5. GENERAL APPEARANCE &
GROOMING
APPEARANCE :-
Appearance includes Apparent Age , Obvious
Physical stigmata , General state of physical
health & Overt Emotional Displays.
GROOMING:-
Includes:-
1. Dressed with neatness
2. Cloths appropriate to season
3. Cloths clean & good.
4. Concern about appearance
5. Hair/nails
5
6. FACIAL EXPRESSION
1. Appropriate or not
2. Is it changed with subject or
not.
3. Look:-
a) Attentive
b) Apathetic-in chronic schizophrenia
c) Indifferent-in severely depressive
6
7. FACIAL EXPRESSION (CONT.)
4 . EXPRESSION :-
a) Elation
b) Fears -Mild Anxiety or
Apprehension,Crying, Perplexed or
Frightened.
c) Anger
d) Sad - Omega sign & Veraguth folds in
Depressed patients.
e) Blank - in schizophrenic patients.
f) Eye to eye contact:- maintain gaze in
anxious patients , Void gaze in
schizophrenic pts , excessive scanning 7
8. POSTURE
1. Relaxed – In obsessive
2. Guarded - in paranoid patients.
3. Limp and sprawled out in chair.
4. Sitting at edge of chair in schizophrenic
patients.
8
9. GAIT & CARRIAGE
Carriage –
Does patient carry himself erect or bends
down.
Gait types:-
1. Normal
2. Brisk
3. Slow- in depressed patient.
4. Desultory-in schizophrenic patients.
5. Dilatory-in manic patients.
6. Unsteady – in organic brain disorders.
9
10. BODY BUILD
1. ASTHENIC - Person narrows in length
with narrow swallow thorax with narrow
sub costal angle.
2. PYKNIC - Person with large body
cavities relatively short limbs and large
sub costal angle with rounded head and
short fat neck.
3. ATHLETIC - Persons with wide
shoulders and narrow hips and well
developed bones and muscles.
10
11. RAPPORT
Define as Harmonious Responsiveness of
Physician to Patient and vice versa.
Patient feels that evaluation is a joint
effort and psychiatrist is truly interested in
his story.
11
13. BEHAVIOUR & PSYCHOMOTOR
ACTIVITY (CONT.)
DIVIDED ON BASIS OF:-
1. Quantity:-
a. Normal
b. Agitation-severe anxiety associated with
motor restlessness.
c. Retardation:-abnormal physical &/or
psychological slowing as a part of any
psychiatric illness. Ranges from lack of
expression, slow movements,mutism to
stupor. 13
15. Tics:-
Def:-short sudden repetitive, rapid movements of
small muscles usually of face & neck.
Types of tics:-
1.Simple motor tics
2. Simple vocal tics
3. Complex vocal tics
Posturing:-
Def.:- Voluntary assumption of inappropriate or
bizarre posture.
Posture maintained voluntarily or imposed by
examiner.maintancence should be at least for 15
BEHAVIOUR & PSYCHOMOTOR
ACTIVITY (CONT.)
16. Rigidity:-
Def:-
Assumption of rigid posture against all
attemts to move.
Waxy flexibility:-
Def:-
Syn flexibilities cerea (wernicke)feeling of
uniform plastic resistance as limb is moved.
Perseveration:-
Def:-
persistent induced repitition of
words,ideas,subject 16
BEHAVIOUR & PSYCHOMOTOR
ACTIVITY (CONT.)
17. Mannerism:-
Def:-unusually performed goal
directed,semipurposive repetitive
verbal/motor actions.
Stereotypy:-
Def.:-repetitive, spontaneous non goal directed
movement which is carried out in uniform
way.
Types:-verbal & motor
Gesture:-
Def.:-a mode of non verbal communication in
which information is conveyed by movement
of hand,arm,parts of body. 17
BEHAVIOUR & PSYCHOMOTOR
ACTIVITY (CONT.)
18. Grimace:-
Def:-
Specific facial expression which is non goal
directed & spontaneous
Restlessness:-
Def:-persistent and generalised diffuse
increase in body movements and inability to
relax.
Automatic obedience:-
Phenomenon of undue compliance with
instructions 18
BEHAVIOUR & PSYCHOMOTOR
ACTIVITY (CONT.)
19. Echolalia:-
Def.:-repetition of a part of sentence or
whole sentence told to patient.
Echopraxia:-
Def:-automatic imitation of another persons
movements like clapping,snapping
fingers.
Negativism:-
Purposeless resistance to all external
suggestions or advice.
Compulsion:-
19
BEHAVIOUR & PSYCHOMOTOR
ACTIVITY (CONT.)
20. SPEECH
1. Spontaneous
2. Tone-pitch & loudness
3. Tempo-speed(150 words per minute is
pressure of speech)
4. Volume-amount the patient speaks on a
particular subject.
5. Reaction time-prolonged or reduced
6. Prosody-melodic intonation and emotional
valence of speech
7. Relevance-answering precisely to the
question.
8. Coherence- 20
21. 9. Deviation:-
a. Neologism:-coining new words or use
words in inappropriate way
b. Echolalia-automatic repitition of
examiners utterence
c. Clang association-speech in which
sounds rather than meaningful
conceptuel relationships governs word
choice
d. Verbigeration-a manifestation of
stereotyoy consisting of morbid repitition
of words,phrasesor sentence. 21
SPEECH
22. MOOD
Def:-
Pervasive and sustained emotion that
colours the person’s perception of the
world(longitudinal & subjective)
1. Euthymic:-normal range of mood
implying absence of depressed or
elevated mood.
2. Elevated mood:-a mood more cheerful
than normal but not necessarily
pathological.
22
23. 1. Elation:-mood consisting of feeling of
joy,euphoria,triumph and intense self
satisfaction or optimism associated with
increased psychomotor activity.
2. Ecstasy:-intense sense of rapyure or
blissfulness
3. Exaltation:-feeling of intense elation and
delusion of grandeur
4. Expansive mood:-expression of feelings without
restraint, frequently with an overestimation of
their significance and importance.
5. Irritable mood:-state in which one is easily
annoyed and provoked to anger.
6. Dysphoria:-unpleasant ,uncomfortable and
dissatisfied mood with an admixture of sadness,
anxiety and irritability. 23
MOOD
24. Mood description in MSE
1. Subjective
2. Objective-
depressed,euphoric,elated,blunted,flat
3. Range-wide,restricted(over a course of
time,horizontal-happy-sad-angry-placid-
fearful).
4. Reactivity-present/absent(in response to
stimulus, longitudinal)
5. Appropriateness
6. Congruity
7. liability 24
25. AFFECT
Def:-
Short lived emotions; defined as patient, present
emotional responsiveness.(cross sectional &
objective)
1. Sthenic-joy,hate,anger
2. Asthenic-fear,saddness,anxiety,shame
3. Flat-near or absolute absence of any signs of
affective expression
4. Blunt-significant reduction in intensity of
emotional expression.
25
26. 1. Constricted-reduction in intensity of
emotion that is less severe than that of
blunted affect.
2. Restricted-mild reduction in range and
intensity of emotional expression.
3. Inappropriate
4. Incongruent- discordance between
affective expression and content of
speech/ideation.
5. Labile affect:-abrupt,rapid,unstable
changes in emotions unrelated to external
stimuli
6. Affective incontinence-total loss of 26
AFFEC
T
27. Disorder of form of thought
Form:-
consistent ,uninterrupted and organized gflow of thinking
towards its goal.
Formal thought disorder:-
Disorder of conceptual or abstract thinking
Two types:-
1. Positive-patients produces false concepts by blending together incongruous
elements.
2. Negative-patient has lost his previous ability to think but does not produce
unusual concepts.
By Cameron:-
1. Asyndenesis-lack of adequate connections between successive thoughts.
2. Metonyms-imprecise approximations in which a substitute term is used instead
of amore exact one.
3. over inclusion-inability to maintain boundaries of problem and to restrict their
operations within their correct limits.
27
28. By Goldstein :-thinking become concrete because of
loss of abstract attitude.
By schneider:-
1. Derailment-one thought slides into other.
2. Substitution-major thought is substituted by a
subsidary one.
3. Omission-senseless omission of a thought or a part
of it.
4. Fusion-hetrogenous elements of thought are
interwoven together.
5. Driveling-disordered intermixture of constituent parts
of complex thought
6. Desultory –speech is grammatically and syntically 28
Disorder of form of
thought
29. DISORDERS OF STREAM OF
THOUGHT
1. Disorders of tempo:-
a) Retarded thinking:-slowing down of train/flow of thought
b) Associated features:-lack of attention & concentration, inability to
make decisions, no clarity in thinking, dull fuzziness in head.
seen in depression and in manic stupor.
c. Flight of ideas:-the flow of thinking is accelerated &
directionless,in which connections between successive thoughts
appear to be due to chance factors(verbal association,clang
association) and final goal is not reached.
d. Circumstantiality-Pattern of speech is indirect and delayed in
reaching its goal idea thinking preceding slowly with many
unnecessary trivial details but finally goal is reached
e. Tangentiality-final goal is not reached and patient losses track of
original question
f. Incoherence-pattern of speech that is essentially
incomprehensible at times
29
30. 2. Disorder of continuity
a. Perseveration
b. Thought block-interruption of train of
speech before a thought or idea has
been completed.
c. Echolalia
30
DISORDERS OF STREAM OF
THOUGHT
31. Disorders of possession of
thought:-
Thought alienation:-patient has experience that his
thoughts are under control of an outside agency
or that others are participating in his thinking.
Criteria of thought alienation:-
External agency
Passive recipient
Against the will.
Thought insertion:-
Patients knows that thoughts are being inserted into
his mind, recognizes them as foreign.
Thought broadcasting:-
Patient knows that is he is thinking everyone else is
thinking unison with him.
31
32. Obsession-
def.:-it is involuntary,ego-dystonic,recurrent
irrational thoughts/impulses/images that
cannot be eliminated from consciousness
Compulsion:-
def. – refer as pathological need to act on an
impulse that,if restricted,produces
anxiety;repititive behaviour in response to
an obsession or performed according to
certain rules
Rumination:-
Prolonged inconclusive chain of thought.
32
Disorders of possession of
thought:-
33. Content of thought:-
1. Obsession
2. Compulsion
3. Ideas of hopelessness-an attitude characterized by an
untoward and unfavorable expectations from self &
environment.
4. Ideas of worthlessness:-
5. Feeling that one is good for nothing and cannot tackle
problems of life with due skill.it is frequent
underestimation of one’s talent, knowledge and
capabilities.
6. Suicidal ideas
7. Homicidal ideas
8. Depersonalization
9. Derealization
10. Idea of reference
11. Delusion
33
34. Delusion
Definitions:-
By stoddart:-
A judgment which cannot be accepted by people of
same class,education,race and period of life as
person who experiences it.
By jasper:-3 components:-
1. They are held with unusual conviction.
2. not amenable to logic.
3. Absurdity or Erroneous of their content is manifest to
other people.
By hamiltom:-
A false unshakeable belief which arises from internal
morbid processes. it is easily recognizable when it is
not keeping with persons educational & cultural
background. 34
35. Types:-
Primary delusion:-
Delusion not occurring in response to
another psychopathological form such
as mood disorder
Secondary delusion:-false belief is
understandable as arising from some
other morbid experience like because of
mood state
35
37. Perception
1. Illusion-misinterpretation of perception
2. Hallucinations:- perception occurring
without external stimulation
3. Depersonalization-patient feels detached
and views himself as strange and in real
4. Derealization-it involves alteration in
sense of reality of outside world
37
38. Hallucinations
Def:-
By esquirol:-
A perception without an object
By jasper:-
A false perception which is not a sensory distortion
or misinterpretation and occurs at same time as a
real perception.
Slades 3 criterion:-1. percept like experience in
absence of external stimulus
2. Percept like experience which has full force and
impact of real percept,
3. Percept like experience that is
unwilled,spontaneous,cannot be controlled.
38
39. Functional hallucinations:-
a stimulus causes hallucination but it is
experienced as well as the hallucination
Reflex hallucination:-
A stimulus in one sensory field produces
hallucination in another.
Extracampine hallucination:-
Patient has hallucination which is outside the limit
of sensory field
Autoscopy hallucination(phantom mirror image)
Patient sees himself and knows that he is
Not just visual hallucination but alsokinesthetic
and somatic sensations are present.
Negative autoscopy-patient look in the mirror and
sees no image.
Internal autoscopy:-person sees his internal 39
41. Hallucination description in
MSE
1. Perception
2. False
3. Timing-awake,hypnogogic/hypnopompic
4. Modality-
visual/auditory/tactile/gustatory/somatic
5. Description-intensity,distance,content,no. of
persons
6. Clarity
7. Control
8. Insight
9. Precipitating factor
10. Patients attitude to hallucination
41
42. Attention
Def:-
It is patients ability to attend to specific
stimulus without being distracted by
extraneous internal or external stimuli
Vigilance:-
Def:-
Refers to a more basic arousal process in
which the awake patient can respond to
any stimulus appearing in environment
42
43. Sustained attention(concentration):-
Def.
It is ability to maintain attention to a specific
stimulus over an extended period
Affected by factors:-
1. Intensity & frequency of stimulus
2. Environmental stressors
3. Emotional factors
4. Lower IQ
43
44. Evaluation of attention:-
1. Observation
subjective rating scaleof 0(high distractibile) to 5
(fully attentive)
2. History
Digit Repetition test:-
Directions:-A tell the patient “I am going to say some
simple numbers.listen carefully and when I
finished say the numbers after me”.
b. Present digit in normal tone of voice at rate of one
digit per second.
c. Numbers should be random, without natural
sequence
d. Not to group digits in pairs
e. Begin with a two number sequence and continue till
patient fail to repeat all numbers correctly.
Scoring:- patients of average intelligence accurately
repeat 5 to 7 digits without difficulty.
44
45. Evaluation of sustained
attention:-
1. “A” random letter test:-
a. Consist of a series of random letters among
which a target letter appears with greater
than random frequency.
b. Patient is required to indicate whenever
target letter is spoken by examiner
Directions:-
Tell the patient “I am going to read you a long
series of letters.whenever you hear the
letter”a”,indicate by tapping the desk.read
letters in normal tone at rate of 1 letter per
second.
45
46. Scoring:-
Average person should complete task
without error.
2. Serial seven subtraction test:-
Count backward from 100 by 7s….
Result influenced by intellectual
capability,education, calculating ability
rather than pathological process.
46
47. Memory
Memory
Def:-
It is a general term for mental process that
allows the individual to store memory for
later recall.
Three stages:-
1. Information received and registered by
particular sensory modality held
temporarily in short term
memory(working memory) 47
48. 2. Storing or retaining information in more
permanent form(long term memory)
3. Recall or retrival of stored information.
48
49. Immediate memory:-
Is used to recall a memory trace after
interval of few seconds.
Evaluation by:-
Digit repetition test
49
50. Recent memory:-
Def:-
Is the patients capacity to remember
current day to day events.
Evaluation:-
Orientation to time place and person are
actually measures of recent memory as
they tests patient ability to learn these
continually changing facts.
50
51. Test items for recent memory
1. Name
2. Age
3. Birth date
4. Location
5. City location
6. Address
7. Date day of week
8. Time of day
9. Season of year.
51
52. Remote memory
Refers to recall of facts or events that occurred years
previously such as names of teacher and old school
friends,bith dates and historic facts.
Evaluation:-
Test items
Personal information
1. Where were you born?
2. School information
3. Vocational history
4. Family information
Historic facts:-
1. names of presidents during patients lifetime
2. last 4 or 5 presidents?
3.major event related to country.
52
53. Intelligence
Higher cognitive functions includes the
manipulation of well learned material, abstract
thinking, problem solving,judgement,arthematic
computations and represent highest intellectual
functioningreadily assessable by formal testing
methods.
Evaluation:-
1.during history taking when asked about patients
adequacy in job performance, management of
personal finances, problem solving ability, overall
judgment.
2. Funds of acquired information or store of
knowledge
53
54. Funds of information
Questions presented in increasing
difficulty.
Continue to ask till test completed or till
failed three successive questions.
54
56. Proverbs interpretation
Interpreting proverbs accurately requires
an intact fund of general information the
ability to apply this knowledge to
unfamiliar situations and ability to think in
abstract,
Directions:-
Tell the patient “I am going to read you a
saying that you may or may not heard
before. explain in your own words what
the saying means.”
Continue until patient fail on two
56
57. Test items
Don’t cry over spilled milk
Rome wasn’t built in one day
A drowning man will clutch at a straw
A golden hammer can break down an iron
door
The hot coal burns the cold ones blackens
57
58. Similarities
Verbal similarities test:-
Requires analysis of relationships,
formation of verbal concepts, logical
thinking.
Directions:-
Tell the patient “I am going ti tell you some
pairs of objects each pair is alike in some
way. please tell me how they are similar
or alike.
58
59. Test items for verbal similarities
test
Turnip-cauliflower
Car-airplane
Desk-bookcase
Poem-novel
Horse-apple.
59
60. Insight
Def:-
Insights is ones ability to understand either
oneself or external situation
Assess by asking patient whether they are
aware of their problem.
60
61. Levels of insight:-
1. Complete denial of illness.
2. Slight awareness of being sick but denying at same
time-in resolution phase of delusion or psychoses or
personality disorder.
3. Awareness of being sick but blaming it in others,on
external factors, on medical or unknown organic factors.
4. Intellectual insight-
Admission of illness and recognition that symptoms
or failures in social adjustment are due ti irrational
feeling or disturbance, without applying knowledge to
future experiences.
5. True emotional insight:-
Emotional awareness of the motives and feelings
within, of the underlying meaning of symptoms; does
awareness leads to changes in personality and future
behavior, openness to new ideas and concepts about
self and the important persons in his or her life.
61
62. Judgment
Social Judgment:-
It is a more complex function that includes
basic knowledge of social situations,
knowledge of socially appropriate
responsesin such situations and ability to
apply the correct response personally
when faced with a actual social situation
It can assess by history from informants
who have witnessed the patients actual
performance in dealing with day to day
events.
62
63. Personal Judgement
The individuals personal
expectations/plans/attitudes are
assessed.
Test judgment:-
This aims at testing the course of action
that a person might take in a socially
difficult or disastrous situation
Example:-
1. fire test:-What you will do if there is
fire? 63
64. REFERENCE
Comprehensive Textbook of Psychiatry 9th
Edition by Kaplan and saddock.
Fish Clinical Psychopathology
2nd edition.
The Mental Status Examination in
Neurology 4th edition by Richard Strub &
william black.
Psychiatric Interview and Examination 1st
Edition by M.S. Bhatia.
NIMHANS Website.
64
