2. Outline
1. Learning objectives
2. General suggested schemes for psychiatric and neurological
mental state examinations
3. The Neurological Mental state examination
4. References
2
3. Learning Objective
• To acquire the needed knowledge and technique to have insight
into a person’s mental state dysfunction
– Neurologic versus psychiatric
– Responsible anatomic location
– Distribution of lesion - Focal/multifocal vs diffuse
• So that the information can be used in directing investigations, do
diagnostic reasoning, reach at a diagnosis and finally provide the
most appropriate management to-date targeting cure and/or
alleviation of the person’s suffering and improve his/her quality of
daily living.
3
4. Mental State Examination (MSE)
• May be classified as having Neurological and psychiatric
component.
• Observation of general appearance is vital to both but quite
different sets of diagnostic entities are suggested in the two
settings.
• Many other parts also tend to overlap.
4
5. Suggested scheme for a psychiatric mental state
examination
1) Appearance; Attitude (Cooperative, hostile, evasive, threatening, obsequious, belligerent); motor behavior
Psychomotor agitation or retardation); self care
2) Affect –
– The physician’s objective observation of the client’s inner emotional state
– Range (expansive, flat); appropriateness; stability (labile, shallow); quality (silly, anxious)
3) Mood –
– The client’s subjective expression of his inner emotional state
– Stated mood in response to question such as How are your spirits, How’s your mood been?
4) Speech –
– Rate (rapid, slow, pressured); volume (loud, soft, monotonous, histrionic); quality (fluent, neologisms, word salad); resonance, and
prosody (variations in pitch, rhythm, and stress of pronunciation)
5) Thought process
– Disorganized, illogical, loose associations, tangential, circumstantial, flight of ideas, perseveration, incoherent
6) Thought content
– Preoccupations, obsessions, overvalued ideas, delusions, suicidal or homicidal ideation
7) Perception
– Illusions, hallucinations
8) Cognition‐
– Orientation, attention & concentration, fund of knowledge, abstract thinking, memory, calculation, comprehension, Judgment and
insight
5
6. Suggested scheme for the neurological Mental State
Examination
1) Consciousness
2) Orientation
3) Attention and concentration
4) Memory
5) Speech & Language
6) Abstract thinking
7) Insight and Judgment
8) Calculations
9) Praxis
6
7. 1. Consciousness
• Awareness and wakefulness represent the two main components of
consciousness.
• Level of consciousness
– the degree of arousal (i.e., is the patient fully awake or does he or she
require stimulation to awaken and respond?),
• Content of consciousness or that wakeful state
– the degree of awareness (i.e., is the patient coherent or is he or she
confused, inattentive, or delusional?).
• Affected by
– Diffuse cortical, medial thalamic or brainstem RAS lesions
7
10. 10
As compared to GCS, The FOUR score
has better prognostication
For in Hospital Mortality by assessing
brain Stem functions better.
It has considerations for
• Locked-in Syndrome
• Vegetative State
It can be used in intubated patients.
FOUR SCORE TEST
12. Mini-mental state examination
1. Orientation to time and place (10)
2. Immediate memory… three unrelated objects(3)
3. Attention & concentration…serial 7 or 3, WORLD backward(5)
4. Delayed memory…previous 3 objects after 5-10min(3)
5. Language
1. Naming two familiar objects(2)
2. Repeating(1)
3. Three stage command(3)
4. Reading comprehension (1)
5. Writing a sentence(1)
6. Copying intersecting pentagons (1)
12
13. Mini-mental state examination…
• Result (out of 30) – several suggestions for interpretations, Tombaugh &
McIntyre suggested
– Normal >24
– Mild cognitive impairment 18 - 23
– Moderate impairment -
– Severe impairment < 17
• Age & educational level considered in interpreting
• Does not reliably exclude dementia
– Sensitivity 80%
– Specificity 98%
• Relatively high false positive rate
• Formal neuropsychological testing may be needed if abnormality identified
13
15. Orientation
• Before assessing orientation, we should check for language and
memory
• Generally, there are two types of orientation:
Spatial and non spatial
• Spatial orientation refers to the network of self-to-object distances
and directions in a given situation.
• Core regions at the precuneus and inferior parietal lobe areas for
multiple orientation domains;
• Posterior areas of the medial prefrontal cortex for time and
anterior for person.
2. Orientation
15
16. Cont….
Orientation to time: Ask time of day, day of week, date, month,
year
Orientation to place: Ask for address, current location,
Hospital, city
Orientation to person: Ask for names and age of family
members
16
17. Attention and Concentration
• Attention is the ability to focus selectively on a selected stimulus
• Concentration is sustained attention.
• Two types of attention
– Visuospatial attention
– Non spatial attention
• A function of Parietofrontal Network of the non dominant
hemisphere
– The Rt. hemisphere directs attention in both hemispaces
– The Lt. hemisphere directs attention within the contralateral right
hemispace
3. Attention and Concentration
17
18. • Inattentiveness & confusion
– seen in toxic or metabolic encephalopathy, frontal lobe or posterior
non‐dominant hemisphere lesions, increased ICP, abulic or frontal
lobe syndromes
• Examples of clinical abnormalities of Attention
– Hemispatial neglect
– Extinction phenomenon
– Anosognosia
• Asomatognosia
• Misoplegia
18
19. • Tests
– Digit span (normal 7+2 forward, 5+1 backward)
– Three step task
– Hemineglect‐ Line cancellation/bisection tests, task detection, clock
face drawing, simultaneous, bilateral stimulation
– Concentration‐ serial 7/3, months backward(<30second)
19
20. • Hemispatial Neglect
– Failure to appreciate the existence of ½ of the world and/or self.
– Patients may fail to:
• dress, shave, or groom the left side of the body
• eat food placed on the left side of the tray
• read the left half of sentences
20
23. • Extinction phenomenon:
– Failure to appreciate the contralateral stimulus with double simultaneous
stimulation on visual field or somatosensory testing
• Anosognosia:
– denial of a neurological deficit (e.g.; hemiplegia)
– Asomatognosia: severe form of anosognosia
• Patient denies ownership of a limb contralateral to the lesion
– Misoplegia
• The phenomenon in which a hemiplegic patient develops a morbid dislike towards
the offending immobile limbs.
• May attack their paretic limbs not recognized as self.
23
24. Memory
• Memory is the ability to register, store, and retrieve
information and can be impaired by either diffuse cortical or
bilateral temporal lobe disease.
4. Memory
24
25. • Temporal stages of memory
– Immediate (working)memory –
• Dorsolateral Prefrontal cortex (…cathecholamines)
• The amount of information a subject can keep in conscious awareness without active
memorization
• The normal human being can retain seven random digits
• It tends to decline with advancing age
– Short term memory (recent)
• Hippocampus and parahippocampal areas of the MTL for both storage and retrieval
• N-methyl-D-aspartate (NMDA) receptors and Cyclic AMP–responsive element-binding (CREB)
protein
• The ability to register and recall information after a delay of minutes or hours
– Long term memory
• Consolidation
• Diffuse cortical…Ach…
• Once memory is well stored in the neocortex, it can be retrieved without use of the hippocampal
system
• Types of memory
– Declarative‐ episodic & semantic memory
– Imperative‐ procedural, & classical/operant conditioning
25
30. Disorders of memory
• Amnestic Syndrome
– Profound loss of the second Stage of short-term (recent) memory
– It may be due to
• Bilateral hippocampal damage
• Wernicke-Korsakoff syndrome
– damage to the mamillary bodies & dorsomedial thalamic nuclei
• Head injury
– Pts. have normal immediate memory and normal ability to recall remote
memories, such as their childhood upbringing and education
– Other cognitive or HCFs may be intact, which distinguishes these Pts. from
those with dementias, such as AD.
30
31. • Anterograde amnesia
– Inability to acquire new information, i.e., to learn or to form new memories
• Retrograde amnesia
– Inability to recall events and other information that had been firmly established
before the onset of the illness
• Transient Global Amnesia
– A sudden temporary episode of all kinds of memory loss that can’t be attributed
to a more common neurological condition, such as epilepsy or stroke.
– Often affects people in middle or older age.
– Usually recover spontaneously and gradually over few hours.
31
32. Speech and Language
• Phonation
– The production of vocal sounds without word formation; it is entirely a
function of the larynx.
– Three types of dysphonia based on dysfunction of the vocal folds
• Adductor spasmodic dysphonia
• Abductor spasmodic dysphonia
• Mixed spasmodic dysphonia
• Vocalization
– The sound made by the vibration of the vocal folds, modified by
workings of the vocal tract.
5. Speech and Language
32
33. Cont….
• Speech is ability to vocalize by coordinating muscle controlling the
vocal apparatus.
– It is mechanical aspects of oral communication
– It consists of words, which are articulated vocal sounds that symbolize
and communicate ideas.
• Articulation is the enunciation of words and phrases;
– It is a function of organs and muscles innervated by the brainstem.
33
34. Cont….
• Language -
– A mechanism for expressing thoughts and ideas: by speech (auditory
symbols), by writing (graphic symbols), or by gestures and pantomime
(motor symbols).
– Any means of expressing or communicating feeling or thought using a
system of symbols.
– It is a function of the cerebral cortex.
• Grammar (or syntax)
– The set of rules for organizing the symbols to enhance their meaning.
34
35. ANATOMY AND PHYSIOLOGY OF ARTICULATION
• Sounds are produced by expired air passing through the vocal
cords.
• Properly articulated speech requires coordination between the
respiratory muscles and the muscles of the larynx, pharynx,
soft palate, tongue, and lips.
• All of these components are referred to as the vocal (oral)
tract.
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36. No matter how garbled the speech, if the patient is speaking in correct sentences, using grammar and
vocabulary commensurate with their dialect and education, they have dysarthria and not aphasia.
36
38. EXAMINATION OF ARTICULATION/SPEECH
• Examination of articulation begins with noting the patient’s
spontaneous speech in normal conversation, usually during taking of the
history.
• The accuracy of pronunciation, rate of speech, resonance, and prosody
(variations in pitch, rhythm, and stress of pronunciation) are noted.
38
40. Language
ANATOMY
• The classical language centers are located in the perisylvian areas
of the language-dominant hemisphere.
• Broca’s speech area lies in the inferior frontal gyrus (Brodmann's
area 44 ).
• Wernicke’s speech area lies in the superior temporal gyrus
(Brodmann's area 22).
• The arcuate fasciculus
40
42. Assessment of language function
Spontaneous speech
Comprehension of spoken language
Naming
Reading
Writing, and
Repetition
42
43. EXAMINATION OF THE PATIENT WITH APHASIA
• Initial appraisal of language function takes place during the
taking of the history.
• Obvious deficits require exploration.
• There may be language deficits that are not readily apparent
during history taking.
• For example, the inability to repeat.
• Some degree of formal assessment is usually prudent.
43
44. Cont….
• In evaluating aphasia, it is important to know about the
patient’s:
handedness
languages spoken
vocabulary, and
intellectual capacity
44
45. Cont….
• About 90% to 95% of the population is right-handed.
• The left cerebral hemisphere is dominant for language in 99%
of right-handers, and 60% to 70% of left-handers.
• Of the remaining left-handers, about half are right-hemisphere
dominant and about half have mixed dominance.
45
46. The main aphasia syndrome
• Broca’s
• Wernicke’s
• Conduction
• Global
• Transcortical motor
• Transcortical sensory
• Transcortical mixed
• Anomic aphasia
46
47. • FLUENCY –
o Normal speech is 100 to 115 words per minute.
o Nonfluent Aphasia
• Speech output is often as low as 10 to 15 words
per minute, sometimes less
• Maximum sentence length is fewer than seven
words.
• Paraphasia –
o a speech error in which the patient substitutes a
wrong word or sound for the intended word or
sound.
o Two types:
o Phonemic -
o More typical of anterior persylvian lesions
o E.g.; “blotch” instead of watch, or
“thumbness” instead of numbness,
“Plentil” for pencil
o Semantic (Verbal) –
o More typical of posterior perysylvian
lesions
o the patient substitutes the wrong word
o E.g.; “ring” instead of watch
47
48. Subcortical aphasia
• Two types
– Anterior syndrome
• Caudate or striatocapsular aphasia
• Slow dysarthric speech with preserved phrase length, i.e., not telegraphic,
preserved comprehension, and poor naming.
• Resemble transcortical motor aphasia with hemiplegia
– Posterior syndrome
• Thalamic aphasia
• Fluent speech without dysarthria, poor comprehension, and poor naming
• Resemble transcortical sensory or wernicke aphasia with hemiplegia
48
49. ABSTRACT THINKING
• The ability to think abstractly is typically tested by asking the
patient to
describe similarities and differences,
find analogies, and
interpret proverbs and aphorisms.
• The patient may be asked how an apple and a banana, a car and an
airplane, a watch and a ruler, or a poem and a statue are alike, or to
tell the difference between a lie and a mistake.
6. Abstract Thinking
49
50. Cont….
• To test for the ability to find analogies,
• “Table is to leg as car is to what?”
• Some commonly used proverbs include:
a rolling stone gathers no moss,
a stitch in time saves nine, and
people who live in glass houses shouldn’t throw stones.
• Impaired abstraction occurs in many conditions but is particularly
common with frontal lobe disorders.
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51. 7. Insight and Judgement
• Insight: awareness of one’s own illness and/situation
• Judgment: ability to anticipate the consequence one’s behavior
and make decision that protect oneself and others in the
context of ones own moral compass.
7. Insight and Judgement
51
52. Cont….
• Common question:
what the patient would do if she found a sealed, addressed,
stamped letter on the sidewalk, or smelled smoke in a crowded
theater
“What would you do if you found a wallet on the sidewalk?”
• Many neurologic conditions may impair judgment, particularly
processes that affect the orbitofrontal regions.
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53. CALCULATIONS
• The ability to calculate depends on native intelligence, innate
number sense or mathematical ability, and educational level.
• The average normal patient can perform mental calculations
that involve two-digit operations and require simple carrying
and borrowing.
8. Calculations
53
54. Cont….
• A commonly used calculation task is subtracting serial 7s from 100
(failing that, serial 3s).
• This function also requires attention and concentration.
• Counting to 20 is more of a remote memory test and counting
backward from 20 more of an attentional task.
• There is little difference in calculating ability across age groups and
little impairment in early AD.
54
55. Cont….
• Impaired calculating ability may occur with posterior dominant
hemisphere lesions, either as an isolated defect or as part of
Gerstmann’s syndrome (non dominant posterior parietal lobe
lesion characterized by agraphia, acalculia, left-right confusion,
and finger agnosia).
55
56. • Praxis, or more specifically, ideomotor praxis, refers to the
performance of learned motor movements in the absence of
primary deficits in motor and spatial abilities.
• Ideomotor praxis is evaluated by asking the patient to perform
increasingly complex motor tasks.
• As an example, use of an object (e.g., comb, hammer, fork) with
and without the actual object in hand.
9. Praxis
56
57. Cont….
• A step-wise series of coordinated tasks "take this piece of
paper, fold it in half, and place it in the envelope" is another
way to demonstrate praxis, in this case, ideational praxis,
which refers to the capacity to carry out a sequential set of
actions toward a final goal.
57
58. Apraxia
• Defined as the inability to carry out on request a motor act in the
absence of any weakness, sensory loss, or other deficit involving
the affected part.
• Apraxia is an inability to correctly perform learned skilled
movements.
• The patient must have intact comprehension and be cooperative
and attentive to the task.
58
60. Cont….
• The major limb apraxias are limb kinetic, ideomotor, and
ideational.
• Limb kinetic apraxia: These patients have difficulty with fine
motor control
• Mild corticospinal tract lesion
• is due to dysfunction of the primary motor pathways.
60
61. Cont….
• Ideomotor apraxia the patient is unable to perform a complex
command:
• e.g., salute, wave goodbye, comb hair, use scissors.
• Ideational apraxia: the patient is able to carry out individual
components of a complex motor act, but patient cannot
perform the entire sequence properly.
61
62. Cont….
• The patient may perform each step correctly, but in attempting
the sequence, she omits steps or gets the steps out of order.
• There is an inability to correctly sequence a series of acts leading
to a goal.
• Ideational apraxia may occur with damage to the left posterior
temporoparietal junction or in patients with generalized
cognitive impairment
62
63. References
• Campell W.W: Dejong the neurologic examination 8th edition
• Bradley’s Neurology in clinical Practice 7th edition
• Fuller G: Neurological examination made easy,5th edition
63
It is important to remember that consciousness is best conceptualized as having two domains: level and content.
Awareness is defined by the content of consciousness, and arousal is defined by the level of consciousness.
The formal MSE usually begins with an assessment of orientation.
Centers important in language. A, angular gyrus; B, Broca’s area; EC,
Exner’s writing center; SP, superior parietal lobule, which with the PCG (postcentral
gyrus) is important in tactile recognition; T, pars triangularis; W, Wernicke’s area.
Reading…check for both reading aloud and reading for comprehension
