4 Classification and assessment in psychiatry4.3 Clinical assessment
4.3.1 History taking and examination of the mental state
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Written by Resident Doctor Committee · Published
Preparation and setting
The history describes change over time, while the mental state examination records what you observe and elicit now. Both keep the patient's account separate from your observations.
Clarify the referral question, and review the records without assuming earlier diagnoses were right.
Arrange privacy, seating, sensory aids and, where needed, a safety plan.
Introduce your role, the purpose and length of the interview, who receives the information and where confidentiality ends.
Types of question
Type | What it is | Example |
|---|---|---|
Open | Leaves the content and wording of the reply to the patient | "Tell me what has been happening." |
Closed | Can be settled with yes, no, a single short fact or a choice of offered answers | "Have you been sleeping?" |
Leading | Worded to imply or press for a particular answer | "You haven't been hearing voices?" |
Compound (double-barrelled) | Bundles two or more enquiries or symptoms into one utterance | "Low and losing weight?" |
Open questions yield a fuller, more informative account in the patient's own words, and a sample of speech and thought form.
At the start of an interview, the main benefit of open questions is rapport and trust, because the patient speaks freely and is listened to without interruption.
Open questions pass control of direction to the patient, whereas closed and focused questions let the clinician steer.
A question is closed if it can be answered with yes, no or one fact, whatever its length, topic or grammar.
Closed questions suit the later part of the interview, to check or exclude less likely symptoms and to contain distracted or overtalkative patients.
Closed questions give poor information early on, with suggestible patients, and when the patient's own account is needed.
The fault in a leading question is its wording, not a closed or narrow format, and it hinders disclosure and an accurate history.
A compound question is unreliable because a single yes or no cannot be attributed to either part.
With a highly suggestible patient, keep rigid, fixed-wording structured questioning to a minimum, because it invites agreement-biased answers. Open, validating, summarising and facilitating techniques do not lead.
Ask about sensitive topics plainly: asking directly about suicide does not increase suicidal thinking.
Interview techniques
Technique | What the interviewer does | Effect or detail |
|---|---|---|
Facilitation | Gives verbal or non-verbal encouragement, such as a nod, open posture or "go on" | Keeps the patient talking on the same subject |
Silence | Makes a deliberate, attentive pause with no demand to respond | Gives time to gather thoughts and feelings, so difficult material may surface |
Clarification | Asks the patient to make a vague term or phrase they used more precise | Stops the interviewer assuming a meaning and can uncover hidden psychopathology |
Restatement | Feeds back the patient's content in other words | |
Repetition | Echoes the patient's words verbatim | "Utterly worthless, you said." |
Summation | Periodically draws several strands together, usually at the end of a topic | The patient confirms, corrects or adds to it |
Transition | Deliberately closes one topic and moves to a new one | Ideally smooth and cued by something the patient has just said |
Redirection | Brings a patient who has drifted onto a side issue back to a topic already raised | Briefly acknowledges the digression first |
Postponement | Consciously and explicitly defers a sensitive topic | Commits to reopen it at a suitable time |
Symptom expectation (gentle assumption) | Presupposes that a behaviour not yet mentioned is present | Makes a flat denial harder and invites an honest account of something often concealed |
Normalisation | Places an embarrassing behaviour within common experience before asking about it | Lowers shame, making a truthful answer easier |
Facilitation is a specific move, whereas rapport is the broad relationship goal of the whole interview.
Transition opens a new topic, whereas redirection returns to one already raised.
Confrontation
Confrontation is calmly and respectfully pointing out a discrepancy or pattern that the patient is missing, minimising or denying, so that they can face it and reflect.
The discrepancy may lie between two statements, between belief and behaviour, or between the patient's account and observed evidence.
Avoidance is a pattern that can be confronted, as in "You change the subject there."
Harsh confrontation ends disclosure.
Supportive techniques
Technique | What it is | Example |
|---|---|---|
Validation | Normalises an emotional response, such as tears, to ease embarrassment so the interview can continue | "Most people would be frightened." |
Legitimation | Tells the patient a feeling is an understandable, reasonable response to their situation, going beyond merely noticing it | |
Acknowledgement | Openly names an emotion or reaction visible in the interview, without questioning or challenging it | Strengthens rapport at painful moments |
Support | The interviewer puts their own role forward, saying they are on the patient's side and will do all they can | |
Encouragement | Builds confidence from the patient's own past coping | Having returned to work after a previous episode |
Reinforcement | Explicitly approves or praises a specific behaviour so that it recurs | "That was hard to say." |
Statement of respect | A genuine, specific comment recognising the patient's strengths or achievements | "Holding that job took some doing." |
Validation is purely supportive and is not used to elicit information.
Reinforcement praises a behaviour, such as disclosing or an achievement, whereas interpretation offers a view of its underlying meaning.
A statement of respect conveys regard and reinforces the behaviour praised, whereas validation acknowledges a feeling as understandable.
Special interview situations
A reticent patient opens up through genuine personal interest, common ground drawn from prior information, a flexible rather than template-driven interview, and time across more than one encounter.
Use a trained professional interpreter, not a relative or bilingual staff member, whose dual role compromises confidentiality and impartiality. Never use children.
Good practice with an interpreter is to brief them, match the dialect, address the patient directly and debrief afterwards.
Drug-assisted (barbiturate) interviewing, or narcoanalysis, makes the sedated subject suggestible, so the framing of questions shapes the answers. It does not guarantee a truthful account.
When a patient discloses a persecutory delusion with risk content, respond with open, non-confrontational enquiry into how the belief arose, neither colluding with it nor contradicting it.
With psychotic patients, acknowledge the distress, ask what they have done about the belief, and expect the suspicion to include you.
Situation | Adaptations |
|---|---|
Children and adolescents | Offer time alone, explain confidentiality, obtain school and parental information |
Intellectual disability | Concrete questions, one idea at a time, no leading or acquiescence-prone questions, collateral history |
Autism | Clear questions, predictable structure, sensory adjustments, processing time |
Cognitive impairment | Shorter, repeated contacts in a familiar place, simple sentences, informant history |
Severe distress | Containment before completeness, shorter contact, return later |
Intoxication and agitation | Defer detail, assess risk and physical state now, attend to exit routes |
Taking the history
Identify each source and its limits, such as intoxication, cognitive difficulty, language or distress, and seek collateral information when cognition, insight, consistency or safety is uncertain.
You may listen to an informant without the patient's consent, but disclosing information needs consent or another justification.
Record discrepancies between accounts rather than silently choosing one.
Area | Record |
|---|---|
Presenting complaints | Onset, course, severity, triggers, functional effect, the patient's explanation |
Previous psychiatric | Episodes, admissions and legal status, self-harm, violence, each treatment's dose, duration and outcome |
Medical and medication | Neurological disease, seizures, head injury; all medicines, including over-the-counter and herbal |
Substances | Amount, pattern, dependence, harms, abstinent periods |
Family | Psychiatric, neurological and medical illness, suicide, relationships and support |
Personal and social | Birth, milestones, education, adversity and abuse, work, relationships, housing, finances, culture |
Premorbid personality | Usual relationships, coping, interests and temperament, judged from earlier functioning and collateral |
Forensic | Charges, convictions, violence, fire-setting, sexual risk |
A brief or low-dose course of treatment may not have been adequate.
Medicines that can cause psychiatric symptoms include corticosteroids, dopamine agonists, interferon, mefloquine and levetiracetam.
A systematic review screens beyond the presenting complaint: mood, anxiety, psychosis, obsessions, trauma, eating, sleep, cognition, somatic symptoms and substance use.
The mental state examination
Domain | Record |
|---|---|
Appearance | Dress, self-care, nutrition and injuries, against age and usual presentation |
Behaviour | Rapport, arousal, psychomotor activity, abnormal movements, responses to unseen stimuli |
Speech | Amount, rate, pressure, volume, rhythm, articulation |
Mood and affect | Mood is the sustained state the patient describes, quoted; affect is its observed expression and congruence |
Thought | Stream, form, content (including delusions and thoughts of harm), ownership |
Perception | Modality, content, conviction, distress; for commands, past responses and ability to resist |
Cognition | Consciousness and attention first, then orientation, memory, language, executive and visuospatial function |
Appearance and behaviour
Describe what you see without assuming its cause, since unusual clothing may reflect style, culture, disability or illness.
In mania, dress is flamboyant, colourful, poorly coordinated and sometimes provocative, with conspicuous accessories, as rated on the Young Mania Rating Scale appearance item.
Behaviour can be sampled by time (recording at preset clock intervals) or by event (recording each occurrence of the target behaviour).
Cognition
Assess attention before other tests, because an inattentive patient gives unreliable memory results, and assess altered awareness for delirium.
Insight and capacity
Insight is graded. Intellectual insight accepts the illness and owns its internal cause without changing behaviour, whereas emotional insight leads to real behavioural change.
Refusing medication alone does not show that insight is lacking.
Capacity is decision-specific and time-specific. Under the Mental Capacity Act 2005, ask whether an impairment of mind or brain leaves the person unable to understand, retain, use or weigh information, or communicate.
Diagnosis, disagreement or limited insight alone does not establish incapacity.
Formulation: the four Ps
Factor | Meaning | Examples |
|---|---|---|
Predisposing | Long-standing vulnerability | Family history, early adversity, poverty |
Precipitating | The specific recent event, shortly before onset, that triggers the current episode | Bereavement, redundancy, medication change |
Perpetuating | Keeps the episode going | Continued substance use, rumination, isolation |
Protective | Strengths that support safety or recovery | Insight, supportive relationships, employment |
Each factor is considered across biological, psychological and social domains, and its role depends on timing and context.