# Clinical Cases: Psychiatric Interview and Mental Status Examination

## Case 1: First Episode Depression - Comprehensive Psychiatric Assessment

### Patient Demographics
- **Age:** 32 years old
- **Sex:** Female
- **Occupation:** Marketing manager

### Chief Complaint
"I can't stop crying and I don't know why. I feel empty inside."

### History of Present Illness
The patient presents to outpatient psychiatry with a 6-week history of persistent low mood, tearfulness, and loss of interest in activities she previously enjoyed. She reports difficulty concentrating at work, leading to performance issues that have been noticed by her supervisor. She has been withdrawing from friends and family, canceling social plans, and spending weekends alone in her apartment. She endorses poor appetite with 10-pound weight loss over the past month, initial and middle insomnia (difficulty falling asleep and waking at 3 AM), and profound fatigue despite sleeping 10-11 hours when she can sleep through the night. She denies suicidal ideation, intent, or plan. She denies any history of manic or hypomanic symptoms.

### Mental Status Examination

**Appearance:** Woman appearing stated age, casually dressed in dark clothing, poor grooming (hair unwashed), slumped posture, poor eye contact

**Behavior:** Psychomotor retardation noted with slowed movements, minimal gesturing, limited facial expressions

**Speech:** Decreased rate, decreased volume, increased latency to respond, normal articulation

**Mood:** "Empty" and "hopeless"

**Affect:** Constricted range, depressed, congruent with stated mood, tearful at times

**Thought Process:** Linear and goal-directed but slowed; no loosening of associations

**Thought Content:** Preoccupation with feelings of worthlessness and guilt about work performance; denies suicidal ideation, homicidal ideation, delusions, or obsessions

**Perceptions:** Denies auditory or visual hallucinations; no illusions

**Cognition:** Alert and oriented x4; attention mildly impaired (required repetition of questions); concentration decreased; memory grossly intact for recent and remote events

**Insight:** Fair - recognizes something is wrong and that she may be depressed

**Judgment:** Fair - sought help appropriately, able to identify that isolating is not helpful

### Psychiatric Workup

**Screening Tools:**
- PHQ-9 score: 21 (severe depression)
- GAD-7 score: 8 (mild anxiety)
- Columbia Suicide Severity Rating Scale: Negative for suicidal ideation

**Laboratory Studies to Rule Out Medical Causes:**
- TSH: 2.4 mIU/L (normal)
- CBC: Within normal limits
- CMP: Within normal limits
- Vitamin B12: 450 pg/mL (normal)
- Folate: 12 ng/mL (normal)

### Diagnosis

**Major Depressive Disorder, Single Episode, Severe without Psychotic Features (F32.2)**

**DSM-5 Criteria Met:**
- Depressed mood most of the day, nearly every day (crying, feeling empty)
- Markedly diminished interest or pleasure in activities (anhedonia)
- Significant weight loss (10 lbs/5% body weight in one month)
- Insomnia (initial and middle)
- Fatigue or loss of energy
- Feelings of worthlessness and excessive guilt
- Diminished ability to concentrate
- Duration >2 weeks
- Causes clinically significant distress and functional impairment
- Not attributable to substance use or medical condition
- No history of manic or hypomanic episodes

### Treatment Plan

**Pharmacotherapy:**
- Start sertraline 50 mg daily, titrate to 100 mg after 1 week if tolerated
- Discussed expected timeline for medication effect (2-4 weeks for initial response)

**Psychotherapy:**
- Refer for Cognitive Behavioral Therapy (CBT), weekly sessions
- Focus on behavioral activation and cognitive restructuring

**Safety:**
- No current suicidal ideation; safety plan reviewed
- Crisis resources provided (988 Suicide & Crisis Lifeline)
- Return precautions discussed

**Follow-up:**
- Return in 2 weeks to assess tolerability and early response
- PHQ-9 at each visit for measurement-based care

---

## Case 2: Psychosis - Importance of Structured Assessment

### Patient Demographics
- **Age:** 22 years old
- **Sex:** Male
- **Occupation:** College student (currently on medical leave)

### Chief Complaint
"My roommate says I've been acting strange, but I think he's part of the conspiracy."

### History of Present Illness
The patient is brought to the emergency department by his college roommate who reports increasingly bizarre behavior over the past 3 months. The patient has become progressively isolated, stopped attending classes, and has been heard talking to himself in his room. The roommate reports the patient has covered all mirrors and windows with aluminum foil and accused him of "recording my thoughts." The patient believes that a government agency has implanted a device in his brain that allows them to hear his thoughts and insert thoughts that are not his own. He reports hearing voices commenting on his behavior and occasionally giving commands. He has not slept more than 2-3 hours per night for the past several weeks, stating he needs to "stay vigilant." He denies drug use, though the roommate reports finding an empty marijuana edible package 4 months ago.

### Mental Status Examination

**Appearance:** Disheveled young man, malodorous, wearing multiple layers of clothing, appears older than stated age, poor hygiene, aluminum foil hat visible under hood

**Behavior:** Hypervigilant, scanning the room frequently, guarded, occasionally appears to be responding to internal stimuli (tilting head as if listening, mouthing words)

**Speech:** Pressured rate at times, normal volume, occasional tangentiality, neologisms present ("They use thoughtweave technology")

**Mood:** "Fine, everyone else has the problem"

**Affect:** Suspicious, labile with periods of inappropriate laughter, incongruent with content

**Thought Process:** Tangential, loose associations at times, circumstantial, occasional thought blocking

**Thought Content:**
- Paranoid delusions: Believes government is monitoring and controlling his thoughts
- Thought insertion: "They put ideas in my head that aren't mine"
- Ideas of reference: Believes news broadcasts contain hidden messages for him
- Denies suicidal ideation
- Denies homicidal ideation but states he "might have to protect myself"

**Perceptions:**
- Auditory hallucinations: Running commentary on his behavior, occasional command hallucinations (to "stay quiet")
- Denies visual hallucinations

**Cognition:** Alert and oriented to person, partially oriented to place (knows he's in a hospital but unsure which one), disoriented to date (off by 2 weeks); attention impaired; memory testing limited by poor cooperation

**Insight:** Poor - does not believe he is ill, believes others are conspiring against him

**Judgment:** Poor - has not been eating regularly, has alienated support system, brought to ED by others

### Psychiatric Workup

**Screening Tools:**
- BPRS (Brief Psychiatric Rating Scale): 62 (severe)
- Columbia Suicide Severity Rating Scale: Negative for current suicidal ideation

**Laboratory Studies to Rule Out Medical Causes:**
- Urine drug screen: Positive for THC
- TSH: 1.8 mIU/L (normal)
- CBC: WBC 7.2 (normal)
- CMP: Within normal limits
- Ammonia: 28 mcg/dL (normal)
- HIV: Negative
- Syphilis screen (RPR): Non-reactive
- CT Head without contrast: No acute abnormalities

### Diagnosis

**Schizophrenia, First Episode, Currently in Acute Episode (F20.9)**

**DSM-5 Criteria Met:**
- Two or more of the following, each present for a significant portion of time during a 1-month period:
  - Delusions (paranoid, thought insertion, ideas of reference)
  - Hallucinations (auditory)
  - Disorganized speech (tangentiality, loose associations)
- Level of functioning markedly below baseline (stopped attending school, self-care deteriorated)
- Continuous signs of disturbance for at least 6 months (3 months of active symptoms with prodromal period)
- Schizoaffective disorder and depressive/bipolar disorder with psychotic features ruled out
- Not attributable to substance use or medical condition

### Treatment Plan

**Acute Management:**
- Voluntary psychiatric admission accepted after extended discussion
- Start risperidone 2 mg BID
- PRN lorazepam 1 mg for agitation

**Pharmacotherapy (Ongoing):**
- Titrate risperidone as tolerated
- Monitor for extrapyramidal symptoms, metabolic effects

**Psychoeducation:**
- Family meeting to discuss diagnosis, treatment, and prognosis
- Discuss importance of cannabis abstinence

**Safety:**
- 1:1 observation initially due to command hallucinations
- Environmental safety precautions

**Follow-up:**
- Coordinate with college counseling center for return-to-school planning
- Connect with early psychosis intervention program

---

## Case 3: The Uncooperative Patient - Biopsychosocial Formulation

### Patient Demographics
- **Age:** 45 years old
- **Sex:** Male
- **Occupation:** Unemployed (former construction worker)

### Chief Complaint
"I don't need to be here. The cops brought me for no reason."

### History of Present Illness
The patient was brought to the emergency department by police after being found walking in traffic on a busy highway. Bystanders called 911 when he appeared confused and was yelling at passing cars. The patient is a poor historian and is uncooperative with the interview. Limited collateral information is available. Police report states he smelled of alcohol and had an empty vodka bottle in his backpack. He is irritable and intermittently threatening, stating "I'll leave when I want to leave." When asked about walking in traffic, he states "I was just trying to get somewhere." He refuses to answer questions about suicidal ideation, stating "That's none of your business."

### Mental Status Examination

**Appearance:** Middle-aged man appearing older than stated age, malodorous (alcohol, body odor), disheveled clothing with stains, unshaven with poor dentition, visible tremor of hands

**Behavior:** Hostile, uncooperative, frequently interrupts interviewer, attempts to leave the room multiple times, pacing when seated

**Speech:** Loud volume, rapid rate, slurred articulation, profane

**Mood:** "Pissed off"

**Affect:** Irritable, labile, dysphoric at times when discussing his situation

**Thought Process:** Difficult to assess due to poor cooperation; appears disorganized with frequent tangents and difficulty staying on topic

**Thought Content:** Limited assessment possible; denies suicidal intent when directly asked but refused to elaborate; no overt paranoid ideation expressed; preoccupied with leaving the hospital

**Perceptions:** Unable to assess thoroughly; no obvious response to internal stimuli observed

**Cognition:**
- Alert but disoriented to date (states "I don't know, maybe Tuesday?" when it is Saturday)
- Attention impaired - unable to complete serial 7s or spell WORLD backward
- Memory: Unable to recall events leading to hospitalization; remote memory grossly intact

**Insight:** Poor - does not acknowledge any problems with substance use or behavior

**Judgment:** Poor - walking in traffic, refusing evaluation, threatening to leave

### Psychiatric Workup

**Screening Tools:**
- Unable to complete standardized assessments due to poor cooperation
- CIWA-Ar score: 12 (moderate withdrawal risk)
- AUDIT-C: Unable to complete

**Laboratory Studies:**
- Blood alcohol level: 285 mg/dL
- Urine drug screen: Positive for alcohol, negative otherwise
- Glucose: 68 mg/dL (low)
- CMP: K+ 3.2 mEq/L (low), Mg 1.4 mg/dL (low), otherwise normal
- CBC: MCV 104 fL (elevated, suggesting chronic alcohol use)
- Liver function: AST 78, ALT 45, GGT 124 (elevated)
- Ammonia: 35 mcg/dL (normal)
- CT Head: No acute intracranial abnormality

### Biopsychosocial Formulation

**Biological Factors:**
- Acute alcohol intoxication (BAL 285)
- At risk for alcohol withdrawal
- Evidence of chronic alcohol use (elevated MCV, LFTs)
- Electrolyte abnormalities (hypokalemia, hypomagnesemia)
- Hypoglycemia contributing to altered mental status

**Psychological Factors:**
- Poor frustration tolerance
- Limited insight into substance use
- Possible underlying depression or trauma (requires further assessment when sober)
- Hostility may represent defense mechanism

**Social Factors:**
- Unemployment
- Apparent homelessness (belongings in backpack)
- Unclear social support
- Brought by police, suggesting limited resources for self-care

### Diagnosis

**Provisional Diagnoses:**
1. Alcohol Use Disorder, Severe (F10.20) - pending confirmation of DSM-5 criteria when patient is sober
2. Alcohol Intoxication (F10.129)
3. Suicidal ideation, unspecified - cannot rule out given behavior and refusal to discuss

### Treatment Plan

**Acute Management:**
- Medical admission for detoxification and medical stabilization
- CIWA-Ar protocol with lorazepam
- IV fluids with dextrose, thiamine, folate
- Electrolyte repletion (potassium, magnesium)
- 1:1 observation until suicidality can be properly assessed

**Re-assessment:**
- Complete psychiatric evaluation when BAL <100 and patient is not in active withdrawal
- Collateral information (attempt to contact family, review prior records)
- Assess for comorbid psychiatric conditions

**Disposition Planning:**
- Social work consultation for housing, benefits
- If alcohol use disorder confirmed, discuss treatment options (inpatient rehabilitation vs. intensive outpatient)
- Assess motivation using motivational interviewing techniques