General impression

Manner of Interaction & Contact

• First contact is socially adequate (introduces themselves, with or without handshake, adjusts adequately to the situation)
• First contact is inadequate given the situation, such as: …

• Eye contact is socially appropriate
• Eye contact is either too intrusive or lacking, such as: …

• Contact and interaction develop adequately during the interview (after initial adjustment becomes more open about the complaint, about worries and emotions, becomes involved in the interaction)
• Contact and interaction develop inadequately (no mutual exchange, interaction becomes tense and demanding, etc.), such as: …
• Attitude during consultation (friendly and cooperative, passive and subdued, demanding and aggressive, dismissive and suspicious, etc.), such as …
• Presentation of complaint (well-informed and emotionally involved; aloof, demanding, exaggerating, etc.), such as …

Physical Appearance

General impression

• Healthy
• Other (ill, specific characteristics), such as …

Age, Vitality & Stress

• Psychological age and vitality in accordance with physical age
• Appears younger or older then physical age

• Appears tired with a lack of energy
• Appears stressed.

Self-care

• Well-groomed and dressed
• Negligent (in self-care, clothing), such as …

Movement

• Normal, undisturbed movement
• Restlessness and inability to sit still
• Involuntary muscle contractions or movements, such as …
• Retardation or absence of movement, such as …

Self

Core

• Experiences themselves as whole and integrated
• Experiences themselves as different from others, such as: …
• Not examined.

Embodiment

• Experiences themselves as being alive and at ease with one’s inner body
• Experiences the body hyperreflexif with enhanced awareness and impairment in functioning, such as: …
• Not examined.

Intentional Arc

• Experiences the ability to create an arc of thought, speech and action
• Experiences an inability to create a continuum of thought, speech and action, such as: …
• Not examined.

Sense of Time

• Experiences themselves in the here and now
• Experiences time as retarded, accelerated or in another sense as disturbed, such as: …
• Not examined.

Sense of agency

• Experiences their sense of agency about any volitional actions within themselves
• Experiences their sense of agency out of their control, such as: …
• Not examined.

Sense of intercorporeality

• Pre-reflective and pre-conceptual experiences implicated in intercorporeality are processed and acted upon in a prosocial, satisfying way
• Experiences limitations in processing one’s own body sensations and movement, and the other’s expressions and behavior involved in intercorporeality, such as: …
• Not examined.

AWARENESS

Consciousness

• Clear
• Clouded in varying degrees during the interview (dissociation)
• Clouded (with deterioration in thinking, attention, perception and memory, and a diminished awareness of the environment)
• Drowsy (with slowed actions, slurred speech, sluggish responses, and lowering of vigilance and awareness of direct environment)
• Coma (with no verbal responses and no responses to painful stimuli).

Consciousness is experienced as:

• Enhanced
• Reduced.

Attention & Concentration

• Normal concentration enabling functioning in social relations, study and work
• Enhanced distractible, such that poor concentration interferes with functioning in relations, study and work.

The quality of attention is:

• Hypovigilant
• Hypervigilant.

MOOD & AFFECT

Mood

Mood

• Normophoric (normal, cheerful)
• Depressed
  • Low mood, despair, tearful, diminished pleasure
  • Dysphoric mood with aggression, easily irritated
  • Partial or complete numbness
  • Diminished or loss of interest
• Euphoric
  • Elated mood
  • Increased energy

Cognition

• Inability to concentrate
• Brooding and worrying
• Excessive feelings of insufficiency, worthlessness and guilt
• Indecisiveness
• Elated, inflated self-esteem, thoughts are racing, grandiosity.

Bodily Functioning

• Lack of energy and drive, heaviness, feelings of cold and being exhausted
• Lack of appetite, weight loss
• Difficulty with sleeping, disturbance of sleep-wake cycle
• Irregularity of menstruation, decrease in sexual functioning
• Retarded motor movement, restless and agitated behavior, increased activity.

Self-Harm & Suicidality

• Wish to cut or harm one-self
• Strong death-wishes
• Concrete and destructive fantasies about suicide
• Recent preparations and attempts to cut one-self or to commit suicide.

Anxiety

Anxious Affect

• Anxious, horror, impending danger, fear for losing control, nightmares and flashbacks
• Anxiety for objects or situations, such as animals, airplanes, school, medical procedures
• Fear of behaving unacceptably in a social situation where subjected to possible scrutiny
• Fear of being in open or closed spaces where there is no escape or no help.

Cognition

• Recurrent, involuntary, and intrusive memories that evoke distress
• Negative cognitions, such as ‘I am unsafe, I am helpless, I am to blame, I am not worth’
• Inability to concentrate
• Worrying about panic attack, because escape might be difficult or help not available
• Worrying about possible harm or disaster
• Worrying about losing important others.

Somatic Symptoms

• Attacks of dizziness or fainting, dry mouth
• Sweating, palpitations, heart pounding, chest discomfort, shortness of breath, feeling of choking
• Trembling, shaking, restlessness
• Burning or itching skin, hot and cold flushes.

Obsessions & Compulsions

• No obsessions & compulsions
• Experiences anxiety and stress (‘just not right’) when not complying with the obsessions and compulsions

Obsessions

• Aggressive obsessions, such as the fear to hurt oneself, the fear to hurt other people,  any aggressive and gruesome images, the fear to hurt another person beyond their control
• Obsessions concerning contamination, such as concern or disgust around excrements (urine, feces, mucus), exaggerated concerns about dirt, germs or bugs, exaggerated concerns about pollution or contamination
• Sexual obsessions, such as prohibited or perverse thoughts, images or impulses, about incest, about homosexuality
• Exactness and magical consequences, such as that bad things will happen when things are not straight
• Religious obsessions, about obsessions with numbers, about intrusive images, etc.
• Obsessions are experienced as ego dystonic, as not how the patient wants to be, as not emanating from themselves
• Other, such as …

Compulsions

• Compulsions around cleaning and washing, such as excessive handwashing, showering, tooth cleaning, toilet rituals, about cleaning household items, about precautions to prevent pollution and contamination
• Compulsions around control, such as checking doors, locks, kitchen apparel, checking whether they have hurt anybody, checking any possible mistakes, checking that terrible things might happen
• Compulsions around repetition, such as reading or writing, counting, walking in and out, opening and closing doors
• Compulsions regarding stocking up
• Other, such as …

Manifestation of Affect

• Normal, modulating
• Subdued, flat
• Exaggerated, appealing.

PERCEPTION

• No disturbance of perception
• Normal perceptions of hearing, vision, taste or smell are distorted, such as …
• Misperceptions of hearing or vision due to emotions or poor visibility, such as …

In Hearing

• Experiences voices of invisible people that are distinct of their own thoughts

These voices:

• Are of a single person, of several persons, of men, women or children, of people they know, such as …
• Talk, shout or abuse the person with questions, comments and commands, threats or even curses, such as …
• Are friendly, are assumed a friend, give healthy advice
• Originate from in their head or from the outside, such as …
• Represent their own ideas and how they want to be as a person, or as repugnant and inconsistent with their own personality, such as …

• In these voices the patient hears their own thoughts spoken aloud
• Experiences other noises, such as radio, tunes, whistling, rattling, and whether words are spoken aloud by these noises, such as …

In Vision

• Sees images that can not be seen objectively by others, such as …
• Experiences these images as awful or threatening
• These images disappear when the attention is focused on another object or on other senses, such as hearing.

In Taste & Smell

• Experiences smells or tastes that can not be smelled or tasted objectively by others

In The Body

• Experiences sensations of touch, movement, or deformation in their body that are not observed by others.

Memory

In this item, the physician examines any disturbances in memory.

Memory: Examines short-term memory

Immediate and short-term memory can be examined in two ways:

• Ask the patient about:
  • What they did yesterday and the day before
  • What they had for breakfast, lunch and dinner on these days.

Or:

• Mention the words: ‘leg, cotton, school, tomato, white,’ and ask the patient to repeat these words. Then, after 5 minutes, ask the patient to call the words again. You are assessing immediate and short-term memory, assessments that are also part of the well-known Montreal Cognitive Assessment  (MoCA).
• Continue with probes, such as: ‘Were ‘towel’ or ‘coton’ mentioned? ‘School’ or ‘shop?’, etc., when your patient shows any impairment in mentioning words.

With these probes you can distinguish whether the impairment involves attention and retainment or the recollection of information.

• When you notice any impairment in short-term memory, you have to examine how the patient deals with the situation: does she acknowledges or denies the impairment, does she slow down, repeat or fill up her words, does she respond frustrated or resigned.

Scoring

• ‘Yes’, when the physician examines short-term memory and registers – in case of any impairment – the response by the patient.

© Crijnen & Kraan 1982 – 2025