4.1

All patients presenting for psychiatric care should receive a comprehensive descriptive psychopathological evaluation. This should include a broad symptomatological assessment specifying the time frames of the findings, as well as a mental state examination at the time of the patient interview (Table 4.1).

Table 1

Evaluation of symptoms and mental state

Broad symptomatological areas (anamnesis)	Major sections of mental state (examination)
Consciousness, orientation, memory and intellect (e.g. decreased intellectual functioning)	Sensorium or alertness (e.g. inattentiveness)
	Memory (e.g. decreased recall)
	Judgement (e.g. holding extreme opinions)
	Insight (e.g. unawareness of illness)
Speech, thinking, perception and self-experience (e.g. persistent delusions, depersonalisation)	Speech and thought processes (e.g. loose associations)
	Thought content (e.g. bizarre ideas)
	Perception (e.g. hallucinations)
Emotions (e.g. sadness)	Mood and affect (e.g. crying)
Physical manifestations of mental disorder (e.g. sleep or weight changes)	Appearance (e.g. self-neglect)
Behaviour and adaptive functioning (e.g. callousness, intentional ineffectiveness)	Overt behaviour (e.g. agitation)

4.2

Five major areas of psychological functioning and psychopathology should be evaluated:

1. (a) consciousness, orientation, memory and intellect

2. (b) speech, thinking, perception and self-experience

3. (c) emotions

4. (d) physical signs and symptoms of mental disorder

5. (e) behaviour and adaptive functioning.

4.3

Standardised definitions of terms should be used in describing the elements of psychopathology. Standardised glossaries should be consulted, such as the World Health Organization's Lexicon of Psychiatric and Mental Health Terms and Schedules for Clinical Assessment in Neuropsychiatry.

4.4

A comprehensive evaluation should document symptoms elicited or observed during the interview, those present in the recent past and relevant to the current illness, as well as those present during the more distant past and relevant to the past psychiatric history.

4.5

The assessment of signs and symptoms requires careful observation of the patient during the interview, listening to the patient's narrative during the presentation of a chief complaint and history, and specific questioning in suspected problem areas. Evidence of signs and symptoms may also come from ancillary information sources, such as records of prior treatment and the reports of relatives, friends, representatives of social agencies, and other professionals.

4.6

The clinical significance of symptoms should be determined by a consideration of their severity. Severity is reflected in the intensity, frequency and duration of symptoms, their tendency to cause subjective distress, and their impact on the patient's functioning. Symptom severity should be documented. Violent and suicidal ideation and behaviours should be thoroughly assessed and documented.

4.7

The evaluation of symptoms should be guided by hypotheses about their diagnostic or syndromic significance. Observations and lines of questioning should be based on the identification of major psychiatric syndromes and the ruling out of specific disorders in differential diagnosis.

4.8

Variations in the presentation of psychopathology according to a patient's age, gender and sociocultural background should be considered in the conduct of the examination and in the interpretation of collected information — for example, depression tends to present predominantly with somatic symptoms in traditional societies. The significance of any behaviour or mental activity, as indicative of psychopathology or as culturally sanctioned should be carefully considered.

4.9

The findings of the mental state examination should be summarised according to standard domains, such as the following:

1. (a) sensorium or alertness

2. (b) memory

3. (c) judgment

4. (d) insight

5. (e) speech and thought processes

6. (f) thought content

7. (g) perception

8. (h) mood and affect

9. (i) appearance

10. (j) overt behaviour.

4.10

Attention should be paid to diagnostic criteria, such as those of the standard international classifications, to guide the evaluation of symptoms and mental state and to appraise their syndromic significance. However, the possibility of cultural and regional variations and of atypical presentations should be considered.