Psychiatry is unique as a specialty. In the past century, medical technology has advanced at breakneck speed supporting diagnostic refinement, yet this has had limited impact in the area of mental health. It is not possible to diagnose mental illness with a blood test, a radiological investigation, or other such investigative tools. It requires a doctor to hone their ‘end of the bed’ observation skills and develop a sophisticated understanding of psychopathology. This familiarity of descriptive psychopathology then needs to be applied in everyday practice to recognize the symptoms being presented, allowing interpretation of illness states. Similar symptoms can present in different illnesses and their relevance needs to be understood in the context of the history of the person. Psychiatric assessments with well-developed interview skills are the cornerstone of psychiatric practice. This can feel a daunting task to medical students and junior doctors who are well used to the protection of many investigation options at their fingertips. Psychiatric patients are often the most challenging to interview. They can present in ways that confront even the most experienced doctor— highly distressed, aggressive, withdrawn, disconnected from reality, or uncooperative, to describe just a few situations. They may not have chosen to see a doctor and may have come willingly or unwillingly due to someone else’s worry about them. These factors often create a difficult starting point from which to engage patients and establish a trusting doctor–patient relationship. The reasons for a person’s presentation, especially in the acute setting, are often highly anxiety provoking—attempted suicide, threatened suicide, or highly disturbed behaviour. This challenges doctors to remain calm in order to maintain the capacity to manage the assessment without relying on the armoury of procedures other specialties often can. A firm grasp of the MSE and the core aspects of a psychiatric history helps to negotiate numerous potential challenges during the interview. Interviewing and interpretative skills can be developed, akin to a cardiologist learning the sounds of different heart murmurs.
Integrating spirituality into the care of older adults
