Psychiatric assessment and

diagnosis 1
The psychiatric assessment is different from a medical • Chairs should be at the same level and arranged at an
or surgical assessment in that: (1) the history taking is of- angle, so that you are not sitting directly opposite the
ten longer and requires understanding each patient’s unique patient.
background and environment; (2) a mental state examina- • Establishing rapport is an immediate priority and
tion (MSE) is performed; and (3) the assessment can in itself requires the display of empathy and sensitivity by the
be therapeutic. Fig. 1.1 provides an outline of the psychiat- interviewer.
ric assessment, which includes a psychiatric history, MSE, • Notes may be taken during the interview; however,
risk assessment, physical examination and formulation. explain to patients that you will be doing so. Make sure
that you still maintain good eye contact.
• Ensure that both you and the patient have an
unobstructed exit should it be required.
INTERVIEW TECHNIQUE • Carry a personal alarm and/or know where the alarm
in the consulting room is, and check you know how to
• Whenever possible, patients should be interviewed in work the alarms.
settings where privacy can be ensured – a patient who • Introduce yourself to the patient and ask them how
is distressed will be more at ease in a quiet office than they would like to be addressed. Explain how long the
in an accident and emergency cubicle. interview will last. In examination situations, it may

Psychiatric history
• Identifying information
• Presenting complaint
• History of presenting complaint
• Past psychiatric history
• Past medical history
• Current medication
• Family history
• Personal history
• Social circumstances
Psychiatric history • Alcohol and substance use
Mental state examination • Forensic history
• Premorbid personality
Physical examination
Risk assessment

Mental state examination

• Appearance
Formulation • Behaviour and psychomotor function
• Rapport
• Speech
• Mood and affect
• Thought form and content
• Perception
• Cognition
• Insight

Risk assessment
Formulation • Self: self-harm, self-neglect, exploitation
• Description of the patient • Others: aggression, sexual assault, children
• Differential diagnosis
• Aetiology
• Management
• Prognosis

Fig. 1.1 Outline of the psychiatric assessment procedure.

3 
 Psychiatric assessment and diagnosis

prove helpful to explain to patients that you may need Identifying information
to interrupt them due to time constraints.
• Keep track of and ration your time appropriately. • Name
• Flexibility is essential (e.g. it may be helpful to put • Age
a very anxious patient at ease by talking about their • Marital status and children
background before focusing in on the presenting • Occupation
complaint). • Reason for the patient’s presence in a psychiatric setting
(e.g. referral to out-patient clinic by family doctor,
admitted to ward informally having presented at casualty)
HINTS AND TIPS • Legal status (i.e. if detained under mental health
legislation)
Arrange the seating comfortably, and in a way that
For example:
allows everyone a clear exit, before inviting the
Mrs LM is a 32-year-old married housewife with two chil-
patient into the room.
dren aged 4 and 6 years. She was referred by her family doctor
to a psychiatric out-patient clinic.

Make use of both open and closed questions when Presenting complaint
appropriate:
Closed questions limit the scope of the response to one- or Open questions are used to elicit the presenting complaint.
two-word answers. They are used to gain specific informa- Whenever possible, record the main problems in the pa-
tion and can be used to control the length of the interview tient’s own words, in one or two sentences, instead of using
when patients are being over-inclusive. For example: technical psychiatric terms. For example:
Mrs LM complains of ‘feeling as though I don’t know who
• Do you feel low in mood? (Yes or no answer)
I am, like I’m living in an empty shell’.
• What time do you wake up in the morning? (Specific
Patients frequently have more than one complaint, some of
answer)
which may be related. It is helpful to organize multiple pre-
Note that closed questions can be used at the very begin- senting complaints into groups of symptoms that are related;
ning of the interview, as they are easier to answer and help for instance, ‘low mood’, ‘poor concentration’ and ‘lack of en-
to put patients at ease (e.g. ‘Do you live locally?’; ‘Are you ergy’ are common features of depression. For example:
married?’; see Identifying information later). Mrs LM complains firstly of ‘low mood’, ‘difficulty sleeping’
Open questions encourage the patient to answer freely and ‘poor self-esteem’, and secondly of ‘taking to the bottle’
with a wide range of responses and should be used to elicit associated with withdrawal symptoms of ‘shaking, sweating
the presenting complaint, as well as feelings and attitudes. and jitteriness’ in the morning.
For example: It is not always easy to organize patients’ difficulties into
• How have you been feeling lately? a simple presenting complaint in psychiatry. In this case,
• What has caused you to feel this way? give the chief complaint(s) as the presenting complaint, and
cover the rest of the symptoms or problems in the history of
the presenting complaint.
COMMUNICATION

Rapport building is vital when working in History of presenting complaint

mental health. Always think why a patient may
have difficulty establishing one with you (e.g.
This section is concerned with eliciting the nature and devel-
opment of each of the presenting complaints. The following
persecutory delusions, withdrawal, apathy). Failure
headings may be helpful in structuring your questioning:
to establish rapport should never be due to the
• Duration: when did the problems start?
interviewer.
• Development: how did the problems develop?
• Mode of onset: suddenly, or over a period of time?
• Course: are symptoms constant, progressively
worsening or intermittent?
PSYCHIATRIC HISTORY • Severity: how much is the patient suffering? To what
extent are symptoms affecting the patient’s social and
The order in which you take the history is not as impor­ occupational functioning?
tant as being systematic, making sure you cover all the • Associated symptoms: certain complaints are associated
essential subsections. A typical format for taking a psy- with clusters of other symptoms that should be
chiatric history is outlined in Fig. 1.1 and is described in enquired about if patients do not mention them
detail below. spontaneously. This is the same approach as in other

4
 Psychiatric history 1

Table 1.1 Typical questions used to elicit specific

• Delusions and hallucinations (psychosis)
psychiatric symptoms
• Free-floating anxiety, panic attacks or phobias
Questions used to elicit… Chapter (anxiety disorders)
Suicidal ideas 6 • Obsessions or compulsions (obsessive-
Depressive symptoms 11 compulsive disorder)
Mania/hypomania 10 • Alcohol or substance abuse
Delusions 9
Hallucinations 9
Symptoms of anxiety 12
Dissociative symptoms 14 HINTS AND TIPS
Obsessions and 13 Depression and obsessive-compulsive
compulsions
symptoms often coexist (>20%), with onset
Somatoform disorders 15 of obsessive-compulsive symptoms occurring
Memory and cognition 7 before, simultaneously with or after the onset of
Problem drinking 8 depression. You may find it useful to have a set of
Symptoms of anorexia and 16 screening questions ready to use.
bulimia
Symptoms of insomnia 25

specialties; for example, enquiring about nausea,

Past psychiatric history
diarrhoea and distension when someone reports This is an extremely important section, as it may provide
abdominal pain. When ‘feeling low’ is a presenting clues to the patient’s current diagnosis. It should include:
complaint, biological, cognitive and psychotic features • Previous or ongoing psychiatric diagnoses
of depression, as well as suicidal ideation, should be • Dates and duration of previous mental illness episodes
asked about. You can also ask about symptom clusters • Previous treatments, including medication,
for psychosis, anxiety, eating problems, substance use psychotherapy and electroconvulsive therapy
and cognitive problems, among others. Also, certain • Previous contact with psychiatric services (e.g.
symptoms are common to many psychiatric conditions, referrals, admissions)
and these should be screened for (e.g. a primary • Previous assessment or treatment under mental health
complaint of insomnia may be a sign of depression, legislation
mania, psychosis or a primary sleep disorder). • History of self-harm, suicidal ideas or acts
• Precipitating factors: psychosocial stress frequently
precipitates episodes of mental illness (e.g.
bereavement, moving house and relationship Past medical history
difficulties). Enquire about medical illnesses or surgical procedures. Past
Table  1.1 directs you to the relevant chapters with ex- head injury or surgery, neurological conditions (e.g. epi-
ample questions for different components of the history lepsy) and endocrine abnormalities (e.g. thyroid problems)
and MSE. are especially relevant to psychiatry.

Current medication
HINTS AND TIPS Note all the medication patients are using, including psy-
chiatric, nonpsychiatric and over-the-counter drugs. Also
It is useful to learn how to screen patients for
enquire how long patients have been on specific medication
common symptoms. This is especially so with and whether it has been effective. Nonconcordance, as well
patients who are less forthcoming with their as reactions and allergies, should be recorded.
complaints. Remember to ask about:
• Low mood (depression) Family history
• Elevated mood and increased energy
(hypomania and mania) • Enquire about the presence of psychiatric illness
(including suicide and substance abuse) in family
members, remembering that genetic factors are

5 
 Psychiatric assessment and diagnosis

implicated in the aetiology of many psychiatric

conditions. A family tree may be useful to summarize COMMUNICATION
information. A history of childhood abuse is important to detect,
• Enquire whether parents are still alive and, if not,
but it can feel awkward to ask about. Most people
causes of death. Also ask about significant physical
respond well to being straightforwardly asked
illnesses in the family.
• Ask whether the patient has any siblings and, if so, ‘Would you say you were ever abused in any way
where they are in the birth order. when you were growing up?’ In young people, or
• Enquire about the quality of the patient’s relationships those you are struggling to build a rapport with,
with close family members. a more graded approach may be preferable (e.g.
‘When was your first relationship? When was your
Personal history first sexual experience? Have you ever had an
unpleasant sexual experience? Sometimes such
The personal history consists of a brief description of the
experiences are unpleasant because they are
patient’s life. Time constraints will not allow an exhaustive
unwanted or because the person is too young to
biographical account, but you should attempt to include
significant events, perhaps under the following useful understand …?’) Leaving the question open allows
headings: the patient room to answer freely, rather than
simply answering ‘yes’ or ‘no’.
Infancy and early childhood
(until age 5 years)
• Pregnancy and birth complications (e.g. prematurity, Social circumstances
foetal distress, caesarean section)
• Developmental milestones (e.g. age of crawling, This includes accommodation, social supports and relation-
walking, speaking, bladder and bowel control) ships, employment and financial circumstances and hobbies
• Childhood illnesses or leisure activities. It is important to identify if the patient
• Unusually aggressive behaviour or impaired social has current frequent contact with children, in case their pre-
interaction sentation raises any child protection concerns.

Later childhood and adolescence Alcohol and substance use

(until completion of higher education) This section should never be overlooked, as alcohol/­
• History of physical, sexual or emotional abuse
substance-related psychiatric conditions are very common.
• School record (e.g. academic performance, number
The CAGE questionnaire (see Chapter 8) is a useful tool
and type of schools attended, age on leaving, final
to screen for alcohol dependence. If a patient answers af-
qualifications)
firmatively to two or more questions, regard the screen as
• Relationships with parents, teachers and peers. Victim
positive and go on to check if they meet criteria for alcohol
or perpetrator of bullying
dependence syndrome (see Chapter 8). Try to elicit a patient’s
• Behavioural problems, including antisocial behaviour,
typical drinking day, including daily intake of alcohol in
drug use or truancy
units, type of alcohol used, time of first drink of the day and
• Higher education and training
places where drinking occurs (e.g. at home alone or in a pub).
If recreational drugs have been or are being used, record
Occupational record the drug names, routes of administration (intravenous, in-
• Details of types and duration of jobs haled, oral ingestion) and the years and frequency of use.
• Details of and reasons for unemployment and/or Also enquire about possible dependence (Chapter 8).
dismissal

Forensic history
Relationship, marital and sexual history
• Puberty: significant early relationships and experiences, Enquire about the details and dates of previous offences
as well as sexual orientation and antisocial behaviour, including prosecutions, convic-
• Details and duration of significant relationships tions and prison sentences. It is important to ask specifi-
Reasons for break-ups cally about violent crime, the age of the patient’s first violent
• Marriage/divorce details. Children. offence and whether the patient has any charges pending.
• Ability to engage in satisfactory sexual relationships. Pending charges may be a source of stress for the patient,
Sexual dysfunction, fetishes or gender identity and in some cases a reason to report mental health symp-
problems (only enquire if problem is suspected). toms with a view to secondary gain.

6
 Mental state examination 1

Premorbid personality By the time you have finished the psychiatric history, you
should have completed many aspects of the MSE, and you
The premorbid personality is an indication of the patient’s should just need to ask certain key questions to finish this
personality and character before the onset of mental illness. process off. The individual aspects of the MSE, which
It can be difficult to ascertain retrospectively. Indirect evi- are summarized in Fig. 1.1, are discussed in more detail
dence of it can be provided from the personal history (e.g. below.
Have they ever been able to hold down a job or been in a There is some variation in the order in which the MSE is
long-term relationship? Have their interests changed?). reported (e.g. speech is sometimes described before mood,
Patients may be asked directly about their personality be- and sometimes before thought form). As long as you in-
fore they became ill, or it may be useful to ask a close family clude the information, the exact order is not important.
member or friend about a patient’s premorbid personality.
For example:
A young man with schizophrenia, with prominent negative HINTS AND TIPS
symptoms of lack of motivation, lack of interest and poverty
Don’t just ask questions and write down answers!
of thought, was described by his mother as being outgoing,
intelligent and ambitious before becoming ill. Appearance and behaviour are vital to the mental
state examination, especially with less communicative
patients. Posture, facial expression, tone of voice,
COMMUNICATION
spontaneity of speech, state of relaxation and
One way to explore premorbid personality in a movements made are all important. You may find
patient with some insight is to ask questions it helpful to practise with a colleague – try writing
such as: ‘How would people have described you down 10 points that describe their appearance and
before?’ ‘How about now?’ behaviour.

MENTAL STATE EXAMINATION Appearance

• Physical state: how old does the patient appear? Do they
The MSE describes an interviewer’s objective impression of appear physically unwell? Are they sweating? Are they
many aspects of a patient’s mental functioning at a certain too thin or obese?
point in time. Whereas the psychiatric history remains rela- • Clothes and accessories: are clothes clean? Are
tively constant, the MSE may fluctuate from day to day or hour accessories appropriate (e.g. wearing sunglasses
to hour. It is useful to try and gather as much evidence as possi- indoors)?
ble about the MSE while doing the psychiatric history, instead • Do clothes match? Are clothes appropriate to the
of viewing this as a separate section. In fact, the MSE begins weather and circumstances, or are they bizarre? Is the
the moment you meet the patient. In addition to noting their patient carrying strange objects?
appearance, you should observe how patients first behave on • Self-care and hygiene: does the patient appear to have
meeting you. This includes their body language and the way been neglecting their appearance or hygiene (e.g.
that they respond to your attempts to establish rapport. unshaven, dirty tangled hair, malodorous, dishevelled)?
Is there any evidence of injury or self-harm (e.g. cuts to
COMMON PITFALLS wrists or forearms)?

The MSE, like a physical examination, is a snap-

shot of a person’s presentation during the interview.
Behaviour and psychomotor
Only record what the patient demonstrates or function
experiences during the interview (e.g. if a patient This section focuses on all motor behaviour, including ab-
reports having had a hallucination 5 minutes before normal movements such as tremors, tics and twitches; dis-
you entered the room, that would be described in plays of suspiciousness, aggression or fear; and catatonic
the history, not the MSE – much as you wouldn’t features. Documenting patients’ behaviour at the start of,
record that someone had had abdominal pain and during, the interview is an integral part of the MSE, and
prior to but not during your physical examination). should be done in as much detail as possible. For example:
Including history in the MSE is a very common Mrs LM introduced herself appropriately, although only
made fleeting eye contact. She sat rigidly throughout the first
mistake in student case reports.
half of the interview, mostly staring at the floor and speaking
very softly. She became tearful halfway through the interview

7 
 Psychiatric assessment and diagnosis

when talking about her lack of self-esteem. After this her pos-
ture relaxed, her eye contact improved and there were mo- COMMON PITFALLS
ments when she smiled. There were no abnormal movements.
Note that disorganized, incoherent or bizarre
The term ‘psychomotor’ is used to describe a patient’s
speech (e.g. flight of ideas) is usually regarded as
motor activity as a consequence of their concurrent mental
processes. Psychomotor abnormalities include retardation a thought disorder and is described later in the
(slow, monotonous speech; slow or absent body move- thought form section.
ments) and agitation (inability to sit still; fidgeting, pacing
or hand-wringing; rubbing or scratching skin or clothes).
Note whether you can establish a good rapport with pa-
tients. What is their attitude towards you? Do they make
good eye contact, or do they look around the room or at
Mood and affect
the floor? Patients may be described as cooperative, cor- Mood refers to a patient’s sustained, subjectively experi-
dial, uninterested, aggressive, defensive, guarded, suspi- enced emotional state over a period of time. Affect refers to
cious, fearful, perplexed, preoccupied or disinhibited (that the transient ebb and flow of emotion in response to stimuli
is, a lowering of normal social inhibitions; e.g. being over-­ (e.g. smiling at a joke or crying at a sad memory).
familiar or making sexually inappropriate comments), Mood is assessed by asking patients how they are feel-
amongst many other adjectives. ing and might be described as depressed, elated, anxious,
guilty, frightened, angry, etc. It is described subjectively
(what the patient says they are feeling) and objectively
HINTS AND TIPS (what your impression of their prevailing mood is during
Observations of appearance and behaviour the interview) For example, her mood was subjectively ‘rock
bottom’ and objectively low. Affect is assessed by observing
may also reveal other useful information (e.g.
patients’ posture, facial expression, emotional reactivity
extrapyramidal side-effects from antipsychotic
and speech. There are two components to consider when
medication). It is useful to remember to look for: assessing affect:
• Parkinsonism: drug-induced signs are most
1. The appropriateness or congruity of the observed
commonly a reduced arm swing and unusually affect to the patient’s subjectively reported mood (e.g.
upright posture while walking. Tremor and a woman with schizophrenia who reports feeling
rigidity are late signs, in contrast to idiopathic suicidal but has a happy facial expression would be
parkinsonism. described as having an incongruous affect).
• Acute dystonia: involuntary sustained muscular 2. The range of affect or range of emotional expressivity.
contractions or spasms. In this sense, affect may be:
• Akathisia: subjective feeling of inner restlessness • Within the normal range
and muscular discomfort, often manifesting • Blunted/flat: a noticeable reduction in the normal
with an inability to sit still, ‘jiggling’ of the legs
intensity of emotional expression, as evidenced by a
monotonous voice and minimal facial expression
(irregularly, as opposed to a tremor, which would
Note that a labile mood refers to a fluctuating mood state
be regular) or apparent psychomotor agitation.
that alternates between extremes (e.g. a young man with
• Tardive dyskinesia: rhythmic, involuntary a mixed affective episode alternates between feeling over-
movements of head, limbs and trunk, especially joyed, with pressure of speech, and miserable, with suicidal
chewing, grimacing of mouth and making ideation).
protruding, darting movements with the tongue.
Thoughts
Problems with thinking are considered under two headings:
Speech thought form (abnormal patterns of thinking) and thought
Speech should be described in terms of: content (abnormal beliefs).
• Rate of production: pressure of speech in mania; long
pauses and poverty of speech in depression Thought form
• Quality and flow of speech: volume, dysarthria Disordered thinking includes circumstantial and tangen-
(articulation difficulties), dysprosody (unusual speech tial thinking, loosening of association (derailment/knight’s
rhythm, melody, intonation or pitch), stuttering move thinking), flight of ideas and thought blocking (see
• Word play: punning, rhyming, alliteration (generally Chapter  9 for the definitions of these terms). Whenever
seen in mania) possible, record patients’ disorganized speech word for

8
 Risk assessment 1

word, as it can be very difficult to label disorganized think- listening or quizzically looking at hallucinatory objects
ing with a single technical term, and written language may around the room.
be easier to evaluate than spoken language.
RED FLAG
Thought content: delusions, obsessions
Elementary hallucinations are more common
and overvalued ideas
in delirium, migraine and epilepsy than in primary
It is diagnostically significant to classify delusions as:
psychiatric disorders.
• Primary or secondary
• Mood congruent or mood incongruent
• Bizarre or nonbizarre
• According to the content of the delusion (summarized
in Table 9.1)
Cognition
See Chapter 9 for a detailed description of these terms. The cognition of all patients should be screened by check-
An obsession is an involuntary thought, image or im- ing orientation to place and time. Depending on the cir-
pulse that is recurrent, intrusive and unpleasant and enters cumstances, a more thorough cognitive assessment may
the mind against conscious resistance. Patients recognize be required. Cognitive tests, including tests of generalized
that the thoughts are a product of their own mind. See cognitive abilities (e.g. consciousness, attention, orienta-
Chapter 13 for more information. tion) and specific abilities (e.g. memory, language, exec-
utive function, praxis, perception), are discussed fully in
Chapter  7. Figure 7.1 and Tables 7.1, 7.2 and 7.6 describe
COMMUNICATION methods of testing cognition.
Some psychiatrists include thoughts of self-harm,
suicide or harm to others under thought content, Insight
while others mention it only under risk assessment. Insight is not an ‘all or nothing’ attribute. It is often de-
As long as you mention it, it doesn’t matter where. scribed as good, partial or poor, although patients really
lie somewhere on a spectrum and vary over time. The key
questions to answer are:
• Does the patient believe they are unwell in any way?
Perception • Do they believe they are mentally unwell?
Hallucinations are often mentioned during the history. • Do they think they need treatment (pharmacological,
However, this is not always the case, so it is important that psychological or both)?
you specifically enquire about abnormal perceptual experi- • Do they think they need to be admitted to hospital (if
ences (perceptual abnormalities are defined and classified relevant)?
in Chapter  9). If patients admit to problems with percep-
tion, it is important to ascertain:
• Whether the abnormal perceptions are
hallucinations, pseudohallucinations, illusions or RISK ASSESSMENT
intrusive thoughts
• From which sensory modality the hallucinations Although it is extremely difficult to make an accurate as-
appear to arise (i.e. are they auditory, visual, olfactory, sessment of risk based on a single assessment, clinicians are
gustatory or somatic hallucinations – see Chapter 9) expected, as far as is possible, to establish some idea of a
• Whether auditory hallucinations are elementary (a patient’s risk to:
very simple abnormal perception; e.g. a flash or a • Self: through self-harm, suicide, self-neglect or
bang) or complex. If complex, are they experienced exploitation by others. Chapter 6 explains the
in the first person (audible thoughts, thought echo), assessment of suicide risk in detail.
second person (critical, persecutory, complimentary • Others: includes violent or sexual crime, stalking and
or command hallucinations) or third person (voices harassment. Chapter 32 discusses key principles in
arguing or discussing the patient, or giving a running assessing dangerousness.
commentary)? • Children: includes physical, sexual or emotional
It is also important to note whether patients seem to be abuse, as well as neglect or deprivation. Child abuse is
responding to hallucinations during the interview, as evi- discussed in more detail in Chapter 30.
denced by them laughing inappropriately as though they are • Property: includes arson and physical destruction of
sharing a private joke, suddenly tilting their head as though property.

9 
 Psychiatric assessment and diagnosis

• Relevant background details (e.g. past psychiatric

RED FLAG history, positive family history)
Risk assessment is a vital part of psychiatric • Positive findings in the MSE and physical
assessment. You should always assess risk to self examination
and others. Table 1.2 shows a case summary as a formulation.

HINTS AND TIPS

When presenting your differential diagnosis,

PHYSICAL EXAMINATION remember that two or more psychiatric disorders
can coexist (e.g. depression and alcohol abuse).
The psychiatric examination includes a general physical In this event, it is important to ascertain whether
examination, with special focus on the neurological and the conditions are independent or related (e.g.
endocrine systems. Always remember to look for signs alcohol abuse that has developed secondary to the
relevant to the psychiatric history (e.g. signs of liver dis- depressive symptoms of emptiness and difficulty
ease in patients who misuse alcohol, ophthalmoplegia or
sleeping).
ataxia in someone withdrawing from alcohol (indicating
Wernicke encephalopathy), signs of self-harm in patients
with a personality disorder and signs of intravenous drug
use (track marks) in patients who use drugs). Also, ex-
amine for side-effects of psychiatric medication (e.g. Differential diagnosis
parkinsonism, tardive dyskinesia, dystonia, hypotension,
obesity and other cardiometabolic sequelae, signs of lith- The differential diagnosis is mentioned in order of decreas-
ium toxicity). It may not be possible to complete a de- ing probability. Only mention conditions that you have ob-
tailed physical examination in an exam situation, but you tained evidence about in your assessment, as you should be
should always recommend that it should be done. Always able to provide reasons for and against all the alternatives
make a point of mentioning your positive physical find- on your list. Table 1.2 provides an example of a typical dif-
ings when summarizing the case. ferential diagnosis.

Aetiology
The exact cause of most psychiatric disorders is often un-
THE FORMULATION: PRESENTING known, and most cases seem to involve a complex interplay
THE CASE of biological, social and psychological factors. In clinical
practice, psychiatrists are especially concerned with the
‘Formulation’ is the term psychiatrists use to describe the question: ‘What factors led to this patient presenting with
integrated summary and understanding of a particular pa- this specific problem at this specific point in time?’ That is,
tient’s problems. The formulation usually includes: what factors predisposed to the problem, what factors pre-
• Description of the patient cipitated the problem, and what factors are perpetuating the
• Differential diagnosis problem? Table 1.2 illustrates an aetiology grid that is very
• Aetiology helpful in structuring your answers to these questions in
• Management terms of biological, social and psychological factors – the
• Prognosis emphasis should be on considering all the blocks in the grid,
not necessarily on filling them.
Description of the patient
The patient may be described: (1) in detail by recounting
Management
all the information obtained under the various headings Investigations
in the psychiatric history and MSE; or (2) in the form of Investigations are considered part of the management plan
a case summary. The case summary consists of one or two and are performed based on findings from the psychiatric
paragraphs and contains only the salient features of a case, assessment. Appropriate investigations relevant to specific
specifically: conditions are given in the relevant chapters. Familiarize
• Identifying information yourself with these, as you should be able to give reasons for
• Main features of the presenting complaint any investigation you propose.

10
 The formulation: presenting the case 1

Table 1.2 Example of a case formulation (differential diagnosis, aetiology, management)

Differential diagnosis
Diagnosis Comments
1. Schizophrenia For: symptoms present for more than 1 month
For: ICD-10 and first-rank symptoms of delusions of control or passivity
(thought insertion); delusional perception; and third person running
commentary hallucinations
For: clear and marked deterioration in social and work functioning
2. Schizoaffective disorder For: typical symptoms of schizophrenia
Against: no prominent mood symptoms
3. Mood disorder (either manic or depressive Against: on mental state examination, mood was mainly suspicious (as
episode) with psychotic features opposed to lowered or elevated) and appeared secondary to delusional
beliefs
Against: no other prominent features of mania or depression
Against: mood-incongruent delusions and hallucinations
4. Substance-induced psychotic disorder Against: long duration of symptoms
Against: no evidence of illicit substance or alcohol use
5. Psychotic disorder secondary to a medical Against: no signs of medical illness or abnormalities on physical
condition examination
Aetiology
Biological Psychological Social
Predisposing Family history of - -
(what made the patient prone to this schizophrenia
problem?)
Precipitating The peak of onset for - Break-up of
(what made this problem start now?) schizophrenia for men relationship Recently
is between 18 and started college
25 years
Perpetuating Poor concordance with High expressed Lack of social support
(what is maintaining this problem?) medication due to lack emotion family
of insight
Management
1. Investigations
2. Management plan below
Term Biological Psychological Social
Immediate to Antipsychotic Establish therapeutic Admission to hospital
short-term medication, with relationship Allocation of care coordinator (care programme
benzodiazepines if Support for family approach)
necessary (carers) Help with financial, accommodation and social
problems
Medium- to long-term Review progress in out- Relapse prevention Regular review under care programme approach
patient clinic work Consider day hospital
Consider another Consider cognitive Vocational training
antipsychotic behavioural therapy and
then clozapine for family therapy
non-response
Consider depot
medication for
concordance problems
Prognosis
Assuming Mr PP has a diagnosis of schizophrenia, it is likely his illness will run a chronic course, showing a relapsing
and remitting pattern. Being a young man with a high level of education, Mr PP is particularly at risk for suicide,
especially following discharge from hospital. Good prognostic factors include a high level of premorbid functioning and
the absence of negative symptoms.

11 
 Psychiatric assessment and diagnosis

Organization). The eleventh revision, ICD-11, is close

CASE SUMMARY to completion at the time of writing (https://icd.who.
Mr PP is a 23-year-old, single man in full-time
int/browse11/l-m/en).
2. DSM-5: the fifth edition of the Diagnostic and
education who recently agreed to informal
Statistical Manual of Mental Disorders (published by
hospital admission. He presented with a 6-month
the American Psychiatric Association, 2013).
history of hearing voices and maintaining
Both the ICD-10 and the DSM-5 make use of a categorical
bizarre beliefs that he was being subjected to
classification system, which refers to the process of dividing
government experiments. During this time, his
mental disorders into discrete entities by means of accurate
college attendance had been uncharacteristically descriptions of specific categories. In contrast, a dimensional
poor, he had terminated his part-time work, and approach rejects the idea of separate categories, hypothesiz-
he had become increasingly socially withdrawn. ing that mental conditions exist on a continuum that merges
He has no history of psychiatric illness and into normality. This better reflects reality but is harder to put
denies the use of alcohol or illicit substances; into clinical practice; for example, would someone whose
however, he did mention that his maternal uncle mood is ‘one standard deviation lower than normal’ be likely
suffers from schizophrenia. On mental state to benefit from treatment with an antidepressant?
examination, he appeared unkempt and behaved The ICD-10 categorizes mental disorders according to de-
scriptive statements and diagnostic guidelines. The DSM-5
suspiciously. He had delusions of persecution,
categorizes mental disorders according to operational defi-
reference and thought control, as well as
nitions, which means that mental disorders are defined by
delusional perception. He also described second
a series of precise inclusion and exclusion criteria. Note that
person command hallucinations and third person the research version of the ICD-10 (Diagnostic Criteria for
running commentary hallucinations. He appeared Research) also makes use of operational definitions.
to have no insight into his mental illness, as he In general, both the ICD-10 and the DSM-5 propose a
refused to consider that he might be unwell. hierarchical diagnostic system, whereby disorders higher on
There were no abnormalities on physical the hierarchical ladder tend to be given precedence. As a
examination. broad rule, symptoms related to another medical condition
or substance use take precedence over conditions such as
schizophrenia and mood disorders, which take precedence
over anxiety disorders. This does not mean that patients
Specific management plan may not have more than one diagnosis (which they may);
It may help to structure your management plan by consider- rather, it means that clinicians should:
ing the biological, social and psychological aspects of treat- • Always consider a medical or substance-related cause
ment (the biopsychosocial approach) in terms of immediate of mental disorder symptoms before any other cause.
to short-term and medium- to long-term management. See • Remember that certain conditions have symptoms
Table 1.2 for an example of this method. in common. For example, schizophrenia commonly
presents with features of depression and anxiety, and
Prognosis depression commonly presents with features of anxiety;
in both cases, the treatment of the primary condition
The prognosis is dependent on two factors: results in resolution of the symptoms – a separate
1. The natural course of the condition, which can be diagnosis for every symptom is not needed.
predicted based on studies of patient populations; these The ICD-10 and the DSM-5 share similar diagnostic cate-
are discussed for each disorder in the relevant chapters. gories and are fairly similar for the most part, with further
2. Individual patient factors (e.g. social support, convergence planned between DSM-5 and ICD-11.
concordance with treatment, comorbid substance abuse) The DSM-5 and the current draft of ICD-11 (not yet pub-
See Table 1.2 for an example. lished) take a lifespan approach to diagnoses. Classification
begins with neurodevelopmental disorders (autism, psy-
chotic disorders), followed by disorders that often present
in early adulthood (bipolar, depression, anxiety) and ending
CLASSIFICATION IN PSYCHIATRY with neurocognitive disorders (dementia).
These classification systems are evolving over time as new ev-
There are two main categorical classification systems in idence about the aetiology of mental disorders arises. Currently,
psychiatry: psychiatric disorders are classified by clustering symptoms, signs
1. ICD-10: the tenth revision of the International and behaviours into syndromes. As yet, they are not based on a
Classification of Diseases, Chapter V (F) – Mental and clear understanding of pathogenesis. As this develops, classifi-
behavioural disorders (published by the World Health cation systems will continue to change and, hopefully, improve.
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 Classification in psychiatry 1

Chapter Summary

• A psychiatric history is like any other history, except that more attention is given to
personal and social circumstances, and a mental state examination is conducted during it.
• A mental state examination, like a physical examination, is a snapshot of how the person
presents at the time you meet them.
• Physical examination is still important, even in patients who don’t report physical
symptoms.
• Psychiatric diagnostic systems are evolving in light of new understanding of mental
disorder aetiology.

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