MENTAL STATUS EXAMINATION Dr. Vijit Jaiswal Junior Resident Deptt. of Psychiatry
WHAT IS IT? The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes the mental state and behavior of the person being seen. It includes both objective observations of the clinician and subjective descriptions given by the patient.
WHY DO WE DO THEM? The MSE provides information for diagnosis and assessment of disorder and response to treatment. A Mental Status Exam provides a snap shot at a point in time If another provider sees your patient it allows them to determine if the patients status has changed without previously seeing the patient
CONTINUED… To properly assess the MSE, information about the patients history is needed including education, cultural and social factors It is important to ascertain what is normal for the patient. For example some people always speak fast!
COMPONENTS OF THE MENTALSTATUS EXAMINATION Appearance and Behavior Motor activity Speech Mood Affect Thought process Thought content Perceptual disturbances Cognition Abstract thinking Insight Judgment
APPEARANCE AND BEHAVIOR:WHAT DOYOU SEE? Stated age, younger/older Build, posture, dress, grooming, prominent physical abnormalities Level of alertness: Somnolent, alert Emotional facial expression Attitude toward the examiner: Cooperative, attentive,interested,frank,seductive,defensive,hostile,playfull, evasive or guarded Eye contact: ex. poor, good, piercing Rapport: measure of the quality of interaction b/w the patient and examiner. Described in actual characteristics of the interaction and changes throughout the interview.
Examples:General self neglect- chronic schizophrenia, dementia, alcohol/drugde-addiction.Bright/ Colorful clothes- ManiaStooped posture,hunched,leaning forward- DepressionSitting on the edge of the seat, gripping the arms of the chair- AnxietyFacial Expression: Sad face with downward corners of the mouth, flattened expressions and vertical furrowing of brows suggest “Depression” Horizontal furrowing of the brows with wide eyes,sweating and dilated pupils suggest “Anxiety” Expressionless face, mask like face suggest“Parkinsonism” Grave’s disease is characterized by exophthalmosEye contact: Reduced in Depression,Unsettled in Autistic disorder or social Anxiety, may appear staring in Parkinsonism/Drug side effects.
MOTOR ACTIVITY Psychomotor activity: ex. retardation or agitation Movements: tremor( Drug side effects), abnormal movements i.e.. Stereotypes, gait ,freedom of movement Apparent restlessness , lip smacking , tongue protrusion- Drug Side effects Difficulty in initiation of movement or slow, stiff movement- Parkinsonism Waxy Flexibility: patient’s movement having the feeling of a plastic resistance e.g. in catatonic schizophrenia Negativism: patient resist attempts to move him and does opposite to what is asked. A sign of Catatonia.
SpeechRate: normal, very slow, rapid, pressure of speechFlow: spontaneous, hesitant, slurring, stuttering, speaksonly on question, muttering, muteVolume: audible, excessive loud, abnormally softAmount: Normal, abundant, scantyTone: normal fluctuations, monotonousCoherence: coherent, incoherentRelevance: relevant, irrelevant
Disorders of Speech:-Aphonia: fails to produce any vol. of sound, e.g. in laryngealor vocal cord disorder. If despite this he/she is able to coughnormally, probably hysterical.Slow speech: may be a feature of psychomotor retardation.Fast speech: normal anxiety but may indicate Mania orSchizophreniaPressure of speech: rapid speech that is increased inamount and difficult to interrupt. Seen in ManiaPoverty of speech: restriction in amount of speech, repliesmay be monosyllabicPoverty of content of speech: speech is adequate in amountbut covers little information due to vagueness, emptinessstereotyped phrases.Echolalia: repetition of sentence just uttered by the examiner.Palilalia: repetition of only last uttered word or phrase said by theexaminer.
MOOD A pervasive and sustained emotion that color the patient’s perception of the world subjectively experienced and reported by the patient. Often placed in quotes since it is what the patient tells you. e.g. “Fantastic, elated, depressed, anxious, sad, angry, irritable, good” Necessary to ask in mood- Depth Intensity Duration Fluctuation
AFFECT The expression of emotions expressed by the patient and observed by the others.It varies over the time in response to changing emotions. Type: euthymic (normal mood), dysphoric (depressed, irritable, angry), euphoric (elevated, elated), anxious Range: full (normal) vs. restricted(reduced in range and intensity), blunted(Severe reduction in intensity of externalized feeling tone) or flat(no sign of affective expression,monotonous voice,immobile face); labile(repeated, rapid and abrupt variability in affective expression) Congruency: does it match the mood-(mood congruent vs. mood incongruent) Stability: stable vs. labile Appropriateness: appropriate to situation or not appropriate to situation.
THOUGHT PROCESS Describes the rate of thoughts, how they flow and are connected.1. Stream of thought : Quote from the patient a).Productivity – abnormalities seen are 1.Overabundance of idea. e.g. Mania 2.Paucity. e.g. depression 3.Flight of Ideas;- In FOI there are rapid shifts in the frame of reference and there associations are incoherent. e.g. Mania 4.Rapid thinking 5.Slow thinking or hesitant e.g. depression and rare condition of manic stupor 5.Spontaneous or only when questioned
b). Continuity of thoughts – abnormalities seen are1. Circumstantial: When thinking proceeds slowly withmany unnecessary detail but eventually get to thepoint. Goal is never completely lost. It can occur incontext of learning disability and in individual withobsessional personality traits,schizophrenia, dementia,and anxiety disorders. 2. Tangential: Move from thought to thought thatrelate in some way but never get to the point.e.g. InPsychosis and Dementia
3. Thought blocking: Sudden arrest of the train of thought,leaving a blank, then entirely a new thought may begin.May be seen in exhausted or very anxious state. Whenclearly present, it highly suggests Schizophrenia.4. Perseveration: Inappropriate repetition of words orphrases. It is common in generalized & local disorders ofbrain, when present provide strong support for such adiagnosis. Also seen in OCD & Psychosis.
Thought Possession/alienation : abnormalities seen are 1. Thought Echo : Hearing one’s own thought being spoken aloud 2.Thought Insertion: Other person or forces are implanting thoughts in a person’s mind 3. Thought Withdrawal: Other person or forces are removing thoughts from a person’s mind 4. Thought Broadcasting: One’s own thoughts experienced as being transmitted to another person or agency All are features of Schizophrenia.
Formal thought disorder - abnormalities seen are1. Loosening of association: Illogical shifting betweenunrelated topics. It is a hallmark feature ofSchizophrenia.2. Derailment : Gradual or sudden deviation in train ofthought without blocking.3. Word Salad: Extreme version of LOA in whichchanges in topics are so extreme and the associations soloose that the resulting speech is completely incoherent .4. Stereotypes: Constant repetition of a phrase(orbehavior) in many different settings, irrespective ofcontext.3. Verbigeration: Disappearance of understandablespeech replaced by strings of incoherent utterance
.4. Metonyms: are word approximation e.g. paper skate forpen5. Clang association: words are chosen or repeated based onsimilar sounds, instead of semantic meaning.Seen in mania6. Neologism : It refers to the new word formation by thepatient or ordinary word that are used in new way.Seen in Schizophrenia.
THOUGHT CONTENT Refers to the themes that occupy the patient’s thoughts and perceptual disturbances. Abnormalities seen are - 1. Overvalued Ideas:- This is a thought, which because of associated feeling tone, take precedence over all other ideas and maintains this precedence permanently or for a long period of time. It tend to be less fixed than delusions and tend to have some degree of basis in reality. (McKenna, 1984).
2. Delusions: False, firm (fixed), unshakable belief that isout of keeping with the patient’s social, cultural, andeducational background. E.g. Control: outside forces are controlling actions Erotomanic: a person, usually of higher status, is in love with the patient Grandiose: inflated sense of self-worth, power or wealth Somatic: patient has a physical defect Reference: unrelated events apply to them Persecutory: others are trying to cause harm
Richard & Richard, 2010, provided the followingdistinction b/w delusion and overvalued ideas –1. Delusional individuals are less likely to identify whatmight modify their belief, less preoccupied and lessconcerned about others’ reactions than those withovervalued ideas.2. Delusions are less plausible and their onset less likelyto appear reasonable.3. Delusions are more likely to have abrupt onset andovervalued ideas have gradual onset.4. Conviction and insight were similar in both groups.5. Belief , conviction and insight may be an inadequatebasis for separating delusion from overvalued ideas.Abrupt onset, implausible content, and relativeindifference to the opinions of others may be betterdistinguishing feature.
CONTINUED....3. Preoccupations About illness Obsessions(repetitive preoccupation with a thought, acknowledged by the patient to be irrational) or compulsions(repetitive acts based on obsession) Phobias(persistent and irrational fear of delineated aspects of nonhuman object or environment) Plans, intentions or recurrent ideas about suicide, homicide Hypochondriacal symptoms(excessive fear and anxiety of having a serious disease) Specific antisocial urges or impulse4. Ideas of reference: The incorrect idea that words and actions of others refer to oneself or the projection of causes of one’s own imaginary difficulties upon someone else. How ideas begin? Content and meaning patient attribute to them.
Perceptions:Process of transferring physical stimulation into psychological information i.e. mentalprocess by which sensory stimuli are brought to awareness.
PERCEPTUAL DISTURBANCES Hallucinations: A false perception which is not a sensory distortion or a misinterpretation, but which occurs at the same time as real perception. Can be auditory (AH), visual (VH), tactile or olfactory,hypnogogic or hypnopompic hallucinations Illusion : Misinterpretation of stimuli arising from an external object. types:- 1.Visual(m.c.)- Delirium 2.Complete – Due to inattention e.g. misreading in newspaper or missing misprints 3.Affect Illusion- arise in context of particular mood state 4.Pareidolia- vivid illusion without any effort by the patient.
o Derealization: Feelings the outer environment feels unreal and detached from environmento Depersonalization: Sensation of unreality concerning oneself or parts of oneself (detached from self)o Distinction b/w illusion and Functional hallucination- Although both occur in response to an environmental stimulus but in a functional hallucination both the stimulus and the hallucination are perceived by the patient simultaneously and can be identified as separate and not as a transformation of the stimulus, this contrast with the illusion in which the stimulus from the environment changes but forms an essential and integral part of the new perception.
COGNITION:-Sensorium: State of functioning of special senses alertness : awareness of the environment, attention span, clouding of consciousness, fluctuation in level of awareness, somnolence, stupor, lethargy, fugue state, coma orientation: time: day or approximate day and time, time spent in hospital place: where he or she is ? person: name of the person with whom patient is in contactDisorders:- disorientation for time and place signifies organic brain disorders like dementia, delirium, acute confusional state, partial seizure, brain tumors and intoxication disorientation for personal identity is rare and is associated with psychogenic or post-ictal fugue states, other dissociative disorders and agnosia.It may occur in panic attacks, PTSD and acute Psychotic state
concentration and calculations: digit repetition test: repeat digit at a rate of one per second, like 3-7 ; 7-4-9 ; 8-5-2-7 ; 2-9-6-8-3 ; 5-7-2-9-4-6 a patient of av. Intelligence can repeat 5 to 7 digits without difficulty serial subtractions like 100-7=?-7=?-7=?-7=?-7=?-7 tasks like 5 multiplied by 4=? whether anxiety or some disturbance of mood or concentration seems to be responsible for difficulty
Memory: It is a process whereby what is experienced orlearned is established as a record in C.N.S.(registration);where it persist with a variable degree of Performance(repetition) and can be recollected or retrieved from storageat will(recall).ImpairmentEffort made to cope with impairment i.e confabulation, denial, catastrophic reaction, circumstantialities used to conceal deficit Whether registration, retention or recollection is impaired Types :- 1. Immediate retention and recall: ability to repeat six figures after examiner dictate them- first forward then backward then after a few minutes’ interruption
2.Recent past memory: past few months3. Recent memory: past few days or breakfast, lunch or dinner4. Remote memory: childhood datas, important events known to have occurred when patient was younger or free of illness, personal matters, neutral materials5. Working memory : Immediate + recent memory
Fund of knowledge• level of formal education• counting and calculations• general knowledge; questions should have relevance to the patient’s educational and cultural background.• Intellectual capacity
Abstract thinking• Manner in which patient conceptualizes or handles his/ her ideas. To test we may ask 1. Similarities and differences b/w similar lookingobjects (e.g., between apple and pears) 2.meaning of simple proverbs(e.g., where there is a will,there is a way)Answer may be concrete( giving specific examples toillustrate the meaning) or overtly abstract(givinggeneralized explanation); appropriate
Insight : Degree of awareness and understanding the patient has that he/she is illGrades :-.1. complete denial of illness2. slight awareness of being ill but denying it at the same time3. awareness of being sick but blaming it on others, external factors, or medical or unknown organic factors4. Awareness that illness is due to something unknown in the patient5. Intellectual insight : admission of illness and recognition that symptoms or failure in social adjustment are due to irrational feelings or disturbances, without applying that knowledge to future experiences.
6.True emotional insight : emotional awareness of motives and feeling within and of the underlying symptoms; whether the awareness leads to changes in personality and future behavior; openness to new ideas and concept about self and important people in patient’s life.
Judgment Social judgment: subtle manifestations of behavior that are harmful to the patients and contrary to acce- - ptable behavior in the culture; whether the patient the likely outcome of personal behavior and is influenced by that understanding Test judgment: the patients prediction of what he or she would do in imaginary situations; for instance, what patient would do with a stamped, own or neigh- -bour’s house on fire, addressed letter found on street . Personal Judgment: Ability for sufficiently realistic future plan in the context of education, job or life situation Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the Frontal lobe of the brain. If a person’s judgment is impaired due to mental illness,there might be concern for the person’s safety or the safety of others
Bibliography 1.C.T.P. 2.Synopsis of Psychiatry 3.Fish’s clinical psychopathology