The Physical Examination in Psychiatry

Abstract

The ph ysical examination is a neglected aspect o f th e psychiat r ic assessment. For example, a survey of ninety-eight practicing psychiatrists, conducted by Patterson (1) in 1978, found that none of them routinely performed ph ysica l examinations on their patients. More than one-half o f th ese psych iat r ists reported that they no longer felt competent to do so . One situation in whic h psychiatrists do often perform physicals is while admitting patients to hospi tal. However, the quality of these examinations is often poor (2 ,3). An indifferent attitude toward the physical examination ha s pers isted in psychiatry despite numerous publications emphasizing th e importance of med ical assessment (2-8). One reason for this may be th e predominantly negat ive emphasis of the existing literature regarding the psychi atric ph ysical examination. In general, the literature is concerned only with th e ability of th e ph ysical examination to exclude non-psychiatric disease. The physical exa m is rare ly described in a positive sense as an opportunity to gather useful information . A negative attitude toward the ph ysical examination is not justifi ed within the diagnostic framework supplied by DSM-Ill-R. In fact , DSM-III-R fr equently uses physical signs as diagnostic criteria and implicitly demands a full phys ica l assessment as an inclusion or exclusion criterion for the majority of its diagn ost ic categories. For example, if a non-organic diagnosis is to be made co rrect ly, DSM-III-R requires that it cannot be established that an organic fact o r in itiated or maintained the disturbance (9). Thus, strictly speaking, a non-organic diagnosis can only be made after an appropriate ph ysical assessment. T he physical exam is as vital as, for example, the mental status findings . This essay is an attempt to discuss the ph ysical examination within a framework consistent with current diagnostic thinking in psychiatry. As such, the essay will discuss the physical examination , not merely as a way of ruling out organic disease, but rather as an important part of the psychiatric evaluation, no different, conceptually, than the history or mental status ex amination. The physical examination is important in the assessment of all psychi atric patients, but it is nowhere more important than in the evaluation of patients with organic mental disorders. Organic disorders can present with a wide range of symptoms and signs and, as a result, they enter into th e differential diagnos is of a large number of psychiatric disturbances. The history and mental status find ings of patients with organic mental disorders may be identical to non-organic conditions. For this reason, a careful search for specific organic fac tors is essential in the clinical approach to patients with symptoms which co uld be caused by an organic disorder. Such symptoms include mood disturbance ,