When writing or talking about medical patients or therapy clients, it is helpful to describe their presentation. You cover things such as appearance and grooming, mood, openness, language, and thought process. How a client looks can reveal a lot about their lives, stressors, and their overall cognitive functioning. How open they are with you as a doctor or therapist is also important to note. Sometimes people are reticent to talk about themselves (which is understandable) and distrustful in general. Some people also don’t know how to talk about themselves, so they don’t.
The language people use also reveals their underlying cognitive functioning. Tangential language, disjointed speech, and slowed speech, for example can mean different things – a thought disorder, depression, acquired brain injury, and so forth. Related to language is a person’s thought process; this is apparent from their language but also in how they describe their problems or their lives.
When discussing mood, there are three general terms doctors use. The first is euphoric – extremely happy. Sometimes it is appropriate for people to exhibit this emotion but it can also be a sign of mania, especially if the positive mood was not seemingly triggered by anything. The next term for a mood state is euthymic, meaning normal, slightly positive mood. This is the mood that most people exhibit most of the time. It is neither positive nor negative (although often interpreted as having a slight positive lean). The last descriptor for mood is dysthymic, which means depressed or having negative affect.
Using these labels when describing patients provides a common, concise set of terms. It is, however, usually better to describe behaviors than just give a label. This means when writing about a patient or client, a report might state, “[The patient] presented as dysthymic, not smiling, becoming tearful at times….” Labels are concise, descriptions are precise.