The Psychiatric Evaluation for Non-Psychiatrists, pt. 1

Overview, and Introduction to The Mental Status Examination

“I think I am well-advised, however, to call these rules ‘recommendations’ and not to claim any unconditional acceptance for them. The extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of the technique…”

—Sigmund Freud, On Beginning the Treatment, 1913

Introduction: What is the Psychiatric Evaluation?

This is part one in a series where I will dissect the psychiatric evaluation. I am writing this so that non-psychiatrists can have a better sense of what we’re doing and what’s going on inside our heads—or at least my head—when we’re doing our jobs. My aim is to strike a balance between re-creating a book-length treatment of the topic (there’s already plenty of those), while giving you more than you’d find in a typical one-page article written for popular consumption.

When I became a resident, I was struck by how often my patients thought psychiatrists could read minds, divine things about people’s past, dispense “happy pills”, give instantly effective life advice for all situations, or enlist various other semi-magical abilities. But even for those who are not under such illusions, psychiatry and the thinking behind it can remain somewhat mysterious. This series will hopefully give you a sense of what I’m thinking about, and how I’m thinking about it, when I’m seeing a patient.

Consider the following gentleman whom I had the pleasure of treating during residency. How would you go about having a conversation with him, establishing a therapeutic alliance, and figuring out whatever is causing his presentation?

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Vignette #1: Mr. A is a 27 year old African American man with unknown medical or psychiatric history, brought to the hospital by ambulance this morning. The EMS report noted he was found walking through the aisles of a grocery store accosting customers with prophecies about the impending end of the world.

I walk into his hospital room to find him pacing back and forth intensely, wearing a tattered tuxedo that is far too tight. He’s about 6’0”, slightly chubby but clearly quite muscular. He appears deep in concentration, mumbling to himself while rapidly tapping his fingers in the air in a piano-playing motion. His short curly hair is thoroughly saturated with what appears to be tomato paste. His eyebrows are painted white with toothpaste, garnished with some sprinkles of glitter.

As I enter he looks up, gives a nod of recognition, and walks toward me. His eyes are wide but with a facial expression that signals interest rather than aggression. I wave and give a quick “Hello, I’m Dr. Greenwald” as he approaches. He towers over me and studies my badge.

“Doctor Greenwald,” he says deliberately, drawing out each syllable as if he were then going to say, “we meet at last”. A wide smile begins to form on his face. He locks eyes with me, then blurts out expectantly, “Are you a Jew?!” Perhaps after seeing (and now smelling) his tomato paste hair I had unconsciously steeled myself for more surprises, as his question didn’t catch me too off guard.

“Eh, Jew…ish, I suppose,” I reply. With no great follow-up coming to mind I add, “uh…are you?”

His response did catch me somewhat off guard.

“Yes, my brother!” he bellows loudly, pumping one fist in the air, the other clasping my arm in what I assumed was solidarity. He launches off at breakneck speed, gesticulating wildly: “I am the resurrected ghost of Anne Frank, yes the Anne Frank, I have returned at last—the ‘Great Burnt-faced Jew’ they call me,” he declares solemnly, gesturing to his face, “raised from the dead, reborn like a Phoenix from the ashes, back from the ovens of Auschwitz and you better believe it baby: I’m bigger and better and blacker than ever, and I’m here to sue the fuck out of lithium and Depakote because they don’t do shit—they say they do but trust me I’m Anne Fuckin’ Frank, ok? Got it? I am the Great Burnt-faced Jew! Mengele and his crew ain’t got shit on me!”

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There are many essays that could be written on “how psychiatrists think”, so why should I structure mine around the psychiatric evaluation? First, it makes my life a lot easier because the exam is already semi-structured, which gives me a natural outline for writing. It also allows me to break the topic up naturally into smaller, more digestible bits. It will also make your life easier because the inherent structure of the psychiatric evaluation will keep us oriented and allow me to convey much more concrete information that I could in some freeform, semi-poetic reminiscence.

What is the psychiatric evaluation?

The answer in practice is “what happens during the first visit,” but I prefer to think of it as a phase of treatment—the initial phase. I am partial to the practice of many psychoanalytically-oriented therapists who see the “initial evaluation period” as lasting somewhere between a few sessions to a few weeks or months, depending on the circumstances. While it’s true that a well-trained psychiatrist with good intuition can glean a decent amount about someone from a single interview, the reality is that it takes time to really get to know someone. Ultimately, as long as new things are being learned, the boundary between “evaluation” and “the rest of treatment” is blurry at best.

That being said, not all circumstances demand or allow for extended evaluations. Hospital-based psychiatrists like myself should—ideally—be able to gather a significant amount of the relevant information about a patient from the first interview. Not that the evaluation stops after the first visit—the evaluation continues for as long as you’re still thinking about the case—but when I leave the patient’s room, my goal is to be able to say, at the very least, I have some good hypotheses for what’s going on, a few promising routes we can take to further clarify things, and a preliminary/provisional treatment plan.  

A significant part of learning the psychiatric evaluation consists in calibrating your evaluation’s style, focus, and level of detail to the particular situation. I use the psychiatric evaluation when I’m seeing a patient for chronic abandonment issues in long-term psychodynamic psychotherapy; I use it with a hospitalized patient in a state of paranoid psychosis who’s just been put in restraints after attacking other patients; and I use it all the cases in between. Needless to say, a one-size-fits-all approach to the psychiatric evaluation does not work. Each encounter is unique, and what the evaluation provides is a framework for approaching the encounter in a way that maintains enough structure to achieve your goal, while allowing enough flexibility to suit the particular patient and circumstance.

The overarching goals of the psychiatric evaluation are:

(1) having a detailed discussion with the patient about his problems. This includes cases in which he is either unaware of, or in denial about, the problem bringing him into treatment (eg. dementia or severe alcoholism, respectively). This involves use of other tools as indicated by the situation, such as the physical or neurologic exam, collateral information from families, laboratory tests, imaging, etc.

(2) Doing all this in such a way that you build a therapeutic alliance with the patient.

(3) Identifying and addressing any acute concerns, such as risk of violence to self or others, confusion or other cognitive impairments, pain, risk of drug withdrawal, erratic behavior, and so on.

(4) Thinking about the patient and his problems in a systematic way that leads to an accurate diagnosis, thereby guiding appropriate treatment.

Much of my job consists in knowing what to look for and how to elicit it. While I’m doing that, I need to incorporate those findings in real time into a constantly evolving differential diagnosis, while mentally reviewing potential treatment plans, foreseeing and avoiding potential future treatment pitfalls, silencing that pager that keeps ringing, all while trying to genuinely listen to whatever it is the patient is actually saying.

Over time, you learn to recognize illness patterns and types (and people patterns and types). Training yourself in certain kinds of pattern recognition is a core part of learning medicine, but if you’re not careful, it can also turn into a crutch and an excuse for not thinking through a problem. The key is to develop the good instincts while not getting lazy and relying on them at the expense of thoroughness and attention to detail.

Below is an outline of the major components of the psychiatric evaluation as it might be structured in a clinic note. As with almost anything I present here, the particular order and details can vary depending on what you read. Most of those differences come down to style or preference.

In practice a truly complete psychiatric evaluation with physical exam is rarely performed in the first meeting. If I am consulted to evaluate a patient with life-threatening malignant catatonia, checking for umbilical hernias or obtaining a detailed employment history are decidedly low-priority. The art consists in having a good sense for what is and isn’t relevant.

Components of the Psychiatric Evaluation:

1. Psychiatric Interview
     a) Chief Complaint
     b) History of Present Illness
     c) Past Psychiatric History
     d) Substance Use History
     e) Developmental and Social History
     f) Medical/Surgical History
     g) Family Psychiatric/Medical History
     h) Review of Systems
2. Exam
     a) Mental Status Exam
     b) Cognitive Exam 
     c) Physical & Neurologic Exam
3. Collateral Information
4. Diagnostic Tests/Procedures 
5. Assessment/Formulation and Treatment Plan

Here I’ll digress for a moment to harp on what I think is an underemphasized point: The interview itself need not and in all likelihood should not follow the order given above, which is laid out to assure thoroughness in acquiring information rather than guiding the direction of conversation. The way information from the evaluation is presented on rounds or in your clinic note doesn’t imply that the conversation goes from item 1 to item 2 in a linear fashion, with clinician questions followed dutifully by patient answers. The extreme version of this is “checklist psychiatry”, in which DSM symptom criteria are practically read off one by one, with the patient either endorsing or denying them. This is a good way to show a patient that you aren’t actually interested in what they have to say. It can also provide patients who have alternate agendas or who are in denial about their illness with a convenient way to evade whatever it is that’s wrong. In contrast, the best psychiatric evaluations are conversations in which most of the information comes out organically, with clarifying questions asked when needed.

The Mental Status Exam

Much of the outline above speaks for itself, and in this series I will go through the whole thing bit by bit. But instead of starting at the beginning, I’m going to parachute in right at the middle and start with the mental status exam, also called the mental state exam (MSE). The psychiatric evaluation is primarily a conversation with the patient, but it is also a chance for me to observe. Whether we’re talking about why he’s in the hospital, or what medications he takes, or what his early childhood was like, I am observing how he comports himself, how he moves, dresses, smells, speaks, reasons, engages with other people, etc. This is in many ways the heart of the psychiatric evaluation, and starting here will give us an anchor and a conceptual framework with which to orient ourselves going forward. Direct observation of the patient is a good place to start in any field of medicine.

What is the MSE? What is it for? It is a systematic method for describing all the relevant observable characteristics of a patient—notably behaviors, such as speech—as well as making inferences about the patient’s mental state from the observed phenomena, at the time of the evaluation. You can think of the MSE as being similar in some ways to the traditional physical exam because, along with the information gathered from the patient’s history, it is the tool most likely to yield a correct diagnosis. In contrast to the physical exam, however, I am not auscultating a heart or palpating an abdomen at some particular point in time, but rather observing and noting the content and patterns of behavior over time. The items on the MSE are are observed continuously throughout the interview and are not checked off one by one “in order”.

The MSE format I will use: 
1. Appearance
2. Level of Alertness & Orientation
3. Attitude/Demeanor
4. Behaviors
5. Speech & Language
6. Mood
7. Affect
8. Thought Process
9. Thought Content
10. Abnormal Perceptions
11. Idiosyncrasies  
12. Cognition
13. Insight
14. Judgment

The MSE is a kind of “snapshot” of the patient during the encounter. As I do a mental status exam every time I see the patient, it is also used for comparison across time. The behavior changes observed in serial MSEs are often essential for tracking the course of an illness. A well written mental status exam, along with some pertinent information from the history of present illness, should point towards a diagnosis, or at least point in a promising direction. Additionally, the MSE helps me communicate what I saw to another psychiatrist.

As with the psychiatric evaluation as a whole, the order of the MSE varies and is basically convention. The cognitive exam can be considered part of the MSE or seperate. Some basic elements of the cognitive exam I’ll merge into the MSE where it makes sense. There are many MSE variations, but all should ultimately capture the same picture of the same patient. Some are more condensed, but I’ll present as full a version as possible.

In part 2, I will go through each element of the MSE along with some basics of the cognitive exam, giving example diagnostic considerations for various findings. Since the only way to truly learn this stuff is by seeing patients, I’ll provide numerous case vignettes for illustration as a substitute for the real thing. Part 3 will bring us back to the “chief complaint”—the beginning of the psychiatric evaluation—where we’ll cover how to prepare for a psychiatric interview and review the general principles of diagnostic interviewing. This will include attention to both the content and process of how an interview proceeds. The remaining installments will take us through the rest of the psychiatric evaluation more or less in the order presented above.

Up Next: MSE Part 2…