MAAS-MI Mental Health

This item refers to questions about the reason for the visit to the physician.

Questions, like: What can I do for you? are intended in this item. These opening questions are very general, and the answers of the patient may be very divergent.

Patients may mention some complaints; they may say that they have been sent by their family or a colleague; they may ask for a prescription or some certificate; in case of a visit to a general practitioner, they may ask for referral.

Scoring

• ‘Yes’, when the physician asks an open question concerning the reason for encounter.

This item is scored subjectively when the physician asks, by means of an open question, for a description of the complaint that formed the incentive for the patient to visit the physician.

The patient can have somatic complaints and/or mental health problems.

Scoring

• ‘Yes’, when the physician asks for a description of the complaints by means of an open question.

This item refers to the physician’s interviewing behavior by which they explore the emotional impact of the complaint or problem on the patient.

Emotions, worries, anxiety, concerns, thoughts, etc. of the patient about the complaint are intended.

Questions, like: How do you feel about this problem? or reflections on the emotional dimension of the patient’s information may be expected.

Patients are often anxious about the prognosis of their complaint or problem and they may sometimes present feelings of guilt and shame, especially in the case of mental health problems.

Scoring

• ‘Yes’, if the physician explores the patient’s emotions concerning his main complaint or problem.

This item asks which immediate motives have effectuated the decision to initiate the medical consultation.

The answer to this question yields about the factors which forced the patient to seek such help.

It yields, moreover, an impression of the severity of suffering. If there has been a need for help for a long time and the patient or his important others have not asked for help, the physician can explore the factors which have delayed help-seeking. Feelings of guilt and anxiety may interfere with the decision to initiate a medical consultation.

Scoring

• ‘Yes’, when this subject is explored by means of an open question.

Questions like: What are, in your opinion, the causes of your problem? are intended.

The answer yields information about causal attributions by the patient.

Since patients often lack a scientific understanding of the causes of their complaints, they will construct a theory based on lay information and prior experience. The verbalization of the patient’s personal constructs provides additional insight and enables modification of the constructs towards a usually more realistic view of the complaints.

The exploration of the attributions of the patient contributes significantly to the favorable climate of the medical consultation. It enhances an atmosphere of trust and understanding.

Scoring

• ‘Yes’, when the physician asks, by means of an open question, about the patient’s causal attributions of the complaint.

Family can respond by means of:

• Reinforcement,
• Defense,
• Help,
• Persuasion to initiate medical consultation, etc

By means of this item is examined:

• Whether the complaint is discussed with family members;
• And how they reacted.

Scoring

• ‘Yes’, when both of these aspects are examined.

By means of this question, the physician explores what treatment has been adopted by the patient themself in order to get relief from their complaint, be it with or without success.

The answer may be for instance: self-medication, changes in life patterns or habits.

Item 2.11 Asks about current professional consultations is related, but concerns any professional treatment.

Scoring

• ‘Yes’, when this question is posed in an open way.

This item deals with the concrete consequences of the complaint or problem for daily life.

The behavioral aspects, intended by this item, have a close relationship with the emotional aspects of Item 1.3 Explores the emotional impact of the complaint. The emotional impact and the behavioral consequences of the complaint for daily life may give an insight into the amount of subjective suffering of the patient.

Scoring

• ‘Yes’, when the physician inquires about these consequences by means of an open question.

In this item, the patient is asked to talk about the problems, complaints or life-circumstances which accompany the main complaint or problem.

The objective is to enquire about temporary relationships which are considered to exist between events and complaints from the patient’s point of view.

The answer to this question may be another important complaint; a stressful life-event that influences the complaint; a totally different problem which has no connection with the main complaint or problem, etc.

Scoring

• ‘Yes’, when this question is posed in an open manner.

This item asks about the coping mechanisms by means of which the patient has solved similar problems in the past.

Scoring

• ‘Yes’, when such an open question is asked.

Scoring

• ‘Yes’, when the interviewer explores, by means of open questions, how the patient estimates the burden they put on their primary group.

Scoring

• ‘Yes’, when acute traumatic circumstances or other heavily emotional events within the last 3 months are asked about.

This item deals with the kind of help the patient wishes to receive.

Although these wishes may have unrealistic aspects, because too much regarding the solution of the problems is expected from the physician, the physician must have an insight into these wishes. The physician has to meet the wishes of the patient as much as possible during the management plan they offer the patient.

In this respect, the difference between wishes and expectations concerning help is of importance. The patient may, for instance, wish for a management plan A, but is expecting, on the ground of previous experience with the physician, that not management plan A, but management plan B will be offered.

Scoring

• ‘Yes’, when the wishes of the patient are asked for explicitly with regards to the help that is desired.

The physician asks for a subjective description of the intensity of the complaint which provided the motive for the consultation.

The intensity is an important aspect of the complaint and provides an estimate of the degree of suffering of the patient. Intensity often becomes evident from the impact of the complaint on the patient’s behavior.

For instance, a stabbing headache may hinder physical exertion; a depression may vary from a low mood after disappointment with few implications for daily life to a psychotic depression which profoundly influences the emotional and thought processes.

Scoring

• ‘Yes’, when the physician asks about the intensity of the complaint.

Scoring

• ‘Yes’, when the physician inquires about the ‘time-intensity graphic’ during the time cycle of the day.

By this item is meant the gathering of information about:

• The start of the complaint;
• Any fluctuations;
• Any complaint-free intervals;
• Any change in character and intensity of the complaint during lifetime.

Scoring

• ‘Yes’, when the physician asks about one or more of these four aspects of the history of the complaint/problem.

This item scores the physician’s questioning behavior in the search for internal or external factor(s) which elicited the complaint.

Provoking factors from history and present time may be revealed. These questions form the ‘interviewing correlate’ of the physician’s clinical problem-solving process.

Scoring

• ‘Yes’, when the physician searches for provoking and triggering factors in past and present.

NB: The quality of the clinical problem-solving process and hypotheses is not judged; only the presence of the ‘search behavior’ of the physician is judged.

The physician, using open or closed – directive – questions, asks about factors that increase already existing complaints/problems.

Open questions will be asked when the physician has no clear hypotheses; closed or directive questions will be asked to test hypotheses.

Scoring

• ‘Yes’, when open or closed – directive – questions are put in order to analyze factors that increase the problems/complaints.

See the comment at Item 2.4.

Scoring

• ‘Yes’, when the physician asks for complaint maintaining factors by means of open or closed – directive – questions.

See the comment at Item 2.4.

Scoring

• ‘Yes’, when the physician, by means of open or closed – directive – questions, asks about factors that decrease or eliminate complaints.

See the comment at Item 2.4.

This question measures whether any other symptoms accompany the main complaint.

These symptoms were experienced by the patient as less salient or les disturbing, went un-noticed, and were therefore not yet mentioned by the patient.

This question can be asked in two ways:

• Through an open-ended question intended to explore the presence of other symptoms;
• Through a closed-ended question when the physician has any specific symptom in mind. In this last case, the physician is likely to enter the Psychiatric Examination or Socio-emotional Exploration in order to examine risks and disorders of the system pertaining to the main complaint.

Scoring

• ‘Yes’, when the physician asks, through an open or closed-ended question, whether other symptoms accompany the complaint.

The physician asks for a ‘historical picture’ of illnesses and (mental) health problems.

A relationship with the present complaint/illness is not necessary.

Scoring

• ‘Yes’, when the physician asked about illnesses and mental health problems in the past.

This item asks about the way the patient has presented their problems/complaints to other professionals in the past and the effects of their treatment.

This item contrasts to self-care, which is asked about in Item 1.7 Asks how the patient has tried to solve the problem by themself.

Scoring

• ‘Yes’, when the physician pays attention to both the kind of treatment and the effects of treatment.

This item refers to the exploration of consultations, diagnostic investigations, and treatment that are being carried out currently, but that are (not) related to the main problem or complaints.

By ‘professional’ is meant (para)medical disciplines as well as professional ‘alternative healers’. Overlap with Item 1.7 Asks how the patient has tried to solve the problem by themself pertaining to self-help may arise when the patient applies prescriptions or advice that has been given in the past to the current complaint on their own initiative.

Scoring

• ‘Yes’, when the patient is asked about current professional consultations (not) related to the main complaints.

This question pertains to current use of prescribed medication as well as self-medication. There may be some overlap with Item 2.10 about past treatments, or Item 4.16 about substance use.

Scoring

• ‘Yes’, when use and abuse of current medication is asked about.

The physician checks whether the complaints have a function in the illness behavior of the patient in the sense of secondary gains of the illness.

This is done in two steps:

• Firstly, the physician asks how important others have reacted to the patient’s illness/complaints. This issue is scored in Item 1.6 Asks how the complaint is discussed with the family;
• Secondly, the physician explores the function that this reaction can have for the patient. A possibility is an excuse function; diminished responsibility; diverting attention from other problems or the control of communication patterns within the patient’s system (rigidity).

Scoring

• ‘Yes’, when the physician explores the function that the reaction of important others has to the patient.

Scoring

• ‘Yes’, when this question is asked.

In this item, the physician examines the experience of self and any disturbances therein.

Complaint Heuristic

1. Examines the nature of the experience of self

• Asks about feelings, such as lacking inner core, not knowing who they really are
• Asks about feelings about being fundamentally different from others.

2. Examines the intensity of this experience

• Asks about the evaluation of these feelings as being ‘wrong’
• Asks about any consequences, such as feelings of profound solitude.

Time-intensity heuristic

1. Examines the unset and course of these experiences

• Asks whether experiences of being different from others, of being a ‘foreign creature,’ etc., originated in childhood and remained stable over time
• Asks whether these disturbed experiences are apprehended as ego-syntonic, as how the patient experiences herself as a person.

Scoring

• ‘Yes’, when both the nature and intensity of experiences of self are examined.

In this item, the physician explores experiences around embodiment and any disturbances therein.

Complaint Heuristic

1. Examines any experiences that the patient is hyperreflexif, meaning that she is well-aware of the nature of the – normally tacit – functioning of the body

• Asks about experiences of awareness or even hyperawareness:
  • Of parts of the body, such as arms, hands, legs
  • Or functions of the body, such as walking, climbing a stair, etc.

2. Examines the intensity of these experiences

• Asks whether the hyperreflexivity resulted in feelings of distancing and alienation of parts or functions of the body
• Asks whether the hyperreflexivity resulted in a mechanical, more conscious, and poorer functioning of the body.

Scoring

• ‘Yes’, when the physician examines both the nature and intensity of experiences of embodiment.

In this item, the physician examines the intentional arc. The intentional arc is understood to be the continuum linking the person’s experiences with their intentions expressed as the integration of feelings, thoughts and movements towards conscious acts. Under normal circumstances, the intentional arc invigorates the intentions and imbues them with a sense of mineness (Fuchs, 2015).

Complaint Heuristic

1. Asks about the nature of the intentional arc

• Examines whether the formation of intentions is experienced as opaque with barriers and resistance
• Examines whether sensations, perceptions and thoughts are experienced without a clue on how to respond or to relate to them

2. Asks about the intensity of the disintegration of the intentional arc

• Examines any experiences of a sense of alienation or a loss of mineness in patterns of perception, movement or thought
• Examines any experiences of fragmentation, mechanization or blocking in motor functioning or thinking and speaking that interferes with functioning

Scoring

• ‘Yes’, when both the nature and intensity of the intentional arc are examined.

In this item, the physician examines the experience of time. Under normal circumstances, your patient is in the here and now, and temporality, the experience of time and thereby of self, is in sync with the unfolding of experiences over time. However, the tenacity of psychopathology can absorb the momentary experience of time and hold the patient in the past, in the – never occurring – future, or prevent the experience of current events (Fuchs, 2019).

Complaint Heuristic

1. Asks about the nature of the sense of time

• Asks how the patient experiences current time:
  • Whether a patient is synchronized with the ‘now’
  • Whether one’s synchronization is accelerated inducing periodes of waiting and boredom
  • Whether one’s synchronicity is retarded which is associated with time pressure, grief and depression
• Asks whether the – normal – flow of time is continuously arrested by feelings of imperfection that one’s actions are ‘not-right’
• Asks whether the patient is preoccupied, concerned, or ruminating about events or experiences in the past
• Asks whether the patient is preoccupied with catastrophic and unavoidable future events that are expected to be unprecedented and unbearable
• Asks whether the patient is currently involved in a flow of frail and hard to catch experiences, such as in mania or substance use
• Asks whether the flow of time (in the intentional arc) is disrupted such that feelings and thoughts become incoherent

2. Asks about the intensity

• Examines whether the disturbed sense hinders the patient to live in and experience the current time

Time-intensity heuristic

1. Asks about the unset and course of the disturbance in the sense of time

• Examines whether the disturbed sense of time waxed or waned lately
• Examines whether the patient can remember a time that they lived in the presence

2. Asks about differences in the sense of time during the day

• Examines when the disturbance in the sense of time is experienced as worse during the day, such as at night

Accompanying Complaints and Conditions Heuristic

1. Asks about any underlying psychiatric symptoms and conditions

• Examines conditions laying open the patient to a disturbance in the sense of time, such as depression and melancholia, obsessive-compulsive disorder, mania and substance use, schizophrenia

Scoring

• ‘Yes’, when both the nature and intensity of any disturbance in the sense of time is examined.

In this item, the physician explores the sense of agency. Sense of agency is the subjective awareness of initiating, executing, and controlling one’s own volitional actions in the world. Under normal circumstances, patients experience and attribute their sense of agency within themselves.

Complaint Heuristic

1. Asks about any experiences that the patient sensed that their agency to initiate and control their actions was reduced or even lost

• Feelings such as that they had not enough power to initiate any actions
• Feelings such as that their body (voice, hands, arms, legs) failed them, were not willing to, or refused to initiate any actions
• Feelings such as that their body operated only with utmost willpower
• Feelings that their actions were under control by powers beyond their control, such as voices or thoughts inserted from outside

2. Asks about the intensity of the loss of agency

• Feelings of despair
• Situations of physical neglect and abandonnement
• Situations of social isolation

Scoring

• ‘Yes’, when the physician examines any disturbances of the sense of agency and their consequences.

In this item, the physician examines intercorporeality. Intercorporeality refers to the pre-reflective and pre-conceptual experiences implicated in the ways a person engages with others. Intercorporeality involves the impression of affect, the resonance of the body, the expression in affect, gesture and posture, and the experience of the other (Fuchs, 2016)

Complaint Heuristic

1. A. Asks about any experiences with local or general bodily sensations when interacting with others

• Examines experiences, such as warmth or chillness, relaxation or tension, titillation or trembling, etc

1. B. Asks about any experiences of intended movement when interacting with others

• Examines – any small but intended – movement, such as any approach, avoidance, being-with, rejection, dominance, submission, more specifically any movements such as avoiding gaze, sinking into the floor, etc.

1. C. Asks about any awareness how the patient expresses these sensations and movement in affect, gesture and posture

• Examines whether the patient is aware how they express these sensations and how comfortable they feel with others, whether they have a hard time to understand their mental state, whether they feel themselves incapacitated and experience a lot of stress with others

1. D. Asks about how the expression in affect, gesture and posture are experienced by their partners

• Examines whether the patient is aware how their expressions are experienced by others on average, whether they run into any experiences that they felt connected and their expressions resonated, whether they had experiences that they felt misunderstood and were unable to make known their expressions

2. Asks about the intensity in the disturbance of intercorporeality

• Examines whether the patient intends to any social isolation or alienation and is aware of this inclination

Time-intensity Heuristic

1. Asks about the unset and course of these experiences

• Explores whether any disturbances in intercorporeality originated in childhood or later in life and remained stable over time

Triggering & Decreasing Factors Heuristic

1. Asks about any events or conditions that may have triggered the disturbance in intercorporeality

• Checks any conditions in early childhood, such as a known episode of maternal depression or other depreciating conditions after childbirth
• Checks any conditions later in life, such as episodes of sexual and physical abuse, rape and neglect

Scoring

• ‘Yes’, when the nature and intensity of a disturbance in intracorporeality is examined.

In this item, the physician examines consciousness. Consciousness is defined as the state of being aware and responsive to one’s surroundings. Under normal circumstances, a person is fully aware of subjective internal experiences, such as body sensations, emotions, thoughts, intentions, as well of one’s surroundings (Oyebode, 2019). Impairment of consciousness, however, makes the subjective experiences out of reach for psychiatric examination and treatment.

In the disturbance of consciousness, three stages are recognized:

• Clouding of consciousness
  • Deterioration in thinking, attention, perception and memory
  • Diminished awareness of the environment
• Drowsiness
  • Slowed actions, slurred speech, sluggish responses
  • Lowering of vigilance and awareness of direct environment
• Coma
  • No verbal responses
  • No responses to painful stimuli.

Consciousness is examined by a combination of medical interviewing, observation and physical examination. The depth of a disturbance of consciousness is expressed in the Glasgow Coma Score. Subtle disturbances of consciousness can be further examined with the Mini Mental State Examination. Any disturbance of consciousness is a serious medical condition and should be responded on accordingly.

Complaint Heuristic

1. Examines any deterioration in wakeful consciousness

• Such as:
  • A deterioration in thinking, attention, perception and memory
  • A diminished awareness of the environment
  • Slowed actions, slurred speech, sluggish responses
  • Marked lowering of vigilance and awareness of immediate environment
  • No verbal, no visual, and no motor responses on verbal and painful stimuli

1. Confirms intensity of disturbance in consciousness as clouded, drowsy, or coma

Accompanying Complaints and Conditions Heuristic

1. Asks about any accompanying symptoms, complaints and conditions not yet considered

• In case of any disturbance in consciousness, a potential disturbance in perception and potential medical conditions, such as epilepsy, alcohol abuse, brain trauma are further examined.

Scoring

• ‘Yes’, when any deterioration of consciousness is both examined and adequately responded on.

In this item, the physician examines dissociation. Dissociation can be examined through the medical interview and observations, as well as through self-assessment.

Complaint Heuristic

1. Asks about any experiences around dissociation

• Such as, experiences of  detachment or disconnection with daydreaming, feelings of being in a fog, of not being there, as though the world is not real, of not feeling any pain in response to overwhelming negative experiences or recollections thereof

1. Observation of signs of detachment during the interview

• Such as, as a reduction in the pace of the interview, a reduction in the ability to recall events, a staring in the distance, and a lack of responsiveness to the interviewing physician

1. Self-assessment through the Back-of-the-Head-Scale

• On an imaginative line through the head, the patient indicates whether they are fully in the present – in front of the head, or distracted and somewhere else – in the head. Dissociated patients grasp the meaning of the scale easily and the BHS helps them to ensure that they stay in the present during interview and treatment.

Time-intensity heuristic

1. Asks about the unset and course of dissociation over the years and over the past weeks

• Explores the first experiences around dissociation and the follow-up
• Explores whether dissociation waxes or wanes over the course of the last weeks
• Asks the patient about their attributions regarding stressors, accompanying conditions and symptoms, such as feelings of insecurity, any threats

2. Asks about dissociation during the day

• Examines dissociation during the morning, the day, and especially the night.

Item 3.7 is related, but asks for consciousness.

Scoring

• ‘Yes’, when complaints of dissociation are examined and, if necessary, any dissociation during the interview is handled adequately.

In this item, the physician examines attention and concentration. Attention is defined as the act of giving heed, where concentration is defined as giving attention for some duration of time. Attention and concentration are considered important, because they are a necessary condition for our grasp on the world and for development, study and achievement (Hughes, 2017). Under normal circumstances, both are directed on something, and for both the intensity can fluctuate considerably. However, normal vigilance, the act of paying attention to the environment, can turn into hypervigilance in cases of trauma and violence. Normal concentration can be flawed in psychiatric conditions, such as in Attention Deficit Hyperactivity Disorder or Major Depressive Disorder, leading to impaired functioning in study and work.

Attention and concentration can be examined through the medical interview and observations.

Complaint Heuristic

1. Asks about the nature of attention and concentration

• Examines whether attention is normal, is too absorbed, is vigilant or hypervigilant aware of the environment
• Examines whether concentration is normal, is hard to concentrate, is too early breaking off tasks, is leaving tasks unfinished, is changing frequently from activity, is losing interest, is easily distracted
• Examines whether other, often chaotic thoughts competed for attention and interfered with concentration
• Examines whether concentration is easily distracted when other people are speaking (in classrooms), by loud noise or unusual movement.

2. Observation of attention and concentration

• Examines whether periods of good concentration are alternated with periods of staring in the distance, blank face, of not comprehending what was said
• Examines when questions are asked: What did you say?

1. Asks about the intensity of the disturbance of attention and concentration

• Examines whether functioning in study or work is impaired
• Examines whether teachers have to stimulate them to stay on task and finish their chores.

Time-intensity heuristic

1. Asks about the unset and course of attention and concentration

• Asks about the unset of the disturbance and impaired functioning
• Asks whether disturbance and impaired functioning were already extant in elementary school
• Asks the patient about their attributions regarding stressors and accompanying conditions and symptoms.

Accompanying Complaints and Conditions Heuristic

1. Asks about any accompanying complaints and conditions not yet considered

• Examines any interference of physical hyperactivity and impulsivity
• Examines any experiences of reduced self-esteem, feelings of insecurity and selfdoubt, depression
• Examines any disturbances in planning, in rigidness and inflexibility, in sleep, in social interaction and expulsion

1. Asks about other underlying psychiatric symptoms and conditions

• Examines signs of ADHD and ODD, anxiety and depression, schizophrenia, any organic disorder, such as delirium, substance use.

Scoring

• ‘Yes’, when both the nature and intensity of attention and concentration are examined.

In this item the physician examines mood and affect. Both mood and emotions are considered to be experiences emanating from the body, but mood is not intended on somebody or something and more a way how we are finding ourselves in the world, whereas affect is always intentionally specific. Our normophoric, depressed or manic mood imbues our current drives, our future goals, or our experiences in the past with fresh energy – or tiredness and exhaustion. Under normal circumstances, we are – almost – unaware of our mood. The concepts of embodiment (item 3.1), sense of time (item 3.4) and intercorporeality (item 3.6) are highly interwoven with the examination of mood (Aho, 2019; Fuchs, 2019).

Complaint Heuristic

1. Examines the nature of the disturbance in mood with the loss of drive and depressed mood

Examines the disturbance in mood

• Asks about any depressed or low mood, feelings of despair, dysphoric mood with aggression, tearful, diminished pleasure, irritation, partial or complete numbness, diminished or loss of interest, increased energy, elated mood

Examines disturbance in bodily functioning

• Asks about any lack of energy and drive, heaviness, feelings of cold and being exhausted, lack of appetite, weight loss, difficulty with sleeping and disturbance of sleep-wake cycle, inability to concentrate, irregularity of menstruation, decrease in sexual functioning, retarded motor movement, restless and agitated behavior, increased activity

Examines disturbance in cognition

• Asks about any depressive brooding and worrying, excessive feelings of insufficiency, worthless and guilt, indecisiveness, any elated, inflated self-esteem, thoughts are racing, grandiosity

Examines self-harm, suicidal ideation and behavior

• Asks about inappropriate feelings of guilt, despair and insufficiency which are beyond reality; asks about feelings of powerless aggression towards oneself and others; about the wish to cut or harm one-self; about strong death-wishes; about concrete and destructive fantasies about suicide; about recent preparations and attempts to cut one-self, suicide attempts.

2. Examines the intensity of the loss of drive and depressed mood

• Asks whether the patient experiences any difficulty in daily functioning at home with the family, at work, in relations
• Asks whether the patient is less connected to long-term projects
• Use a scale of 1-10 where 10 is extremely despaired and hopeless.

Time-intensity heuristic

1. Examines the unset and course of the loss of drive and depressed mood over time

• Asks whether any triggering factor (see Triggering Factors Heuristic) preceded the unset of complaints
• Asks about the duration of the complaints, about any changes in the intensity over time, about the duration and intensity of any preceding, chronic episodes
• Asks whether, when the intensity of the loss of drive and depressed mood increased, gradually more aspects of bodily disfunctioning were involved
• Asks whether, when the intensity of the loss of drive and depressed mood increased, the patient was less involved in the near future and more living in the past
• Asks whether the patient is ruminating about mistakes or infractions in the past.

2. Examines the loss of drive and depressed mood during the day

• Asks about the intensity of the complaints in the morning.

Triggering & Decreasing Factors Heuristic

1. Examines any events or conditions that triggered the loss of drive and depressed mood

• Asks whether the patient experienced any social or existential stressor, such as death, divorce, adversity, unemployment, parenthood, increased responsibilities, empty nest, retirement, or other losses
• Asks whether the disturbance in mood is related to the menstrual cycle.

Accompanying Complaints and Conditions Heuristic

1. Examines any accompanying complaints and conditions not yet considered

• Asks about feelings of low self-esteem, hopelessness due to the chronicity of the depression
• Asks whether the patient feels less involved and attuned to important others, such as spouse, children, family and friends
• Asks whether time flows excruciatingly slowly.

1. Examines other underlying psychiatric symptoms and conditions

• Asks whether the patient experiences any obsessive-compulsive symptoms, such as counting time
• Asks about any delusions, such as hypochondric delusions, delusions of guilt, nihilistic delusions of being dead (Cotard’s syndrome)
• Asks about any experiences of trauma and sexual, physical or emotional abuse.

Item 3.2 Embodiment, item 3.4 Sense of time, item 3.6 Intercorporeality, item 3.11 Examines anxiety & agression, and item 4.17 Explores suicidal ideation are related.

Scoring

• ‘Yes’, when each of these 4 comprehensive sets of questions regarding loss of drive and reduced mood is asked.

In this item, the physician examines affect, such as anxiety and aggression. Emotions are considered to be embodied, biological reactions of fear, surprise, anger, joy and sadness. Emotions matter to us as they touch or affect us and move us to feel, think, or act in a particular way. Here, we try to describe the features of the immediate experiences of the emotions of our patient while acknowledging that these ‘affective impressions … are not easily grasped (Rosfort, 2019).’

In addition to the systematic analysis as in phenomenological psychiatry (Rosfort, 2019), a number of search-strategies for case-conceptualisation and treatment (Hornsveld et al., 2022) are included. Here, we focus on anxiety.

Complaint Heuristic

1. Examines the nature of symptoms of anxiety disorder

Affective symptoms

• Asks about anxiety, such as fear, horror, having a sense of impending danger, fear for losing control
• Asks about nightmares and flash backs
• Asks about persistent anxiety for objects or situations, such as animals, airplanes, school, medical procedures
• Asks about fear of behaving unacceptably in a social situation where subjected to possible scrutiny
• Asks about fear of being in open or closed spaces where there is no escape or no help
• Asks about anger, verbal or physical outbursts in addition to anxiety.

Cognitive symptoms

• Asks about any recurrent, involuntary, and intrusive memories that evoke distress
• Asks about negative cognitions, such as ‘I am unsafe, I am helpless, I am to blame, I am not worth’
• Asks about any impairment in concentration
• Asks about worrying about panic attack, because escape might be difficult or help not available
• Asks about worrying about possible harm or disaster
• Asks about worrying about losing important others.

Somatic symptoms

• Asks about attacks of dizziness or fainting, dry mouth
• Asks about sweating, palpitations, heart pounding, chest discomfort, shortness of breath, feeling of choking
• Asks about trembling, shaking, restlessness
• Asks about burning or itching skin, hot and cold flushes.

1. Examines intensity

• Asks about any avoidance, social isolation, restriction in behavior, such as refusal to go away from home
• Use a scale of 1-10 where 10 is extremely anxious to assess intensity.

Time-intensity heuristic

1. Examines the unset and course of the complaint(s)

• Asks when the complaint(s) started
• Asks how the complaints waxed or waned over the course of time.

2. Examines emotions during the day

• Asks about the number of attacks in the last week and how long they lasted
• Asks to describe the worst attack in the last days.

Triggering & Decreasing Factors Heuristic

1. Examines any events or conditions that triggered the complaints

• Asks at what the emotion was directed at
• Asks in what circumstances the emotion occurred
• Asks whether anything – bad – happened around the unset of the complaint(s)
• Asks which memory evokes most complaints
• Asks about their attributions regarding any stressors.

Accompanying Complaints and Conditions Heuristic

1. Examines any accompanying complaints and conditions not yet considered

• Asks about feelings of guilt and shame
• Asks about any disturbance in sleep
• Asks about detachment or estrangement from others.

Scoring

• ‘Yes’, when both the nature and intensity of symptoms of anxiety disorder are examined.

In this item, the physician examines obsessions and compulsions.

Obsessions are:

• Recurrent, persistent and distressing thoughts, images or urges
• That provoke anxiety and unease.

Compulsions are:

• Acts, carried out ritualistic and stereotypical
• That are acted out to reduce the anxiety induced by the obsessions.

Characteristic is that patients are preoccupied (meaning: obsessed) with both the obsessions and the compulsions itself – the content, and with their strict compliance with obsessions and compulsions – the process (Ahern et al., 2019). The intrusiveness of the obsession interferes with the patient’s attention for the direct environment and world, which is experienced as disturbing, whereas in the compulsion the world is experienced as disturbing when the environment asks for attention as the patient has to carry out the behavior to counter feelings of anxiety.

Obsessions are experienced as distressing, because they are valued as repugnant and objectionable, and therefore as contradicting one’s self (Ahern et al, 2019). In addition to the anxiety provoked by the obsessions, they also challenge one’s moral acceptability. Persons with obsessions overestimate threats, value themselves as critically responsible for preventing any suffering, and therefore seek for absolute certainty and perfection thereby prolongating the obsessions and compulsions. They can ‘never be sure’ and things are ‘never just right’.

These patients have insight and know that their distressing thoughts are coming from within, are unreasonable, and that they have control, but they feel unable to resist. As a result of their preoccupation, patients lose the world and important others, they lose themselves and often feel isolated. By themselves, obsessions and compulsions can only get worse, because the exclusive attention given to these thoughts and the behavior to counter the anxiety only reinforces their presence. Patients have the feeling that they, involuntarily, are forced to think exactly these thoughts and do those acts; these thoughts are therefore experienced as egodystonic – as not of themselves. At the core of the disorder is the idea that they are ‘just not’ sure that … where this loss of control and insecurity induce their desire for absolute control and certainty (Denys, 2007).

Presence and severity of complaints of obsessive-compulsive disorder are well measured with the Y-BOCS where more examples can be found.

Complaint Heuristic

1. Examines the nature of obsessive-compulsive complaints

Examines obsessions

• Asks about 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
• Asks about obsessions concerning contamination, such as concern or disgust around excrements (urine, faeces, mucus), exaggerated concerns about dirt, germs or bugs, exaggerated concerns about pollution or contamination
• Asks about sexual obsessions, such as prohibited or perverse thoughts, images or impulses, about incest, about homosexuality
• Asks about exactness and magical consequences, such as that bad things will happen when things are not straight
• Asks about religious obsessions, about obsessions with numbers, about intrusive images, etc.
• Asks whether these obsessions are egodystonic, as not how the patient wants to be, as not emaneting from themselves.

Examines compulsions

• Asks about 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
• Asks about compulsions around control, such as checking doors, locks, kitchen apparail, checking whether they have hurt anybody, checking any possible mistakes, checking that terrible things might happen
• Asks about repetitive compulsions, such as reading or writing, counting, walking in and out, opening and closing doors
• Asks about compulsions regarding stocking up.

2. Examines the intensity of obsessive-compulsive complaints

• Asks how much anxiety and stress (‘just not right’) the patient experiences when not complying with the obsessions and compulsions
• Asks how many hours a day the patient is preoccupied with the obsessions or with carrying out compulsions
• Asks how obsessions and compulsions interfere with functioning in daily life
• Asks how hard it is to resist obsessions and compulsions.

Time-intensity heuristic

1. Examines the unset and course of obsessive-compulsive complaints

• Asks when the complaints started, whether they waxed or waned over the course of months or years
• Asks whether these complaints already originated in childhood and remained stable over time.

2. Examines obsessive-compulsive complaints during the day

• Asks the patient carefully and subsequently about any complaints they experience during the day.

Triggering & Decreasing Factors Heuristic

1. Examines any events or conditions that triggered the complaints

• Asks whether complaints were triggered during a period of stress.

2. Examines about any conditions that increased the complaints

• Asks whether the complaints increased the more attention was given to them and the more they were carried out.

Accompanying Complaints and Conditions Heuristic

1. Examines about any accompanying complaints and conditions not yet considered

• Asks about feelings of shame, anger, guilt
• Asks whether these feelings prohibited the patient from involving parents, spouse, and from seeking help
• Asks whether the patient feels isolated, estranged from others
• Asks whether the patient feels discouraged about the future given the persistence of the complaints.

Item 3.1 Sense of self is related.

Scoring

• ‘Yes’, when both the nature and intensity of obsessive-compulsive complaints are examined.

In this item, the physician examines any disturbances in perception, such as vision, hearing, taste and smell. Under normal circumstances, the subjective experience of the perceptions is congruent with the external stimulus.

Complaint Heuristic

1. Examines the nature of the disturbance in perception

• Asks about any experiences that resemble perception in hearing, vision or taste and smell, in the absence of an external stimulus

In hearing

• Asks about hearing any voices of invisible people that are distinct of one’s own thoughts
• Asks whether these voices are of a single person, of several persons, of men, women or children, of people they know
• Asks whether these people talk, shout or abuse them with questions, comments, threats or even curses
• Asks whether one of these voices is friendly, is assumed a friend, gives healthy advice
• Asks whether the voices originate from in their head or from the outside
• Asks whether the voices represent their own ideas and how they want to be as a person, or as repugnant and inconsistent with their own personality
• Asks whether the patient hears their own thoughts spoken aloud
• Asks about hearing any other noises, such as tunes, whistling, rattling, and whether words are spoken aloud by these noises.

In vision

• Asks about seeing any images that can not be seen objectively by others
• Asks to describe the images
• Asks whether these images are experienced as awful or threatening
• Asks whether the images disappear when the attention is focused on another object or on other senses, such as hearing.

In taste & smell

• Asks about any smells or tastes that can not be smelled or tasted objectively by others.

1. Examines the intensity of the disturbance in perception

• Asks whether the disturbance in perception is experienced as real or whether there is some doubt.

Time-intensity heuristic

1. Examines the onset and course of the disturbance in perception over time

• Asks whether the experiences waxed or waned over the course of time
• Asks the patient about their attributions regarding stressors, accompanying symptoms and conditions.

1. Examines the experiences of disturbed perception during the day

• Asks about the experiences during the day, such as at night, in the morning
• Asks about the number of times or amount of time spent on disturbing perceptions.

Triggering & Decreasing Factors Heuristic

1. Examines any events or conditions that may have triggered the disturbance in perception

• Asks whether the patient experienced any trauma, such as sexual or physical abuse in childhood.

Accompanying Complaints and Conditions Heuristic

1. Examines any accompanying complaints and conditions not yet considered

• Asks about any feelings of distress, disempowerment, helplessness.

1. Examines other underlying psychiatric symptoms and conditions

• Asks about minimal self, schizophrenia, posttraumatic stress disorder, psychotic depression, bipolar disorder, borderline personality disorder.

Items 3.1 – 3.6 are related and examine any disturbance in self.

Scoring

• ‘Yes’, when both the nature and intensity of any disturbance in perception are examined.

In this item, the physician examines any disturbances in 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.

Narrative, long-termed memory can be examined by asking the patient about childhood memories, major events in the life of the patient, events before the unset of the disorder. See also item 4.21 Explores history of education and professional life, as well as item 4.22 Explores early development up to adolescence.

However, how important the content of these memories may be, as important is how the patient deals with these memories or with any problems with the retrieval of early memories. Patients may only touch upon some memories, present rambling memories, or be very verbose concealing any problems they experience with retrieving memories.

Scoring

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

In patients where disturbances in memory functioning have been established, the psychiatric examination can be complemented with a further examination of embodied memory (Fuchs & Schlimme, 2009.)

Even when dementia robs the patients of their explicit memories, they still retain their body memory, that means, their familiarity with environments, habits, sensory and motor memories (Fuchs, 2020)

Explores functioning of procedural memory, such as well-practiced habits, skillful handling of objects, patterns of perception

Habits acquired through repetition and practice remain intact long after the unset of loss of explicit memories. Habits reflecting the functioning of procedural memory refer:

• To recognizing familiar faces
• To dealing with objects, such as affordances for eating, self-care
• To skills practiced professionally or in spare time, such as crafts, music instruments, sports.

Explores functioning of situational memory, such as the ability to recognize familiar objects and situations and to cope with them skillfully

Situational memory is built by the countless encounters of the body with the surrounding space, such as a room or the house, and includes the experiences of touch as well as sound, smell, and vision. Implicit in situational memory is an understanding of the function of affordances, such as a chair – to sit, a table – to sit and eat, a cup –  to drink.

Explores functioning of incorporative memory, such as longstanding routines and patterns of behavior

Incorporative memory refers to ways of acting, such as skills, styles, tastes that characterize a person. As incorporative memory is built on patterns of behavior developed in the past, the behavior may not be appropriate in the current situation, but can be understood from the personality and traits in the past.

Explores functioning in intercorporeal memory, such as understanding, showing and responding to non-verbal expressions

Ultimately, intercorpereal memory is the final pathway by which, through  the expressions of the face, a patient can express how they feel and what they wish.

Scoring

• ‘Yes’, when the physician examines, in cases where disturbances in short- en long-term memory are established, at least three of four aspects of embodied memory.

Complaint Heuristic

• Examines the nature of the disturbance in movement
  • Asks about any involuntary muscle contractions of short duration whether or not accompanied by loss of muscle power
  • Asks about any involuntary muscle contractions leading to repetitive movements and aberration of posture, especially around the head and neck, such as the eyes, the mouth, the tongue, the neck, but also of trunk and arms
  • Asks about any involuntary movements:
    • Of tongue, lips, cheek or face, such as chewing, bulging of the tongue or lips, blinking of the eyes
    • Of trunk or limbs, such as fingers, hands, feet or toes
    • Or of the lungs, such as irregular and fast breathing
  • Asks about an agonizing – feeling of – restlessness, especially in the legs, but also in hands, fingers or arms
  • Asks about any retardation or even absence of movements, such as a slowness or stiffness of movement, retardation in facial expressions, a voice without emotion
  • Asks about any tremor in the hands or cheek while resting.

• Examines the intensity of the disturbance in movement
  • Asks about the inability to sit still
  • Asks about any interference in daily functioning, such as difficulty with eating, writing, walking
  • Asks whether the patient tries to conceal the disturbance in movement or to avoid any situations.

Time-intensity heuristic

• Examines the onset and course of the disturbance in movement over time
  • Asks whether the disturbance in movement waxes or wanes over the course of weeks
  • Asks the patient about their attributions regarding stressors, accompanying conditions and symptoms, such as psychiatric medication
  • Asks whether the intensity of the disturbance in movement is associated with the dose of medication.
• Examines whether the disturbance in movement waxes or wanes during the day
  • Asks whether the movements and restlessness wane at night.

Triggering & Decreasing Factors Heuristic

• Examines any events or conditions that triggered the disturbance in movement
  • Asks whether the contractions, movements, restlessness, or tremor were triggered within hours, days, months or even years after the start or augmentation of psychiatric medication.

Accompanying Complaints and Conditions Heuristic

• Examines any accompanying complaints and conditions not yet considered
  • Asks about any difficulty with speaking, breathing, sleeping
  • Asks about any pain due to forceful and longstanding contractions
  • Asks about feelings of anxiety, about depression and despair
  • Asks about any somatic disorders, including medication and substance use.

Item 2.12 Asks about current (ab)use of medication and substances is related.

Scoring

• ‘Yes’, when the nature of the disturbance in movement and the relation with medication are examined.

In this item, the physician explores sleep and any disturbance which is often backed up by a sleep diary.

Complaint Heuristic

1. Examines the nature of the sleep

• Asks whether the patient sleeps well
• Asks whether the patient doesn’t sleep well and feels not rested in the morning
• Asks what bothers the patient most about the disruption of the sleep.

• Asks whether the patient has trouble falling asleep
• Asks whether the patient lies awake for a long time at night
• Asks at what time the patient goes to bed and how long it takes to fall asleep on average
• Asks whether there is any regularity at bedtimes during the week and the weekend
• Asks at what time the patient awakes by themself or the alarm clock
• Asks how many hours the patient sleeps on average
• Asks whether the patiënt sleeps well over 10 hours but still feels tired and naps during the day
• Asks whether the patient falls asleep during the day which can be accompanied by sudden attacks of muscle relaxation.

1. Examines the intensity of the disturbance of sleep

• Asks whether the patient feels tired and is lacking energy during the day
• Asks whether the patient feels impaired in daily functioning, e.g. in concentration or memory.

Time-intensity heuristic

1. Examines the onset and course of the disturbance in sleep over time

• Asks about the onset and subsequent course of the disturbance in sleep over time.

1. Examines sleep during the day

• Asks about any naps or sleep attacks during the day.

Accompanying Complaints and Conditions Heuristic

1. Examines any accompanying complaints and conditions not yet considered

• Complaints around anxiety and stress
  • Any worries or stress
  • Any nightmares that induce anxiety and are experienced as threatening
  • Short periods of intense anxiety accompanied by screaming and yelling
• Complaints around sleep
  • Loud snoring and the feeling of suffocating
  • Short periods of arousal during which the patient feels confused and disoriented
  • Sensorial or visual hallucinations during the transitions from waking to sleeping or from sleeping to waking
• Complaints around movement
  • Short periods of sleepwalking sometimes accompanied by compulsive eating
  • Periods of movement and speaking out loud that are often accompanied by aggressive behavior in which the patient portrays their dreams
  • Short periods of paralysis or inability to move that are often accompanied by hallucinations
  • Uncomfortable sensations in the legs that urge the patient to move at night and during sleep
  • Periodic movements of the limb(s) that interfere with the sleep and lead to arousal
  • Grinding teeth during sleep such that the patient experiences premature wear or pain in their tooth
  • Rhythmic and repeated movements of head or body that interfere with the sleep
  • Abrupt, involuntary movements during the transition from waking to sleeping.

1. Examines other underlying psychiatric symptoms and conditions

• Asks about any accompanying episode of psychosis, including schizophrenia, of anxiety and depression, including obsessive-compulsive disorder and posttraumatic stress disorder, of ADHD and delayed sleep-wake phase, of autism and the impact on functioning, of personality disorder including borderline disorder
• Asks about the use of any medication and drugs, including alcohol, benzodiazepines, cannabis, caffeine, nicotine, opioids, stimulants.

Scoring

• ‘Yes’, when the nature and intensity of any disturbance in sleep are explored.

In this item, the physician explores the risk and plans for a suicide attempt in order to reduce the risk and provide a treatment plan.

Complaint Heuristic

1. Asks about the nature of the suicidal ideation, such as feelings of despair and hopelessness and the intention to kill oneself

• Feelings and ideation (despair and hopelessness, the feeling to fail, longing for being dead, impetuous and haste, irritability and impulsivity, hostility towards others and oneself)
• Plans and preparations to commit suicide
• Nature and lethality of the attempt

2. Asks about the intensity of the suicidal ideation

• Longing for being dead and committing suicide
• Experienced distress and suffering, including being a burden for important others
• (Lack of) control about their impulses and behavior
• Use a scale of 1-10 where 10 is extremely despaired and hopeless

Time-intensity heuristic

1. Asks about the unset and course of suicidal ideation over the past weeks

• Checks whether suicidal ideation waxes or wanes over the course of weeks
• Asks the patient about their attributions regarding stressors, accompanying conditions and symptoms, such as loss and offences, somatic and psychiatric complaints, substance abuse

2. Asks about suicidal ideation during the day

• Number of times and amount of time spent on suicidal thoughts a day
• In the morning, when the patient feels most depressed and experiences no incitement to wake up
• During the night, when the patient feels lonely and hunted by their thoughts
• Or any other moment and explores the circumstances or factors contributing to suicidality

3. Asks about expectations and plans for the near future

• Asks how the patient considers the future
• Asks whether any improvement regarding the conditions can be expected

Triggering & Decreasing Factors Heuristic

1. Asks about any events or conditions that triggered the suicidal ideation

• Checks whether the patient experienced any loss or offences and whether the stress increased

2. Asks about any conditions that increased the suicidal ideation

• Checks whether the patient experienced any somatic complaints or conditions, including pain
• Checks whether the patient experienced any psychiatric symptoms or conditions, such as symptoms of psychosis or depression, or symptoms of posttraumatic stress after sexual or physical abuse

3. Asks about any conditions that decreased the suicidal ideation

• Checks whether the patient feels connected to, supported, and protected by important others, such as spouses, friends, and parents
• Checks whether the patient experienced a reduction in the level of stress recently and explores the conditions that contribute to the improvement
• Checks whether any safety measures were taken and how they contribute to safety and the reduction of risk

Accompanying Complaints and Conditions Heuristic

1. Asks about any accompanying complaints and conditions not yet considered
2. Asks about other underlying psychiatric symptoms and conditions

• Checks whether the patient experiences any impulsivity and is afraid to be out of control
• Checks symptoms of obsessive-compulsive disorder, including ‘voices’ that urge the patient to hurt themselves, and ‘voices’ that belittle, humiliate, or hold the patient in contempt
• Checks symptoms of developmental disorder and personality disorder, such as rigidity, black and white thinking, acting out behavior

Item 30 Suicidal Ideation is related, but asks for suicidal ideation as a symptom of depressive disorder.

Scoring

• ‘Yes’, when each of these 4 comprehensive sets of questions regarding suicidal ideation and plans is asked.

Scoring

• ‘Yes’, when such feelings originating from the patient have been asked about.

Scoring

• ‘Yes’, when such questions are asked.

This item pertains to life cycle problems.

Scoring

• ‘Yes’, when open questions on perspective, aspirations and their fulfilment are asked.

Caregiving may be accompanied by satisfaction as well as by too heavy a physical or emotional burden.

Scoring

• ‘Yes’, when a question is asked about caregiving with the accompanying effects.

Scoring

• ‘Yes’, when open questions on this subject are posed.

In this item, the physician explores feelings around religion and purpose in life, and their relation with the mental health problem.

1. Examines the nature of the religious feelings

• Asks whether the patient adheres to any religious belief
• Asks whether the patient acts in conformity with their belief
• Asks whether the patient relies in a special way on any person in their community.

1. Examines how these feelings interfere with the mental health problem

• Asks whether the mental health problem has any religious meaning for them
• Asks whether the patient feels supported by their religion
• Asks whether the religious feelings interfere with their problems in a negative way.

1. Examines how these feelings interfere with the treatment plan
   • Asks the patient to consider how religion is involved in the treatment plan, such as that the patient experiences relief, hope or support, or that some medication is prohibited, etc 
   •  Asks how some persons in the family or community can or should be involved in the treatment.

Scoring

• ‘Yes’, when the nature of religious feelings and their impact on the mental health problem and treatment is explored.

The patient is asked to describe his character.

The interviewer asks about personality traits which cause vulnerability to mental health problems, such as dependent, paranoid, compulsive, histrionic, schizoid, anti-social, borderline, passive-aggressive, avoidant traits.

Scoring

• ‘Yes’, when the patient is asked: for a character self-description and/or two or more questions about the above-mentioned personality traits.

As features of these relationships, the following aspects may be considered:

• Flexibility in the case of changing situations;
• Flexibility of roles and positions;
• Differentiation of roles and tasks;
• Possibilities of emotional and social support;
• Flexibility and tolerance in norms and values.

Scoring

• ‘Yes’, when two or more of these features are explored.

This item pertains to the social support system of patients.

Scoring

• ‘Yes’, when the physician asks whether, in the patient’s social orbit, there are persons who support him emotionally or materially.

Confrontation with habits, values, and norms of different (sub)cultures may entail adaptation problems.

Scoring

• ‘Yes’, when such a question is asked.

By ‘professional functioning’ is meant any functioning in profession, household or study.

Scoring

• ‘Yes’, when the physician asks for the experienced quality of one of these three aspects.

Scoring

• ‘Yes’, when the physician explores satisfaction in functioning during leisure time.

The physician explores:

• The amount and kind of daily exercise;
• The involvement in sport, currently and in the past;
• Any concerns the patient has about insufficient or lack of daily exercise and health issues, such as weight, lack of breath, hypertension, diabetes mellitus, medication, etc.

Scoring

• ‘Yes’, when the physician explores at least two of these three issues.

In this item, the physician explores:

• The eating habits of the patient (appetite, dietary habits);
• Possible disturbances, such as fear of becoming obese, extreme weight loss, periods of bulimia, disgust.

Scoring

• ‘Yes’, when:
  • The physician asks about appetite and eating habits;
  • In the case of disturbances, explores their nature.

This item asks for the quality of sexual functioning.

In case of dysfunctioning (e.g. inhibited desire, excitement and orgasm; dyspareunia; vaginismus; premature ejaculation), the nature of the disturbance should be explored.

Scoring

• ‘Yes’, when the physician asks about satisfaction with sexual functioning and – in case of dysfunctioning – its nature.

Medication and substances are:

• Self-medication;
• Professionally-prescribed medication;
• Drugs, e.g. smoking, alcohol;
• Soft- and harddrugs.

A physician should explore the following 5 aspects:

• What medication is used?
• What drugs are used?
• The quantity of use?
• Any impairment in social and occupational functioning?
• The degree of physical and psychological dependence?

Scoring

• ‘Yes’, when the physician explores these 5 aspects.
• ‘No’, when medication and substance use are not or insufficiently explored

There may be some overlap with Item 2.12 Asks about current (ab)use of medication and substances.

In cases of dissatisfaction:

• Objective data should be collected about the housing situation;
• And assessed what changes the patient has in mind.

Scoring

• ‘Yes’, when the patient is asked about their satisfaction with their housing situation and, in case of dissatisfaction, for objective data concerning the housing situation and the desire for change.

In this item, the physician explores the financial situation and any consequences.

1. Asks about (dis)satisfaction with the financial situation

• Asks about any worries and concern around finances
• Asks for objective data about the financial situation in case of dissatisfaction
• Asks what changes the patient has in mind.

2. In case of dissatisfaction or poverty, asks about the consequences

• Asks whether the patient is isolated because they can not afford to participate in public transportation, sports, spare time, education and work activities
• Asks whether the patient feels unqualified because they can not afford certain self care, clothes or hospitality.

Scoring

• ‘Yes,’ when the physician explores the financial situation and, in case of hardship or poverty, the consequences.

In this item, the history of functioning in professional life and education, and the satisfaction with this functioning is explored, in addition to Item 4.11, which examines current professional functioning.

Scoring

• ‘Yes’, when the physician asks about:
  • Historical facts in education and professional life;
  • Satisfaction or problems experienced.

Infancy: Pregnancy, Birth & First Year

• Was the pregnancy planned?
• Were there any reasons for treatment around fertility?
• How did you experience the pregnancy?
  • How did you find out you were pregnant, how did you and your partner respond?
  • Did you have any pregnancy-related complaints?
  • Were there any stressful conditions or emotional constraints, such as: adversity, poverty, sexual or physical abuse?
• Did you use any substances, such as: alcohol, cigarettes, medication, other drugs?
• How did you experience delivery and postpartum period?
  • How do you feel about it (powerful, satisfied, overwhelmed, traumatized, etc.)?
  • Were there any medical complications?
  • Did mother and child do well during and after delivery?
• Could your child regulate any distress?
  • Were there any problems around sleeping, crying, eating? How was the mood?
  • How could you sooth your child? Could you attach and interact with your child?
• How did you feed your child: bottle or breastfeeding? Was feeding satisfying for you and your child?
• Were there any separations between you and your child in the first year? How did your child respond?
• Milestones in the first year: first smile, sitting, first steps, first words: ‘dada’, ‘mama’?

Socio-emotional Development

• Toddler:
  • Can you describe your child’s temperament and character?
  • How dit your child get along with other children?
  • Were there any problems regarding crying, sleeping, food and nutrition, anxiety?
  • Did your child visit any childcare facility?
• School-age:
  • Can you describe your child’s temperament and character?
  • How did your child get along with other children?
  • Were there any problems regarding behavior, or at school?

Psychosexual Development

• Did you provide any sexual education to your child?
• Were you ever concerned about your child’s sexual development?
• Makes anything in your personal development you vulnerable on how to communicatie about sexuality with your child?

Life-events & Traumatic Experiences

• Has your child been separated from you? How did the child respond?
• Has your child experienced any traumatic event, such as illness and hospitalization, accidents, illness or death in the family?
• Was there any sexual or physical abuse, neglect or intimate partner violence?

Physical Development

• How did your child develop physically?
• How did speech and language develop? Did you have to involve a speech therapist?
• How did toilet training (stool; urine during the day, at night) proceed?

Scoring

• ‘Yes’, when at least two of these areas are explored.

The physician mentions a – probable – diagnosis or any other definition of the problem, sometimes an important ‘rule-out’.

The information is mainly on a descriptive level. For instance: The symptoms are indicative for measles. Etiology is not considered here but in the next item (e.g. Measles are a contagious infection caused by a virus). Nevertheless, there may be some overlap with the next item.

If the physician does not have any – probable – diagnosis, but has made some important ‘rules-out’ (e.g. The chest pain probably does not mean a heart disease), these statements are also valid in this item.

It is important that the physician does not use any jargon or terms which do not match the intellectual or/and socio-cultural level of the patient.

Scoring

• ‘Yes’, when the physician gives descriptive information about what is wrong (or not wrong) in terms understandable to the patient.

This item means an explanation of the complaint in terms of psychological mechanisms. As in the former item, the patient must be able to understand the explanation.

Scoring

• ‘Yes’, if etiological explanation and understandability are present in the given information.

The prognosis of a disease may be strongly influenced by medical treatment.

The physician should include minimally some information about the severity of the illness consisting of a description of the natural course of the disease.

In addition, information about the disease after treatment should be given.

Scoring

• ‘Yes’, when information concerning the prognosis of the disorder/problem is conveyed – in treated as well as untreated conditions.

Expectations always have a factual and emotional aspect.

We draw attention to the difference between wish and expectation as explained in Item 1.13 Asks the patient to state what help they desire. In short, wishes tend to reflect unrealistic hopes, whereas expectations are hopes which have been moulded by reality.

For example: the patient wishes to obtain a thorough explanation from the physician, but he expects to receive only a prescription which does not resolve all his worries or fears. This item must be distinguished from Item 1.13 although some overlap may be inevitable.

Scoring

• ‘Yes’, when both factual and emotional aspects of the expectation concerning help and solutions for the problems are explored.

Scoring

• ‘Yes’, when the physician explores how much responsibility the patient is prepared to take for the method of treatment (rules, obligations, efforts, time investment, etc.) and for the determination of the objectives of treatment.

This proposal may consist of:

• Further history-taking,
• Further investigations (with or without referral),
• Treatment,
• Preventive advice.

The physician may offer possible alternatives, of which one is always no further professional help.

This gives the patient the opportunity to make a choice for which they take responsibility.

Scoring

• ‘Yes’, if the physician introduces a proposal for help with one or more alternatives.

Scoring

• ‘Yes’, if the physician offers this explanation (related to the problem stated in Item 5.1) in an understandable way.

Information about pros and cons is intended to support the patient by choosing the most suitable solution to his problem.

The pros and cons must be weighed against the patient’s situation in order to result in a feasible plan. Pros and cons may be:

• Adverse and beneficial effects (e.g. medication);
• Estimated probability of success or failure;
• Impact on daily life;
• Social restrictions;
• Cost, waiting list, etc.

Scoring

• ‘Yes’, when the physician discusses at least one pro and con of the proposed help with the patient.

The doctor shares sound and reliable resources on the internet:

• Either by opening the link during the consultation and sharing the screen with the patient
• Or by providing a link so that the patient and family members can consult the information later.

The aim of sharing sound and reliable resources on the internet regarding the patient’s diagnosis and treatment plan is twofold:

• To enhance insight and intention to comply in order to support a patient’s autonomy and improvement in health status
• To counter the detrimental effects of misinformation and alternative facts on a patient’s insight and health behaviour.

The intention is that the information is sound and reliable from a professional point of view, but the doctor should be aware that the patient may disagree (see also item 3.12 Explores different opinions and item C. Communication Skills).

The doctor should be also aware that the volume and haphazard nature of information on the internet can easily overwhelm the patient and lead to cognitive overload. The doctor can help the patient by:

• Providing an overview or structuring the information
• Highlighting one or two salient topics of immediate relevance to the patient.

Scoring

• ‘Yes’, if the doctor refers to sound and reliable resources on the internet regarding diagnosis and treatment plan.

Scoring

• ‘Yes’, when the physician explores the patient’s attitudes towards the proposed solution.

There may be a mutual influence on each other of proposed help and the important others of the patient.

For example:

• The proposed help implicates involvement of important others in the treatment;
• The proposed help may be unacceptable for important others;
• Considerable support may be asked for in the compliance of the proposed help; etc.

Scoring

• ‘Yes, when mutual influence on each other of the proposed help and important others is explored.

While giving information, it may become clear that the patient does understand the physician, but holds a different opinion on some part. The physician should then check this difference in point of view explicitly.

The physician should discuss the possible difference in viewpoint and clarify the exact point of difference.

By discussing, we do not mean arguing with the patient about his point of view. This item refers only to a discussion of different points of view. When arguing takes place and the physician obliges the patient to adopt his opinion, this item will be scored ‘no’.

Scoring

• ‘Yes’, when the physician explores the presence of a different point of view on problem-definition or treatment plan and when possible differences in points of view are clarified;
• ‘No’, when the physician does not check any possible differences in points of view or when he tries to persuade the patient to change his opinion.

After proposing alternatives of help, after discussion of their feasibility, and after exploration of the patient’s opinion, the physician asks the patient to make a choice between the alternatives.

Scoring

• ‘Yes’, when the physician asks the patient to make a selection from alternatives of help (of which one is – of course – no help!).

After reaching a decision about the advice, the physician should explain how this advice has to be followed.

If the explanation is of good quality, it will increase the patient’s compliance and therapeutic results. Good advice must always be given in terms of concrete behavior so that it enables the patient to carry out the advice.

For example: when rest is advised it should be clear whether the patient should sleep longer, should seek situations of relaxation, should avoid conflicts, or should stay in bed day and night with someone to look after him.

Scoring

• ‘Yes’, when, according to the observer’s opinion, the advice given is formulated concretely enough for the patient to follow adequately.

After having made clear in terms of concrete behavior how the patient should follow the advice, the physician should check whether the patient has understood the advice.

There are several ways to do this:

• The physician can ask the patient if they have understood the advice;
• They can ask the patient to repeat the advice.

Scoring

• ‘Yes’, when the physician makes sure that the advice given is understood by the patient.

The following subjects can be arranged:

• What is going to happen;
• Who is doing what;
• Who takes initiatives;
• At what time.

Scoring

• ‘Yes’, when all four subjects are treated concretely;
• ‘No’, when otherwise.

This item relates to two subjects, namely, the introduction and the clarification of the relationship.

Since the MAAS is used in a variety of situations, it can be the case that one or either subject may not be applicable, because they are already known to the patient, e.g. in the practice of a general practitioner.

Clarifying the functional relationship is not only important for physicians and students in training situations, but also for physicians communicating with patients via different functional connections, such as physicians in examining advising relationships; physicians standing in temporarily; or physicians cooperating in different situations all of whom have to explain their functional relationship with the patient.

Sometimes, when the patient is accompanied by an important other, the nature of their relation and their role should be clarified.

Scoring

• ‘Yes’, only if both introduction and clarification actually take place.

Having clarified the reason for the encounter, the physician frames a plan in which they explain how they wishe to handle this request for help from the patient. This design for the rest of the interview includes:

• The subjects the physician wishes to bring under discussion,
• The physical exam they wish to perform,
• And the intended sequence.

Scoring

• ‘Yes’, only if such a plan is offered to the patient.

This item checks whether the reason for encounter is well understood by the interviewer and is done by means of a summary.

We wish to emphasize that a summary always has a testing character. The physician invites the patient to react to the summary by means of the content of the summarized information and the interval afterwards. If the reason for encounter is understood sufficiently, the physician will continue by asking more directive questions stemming from History-taking and the Psychiatric Examination or Socio-emotional Exploration.

Theoretically, the following possibilities can occur with regard to this item:

• The request for help is implicit (the patient comes for the results of investigations done before) or the request is being verbalized by the patient spontaneously. In both cases, a summary has still to be made in order to test whether the physician has understood the request well. In the first case, a (closed-ended) question like Did you come for the results? will suffice.
• The request for help has not (yet) been verbalized properly by the patient which means that the summary comes too quickly and is, by definition, incomplete. This becomes obvious, because the patient adds further information to the summary.

When the request for help has not been explored sufficiently, the exploration has to be continued and has to be concluded with a summary again.

This item measures the concluding function of the summary. The quality of the summary is assessed by item C.3 Makes proper summaries.

Scoring

• ‘Yes’, if a summary is made at the end of Exploring Reasons for Encounter or if the summary is perfected after another try.

The physician mentions the main problems which have come up during Exploring Reasons for Encounter, History-taking, Psychiatric Examination and Socio-emotional Exploration.

This summary originates from the physician’s frame of reference and differs in this respect from a summary which originates from the patient’s frame of reference.

With the ordering, the physician closes the first phases of the initial interview.

Scoring

• ‘Yes’, when the information is ordered after Exploring Reasons for Encounter and the directive questions pertaining to the History-taking, Psychiatric Examination and Socio-emotional Exploration section.

In the medical interview, physicians frequently switch between different sections which appears to have confounding effects on the patient. Ideally, the section with History-taking, Psychiatric Examination and Socio-emotional Exploration questions is preceded by the exploration of the request for help.

Scoring

• ‘Yes’, if, according to the observer’s opinion, the request for help has been explored sufficiently before the physician continues with History-taking, Psychiatric Examination and Socio-emotional Exploration.

Scoring

• ‘Yes’, if Exploring Reasons for Encounter, History-taking, Psychiatric Examination and Socio-emotional Exploration have been sufficiently completed before solutions are presented;
• ‘No’, if one of the following cases is present:
  • The physician goes back to items from former phases when parts of Presenting Solutions have already been under discussion;
  • The phases of Exploring Reasons for Encounter, History-taking, Psychiatric Examination and Socio-emotional Exploration have not been elaborated extensively enough in the observer’s opinion.

Scoring

• ‘Yes’, when the physician introduces Presenting Solutions with information about a probable diagnosis, a problem definition or an important rule-out of the problem/complaint;
• ‘No’, if this does not happen.

Scoring

• ‘Yes’, when the physician asks this question.

This item requires the observer to give a global judgment of the quality of the physician’s facilitating behavior during the interview.

Facilitating is necessary to stimulate the patient to speak from his own frame of reference and experience, and to express emotions and concerns. Also is it important to ask questions about factual information in a facilitative way.

Facilitation is given concrete form in the following ways:

• Well-indicated open questions, especially during Exploring Reasons for Encounter, and the exploration of emotions, concerns and ambivalence during Presenting Solutions;
• Stimulating questioning behavior within the patient’s frame of reference;
• Reflections and remarks stimulating to openness, such as Tell me… or What else …?;
• A listening attitude which becomes apparent by means of well-timed, short periods of silence;
• Physician’s self-disclosure.

Scoring

• ‘Yes’, when at least 4 aspects are shown during the interview;
• ‘Indifferent’, when 2 or 3 different aspects are shown;
• ‘No’, when 1 or fewer aspects are shown.

This item covers reflections about verbally or non-verbally expressed emotions by the patient. Reflections form the most important interview behavior for the physician to react to the patient’s emotions.

Reflections on emotions are used in the proper way, when:

• Reflections are timed adequately, meaning at or directly after the moment that the emotions are expressed. The relation between the patient’s emotion and the reflection has to be clear;
• Non-verbally expressed emotions are recognized and reflected upon;
• The right content of the emotion is reflected, which means congruence between emotion and reflection.

Scoring

• ‘Yes’, when 80% of reflections on emotions are used according to the criteria;
• ‘No’, when less than 80% of the reflections of emotions are used according to the criteria, or when the physician does not react to clearly expressed emotions;
• ‘Indifferent, when no reflections on emotions are used, and when they are also not necessary.

This item refers to the physician’s reactions to emotional expressions of the patient directed against the physician. When the patient expresses sadness, disappointment, anxiety, anger, blame or cynicism against the physician, they have to try to keep the communication ongoing.

The communication can be disturbed when the physician does not handle these emotions well, and  presents different defense mechanisms against the emotions, e.g.:

• Denial, negotiation, minimizing, rationalization, shifting, reacting by the counterpart;
• Antagonistic behavior, e.g. discussion, quarreling.

Scoring

• ‘Yes’, when the physician handles emotions, which are directed towards them, in the appropriate way, with the result that the communication keeps going;
• ‘No’, when the physician uses defense mechanisms or antagonistic behavior;
• ‘Indifferent’, when the patient does not express emotions which are directed towards the physician.

This item refers to the physician’s questions about the feeling the patient has during the interview.

The questions are most likely to occur during Presenting Solutions. The questions have the characteristics of open-ended questions, and pertain to the momentary feelings and emotions of the patient.

Open-ended questions are asked in a proper way when:

• The physician asks questions within the patient’s frame of reference;
• The question does not rule-out any categories for answering;
• Each question deals with one subject.

Scoring

• ‘Yes’, when these questions are asked in the appropriate way in 80% or more of the cases;
• ‘No’, when these questions are asked in the appropriate way in only 50% or less of the cases;
• ‘Indifferent, when this interview behavior is not shown or handled appropriate in only 50-80% of the cases.

The physician makes meta-communicative comments to stimulate an inhibited communication.

Inhibition of communication may have several causes, but results mostly from inadequate and not corrected interview behavior earlier in the interview.

Examples:

• Neglecting or minimizing strong emotions;
• Inadequate reassurance;
• Asking questions which have nothing to do with the case.

Inhibited communication is expressed and can be detected by several characteristics of the physician-patient communication:

• Defensive behavior of the patient, e.g. negativism, denial, refusal;
• Obstinate discussion;
• Frequent misunderstanding;
• Long periods of silence;
• Repetition.

The result is that communication is hampered over the course of several phases of the medical interview. Inhibited communication can be addressed by meta-communicative comments, like: It seems that we are going around in circles here, or How can it be that we frequently misunderstand each other?

Scoring

• ‘Yes’, when inhibited communication is stimulated by meta-communicative comments;
• ‘No’, when in the case of inhibited communication, the physician does not make meta-communicative comments, or when they make unnecessary meta-communicative comments which have a further inhibiting influence on the communication;
• ‘Indifferent’, when meta-communication is not shown and not necessary.

Physicians should briefly explain why they want to ask a number of directive questions, and these questions should not take too much time and attention.

Directive medical questions during History-taking, Psychiatric Examination and Socio-emotional Exploration should not lead to endless rows of questions, as they can stimulate feelings of uncertainty and anxiety, and are likely to be misunderstood.

Scoring

• ‘Yes’, when the physician briefly explains why they want to ask a number of directive questions, and when these questions do not take too much time and attention in the observer’s opinion;
• ‘No’, when directive medical questioning does not fulfill both criteria;
• ‘Indifferent’, when there is no history-taking.

This item refers to specific and explicit behavior which is aimed at putting the patient at ease.

It can be necessary to put the patient at ease:

• To make acquaintance with the physician;
• During physical examination;
• After the expression of strong emotions during Exploring Reasons for Encounter or Presenting Solutions.

Scoring

• ‘Yes’, when the physician shows explicit behavior which is meant to put the patient at ease;
• ‘No’, when this behavior is necessary, but the physician fails to perform it in the observer’s opinion;
• ‘Indifferent’, when such behavior is not necessary and is not shown.

The pace of an interview is strongly related to facilitative behavior and to ‘directivity’, the patient’s feeling that the physician would like to take over interview and treatment plan. The proper pace is considered as such an important quality of an interview.

Scoring

• ‘Yes’, when the physician regulates the pace of the interview smoothly;
• ‘No’, when:
  • Periods of silence disturb the pace of the interview;
  • The physician jumps too quickly from one subject to another;
  • The physician interrupts the patient;
  • The physician allows the patient too much discussion of subjects which are not of evident importance for the present complaint/problem;
• ‘Indifferent’, when there is a mixture of ‘proper’ and ‘improper’ pace.

This item is best scored by first judging the non-verbal behavior of the physician, and then comparing the nature of the verbal behavior with that of the non-verbal behavior. Afterwards, the observer judges whether or not they agree.

Cues for non-verbal behavior are:

• Look/eye-contact;
• Tone of voice;
• Expression;
• Body expression;
• Gestures.

Scoring

• ‘Yes’, when the non-verbal behavior agrees with the verbal behavior;
• ‘No’, when incongruent behavior is present in the interview;
• ‘Indifferent’, when the observer finds it impossible to decide either ‘Yes’ or ‘No’.

Scoring

• ‘Yes’, when normal eye-contact is maintained;
• ‘No’, when the physician avoids eye-contact, or continues to gaze at their file or at some other object;
• ‘Indifferent’, when no judgement is possible (for instance in case of an unsuitable camera position in taped consultations).

The physician asks closed-ended questions in a proper way when:

• The question does not contain a suggestion for an answer;
• The question deals with one subject only;
• This type of question is used on the proper indication.

Closed-ended questions are indicated when:

• The physician searches for factual information;
• The patient deviates from the subject;
• The patient resists the discussion of a subject.

Closed-ended questions are not-indicated when:

• There is a chance that the physician will miss the relevant answer by limiting the answer categories;
• They are used instead of open questions, e.g. during Exploring Reasons for Encounter, or the exploration of emotions and concerns in general.

Scoring

• ‘Yes’, when 80% of all closed-ended questions are used in the proper way;
• ‘No’, when less than 60% of all closed-ended questions are used in the proper way;
• ‘Indifferent’, when 60-80 % of all closed-ended questions are used in the proper way.

N.B. While scoring the item, it can be helpful to use the scoring stave on the scoring list. Each closed-ended question can be scored right or wrong. At the end of the interview, the item can then be scored.

The physician invites the patient to express themself in a more clear, personal and specific way.

Concretization is necessary when the patient speaks in a vague, impersonal, general or unclear way about subjects related to the complaint.  If one of these aspects is evident, then the intervention is done in an appropriate manner.

Scoring

• ‘Yes’, when the physician concretizes in the proper manner and in an appropriate situation;
• ‘No’, when the physician does not concretize when it is necessary, or when they do not concretize in the proper manner, or when they concretize too much;
• ‘Indifferent’, when it is not necessary to concretize and it is not done.

A summary is a restatement of important information given by the patient but verbalized in the physician’s own words.

A summary is close to the patient’s frame of reference, in contrast with ordering, which stems from the physician’s frame of reference. In this item the observer makes a judgement on the proper content of the summary.

Scoring

• ‘Yes’, when 80% or more of the summaries are an appropriate restating of the content of the patient’s utterances;
• ‘No’, when 60% or less of the summaries restate the content of the patient’s utterances appropriately;
• ‘Indifferent’, when this interview behavior is not shown or when 60-80% of the summaries are appropriate.

Recall of information can be stimulated by providing information in small amounts.

During the presentation of solutions, the physician provides the patient with information which has to be understood and remembered. Small amounts are considered to be two or three sentences.

Scoring

• ‘Yes’, when 80% or more of information is provided in small amounts;
• ‘No’, when less than 80% of the information is provided in small amounts;
• ‘Indifferent’, when no information is provided.

After providing information about diagnosis, causes, prognosis and treatment plan, the physician has to check whether the patient has understood the information.

Scoring

• ‘Yes’, when the physician checks whether the patient has understood the information 3 or more times;
• ‘No’, when the physician does not check;
• ‘Indifferent’, when the physician checks whether the patient has understood the information once or twice. 

A physician’s ability to make proper confrontations is measured in this item. Proper refers to situations in which confrontations are necessary because communication is inhibited by contradictions.

This situation occurs when:

• There are contradictions in the patient’s words;
• There are contradictions between the patient’s words and their nonverbal behavior;
• There are contradictions between the past and present behavior of the patient.

Scoring

• ‘Yes’, when the physician makes proper confrontations which stimulate the communication;
• ‘No’, when the physician fails to make proper confrontations and the communication remains hampered or when the physician makes unnecessary confrontations which inhibit the communication;
• ‘Indifferent’, when the behavior is not shown and is not necessary.

Language-use that can be understood by the patient is of pivotal importance for patient-centered communication and a shared understanding of complaints, disease and treatment plan.

Scoring

• ‘Yes’, when comprehensible language is used during the interview;
• ‘No’, when, according to the observer’s opinion, several difficult words, such as medical jargon or words from a different social class, are used, or when problems arise from using out-of-place dialect;
• ‘Indifferent,’ when this category is not applicable in this item.