voice, or gripping the arms of the chair. When there is
or frightened by the interviewer’s questions. During any patient concern about safety, the interviewer should avoid any behavior that
encounter, clinicians should be aware of strong emotions such as could be misconstrued as threatening, such as touching or unnec-
fear, anger, or frustration and be careful not to judge or react to the essary staring, and should interview the patient in the presence
patient. Overall, the best approach is to remain calm and respect- of another healthcare provider. Both the patient and interviewer
ful, use shorter or closed-ended questions, and seek only essential should have equal access to leave the room if either becomes too
information until the patient is less paranoid. Patients can become uncomfortable. If a patient becomes threatening to the interviewer,
agitated and occasionally violent. Often violence is preceded by the interviewer should not hesitate to leave the room and call for
increased psychomotor agitation as evidenced by pacing, speaking help. If a patient describes suicidal thoughts, he or she should be
Copyright © 2014 McGraw-Hill Education. All rights reserved.
302
further assessed using the questions outlined in eTable 20-2. If con-
cerns about the patient’s safety persist, further assessments should
Mental Status Examination
7 The mental status examination (MSE) is a key patient assess-
be directed to the appropriate type of care, including either an
emergency department visit or direct hospitalization for patients at ment tool in psychiatry and is analogous to the physical examina-
immediate risk of harming themselves. A suicidal patient should tion in medicine. The MSE is completed through a direct patient
never be left alone. Asking a patient about suicidal thoughts will interview and provides a systematic method of organizing and
not increase the risk. The risk is greater if these questions are never reporting current behaviors, thoughts, perceptions, and function-
asked or signs of distress are ignored. In summary, applying MI ing. The MSE has several components (e.g., Appearance, Attitude,
skills or just remaining calm, quiet, and respectful may deescalate Activity, Speech and Language, Mood and Affect) and is combined
SECTION

the agitated patient, preserve the therapeutic alliance, and improve with other aspects of the patient workup (history of present illness,
overall treatment adherence.29 physical examination, appropriate laboratory tests, and medical and
psychiatric history) to give a full picture of the presenting problem
and factors contributing to the mental disorder.7,8,10 The addition
Clinical Controversy. . .
  

of symptom rating scales incorporated into the MSE can greatly

2 Mental health professionals are not immune from stereotyping

enhance the clinical assessment. Consistent identification and track-
ing of symptoms with rating scales can even enable both the clini-
people with mental disorders, which can negatively impact cian and patient to mutually construct specific treatment goals and
how professionals assess and manage patients. A team measure clinical progress such as changes in symptom frequency
Organ-Specific Function Tests and Drug-Induced Diseases

approach to patient care is one way to help guard against or severity over weeks or months.33 Although terminologies can be
personal biases influencing clinical decision making. misleading, the MSE should not be confused with the Mini Mental
Status Exam (MMSE) ,which is discussed in the Systematic Mea-
surement of Cognitive Function section later. The components of
the MSE include:
Psychiatric History
Both the patient’s and the patient’s family history of mental disor- Appearance and Attitude Toward the Examiner
ders provide important information when formulating a diagnosis and The appearance of the patient throughout the interview should be
treatment plan. Information should include the current and previous noted, including age, dress, grooming and hygiene, use of cosmet-
psychiatric diagnoses, clinical presentation of each mental disorder, ics, and facial expressions. A description of appearance also should
time frame between episodes, level of functioning between epi- include unusual physical characteristics and the general state of
sodes, length of each episode, total duration of the mental disorder, physical health. The interviewer should note whether the patient is
and treatment given during each episode as well as response to those cooperative, mute, hostile, paranoid, guarded, or withdrawn.
treatments. Baseline functioning or the highest level of functioning
achieved in the last few years is important because it helps to define Activity
a treatment goal. Information on the history of the current episode
Motor activity may be excessive or diminished. Overactivity dur-
and reasons for presenting to the clinician should also be gathered. A
ing the interview can range from hand wringing; restless leg move-
family history should include a medication history of the immediate
ments; and picking at clothing, skin, or hair to severe back and forth
relatives because a family member’s response to a given medication
pacing in the room. Underactive patients move less than expected.
might predict an individual patient’s response to that same medication.
Patients with rigid posture, an absence of movement, and failure to
communicate may be catatonic or paranoid or experiencing medica-
Social History tion-induced adverse effects.
A social history should include educational and occupational back-
ground; religion; marital status; substance-use patterns, including Speech and Language
tobacco, alcohol, and caffeine; and current living situation. By The quantity, flow, and speed of speech and the amount of eye con-
understanding a patient’s living environment and social situation, tact should be noted. The appropriateness and degree of eye contact
strategies to foster treatment adherence, reduce stress, and increase varies significantly among cultures, and before poor eye contact is
social support can be developed. To probe this area initially, the cli- interpreted, the patient’s cultural background should be considered.
nician can ask patients to describe their social support network. This Speech should be assessed as to whether it proceeds logically in a
can be followed by more specific questions such as: “To whom are goal-directed manner or whether the content is vague and poorly
you closest?” or “In whom do you confide?” organized. Abnormal speech characteristics include thought block-
ing, whereby the person suddenly stops speaking without any obvi-
Medication History ous reason. Thought blocking usually occurs when a hallucination
6 A thorough medication history is one of the most important or delusion intrudes into the person’s thinking or when upsetting
contributions a clinician can make to treatment planning. The his- issues are discussed. Circumstantial speech lacks a clear direction
tory should include medications for both psychiatric and medical because of excess unnecessary information, but the circumstantial
conditions and list all medications, including over-the-counter and patient eventually will make his or her point. In tangential speech,
herbals, taken by the patient. The history should also report how however, the ultimate point is never made. Perseveration is repeti-
each drug was tolerated and describe the responses to a single drug tion of an original answer to subsequent questions. Flight of ideas is
or combination of drugs. All allergies must be noted. Because most overproductive, rapid speech during which the patient jumps rapidly
psychiatric medications have a delayed onset of effect, it is impor- from one idea to the next. Mutism is identified when the patient does
tant to determine whether an adequate trial (dose and duration) was not respond even though he or she is aware of the discussion.
provided before the patient is deemed “nonresponsive” to that drug.
If a patient has a history of nonadherence, specific causes should Affect and Mood
be investigated. Causes of nonadherence may include, but are not Affect describes the patient’s current emotional tone, as expressed
limited to, drug cost, complicated dosing schedules, lack of insight, through facial expression, body posture, and tone of voice, all of
and adverse effects. which can be objectively observed by the clinician. Mood describes
Copyright © 2014 McGraw-Hill Education. All rights reserved.
 303
feelings, which are subjectively reported by the patient. Changes assesses short-term memory. Asking a patient to recall three objects
in facial expression and the presence of tears, flushing, sweating, 5 minutes after they are learned is the definitive test for short-term
or tremors should be noted. Affect can be described further by its memory. Deficits in short-term memory may be seen in depression
range, appropriateness, intensity, and stability. For example, in and anxiety, but this finding is the hallmark feature of dementia.
individuals with schizophrenia or depression, the affect can be flat, Asking the patient to do a certain task (e.g., pick up a pen with his
whereby no change in expression occurs throughout the interview. or her right hand and then fold a piece of paper and pass it to the
In contrast, during a manic episode, the affect is very intense and examiner) or spelling a five-letter word in reverse are examples of

e|CHAPTER  
often excited. Blunted affect denotes that the range of emotional testing working memory. Patients with cognitive deficits, such as
expression is reduced but not absent. An example of inappropriate those seen in dementias and schizophrenia, can exhibit deficits in
or incongruent affect is when a patient laughs in a situation that working memory. Remote memory is assessed by asking patients
would be expected to produce sadness. A rapidly shifting affect to recall old facts about their lives, such as where they were born
from one extreme to the other is described as labile. or where they went to school. Whereas remote memory usually
remains intact the longest in patients with intellectual decline, the
Thought and Perceptual Disturbances ability to create new memories is generally the first sign of a mem-
A variety of thought disturbances can occur in mental disorders.
Many of these disturbances generally indicate the presence of psy-
ory deficit. Abstraction is the ability to interpret information such as
a proverb (e.g., “People in glass houses shouldn’t throw stones”) or
20
chosis or impaired reality testing. Delusions are fixed, false beliefs identify similarities or differences between words (e.g., apple and

Evaluation of Psychiatric Disorders

that are not based in reality or consistent with the patient’s religion orange). Abstraction is influenced by education, cultures, and lin-
or culture. Delusions can be paranoid, somatic, or grandiose in guistic fluency; thus, an inability to abstract is not always a sign
nature. Delusions are often unshakable, and although the clinician of a psychiatric disorder. Persons with schizophrenia often provide
can challenge the delusional thinking, one should not attempt to concrete (literal or superficial interpretations) or bizarre responses
talk a patient out of a delusion. The lack of awareness of a men- to probes of abstraction.
tal disorder (anosognosia) can often accompany delusions. Thought
broadcasting is the belief that one’s thoughts are audible to oth- Insight and Judgment
ers. Hallucinations are false sensory impressions or perceptions Insight refers to patient awareness that he or she has a mental disor-
that occur in the absence of an external stimulus. Hallucinations can der and the impact of that disorder on his or her life. Anosognosia
be auditory, visual, olfactory, tactile, or gustatory and can be con- is a term used to define the complete lack of insight or awareness
tinuous or intermittent. In contrast, illusions are visual mispercep- of a mental disorder. Because lack of insight is associated with high
tions involving a misinterpretation of a real sensory stimulus. For morbidity and mortality rates among patients with mental disorders,
example, a person experiencing an illusion may react in fear if he or there is much interest in this area as a focus of research.34 For exam-
she momentarily misperceives the wind moving a curtain to be an ple, the symptom of poor insight is thought to be the main cause
intruder. This phenomenon does not always indicate a psychiatric of poor judgment such as nonadherence with prescribed medica-
disorder and can be seen in persons without mental disorders. Not tions.29,34,35 Levels of insight may be variable based on the level of
all thought disturbances are indicative of psychosis. For example, acuity of the mental disorder.
the couplet of obsessions and compulsions can indicate the presence Judgment is the ability to make decisions appropriate to the
of obsessive-compulsive disorder, which is not considered to be a situation and can be impaired in people with a variety of mental
psychotic disorder. Obsessions are unwanted thoughts or ideas that disorders. Judgment can be assessed by asking patients how they
intrude into a person’s thinking. Compulsions are actions performed would handle either their current or a hypothetical situation. As
in response to the obsessions or to control anxiety associated with with insight, judgment also can be fluid. For example, intoxicated
the obsession. patients can demonstrate poor insight and judgment only to improve
over several hours as their blood alcohol concentration decreases.
Evaluation of Cognition In summary, the MSE is the clinician’s observations and expert
The MSE assesses sensorium, attention, concentration, memory, opinion based on the patient’s history, verbal responses, nonverbal
and higher cognitive functions such as orientation and abstraction. reactions, appearance, and behaviors. The MSE is primarily used
If deficits in memory and concentration are primary or secondary to establish the patient’s diagnosis, target symptoms, response, and
complaints of the patient or these deficits are apparent during the treatment plan. In addition to the MSE and based on the discretion
interview, more formal or standardized mental status testing (e.g., of the clinician, a physical examination, laboratory assessments,
MMSE) may be required. The clinician should document whether objective rating scales, and psychological testing may be needed
the patient has received medications with sedative properties for a comprehensive mental health assessment and follow up. These
because the outcome of the examination can be altered if central assessment tools are described in the following sections.
nervous system depressants were recently taken.
Sensorium, or level of consciousness, refers to the alertness of
the patient, and if he or she is not fully alert, the amount of stimula-
tion needed to awaken the patient. Attention and concentration can PHYSICAL EXAMINATION AND
be further assessed using serial subtraction by 7s (“serial 7s”) or 3s
or by having the patient spell a five-letter word backward (e.g., d-l-r-
LABORATORY ASSESSMENT
o-w). General intelligence can be assessed loosely by asking factual 8 There is no consensus about specific laboratory tests for diagnos-
information about current news items, recent presidents, or popular ing or evaluating mental disorders.4,7 The identification of biologic
television shows or sporting events. Memory is the ability to recall markers (e.g., pharmacogenomics) as diagnostic tools, predictors, or
prior information and experiences. There are many descriptors indicators of drug response is of great interest. Recent developments in
referring to specific types of memory such as working memory (i.e., brain imaging (functional magnetic resonance imaging [fMRI]) using
the capacity to hold information such as a phone number in mind computer algorithms are being studied and show promise in diagnos-
for a few seconds), short-term memory (i.e., the ability to recall tics. For example, a recent meta-analysis found evidence for diagnos-
newly acquired information after several minutes), and long-term tic specificity for emotional processing in schizophrenia and bipolar
or remote memory (historical facts) that are commonly assessed as disorder.36 Although there are no diagnostic tests to definitively indi-
part of the MSE. Orientation to time, place, person, and situation cate that a patient has a specific mental disorder (e.g., schizophrenia
Copyright © 2014 McGraw-Hill Education. All rights reserved.
304
or bipolar disorder), physical assessments and laboratory tests are screens and blood alcohol tests play an important role in identifying
important to clarify the etiology of presenting symptoms. the contribution of illicit substances to the presenting symptoms.
Additional testing can include an electroencephalogram to evaluate
for the presence of seizure activity and other neurologic conditions,
Physical Assessment CT scans or MRIs to detect structural abnormalities, sedimentation
Patients who present with psychiatric symptoms need a careful rate and antinuclear antibodies for autoimmune disorders, an HIV
medical assessment because of overlapping symptoms from dif- test, thyroid function tests, and vitamin B12 and folate concentra-
fering causes.3–5,8 A complete physical examination, along with a tions for anemias.4 Laboratory tests should be individualized to the
detailed medical and medication history, vital signs, body weight patient’s age, medical and medication history, cooperativeness, and
SECTION

and body mass index, a pregnancy test when indicated, and routine physical health, but extensive testing is usually unnecessary and not
blood chemistry are commonly part of the workup of persons with cost effective.
a mental disorder. In most cases, a physical examination should be Clinicians also use diagnostic tests to evaluate the relative
chaperoned in the mental health setting. safety of specific medications, such as pregnancy monitoring with
  

Presenting symptoms can have multiple etiologies (i.e., medi- divalproex, renal status when using lithium, or an electrocardiogram
2 cal, medications, and mental disorders). Medical and psychiatric
disorders and medications can cause symptoms that are often indis-
when using medications that prolong QT interval (e.g., tricyclic
antidepressants such as amitriptyline). Serum concentration moni-
tinguishable. Patients with psychiatric disorders, especially depres- toring is recommended for medications with a narrow therapeutic
Organ-Specific Function Tests and Drug-Induced Diseases

sion and anxiety disorders, may present to primary care providers index (e.g., lithium, divalproex, carbamazepine). Serum concentra-
with only nonpsychiatric physical or somatic complaints and thus tion monitoring can also be useful for assessing medication adher-
receive unnecessary medication or medical treatment, while the root ence when there is an inadequate response. With the exceptions of
psychiatric cause is overlooked. lithium, divalproex, and clozapine, there are minimal data to support
In contrast, psychiatric disorders may cause or lead to medical obtaining serum concentrations for optimizing medication efficacy
complications. For example, patients with SPMI have a high preva- in patients with psychiatric disorders. Finally, clinicians must also
lence of modifiable risk factors such as poor nutrition and obesity, be aware of pharmacokinetic and pharmacodynamic drug–drug and
substance abuse or dependence (e.g., smoking, alcohol consump- drug–food interactions that occur with many medications, which
tion), and sedentary lifestyles, leading to increased morbidity and raise the probability of adverse effects, toxicity, or loss of efficacy.
mortality.14,16 As a result, these patients die on average 25 years ear- Pharmacogenomics may help future clinicians predict and minimize
lier than the general population, with 60% of these premature deaths drug and disease interaction risks and adverse drug reactions (e.g.,
caused by comorbid medical conditions, including cardiovascular cardiovascular disease and hyperprolactinemia with antipsychotic
disease, diabetes, respiratory disease (influenza, pneumonia), and agents).42,43
infectious disease (HIV/AIDS).17,37 In summary, a range of assessments aid clinicians in conduct-
Psychiatric medications can also cause or exacerbate medical ing problem-focused workups to verify diagnoses and identify
conditions, such as diabetes mellitus, hyperlipidemia, or cardiac underlying or potential drug-related problems.44 Although the MSE
arrhythmias, necessitating an initial assessment and ongoing mon- remains the cornerstone of the psychiatric workup, experts in the
itoring for these conditions while continuing treatment.38,39 Psy- field recommend selective medical tests; a good medical, psychiat-
chiatric medications, especially antipsychotic agents, have many ric, and medication history; and a thorough physical examination or
Federal Drug Administration black box warnings and precautions, referral to primary care. Awareness of overlapping chronic medical
requiring baseline and ongoing assessment. Baseline informa- diseases, mental disorders, and psychiatric medications requires a
tion is often needed to help document future adverse effects from more collaborative care approach to both the mental and physical
medications (e.g., lithium-induced hypothyroidism, clozapine- health needs of the patient.
induced leukopenia, antipsychotic-induced diabetes mellitus). For
example, the 2004 expert consensus recommends that patients
taking antipsychotic agents should be screened for symptoms of MEASUREMENTS OF PSYCHIATRIC
metabolic syndrome, including body weight, waist measurements,
blood pressures, and fasting serum lipids and glucose.38–41 For SYMPTOMS AND COGNITIVE
more in-depth information, refer to the chapter on schizophrenia.
The rapidity of onset of psychiatric symptoms is an important
FUNCTION
clue that a medical cause (e.g., delirium from an encephalopathy) 9 In addition to the MSE, symptom-based rating scales are use-
may be present. Whereas most chronic mental disorders have a pro- ful tools to provide an objective way to measure subjective data
dromal period, medically based psychiatric symptoms generally (e.g., feelings, thoughts, and perceptions) and to screen or diag-
have a more rapid onset of symptoms. Patients older than 40 years nose specific disorders. Because there are many types of scales
at first presentation are more likely to have a medical cause for from which to choose, the clinician rater needs training and expe-
their psychiatric symptoms because major mental disorders, such rience to select and effectively use the most appropriate scale.
as schizophrenia and bipolar disorder, usually first present in ado- Rating scales are used in a variety of settings, including research
lescence or early adulthood. Family history can provide additional and patient care, and can serve an administrative purpose, such as
clues. Patients with fluctuating levels of consciousness, disorienta- quality control.6
tion; memory impairment; or visual, tactile, or olfactory hallucina- Some rating scales are self-administered (“patient rated”) and
tions are more likely to have a medical basis for their presentation do not require a staff member to collect the data; thus, they require
that can be diagnosed by medical diagnostics (e.g., laboratory tests, minimal resources to administer and can provide valuable informa-
computed tomography [CT], magnetic resonance imaging [MRI]). tion, although some patients may be unable to self-administer a
questionnaire for a variety of reasons, including limited literacy and
severity of symptoms.
Laboratory Assessment In contrast, “clinician-rated” scales may provide a more
General laboratory screenings are useful for medication monitor- consistent measure of target symptoms or behaviors. However,
ing and ruling out medical causes of mental disorders. Urine drug a major drawback includes the substantial time commitment for

Copyright © 2014 McGraw-Hill Education. All rights reserved.

 305
eTABLE 20-3 Adverse Effects Measuring Instruments
Rating Scale Type Scoring Comments
Systematic Assessment Structured interview Summary scores of number of events, 5–10 minutes to complete. Baseline and weekly
for Treatment Emergent and global average severity, and impairment evaluations. Easy to administer. The specific reported
Events–General Inquiry assessment information might be more useful than an overall
(SAFTEE-GI) summary score.
MED Watch Global assessment No scoring involved Minutes to complete. The one-page form requires

e|CHAPTER  
a narrative description of the problem or adverse
reaction. Online submission: www.fda.gov/medwatch.
Abnormal Involuntary Tardive dyskinesia 12-item, 5-point severity scale. Items 5–10 minutes to complete. Most commonly used.
Movement Scale (AIMS) (TD) assessment 1–4 orofacial movement; 5–7 extremity Diagnostic criteria: at least 3 months of antipsychotic
and truncal movement; 8–10 global treatment. Mild severity score (2) in two discrete areas
severity; 11 and 12 problems with teeth or moderate severity (3) in one area (e.g., orofacial)
or dentures (yes or no) indicates TD. Tremor is not counted.
Dyskinesia Identification
System: Condensed User
Scale (DISCUS)
Tardive dyskinesia
assessment
15-item, 5-point severity scale. Items 1,
2 face; 3 eyes; 4, 5 oral; 6–9 lingual; 10,
11 head, neck, or trunk; 12, 13 upper
5–10 minutes to complete. More descriptive criteria for
scoring severity than the AIMS. Scoring based on three
dimensions: frequency, detectability, and intensity.
20
limb; 14, 15 lower limb Tremor is not counted.

Evaluation of Psychiatric Disorders

Rating Scale for Drug-induced 10-item, 5-point anchored severity 5–10 minutes to complete. Item domains include
Extrapyramidal Side Parkinson’s scale. Mean score is obtained by adding gait, arm dropping, shoulder shaking, elbow rigidity,
Effects (Simpson–Angus and dystonia all scores and dividing by 10. A mean wrist rigidity, leg pendulousness, head dropping, eye
EPS Scale) assessments score of 0.3 is the upper limit for no EPS blinking, tremor, and salivation.
Barnes Akathisia Scale Drug-induced Four items, including three 4-point 10 minutes to complete. Items 1–3: objective
(BAS) akathisia anchored severity scored items and a observation of restlessness, subjective awareness
5-point global rating score item. Total of restlessness, and subjective distress related to
score of 12 possible restlessness. Diagnostic criteria: require both objective
and subjective ratings of at least one in either two
subjective items.

EPS, extrapyramidal symptoms.

Data from Guy,49 Schooler et al, 51 and Sajatovic and Ramiriz.52

staff to administer the tests and the inability of some patients to

tolerate these interviews, especially patients who are severely
Psychiatric Rating Scales
paranoid or agitated. In addition, repeated ratings are usually nec- Psychiatric rating scales provide the clinician or researcher with
essary to objectively describe longitudinal changes over a defined a consistent measure of medication side effects and symptoms
treatment period as opposed to a snapshot of a complex clinical that are present in psychiatric disorders (e.g., tardive dyskinesia
situation. [eTable 20-3], psychosis [eTable 20-4], depression and bipolar dis-
Sensitivity, specificity, reliability, and validity are important orders [eTable 20-5], anxiety [eTable 20-6]). Symptom-based rat-
considerations when selecting a rating scale. Sensitivity refers to a ing scales (e.g., Positive and Negative Syndrome Scale, Hamilton
test’s ability to detect a symptom or illness given that the symptom Depression scale, Abnormal Involuntary Movement Scale [AIMS])
or illness is present. Specificity refers to a test’s ability to correctly are used to measure the presence or severity of symptoms and
determine that a symptom or illness is absent when the person does assist in the diagnostic formulation.48–52 In contrast, global assess-
not have the illness.45 ment scales can be used to identify any adverse medication side
Reliability is the extent to which the score on the scale reflects effects (eTable 20-3) and the overall severity of mental disorders
the hypothetical “true” score and how much interference occurs (eTable 20-7) based on a rater’s clinical experience (e.g., Clinical
from outside influences.46,47 Reliability is reported by the correla- Global Impressions Scale [CGI]).51,53
tion coefficient, which represents a chance correlation (0.00) or per- In summary, patient-and clinician-rated scales are widely
fect correlation (1.00). Rating scales with correlation coefficients of used in psychiatric research and recommended in clinical settings
less than 0.7 are usually considered unreliable for clinical studies. to monitor schizophrenia, depression, bipolar disorder, and anxiety
­Interrater reliability—agreement in rating scores among clinician disorders.9,11,48–50,54–57
raters—is important to achieve when multiple clinicians rate the
same patient or population. Interrater reliability is established by Neuropsychiatric Rating Scales
having all raters independently rate individual patients at the same Neuropsychiatric rating scales provide specific information, such
time to determine the correlation of their scores. as the rate of change and severity of cognitive decline or improve-
Validity, in contrast, is the ability of a scale to measure what ment. They are useful when repeated measurements of a patient’s
it was designed to measure. Various validity tests are performed mental status are needed because they allow the clinician to deter-
on a rating scale to ensure that the scale assesses the appropri- mine response to an intervention (e.g., medication) in a more sys-
ate aspects of the illness (content validity), the correlation with tematic manner. In addition, some cognitive function measures are
diagnoses or clinical change (criterion-related validity), and the useful screens for Alzheimer’s disease and other causes of cognitive
extent to which the scale measures symptom traits in contrast to decline. A number of cognitive rating scales are available, the most
a specific symptom (construct validity).47 Before administering common being the MMSE.
any rating scale, the clinician should be trained or observed using The MMSE is a structured interview that globally assesses
the rating scale and have thorough knowledge of the rating scale’s many cognitive domains, including orientation, visuospatial orga-
strengths and limitations. nization, memory, and reasoning, to determine an overall score of

Copyright © 2014 McGraw-Hill Education. All rights reserved.

306
eTABLE 20-4 Psychosis Rating Scales
Rating Scale Type Scoring Comments
Brief Psychiatric Clinician rated 18 items, 7-point severity scale: mildly ill 32, The anchored BPRS provides descriptions of each severity
Rating Scale (BPRS) moderately ill 44, markedly ill 55, and severely rating to increase the interrater reliability. The BPRS has
ill 70 when correlated to the CGI (Clinical Global four clusters of symptoms: thinking disturbance, anxious
Impressions Scale; see eTable 20-7) depression, withdrawal-retardation, and hostility-
suspiciousness.
Positive and Clinician rated 30-item scale, 7-point severity scale: mildly ill Based on the 18-item BPRS for assessing the presence
Negative Syndrome 57, moderately ill 75, markedly ill 95, and or absence of positive and negative symptoms, and
SECTION

Scale (PANSS) severely ill 116 when correlated to the CGI psychopathology of schizophrenia.

Data from Leucht et.al.48,50 and Sajatovic and Ramiriz.52

  

eTABLE 20-5 Depression and Bipolar Disorder Rating Scales

2 Rating Scale Type Scoring Comments
Hamilton Depression Scale Clinician 17-item scale; <6 = normal mood; 17–25 = Used to screen patients for drug studies and to
(HAMD or HDRS) rated moderate depression; >25 = severe depression determine severity of symptoms and treatment
Organ-Specific Function Tests and Drug-Induced Diseases

outcome. HDRS is the standard to compare other

depression rating scales against.
Montgomery–Asberg Clinician 10-item, 7-point scale. For each item: 0 = no Differentiates among all the intermediate grades of
Depression Rating Scale rated symptoms; 6 = severe symptoms depression. Decreases bias in patients with other
(MADRS) medical illnesses and increased somatization (varied
unexplained physical symptoms).
Beck Depression Inventory Patient 21-item scale; 0–9 = normal; 10–15 = mild The standard for depression self-rating scales and an
(BDI) rated depression; 16–19 = mild-moderate; 20–29 = objective measure of change in symptoms as a result
moderate-severe; 30–63 = severe depression of treatment.
Zung Self-Rating Depression Patient 20-item scale, 4-point severity; <50 = normal; Severity rated by frequency of occurrence of
Scale (ZSDS) rated 50–59 = minimal-mild; 60–69 = moderate- symptoms. May not be as sensitive in measuring
marked; ≥70 severe depression changes in severity of symptoms.
Patient Health Questionnaire Patient 9-item, 4-point scale. For each DSM-IV Commonly used in primary care to establish a
(PHQ-9) rated depression criteria item: 0 = not at all; diagnosis of depression and assess severity of
3 = nearly every day. Score <10 = minimal depressive symptoms.
depression symptoms.
Quick Inventory of Depressive Clinician 16-item scale; scores range from 0–27; 0–5 = Used to assess symptom severity and symptomatic
Symptomatology (QIDS-C and patient none; 6–10 = mild; 11–15 = moderate; 16–20 = change. QIDS-SR found to be as sensitive to symptom
[Clinician] and QIDS-SR rated severe; 21–27 = very severe change as the HDRS. Has usefulness in both clinical
[Patient]) and research settings.
Young Mania Rating Scale Clinician 11-item scale; 5-point severity; 13 = minimal; Used to screen patients for drug studies and to
(YMRS) rated 20 = mild; 26 = moderate; 38 = severe determine severity of symptoms and treatment
outcome. YMRS is the standard to compare other
mania rating scales against.
Mood Disorder Questionnaire Patient 15-item scale; score of ≥7 suggestive of bipolar Screens for a lifetime history of mania or hypomania.
(MDQ) rated spectrum disorder Does not assess severity of illness.

DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
Data from Sajatovic and Ramiriz LF,52 Fankhauser and German ML,54 and Montgomery and Asberg.55

eTABLE 20-6 Anxiety Rating Scales

Rating Scale Type Scoring Comments
Hamilton Anxiety Scale (HAM-A Clinician rated 14 items, 5-point scales; scores Consists of subscales to measure somatic and psychic anxiety
or HAM-AS or HAMRS) of ≥18–20 for moderate anxiety
Self-Rating Anxiety Scale (Zung Patient rated 20-item scale; 4-point intensity Correlates to the clinician-rated Anxiety Status Inventory (ASI);
SAS) ratings however, there is little information on the validity of either test
Sheehan Panic and Anticipatory Patient and Three-part scale Measures panic attacks, anticipatory anxiety, and limited
Anxiety Scale (SPAAS) clinician rated symptom attacks
Yale–Brown Obsessive- Clinician rated Semi-structured interview Consists of several clusters of obsessions and compulsions; used
Compulsive Scale (YBOCS) to assess baseline severity and change in treatment studies

Data from Sajatovic and Ramiriz LF,52 Sheehan,5 and Goodman et al.57

eTABLE 20-7 Global Illness Assessment Scales

Clinical Global Impressions (CGI) Scale Clinician rated Severity of illness and global Observational and nonsymptom-specific
CGI (S): Severity of Illness improvement on 7-point rating scales. for assessing three global subsets: severity
Efficacy index: 1–4 marked improvement; of illness, global improvement, and efficacy
CGI (I): Global Improvement 5–8 moderate; 9–12 minimal; 13–16 index measures both therapeutic and side
CGI: Efficacy Index unchanged or worse effects

Data from Sajatovic and Ramiriz52 and Busner and Targum.53

Copyright © 2014 McGraw-Hill Education. All rights reserved.

 307
cognitive function. The maximum score is 30, and a score of 23 or fMRI functional magnetic resonance imaging
less is indicative of significant cognitive impairment. The MMSE GAF global assessment of functioning
takes 5 to 10 minutes to administer and is used routinely in the HDRS Hamilton Depression Rating Scale
clinical setting.58 Other examples of cognitive rating scales include MADRS Montgomery-Asberg Rating Scale
the Blessed Information Memory Concentration test (BIMC), the MDQ Mood Disorder Questionnaire
Dementia Rating Scale (DRS-2), the Clock Drawing test (CDT), MI motivational interviewing
and Alzheimer’s Disease Assessment Scale (ADAS).59–62 MMPI-2 Minnesota Multiphasic Personality Inventory-2

e|CHAPTER  
Most of the rating scales involve a structured interview that MMSE Mini-Mental Status Examination
requires clinician training to ensure accurate administration. Noise MSE mental status examination
and distraction can affect the patient’s performance ability; there- NAMI National Alliance on Mental Illness
fore, the interview should be conducted in a quiet area with adequate OARS open-ended questions, affirmations, reflective
lighting. The interviewer should speak slowly and clearly to the listening, and summary
patient when providing instructions and asking questions. PANSS Positive and Negative Syndrome Scale
PHQ-9 Patient Health Questionnaire for assessment of

PSYCHOLOGICAL TESTING QIDS-C

depression
Quick Inventory of Depressive Symptomatology-
20
Clinician rating scale

Evaluation of Psychiatric Disorders

Although most clinicians do not administer psychological testing, QIDS-SR Quick Inventory of Depressive Symptomatology-
they can use the results to evaluate the role of medication in relation- Subject rating scale
ship to the diagnosis. Psychological testing alone cannot establish ROI release of information
a firm diagnosis but can be a useful diagnostic tool when coupled SAFTEE-GI Systematic Assessment for Treatment Emergent
with clinical judgment. Types of psychological testing include per- Events-General Inquiry
sonality tests (e.g., Minnesota Multiphasic Personality Inventory-2), SPAAS Sheehan Panic and Anticipatory Anxiety Scale
intelligence tests (e.g., Wechsler Adult Intelligence Scale—Revised, SPMI severe and persistent mental illness
Wechsler Intelligence Scale for Children—Revised), projective TD tardive dyskinesia
tests (e.g., Rorschach), and neuropsychologic tests (e.g., Bender YBOCS Yale–Brown Obsessive-Compulsive Scale
Visual Motor Gestalt Test).3 Neuropsychological and intellectual YMRS Young Mania Rating Scale
assessments generally require special training or a patient referral to ZSDS Zung Self-Rating Depression Scale
a specialist, such as a licensed psychologist or neuropsychologist,
and should not be confused with psychiatric rating scales, which can
be administered by most clinicians. As with physical examinations,
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