Second edition

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Concluding the interview
Once the directive portion of the interview has been completed
it is appropriate to give the patient an opportunity
to speak freely again. If asked whether they have anything
else to add, many patients will offer important information
that they may have either withheld or simply not recalled
earlier. Asking patients whether they have anything they
wish to ask the physician is also appropriate, as the
patients’ questions may reveal much about the concerns
that brought them to the hospital in the first place.
Collateral history
According to Brain (1964), ‘the history obtained from the
patient should always be supplemented, if possible, by an
account of his illness given by a relative or by someone who
knows him well’. This is especially the case when patients
are confused or suffer from poor memory: it is remarkable
how often a collateral history will change a diagnostic
impression, guide further testing or alter proposed treatments.
In obtaining the collateral history, particular attention
should be paid to establishing the patient’s pre-morbid
baseline ability to perform such routine activities of daily
living as bathing, dressing, cooking, feeding, doing housework,
shopping, driving or using public transportation,
and paying bills. Inquiry should also be made regarding
hobbies, such as playing cards or chess, or doing crossword
puzzles. In cases characterized by cognitive deficits, the loss
of these abilities may serve to establish the onset of the current
illness.
Some have expressed concern that interviewing the family
or acquaintances may violate patient confidentiality but
this is simply not the case, provided that the contact knows
already that the patient is in the hospital and that the physician
reveals nothing about the patient while interviewing
the collateral contact. No confidentiality is breached by
introducing oneself as the patient’s physician or by asking
collateral contacts what they know about the patient.
Finally, it is also essential to review old records. This is
sometimes a tedious task but, as with interviewing collateral
sources, it may reveal critical information.
1.2 MENTAL STATUS EXAMINATION
The mental status examination constitutes an essential part
of any neuropsychiatric evaluation and, at a minimum,
should cover each of the items discussed below. Many of
these may be determined during the non-directive portion
of the interview; however, some, especially those concerning
cognition (e.g., orientation, memory), require direct
testing. As some patients may object to cognitive testing, it
is important to smooth the way by indicating that these are
‘routine’ questions to test ‘things such as memory and
arithmetic’, perhaps adding that ‘patients who have had a
1.2 Mental status examination 5
stroke (or whatever illness the patient feels comfortable
discussing) often have difficulties here’. Should patients
remain uncooperative, it may at times be possible to infer
their cognitive status indirectly; for example, during history
taking, by asking the date of a recent event brought up
by the patient.
As noted below, abnormalities on the mental status
examination typically indicate the presence of one of the
major syndromes, such as dementia (Section 5.1), delirium
(Section 5.3), amnesia (Section 5.4), depression (Section
6.1), apathy (Section 6.2), mania (Section 6.3), anxiety
(Section 6.5), psychosis (Section 7.1), and personality
change (Section 7.2), especially the frontal lobe syndrome.
Grooming and dress
Good habits of grooming and dress may suffer in certain
illnesses, sometimes with diagnostically suggestive results.
Depressive patients may find that hopelessness, fatigue,
and anhedonia make them give up all hope of maintaining
their appearance, with the result that grooming and dress
are left in a greater or lesser degree of disarray. Manic
patients, overflowing with exuberance, may truly make a
spectacle of themselves with decorations of make-up and
garish clothing. Patients with psychosis, especially schizophrenia
(Section 20.1) may be quite unkempt and at times
dirty, and their clothing may be bizarre, as, for example,
with multiple layers and a woollen cap, even in the summer;
overall dishevellment may also be seen in frontal lobe
syndrome, dementia, or delirium. Rarely, one may see evidence
of neglect wherein dress and grooming suffer on
only one side of the body (Section 2.1).
General description
An overall and general description of the patient’s behavior
is essential, and gives room for the exercise of whatever literary
talents the physician may possess.
Comments should be made on the relationship of the
patient to the interviewer, noting, for example, whether the
patient is cooperative or uncooperative, guarded, evasive,
hostile, or belligerent. The overall quality of the relationship
may also be of diagnostic importance. For example, as
noted by Bleuler (1924), in schizophrenia, there is often a
‘defect in ... emotional rapport’ (italics in original), such
that ‘the joy of a schizophrenic does not transport us, and
his expressions of pain leave us cold’. By contrast, in
mania, as noted by Kraepelin (1921), ‘the patient feels the
need to get out of himself, to be on more intimate terms
with his surroundings’, such that the physician, willingly or
not, often feels engaged, in one fashion or another, with
the patient; in the case of a euphoric manic it is the rare
physician who can keep from smiling, and in the case of an
irritable manic most physicians will find themselves
becoming, at the very least, on edge.