[The Mental Status Examination]

[Footsteps as man walks heavily down a hospital corridor.]

[Psychiatric Clinic] 

[Muffled talking near the receptionist desk.] 

[Mr. Hawley:] Morning, my name is Hawley, and they told me downstairs at the clinic...

well, they said to come up here...

[Dr. Summers:] Oh yes, Mr. Hawley. I've been expecting you.

[Mr. Hawley:] You, you weren't, I mean, I'm supposed to see a doctor, Dr...

[Dr. Summers:] Summer, that's me.[Mr. Hawley:]  And...

[Dr. Summers:] Won't you come on in?

[Mr. Hawley:] Doctor, is it all right if I go to the bathroom first?

[Dr. Summers:] Why, certainly. Just right out this door and down to your right.

[Narrator:] As physicians, we learn to observe and evaluate the physical status of our patients. 

Often it's necessary to make a similar assessment of mental status. 

The purpose of this film is to demonstrate through technique developed and used by psychiatrists

how we can evaluate the psychological state of an individual from 

from information revealed in an interview. 

Traditional principles of a general medical exam are used in the psychiatric interview. 

However, there are some differences in technique. 

Routinely, with a general medical problem, the doctor first takes a history 

and then does an examination.

The psychiatric portion of the examination, on the other hand, begins at the first contact

with the patient, often before we even begin to take a history. 

Frequently, patients reveal a great deal about themselves in the first moments,

before they officially start talking about their problems. 

The data obtained while taking a history forms an essential part of the psychiatric examination. 

While the physical exam is generally done in a structured sequence of bodily regions and systems,

the psychiatric examination is much less direct and circumscribed, much more flexible and personal, 

and incidentally a good bit of psychological information is uncovered during the physical exam. 

While the usual physical examination requires little activity on the part of the patient,

a psychiatric examination demands the highest degree of active participation by the patient.

He alone can tell us his thoughts and feelings. 

A thorough psychological examination usually takes a number of interviews 

and often many hours. 

What you will see here are pertinent sections of such an examination, a recent interview

with a Mr. Hawley. 

The patient is 45 years old. 

He has mild hypertension, is overweight, complains of back and leg pains 

and feels he can't work. 

He's been on several drugs including hydrazine and phenobarbital. 

His last recorded blood pressure was 118/80.

[Mr. Hawley:] Well, doctor, it's mostly my nerves. 

They got my blood pressure down pretty good at that clinic I went to. 

But it's mostly my nerves now. 

They, they just stay tore to pieces all the time.

[Dr. Summers:] I see. Other things besides your nerves that's been troubling you?

[Mr. Hawley:] No, mostly, mostly my nerves. 

They bother me a lot at night. 

I just can't hardly sleep at night unless that little bottle of medicine they give me...

I take about a teaspoonful of that. 

It's just like that all the time. 

Like I mean, if I'm doing a little old job for anybody and they just say a little old something to me, I...

it just tears me all up inside. 

And I used to could get along with anybody, but it's just getting worse and worser, Doc, 

ever since the accident.

[Dr. Summers:] Accident? What happened? 

[Mr. Hawley:] Well, we was tearing down this building over on the west end, and I was starting up

this ladder to get some bricks and there was some fellas up there on the top, 

and when I started up the ladder, they yelled at me, "Look out!" 

And then this brick came down and hit me right on top of the head.

[Dr. Summers:] This was how long ago?

[Mr. Hawley:] About two years ago. 

I was working with a bunch of brickmasons then. 

I uh, I ain't no brickmason. I'm just a helper.

[Dr. Summers:] What other trouble have you had besides your nerves?

[Mr. Hawley:] Well, I don't have any trouble, before the accident. 

I had some nerve trouble but not so bad. 

Then I mostly worried, worried about work, paying the rent, what I was going to do about my family, 

just tearing me all to pieces, but not all the time, like now.

Ever since that brick hit me on the head, it’s just been getting worse and worser.

[Dr. Summers:] Did the brick knock you out?

[Mr. Hawley:] No, not completely. 

I had a leather cap on, and I wouldn't be here now. 

But that brick came down endwise and hit me right there on top of the head, taking five stitches.

Doctor sewed me up.

[Dr. Summers:] Anything else bother you, besides your nerves?

[Mr. Hawley:] Well, them blackout spells I have. 

I can be walking along just anywhere, and everything will just completely black out.

[Dr. Summers:] You ever have these spells before the accident?

[Mr. Hawley:] No, sir. No, sir. 

Never did have them, not at all. 

Not until I got that lick on the head.

[Dr. Summers:] Did you go back to work after the accident?

[Mr. Hawley:] Yeah, for a while, Doc, but see my problem is that I can't climb anymore. 

I used to could climb anything. 

Now, I can't get six feet off the ground. I, I just fall.

[Dr. Summers:] Has it been a while since you worked?

[Mr. Hawley:] Well, I picked up a little work about a week ago, just a little, two days. 

This last man I worked with, him, I worked for that man for six years, 

and he won't hire me no more, not now.

[Dr. Summers:] How do you feel about this?

[Mr. Hawley:] Well, Doc, it's awful. 

I tell you right now it's awful. 

You with a family that you gotta support. Doc, it's just awful! 

I was getting a little old check there from the welfare, and they cut that off.

[Dr. Summers:] You worked for this boss for six years, and now he won't hire you? 

How do you feel about it?

[Mr. Hawley:] Well, I felt like cussing him out. 

But that won't do no good, they're all like that.

[Dr. Summers:] Well, how does this make you feel inside?

[Mr. Hawley:] I don't know, Doc, pretty upset I guess.

[Dr. Summers:] Upset?

[Mr. Hawley:] Yeah, kind of stirred up, sorta riled.

[Dr. Summes:] Riled? 

Is this the way you feel every time you go in looking for a job,

and people say they just can't hire you? 

[Mr. Hawley:] Doc, a man my age just can't hardly find a job anyway, and when you do get one, 

you gotta take one that nobody else wants. 

And the first thing they want to know is when was the last time you went to see a doctor? 

And you got to tell them or they'll find out. 

So there you are.

[Dr. Summers:] They got you in a fix? 

[Mr. Hawley:] They sure have and a bad fix, too.

[Narrator:] Well, that's just the beginning of the interview and already the psychiatrist,

limiting his own role to the minimum, a question, a word, a nod, just enough to keep the patient talking

and on the right track, has learned a good deal. 

It's the organization of this information, much of it seemingly unrelated,

that we would like to demonstrate here. 

One convenient system is to arbitrarily divide information into four general areas.

The first area we consider includes those things that are most noticeable about the patient:

his behavior and appearance. 

Here we inspect the patient just as we do at the first of a physical examination. 

The obvious strikes us immediately. 

Later, many modifications and nuances will become apparent. 

Secondly, we consider the intellectual processes, 

the content, tempo, and meaning of the patient's thoughts. 

Thirdly, we take into account the emotions, their intensity, range, 

and relationship to external events. 

Fourth, we look at the patient's perceptual functioning, how he sees the world

and his surroundings, whether clearly or with distortions. 

Now using this framework and the patient in our interview, let us go a little more deeply into these four areas

of investigation, describing what we look for, and classifying specific information obtained in this case. 

We consider such things as the patient's age, height, bodily build and posture,

his apparent state of health. 

We look at his clothing, its appropriateness to the occasion and to his situation in life.

Mr. Hawley seems to be in his late 40s. 

He is short and overweight. 

He wears working man's clothes that are neat but rather worn. 

In behavior, we look for mannerisms, compulsions, peculiar habits, for excessive

or diminished activity, for the appropriateness of behavior to the particular situation. 

It's apparent at the start of the interview that the patient is hesitant and ill at ease. 

His manner is deferential. 

His hands are constantly busy. 

His speech is halting and ungrammatical.

We're also interested in the intelligence of the patient, in his memory, recent and remote, 

his general information and knowledge, his capacity for abstract thoughts. 

Thought processes and thought content are of special significance. 

Does the patient think quickly or slowly? 

Coherently or incoherently? 

In an organized or disorganized manner? 

What are his preoccupations, obsessions, delusions, dreams if any? 

Mr. Hawley's thoughts flow smoothly. 

He's preoccupied with ailments and the inability to find work. 

He blames the accident and the resultant damage to his nerves for his predicament.

Emotions...is the patient gay or somber? 

What is the intensity and range of his feelings? 

Are they appropriate to the occasion? 

We can see that Mr. Hawley is anxious, worried, depressed. 

He talks repeatedly of his physical symptoms. 

He's concerned over his family and pessimistic about the chances of finding a job. 

At the same time, he shows a partially hidden rage against those persons and those forces 

whom he believes are responsible. 

He has pretty much withdrawn from the struggle, resigned himself to his fate. 

In perceptual functioning, we consider such things as alertness, attention and orientation. 

We look for evidence of confusion, illusions, and hallucinations. 

We want to know how the patient relates to his surroundings. 

A little later, the interviewing doctor will steer the investigation toward this subtle area. 

It should be remembered that all four areas are interrelated and frequently overlap,

and the revealment of information is gradual and cumulative.

The flashes of insight we receive, no matter how striking, must be sorted and weighed,

not peremptorily judged. 

Now let's pick up the interview shortly after the point where we left off. 

The conversation has turned to family matters.

[Dr. Summers:] So then you and your wife get along pretty well?

[Mr. Hawley:] Yeah, yeah. 

We get along pretty well. 

You see, we've been married 27 years now. 

That's, that's a pretty long time, Doc, and of course we've had our...well, she's a pretty good person. 

She tries to live right. 

She goes to church regular. 

She tries to make me live right and sometimes, well, she's a pretty nice person.

She's been sick. 

She's been sick, and she's still sick. 

She, uhhh. Doc, here's the thing. She needs an operation. 

For an ulcer, ulcer of the stomach. 

That's what the doctor said.

Not so long ago, she had an operation on her eye, and they cut way down

underneath that socket there. 

Now, now it's her stomach.

[Dr. Summers:] Well, how did you take these sicknesses and operations of your wife?

[Mr. Hawley:] Well, I took it pretty bad, Doc. 

I worried about her a lot, and I...well, I just took it very bad. 

I worry about her when she's sick, and that makes me worser and makes her worser, 

and then she worries about me when I'm sick. 

That's the way it goes. We worry about each other. 

We worry about the kids.

[Dr. Summers:] How old are your children?

[Mr. Hawley:] We have one ten and one 12, the ones at home. We got two more, married.

[Dr. Summers:] Younger ones give you much trouble?

[Mr. Hawley:] Well, no, except sometimes when they're making a racket, and they, they make

an awful lot of racket, playing and horsing around. 

I just go upstairs and lay down.

[Dr. Summers:] How do you feel then?

[Mr. Hawley:] Just mad, just mad. 

And trouble is I don't know who at. 

It's just when they start hollering and carrying on like that, my nerves go PWOO.

That's it. Just like that.

[Dr. Summers:] Well, actually, you haven't had much fun, been able to enjoy yourself very much,

have you lately?

[Mr. Hawley:] No. You can say that again.

[Dr. Summers:] Do you ever have spells when you just break down and cry?

[Mr. Hawley:] No, sir. No, sir. 

But I reckon, you know Doc, you just get so worried. 

You get so upset and sometimes a fellow, a fellow just wishes, you just can't cry

but sometimes you wish you could. 

I tell you, Doc, a man that's worked hard, that's worked hard all his, Doc, 

I've worked hard all my life. 

I've worked hard, ever since I was just knee-high, and...

[Dr. Summers:] Well, tell me a little about that.

[Mr. Hawley:] I was out there plowing when I was so little I had to reach up to put my hands

on the stock handles to plow there. 

But my Daddy most of the time he wasn't, he just wasn't hardly able to do nothing.

He had that old asthma. 

He was a hard worker, but he couldn't do nothing when he got them spells. 

He was afraid of them spells. 

Not so much from the children but, but they kept him from work.

And I think that was the thing he was a'feared of most, our not making out.

[Narrator:] A fear of not providing for his family, a fear that the patient has picked up

and now dominates much of his thinking. 

He's also deeply concerned over the ailments of his wife, but basically is disturbed

by his own feelings of inadequacy. 

While Hawley gallantly praises his wife and claims they get along pretty well, he indicates that there's 

considerable friction between them because of his unproductivity. 

The children are also a constant reminder to Hawley of his failure as a provider. 

Seeing himself as a poor disciplinarian increases his feelings of guilt. 

He escapes to his room, withdrawing not even aware of the nature or extent of his feelings. 

His memories of childhood are dominated by a feeling of deprivation. 

Even now, he sees himself as a helpless little boy. 

His father's incapacity threw much of the family responsibility on him,

a responsibility that was too great for one so young. 

His father's fear of enforced inactivity was communicated to him and early developed in him 

a background for his present illness. 

And now let's return to the interview. 

Mr. Hawley is describing his schooling or rather, lack of it.

[Mr. Hawley:] They'd send us. 

They thought sure we was there. 

But we wasn't. 

We'd lay out in the woods 'til school was over at the end of the day and then we'd go on home.

[Dr. Summers:] We?

[Mr. Hawley:] Me and some of the neighbor's kids and sometimes one or two of my brothers.

[Dr. Summers:] Wonder why you did that?

[Mr. Hawley:] I don't know, Doc. I don't know. 

I just...well, I don't know!

See, I wisht I had my time to live over again. 

I'd make it to that little old schoolhouse every day, 'cause I know what it is 

to try to make a living without an education. 

You just can't do it, Doc.

[Dr. Summers:] So now you're blaming yourself?

[Mr. Hawley:] I was just bull-headed, that's all, Doc. 

And I thought I was getting away with something. 

And now I wish my folks had whipped me more and made me go.

[Dr. Summers:] What about your brothers and sisters? 

Did they stay away from school very much?

[Mr. Hawley:] Well, once in a while, but not near as much as I did. 

The rest of them, they got a pretty good education. 

They got pretty good jobs. 

And I ain't got nothin'.

I'm just a black sheep in the family.

[Dr. Summers:] So you feel you're the black sheep?

[Mr. Hawley:] That's right. 

They get along fine, and I, well, I just ain't got nothing. 

I tell you, Doc, I don't blame nobody but myself. 

All them whippings that I got for not going to school, and then I still didn't go. 

Doc, I tell you, there's just gotta be something wrong with me somewheres.

[Dr. Summers:] When you were little, you were kind of angry. 

[Mr. Hawley:] Well, yeah. 

Yeah, and another thing, I was always fighting. 

I just couldn't get along with the boys at school until they...always scrappin' too, until one day...

they just ganged up and beat me real good, and that slowed me down some.

[Dr. Summers:] Well, tell me, Mr. Hawley, when you're home, say on weekends, 

what do you like to do?

[Mr. Hawley:] Well, I don't know. 

Most of the time my wife and me, we just sit and watch TV.

[Dr. Summers:] What are your favorite programs?

[Mr. Hawley:] Well, lemme see. I like them westerns pretty good. 

They're all right. 

And the wrestling matches, I like them the most. 

Doc, that may be what keeps my nerves tore up all the time, watching that dadburn wrestling. 

I get so tied up in this thing, and I get excited, and I turn from side to side, and the man I want to win, 

he don't win, I get so mad! 

Of course, I don't watch them as much as I used to.

[Dr. Summers:] Besides wrestling, have you been keeping up with other things in radio, 

newspapers? 

[Mr. Hawley:] No, no, sir. I don't keep up with it.

[Dr. Summers:] Well, what's going on down in Washington?

[Mr. Hawley:] I wouldn't know about that.

[Dr. Summers:] What do you think about this race for mayor?

[Mr. Hawley:] I wouldn't, I wouldn't know about that at all.

[Narrator:] In this section of the interview, we're given several additional clues. 

Mr. Hawley lay out in the woods instead of going to school, rebelling against his family

and the hardships of his early life. 

He says that he blames only himself for his lack of education, and yet there is hidden anger 

against his parents for, as he says, not making him go to school.

He also harbors some resentment toward his brothers and sisters. 

They are getting along comfortably, he claims, and he has nothing. 

He feels that they look down on him, think of him as the black sheep of the family. 

There's got to be something wrong with me somewhere, he declares, 

underlining his self-recrimination and guilt. 

When he was a little boy, he wanted to fight all the time. 

This rage was repressed at adolescence. 

The feeling he describes while watching television shows that he is still angry

beneath the surface. 

The fact that the patient prefers simple television programs filled with aggression and violence, 

identifying himself with the participants and action, sheds some light on his intellectual

as well as emotional functioning. 

To test basic intelligence, thought processes, memory and capacity for abstract thinking, 

we frequently use abbreviated psychological tests borrowed from more extensive tests 

employed by clinical psychologists.

This more formal part of the mental status exam is accomplished through questions

on current events, proverbs, vocabulary, and the like. 

Hawley shows little knowledge or interest in what is going on outside his limited sphere. 

He's handicapped by his lack of education. 

In this connection, we must remember not to correlate or confuse knowledge with intelligence.

[Dr. Summers:] Mr. Hawley, I'd like to name some words now and have you tell me what they mean. 

Some of them will be pretty simple. 

Some might be kind of complicated. 

It'll help a little bit in understanding what's going on with you. 

First word is envelope.

[Mr. Hawley:] Envelope. 

Envelope. That's to put a letter in.

[Dr. Summers:] That's right. What about juggler?

[Mr. Hawley:] Juggler. Nah, I don't know about that one.

[Dr. Summers:] How about regard?

[Mr. Hawley:] Regard.

[Dr. Summers:] Like to guess?

[Mr. Hawley:] You got me on that one.

[Dr. Summers:] What about the word stave?

[Mr. Hawley:] Stave? You got me there.

[Dr. Summers:] You never heard the word stave? 

What do they make barrels out of?

[Mr. Hawley:] Barrels? 

Oh, you mean staves? 

Yeah. A stave is you, you cut them out of a log you see, at a stave mill. 

You put your little old log on this carriage, and then you just shove that carriage 

back and forth like that, and it just drops the staves out.

[Dr. Summers:] That's right. 

You knew that all along, didn't you?

[Mr. Hawley:] I just didn't, I didn't connect it, Doc. 

I just didn't get ya at all.

[Narrator:] We have now accumulated quite a bit of information on this patient, his behavior, 

intellectual functioning, and emotions. 

As to perceptual functioning, the patient is alert and attentive. 

There is no apparent evidence of gross distortions, hallucinations, or estrangements. 

These signs of a very disturbed person are generally encountered

far less frequently than other symptoms. 

In addition to the four areas of investigation indicated here, the doctor before making an evaluation,

considers one other source for clues to the difficulty, his own response to the patient.

Certain kinds of behaviors, speech, and emotions on the part of a patient 

tend to bring out characteristic responses within ourselves. 

Accordingly, we can use our own reactions as a psychic barometer, so to speak,

to determine what it is about the patient that produces such feelings. 

Although objective in his thinking, trained not become emotionally involved,

the doctor, being human, will still find certain feelings aroused within himself by different patients. 

Here, his occasional irritation gives him a clue as to how Hawley must exaggerate his difficulties,

especially with employers, and create annoyance in others. 

While we have dealt here with the problems of a man who toils with his hands,

the same procedures and techniques are applicable at all psychiatric interviews. 

For example, here's another patient, a woman who blames her husband

for all the friction between them.

[Patient:] Well, it's hard to explain, doctor. It's his fault, though.

[Psychiatrist:] What do you mean by it's his fault? 

Does he say anything or do anything?

[Patient:] He's absolutely impossible to live with. 

Well, he's just a child, a 37-year-old infant who has a tantrum if I so much as criticize

one little word he says or does...well, if I even as much as look at another man. 

The other night when I, when he was out of town and I was having drinks  

with a very good old friend, you know, what am I supposed to do, sit home and just twiddle my thumbs? 

Well, you should have seen him hit the roof. 

He practically accused me of sleeping around. 

Now, he calls me immature. 

I do everything in my power to make this man happy, and doctor, 

do you know what he calls me?

[Narrator:] Notice the demonstrativeness, her attempt to extract sympathy, 

to involve the doctor so that he will take care of her. 

This would be quite a task for anyone as in reality her demands are virtually insatiable. 

The doctor's attitude toward the patient is one of general sympathy, tempered by wariness

and vestiges of distaste. 

He recognizes that she's trying to influence him, to use her sexual attractiveness

to her advantage. 

While he finds himself not totally unresponsive to her charms, he is aware that she basically

is looking for someone to take care of her. 

Here we have quite a different patient.

[Patient 2:] I can't...can't seem to get my work done. 

There's this fellow at the office who says that...

I felt that maybe if I took a trip and got away, some place away.

[Narrator:] Note the apparent lack of feeling. 

His thoughts are disorganized, and he shows a disturbance known as blocking. 

Again, the doctor takes into consideration his own reactions and finds it difficult

to establish rapport with the patient. 

Now, back to Mr. Hawley. 

In the first interview, the doctor has established a relationship with the patient

and secured his cooperation. 

He's obtained several clues to Hawley's main problem. 

The patient apparently sees himself as still a helpless little boy. 

His basic fear is that of impoverishment and has been magnified by his current unemployment,

for which he blames an accidental injury. 

We see a continual pattern of childhood rage against parents and parental figures. 

Later, the rage became covert, dammed up, and yet he's angry with prospective employers

and his wife. 

Guiltily, he sees himself as the black sheep. 

With this information, the doctor has already initiated supportive therapy. 

He plans to have several more interviews with the patient

in which he'll explore the situation more fully. 

Through interviewing the patient and utilizing the techniques illustrated here, 

any doctor can assess the nature and degree of pathology encountered

in the four areas we have discussed. 

Such an assessment is the first step in formulating a rational treatment for the patient.

[Dr. Summers:] Well, now that we spent a little time together, I think it'd be worthwhile

going into these things some more. 

What would you say about coming back next Wednesday at the same time?

[Mr. Hawley:] I'd say fine.

[Sounds of Mr. Hawley leaving the office and walking down the hall.]

[Music]

[Consultants... C. Knight Aldrich, M.D.  Karl A. Menninger, M.D  Russell R. Monroe, M.D  

Peter F. Regan III, M.D.  James W. Osberg, M.D.]

[Technical Advisor... Sheldon B. Cohen, M.D., Department of Psychiatry 

Emory University School of Medicine] 

[Directed by... Jack C. Kirkland] 

[The End CDC-561]