Lecture 4

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Lecture 4

  1. 1. V550 Mental Status Richard E. Meetz, OD, MS 2009v3
  2. 2. Mental Status <ul><li>After the Hx is recorded, you will need to make an assessment of the patient’s mental status. </li></ul><ul><li>NOTE: The mental status is actually part of the Objective examination and not part of the history, but the status is assessed as the history is conducted. </li></ul>
  3. 3. Mental Status <ul><li>By evaluating the patient’s </li></ul><ul><ul><li>Appearance and behavior </li></ul></ul><ul><ul><li>Speech and language </li></ul></ul><ul><ul><li>Affect and mood </li></ul></ul><ul><ul><li>Orientation </li></ul></ul><ul><ul><ul><li>To person, place and time </li></ul></ul></ul><ul><ul><li>Thought and perceptions </li></ul></ul><ul><ul><ul><li>Cognitive functions </li></ul></ul></ul>
  4. 4. Appearance and Behavior <ul><li>A patient’s appearance and behavior are important indicators of general level of function. </li></ul><ul><ul><li>A well-dressed, well-organized patient is “probably” functioning at a higher level than one who is disheveled and unkempt. </li></ul></ul><ul><ul><li>Important to note “is the dress appropriate for the situation and weather.” </li></ul></ul>
  5. 5. Appearance and Behavior <ul><li>Posture </li></ul><ul><ul><ul><li>(see earlier lecture on patient types) </li></ul></ul></ul><ul><li>Grooming and personal hygiene </li></ul><ul><ul><ul><li>Deteriorate in some disorders </li></ul></ul></ul><ul><ul><ul><ul><li>Depression, schizophrenia & dementia </li></ul></ul></ul></ul><ul><ul><ul><li>Excessive care in obsessive-compulsive disorder (OCD) </li></ul></ul></ul><ul><ul><ul><li>One sided neglect seen in some strokes or lesions of the non-dominate parietal cortex </li></ul></ul></ul>
  6. 6. Speech and Language <ul><li>The character of the patient’s speech provides insight into the patient’s mental state. </li></ul><ul><li>Aspects of speech; </li></ul><ul><ul><li>Amplitude or loudness </li></ul></ul><ul><ul><li>Volume or amount </li></ul></ul><ul><ul><li>Prosody or fluidity </li></ul></ul>
  7. 7. Speech and Language <ul><li>Language can be assessed by evaluating: </li></ul><ul><ul><li>Spontaneous speech </li></ul></ul><ul><ul><li>Repetition </li></ul></ul><ul><ul><li>Comprehension of spoken & written material </li></ul></ul><ul><ul><li>The ability to write </li></ul></ul>
  8. 8. Speech and Language <ul><li>Language and vocabulary are fairly good indicators of intelligence. </li></ul><ul><li>They are relatively unaffected by any but the most severe disorders. </li></ul><ul><ul><li>Can help distinguish between a mentally retarded adult (limited vocabulary) from those with mild or moderate dementia and a fairly well preserved vocabulary. </li></ul></ul>
  9. 9. Speech and Language <ul><li>Disorders of Speech </li></ul><ul><ul><li>Fall into 3 groups </li></ul></ul><ul><ul><li>The voice </li></ul></ul><ul><ul><li>The articulation of words </li></ul></ul><ul><ul><li>The production & understanding of language </li></ul></ul>
  10. 10. Speech and Language <ul><li>Disorders of Speech: the voice </li></ul><ul><ul><li>Aphonia : loss of voice 2° to nerve or larynx disease or it’s nerve supply (CN X) </li></ul></ul><ul><ul><li>- cancers </li></ul></ul><ul><ul><li>- stroke </li></ul></ul><ul><ul><li>Dysphonia: less severe impairment in volume, quality or pitch (hoarseness) </li></ul></ul><ul><ul><li>- laryngitis </li></ul></ul><ul><ul><li>- local damage (intubation, strain, smoking) </li></ul></ul>
  11. 11. Speech and Language <ul><li>Disorders of Speech: articulation </li></ul><ul><ul><li>Dysarthia : defect in muscular control 2° to motor lesions, (lips, tongue, palate, ect) </li></ul></ul><ul><ul><li>Words maybe: </li></ul></ul><ul><ul><li>- nasal, slurred or indistinct </li></ul></ul><ul><ul><li>But language remains intact </li></ul></ul><ul><ul><li>Causes: </li></ul></ul><ul><ul><li>- parkinsons </li></ul></ul><ul><ul><li>- cerebellar Dz </li></ul></ul><ul><ul><li>- both CNS & perpheral NS defects </li></ul></ul>
  12. 12. Speech and Language <ul><li>Disorders of Speech: language </li></ul><ul><ul><li>Aphasia : central NS defect in producing or understanding language. </li></ul></ul><ul><ul><li>Types: </li></ul></ul><ul><ul><li>Receptive (fluent) </li></ul></ul><ul><ul><li>Expressive (non fluent) </li></ul></ul>
  13. 13. Speech and Language <ul><li>Disorders of Speech: language </li></ul><ul><ul><li>Aphasia : Receptive (fluent) </li></ul></ul><ul><ul><ul><li>Speech is rapid without effort </li></ul></ul></ul><ul><ul><ul><li>Speech may lack meaning, made-up </li></ul></ul></ul><ul><ul><ul><li>Reading, writing and Word comprehension are impaired </li></ul></ul></ul><ul><ul><ul><li>Naming objects is impaired </li></ul></ul></ul><ul><ul><ul><li>Repetition is impaired </li></ul></ul></ul>
  14. 14. Speech and Language <ul><li>Disorders of Speech: language </li></ul><ul><ul><li>Aphasia : Expressive (non fluent) </li></ul></ul><ul><ul><ul><li>Speech is slow, few words, laborious </li></ul></ul></ul><ul><ul><ul><li>Inflection & articulation are impaired </li></ul></ul></ul><ul><ul><ul><li>Speech is meaningful with good construction </li></ul></ul></ul><ul><ul><ul><ul><li>Nouns & verbs </li></ul></ul></ul></ul><ul><ul><ul><li>Word comprehension & reading is fair to good </li></ul></ul></ul><ul><ul><ul><ul><li>But writing is impaired </li></ul></ul></ul></ul><ul><ul><ul><li>Naming objects is impaired </li></ul></ul></ul><ul><ul><ul><ul><li>But are recognized </li></ul></ul></ul></ul><ul><ul><ul><li>Repetition is impaired </li></ul></ul></ul>
  15. 15. Speech and Language <ul><li>Speech and Language pathology: </li></ul><ul><ul><li>Parkinson’s Dz patients will speak with a hypophonic, hushed quality. </li></ul></ul><ul><li>Note:Facial features: </li></ul>- Masklike face with decreased blinking. (2-3/min) -Classic stare with chin down and fixation peering upwards
  16. 16. Speech and Language <ul><li>Speech and Language pathology: </li></ul><ul><ul><li>A Parkinson’s patient will also write extremely small “micrographia” that becomes progressively smaller over time. </li></ul></ul>
  17. 17. Speech and Language <ul><li>Speech and Language pathology; </li></ul><ul><ul><li>In strokes the type of speech pattern will help localized the lesion </li></ul></ul><ul><ul><ul><li>In frontal lobe lesions, the patient will have non-fluent speech, </li></ul></ul></ul><ul><ul><ul><ul><li>“ Broca’s aphasia,” with hemiparesis </li></ul></ul></ul></ul><ul><ul><ul><li>In temporal lobe lesions, the speech will be fluent but makes little to no sense </li></ul></ul></ul><ul><ul><ul><ul><li>Wernicke’s Aphasia </li></ul></ul></ul></ul>
  18. 18. Thought and perceptions <ul><li>Assess the logic the patient uses in words and speech throughout the history taking. </li></ul><ul><li>Does the speech/thinking progress in a logical manner? </li></ul><ul><li>Is the content of their answers relevant to the question asked? </li></ul>
  19. 19. Thought and perceptions <ul><li>Assess the patients insights and judgment </li></ul><ul><ul><li>Insights </li></ul></ul><ul><ul><ul><li>After the RFV ask what they think might be causing their complaint </li></ul></ul></ul><ul><ul><ul><ul><li>Pts with psychotic disorders often lack insight into their problems </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pts with neurologic disorders often are in denial of their problems </li></ul></ul></ul></ul>
  20. 20. Thought and perceptions <ul><li>Assess the patients insights and judgment </li></ul><ul><ul><li>Judgment </li></ul></ul><ul><ul><ul><li>Note pts response to “How did you…” type of questions </li></ul></ul></ul><ul><ul><ul><ul><li>Use of money, conflicts, job or family situations </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pts with disorders often lack good judgment </li></ul></ul></ul></ul><ul><ul><ul><li>Note whether decisions and actions are based on reality </li></ul></ul></ul><ul><ul><ul><ul><li>Impulse, wish fulfillment, values </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Note there are some cultural variations </li></ul></ul></ul></ul></ul>
  21. 21. Thought and perceptions <ul><li>Variations & abnormalities of speech </li></ul><ul><ul><li>Circumstantiality (delay 2° to detail) </li></ul></ul><ul><ul><li>Derailment (Loosening of associations) </li></ul></ul><ul><ul><li>Flight of ideas (accelerated flow) </li></ul></ul><ul><ul><li>Neologisms (invented or distorted words) </li></ul></ul><ul><ul><li>Incoherence (lack of connections disordered grammar or words) </li></ul></ul><ul><ul><li>Blocking (sudden stop before end of thought) </li></ul></ul><ul><ul><li>Confabulation (fabrications of facts) </li></ul></ul><ul><ul><li>Perseveration (persistent repetition of words) </li></ul></ul><ul><ul><li>Clanging (using rhyming & punning speech) </li></ul></ul>
  22. 22. Thought and perceptions <ul><li>Abnormalities in content </li></ul><ul><ul><li>Neurotic disorders </li></ul></ul><ul><ul><li>Compulsion (repetitive behaviors or mental acts) </li></ul></ul><ul><ul><li>Obsessions (recurrent, uncontrollable thoughts) </li></ul></ul><ul><ul><li>Phobias (persistent, irrational fears) </li></ul></ul><ul><ul><li>Anxieties (apprehensions, fears & tensions) </li></ul></ul><ul><ul><ul><li>Focused = phobia </li></ul></ul></ul><ul><ul><ul><li>Free floating = ill-defined dread or doom </li></ul></ul></ul>
  23. 23. Thought and perceptions <ul><li>Abnormalities in content </li></ul><ul><ul><li>Psychotic disorders </li></ul></ul><ul><ul><li>Feeling of unreality (feeling that all is unreal or remote) </li></ul></ul><ul><ul><li>Feeling of depersonalization (detached from self) </li></ul></ul><ul><ul><li>Delusions (false fixed beliefs) </li></ul></ul>
  24. 24. Thought and perceptions <ul><li>Abnormalities in perception </li></ul><ul><ul><li>Illusions </li></ul></ul><ul><ul><li>Hallucinations </li></ul></ul>
  25. 25. Thought and perceptions <ul><li>Abnormalities in perception </li></ul><ul><ul><li>Illusions </li></ul></ul><ul><ul><li>Misinterpretations of real external stimuli </li></ul></ul><ul><ul><li>Can occur in grief reactions, delirium, traumatic stress disorders & schizophrenia </li></ul></ul>
  26. 26. Thought and perceptions <ul><li>Abnormalities in perception </li></ul><ul><ul><li>Hallucinations </li></ul></ul><ul><ul><li>Sensory perceptions in the absence of relevant external stimuli </li></ul></ul><ul><ul><li>May be auditory, visual, olfactory, tactile, ect </li></ul></ul><ul><ul><li>May occur in delirium, dementia, alcoholism, traumatic stress disorders & schizophrenia </li></ul></ul><ul><ul><li>Perceptions associated with dreaming are not classified as hallucinations </li></ul></ul>
  27. 27. Affect <ul><li>How a person reacts to various topics. </li></ul><ul><li>The “affect” is not the assessment of mood but the observation of voice, facial expression or demeanor in response to topics . </li></ul>
  28. 28. Mood <ul><li>Mood is a more sustained emotion. </li></ul><ul><li>Refers to a person’s persistent emotional state. </li></ul><ul><ul><ul><li>Includes sadness, melancholy, contentment, joy, euphoria,anger & rage, anxiety & worry. </li></ul></ul></ul><ul><li>Abnormality of mood fall into either depression or mania (bipolar). </li></ul>
  29. 29. Mood <ul><li>Depression is seen in a number of neurological Dz. </li></ul><ul><ul><li>Parkinson’s Dz </li></ul></ul><ul><ul><li>Huntington’s Dz </li></ul></ul><ul><ul><li>Strokes affecting the dominant hemisphere </li></ul></ul><ul><li>Mania may be seen occasionally in cerebral lesions. </li></ul>
  30. 30. Mood <ul><li>Evaluation of Depression & risk of suicide </li></ul><ul><ul><li>Ask: </li></ul></ul><ul><ul><ul><li>Do you get pretty discouraged? </li></ul></ul></ul><ul><ul><ul><li>How do you feel? </li></ul></ul></ul><ul><ul><ul><li>Do you think your depressed? </li></ul></ul></ul><ul><ul><ul><li>Do you feel like you want to end it? </li></ul></ul></ul><ul><ul><ul><li>Do you have a plan? </li></ul></ul></ul><ul><ul><ul><ul><li>If yes think: SAL </li></ul></ul></ul></ul><ul><ul><ul><ul><li>1. Is the method specific ? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2. Is it available ? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>3. Is it lethal ? </li></ul></ul></ul></ul>
  31. 31. Affect Assessment <ul><li>You need to observe if the affect varies appropriately with the topic under discussion. </li></ul><ul><li>Does the patient look sad as they talk of the death in their family or do they laugh? </li></ul>
  32. 32. Affect Descriptors: <ul><li>Normal </li></ul><ul><ul><li>“ Appropriate” (for the situation) </li></ul></ul><ul><ul><li>“ Full range” </li></ul></ul><ul><li>Abnormal </li></ul><ul><ul><li>Apathy </li></ul></ul><ul><ul><li>Blunted </li></ul></ul><ul><ul><li>Flat </li></ul></ul><ul><ul><li>Labile (fluctuating more than “normal”) </li></ul></ul>
  33. 33. Orientation <ul><li>Is the patient oriented to person, place and time? </li></ul><ul><ul><li>Person: Who they are and who you are, relatives? </li></ul></ul><ul><ul><li>Place: Where they are now, residence? </li></ul></ul><ul><ul><li>Time: Approximate date, time of day, year, season? </li></ul></ul>
  34. 34. Orientation <ul><li>For normal patients we use: </li></ul><ul><li>‘ Patient Oriented X3’ </li></ul><ul><li>as the recorded observation. </li></ul><ul><li>Abnormal orientation would be recorded as: </li></ul><ul><li>‘ Patient Oriented X2, confused for time/day’ </li></ul><ul><li>… with the missing component noted. </li></ul>
  35. 35. Recording Mental Status: <ul><li>In the patient’s chart both affect and orientation are recorded. </li></ul><ul><li>Examples : </li></ul><ul><ul><li>“ Appropriate & Oriented X3” for normal patients </li></ul></ul><ul><ul><li>“ Inappropriate & Oriented X3” for a patient who laughs at all our questions </li></ul></ul>
  36. 36. Recording Abnormal Mental Status: <ul><li>Examples (cont’d): </li></ul><ul><ul><li>“ Flat & Oriented X3” - might be seen in a patient with early Parkinson’s. </li></ul></ul><ul><ul><li>“ Apathetic & Oriented X2” – confused for time or date, might be seen in dementia. </li></ul></ul><ul><ul><li>“ Labile & Oriented X3” - might be seen in a patient with grief. </li></ul></ul>
  37. 37. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status </li></ul><ul><ul><li>Assessment of cognitive functions </li></ul></ul><ul><ul><ul><li>Attention </li></ul></ul></ul><ul><ul><ul><li>Remote memory </li></ul></ul></ul><ul><ul><ul><li>Recent memory </li></ul></ul></ul><ul><ul><ul><li>Learning ability </li></ul></ul></ul><ul><ul><ul><li>Vocabulary </li></ul></ul></ul><ul><ul><ul><li>Math ability / calculation </li></ul></ul></ul><ul><ul><ul><li>Abstract thinking </li></ul></ul></ul><ul><ul><ul><li>Construction ability </li></ul></ul></ul>
  38. 38. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status </li></ul><ul><ul><li>Assessment of cognitive functions </li></ul></ul><ul><ul><ul><li>Attention </li></ul></ul></ul><ul><ul><ul><ul><li>Digit span </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Give the patient a series of numbers two at a time, asking the patient to repeat them back to you. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>After several correct try again with three then four. </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Serial 7s </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Have the patient count backwards in 7s from 100 </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Spelling backwards </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Have the patient spell a word backward </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Typically most use the word “world” </li></ul></ul></ul></ul></ul>
  39. 39. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status </li></ul><ul><ul><li>Assessment of cognitive functions </li></ul></ul><ul><ul><ul><li>Remote memory </li></ul></ul></ul><ul><ul><ul><ul><li>Long term memories; family birthdays, grade schools, jobs, events relevant to patients past </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May be impaired in late stage dementia </li></ul></ul></ul></ul><ul><ul><ul><li>Recent memory </li></ul></ul></ul><ul><ul><ul><ul><li>Events of the day, meals, weather, ect </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Impaired in Anxiety, dementia, delirium </li></ul></ul></ul></ul><ul><ul><ul><li>Learning ability </li></ul></ul></ul><ul><ul><ul><ul><li>Tell the patient you are going to give them 3 unrelated words to remember, then after 3 to 5 min ask the patient to recall the words </li></ul></ul></ul></ul>
  40. 40. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status </li></ul><ul><ul><li>Assessment of cognitive functions </li></ul></ul><ul><ul><ul><li>Vocabulary </li></ul></ul></ul><ul><ul><ul><ul><li>Estimate of patients intelligence </li></ul></ul></ul></ul><ul><ul><ul><li>Math ability / calculation </li></ul></ul></ul><ul><ul><ul><ul><li>Ask simple addition & multiplication </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ask example of change making problem </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>“ You pay for a 78 cent item how much change should you get?” </li></ul></ul></ul></ul></ul>
  41. 41. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status; other tests: abstract thinking </li></ul><ul><ul><li>Tests the capacity to think beyond the Q </li></ul></ul><ul><ul><li>Proverbs </li></ul></ul><ul><ul><ul><li>Ask the patient what people mean when they use the a saying or proverb such as: </li></ul></ul></ul><ul><ul><ul><ul><li>“ The squeaking wheel gets the grease” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>“ A stitch in time saves nine” </li></ul></ul></ul></ul><ul><ul><ul><li>A concrete response is often given by people with MMR, delirium, schizophrenia or dementia </li></ul></ul></ul><ul><ul><ul><ul><li>A schizophrenic may also give a normal or odd ans </li></ul></ul></ul></ul>
  42. 42. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status; other tests: abstract thinking </li></ul><ul><ul><li>Tests the capacity to think beyond the Q </li></ul></ul><ul><ul><li>Similarities: </li></ul></ul><ul><ul><ul><li>Ask the patient how the following are alike: </li></ul></ul></ul><ul><ul><ul><ul><li>An orange and an apple </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Wood and coal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>A cat and a mouse </li></ul></ul></ul></ul><ul><ul><ul><li>An abstract response would be both are animals </li></ul></ul></ul><ul><ul><ul><li>A concrete response would be both have tails </li></ul></ul></ul>
  43. 43. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status; other tests: Constructional ability </li></ul><ul><ul><li>Clock test </li></ul></ul><ul><ul><ul><li>Patient draws a clock face </li></ul></ul></ul><ul><ul><ul><li>If poor suggests dementia or parietal damage </li></ul></ul></ul>
  44. 44. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status </li></ul><ul><ul><li>Mini-mental status examination (MMSE) </li></ul></ul><ul><ul><ul><li>Highly reliable & validated 30-pt test </li></ul></ul></ul><ul><ul><ul><ul><li>Check orientation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Repeat the names of 3 objects </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Concentration “spell WORLD backward” or serial 7s </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Name 2 objects </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Repeat: “No ifs, ands, or buts” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Write a sentence </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Read and enact a sentence “close your eyes” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Copy a figure (two interlocking pentagons) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Recall the 3 names of object repeated earlier </li></ul></ul></ul></ul><ul><ul><ul><li>However, Insensitive in detecting dementia </li></ul></ul></ul>
  45. 45. Abnormal Mental Status: <ul><li>Evaluation of abnormal mental status; other tests </li></ul><ul><ul><li>Cognitive Impairment Test (CIT) </li></ul></ul><ul><ul><ul><li>Shorter 6 item test </li></ul></ul></ul><ul><ul><ul><li>Correlates well with the MMSE </li></ul></ul></ul><ul><ul><ul><li>Sensitive in detecting dementia </li></ul></ul></ul>
  46. 46. Mental Status Exam; CIT
  47. 47. Abnormal Mental Status: <ul><li>Mental Health Disorders in 1° care </li></ul>
  48. 48. Abnormal Mental Status: <ul><li>Mental Health Disorders in 1° care </li></ul><ul><ul><li>Est. 20% of 1° care patients </li></ul></ul><ul><ul><ul><li>> 50% undiagnosed </li></ul></ul></ul><ul><ul><li>Prevalence: </li></ul></ul><ul><ul><ul><li>Anxiety 20% </li></ul></ul></ul><ul><ul><ul><li>Mood Disorders 25% </li></ul></ul></ul><ul><ul><ul><li>Depression 10% </li></ul></ul></ul><ul><ul><ul><li>Somatoform Disorders 10 to 15% </li></ul></ul></ul><ul><ul><ul><li>Alcohol & substance abuse 15 to 20% </li></ul></ul></ul>
  49. 49. Abnormal Mental Status: <ul><li>Mental Health Disorders in 1° care </li></ul><ul><ul><li>Unexplained symptoms </li></ul></ul><ul><ul><ul><li>1/3 of patients medical patients </li></ul></ul></ul><ul><ul><ul><li>20 to 25% chronic Sx </li></ul></ul></ul><ul><ul><ul><li>50% assoc with depression or anxiety </li></ul></ul></ul><ul><ul><ul><li>Co-occurrence of functional Sx reach 30 to 90% </li></ul></ul></ul><ul><ul><ul><ul><li>IBS, TMJ, fibromyalgia, chronic fatigue, Mult Chem Sen </li></ul></ul></ul></ul><ul><ul><ul><li>Near 80 to 90% Sx overlap with: fatigue, sleep disturbance, HA, GI Sx </li></ul></ul></ul>
  50. 50. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Somatoform Disorders </li></ul></ul><ul><ul><li>Character Disorders </li></ul></ul><ul><ul><li>Disorders of Mood </li></ul></ul><ul><ul><li>Anxiety Disorders </li></ul></ul><ul><ul><li>Psychotic Disorders </li></ul></ul><ul><ul><li>Temporal lobe epilepsy </li></ul></ul><ul><ul><li>Dementias & Alzheimer’s </li></ul></ul>
  51. 51. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Somatoform Disorders </li></ul></ul><ul><ul><ul><li>Defn: Chronic, multisystem complaints lacking an adequate medical or physical explanation </li></ul></ul></ul><ul><ul><ul><li>Sx include pain, GI, sexual dysfunction and neurologic symptoms </li></ul></ul></ul><ul><ul><ul><li>Onset early in life, psychosocial & vocational achievements are limited </li></ul></ul></ul>
  52. 52. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Somatoform Disorders </li></ul></ul><ul><ul><ul><li>Pain disorder </li></ul></ul></ul><ul><ul><ul><ul><li>1° Sx is pain of psychological origin </li></ul></ul></ul></ul><ul><ul><ul><li>Conversion disorder </li></ul></ul></ul><ul><ul><ul><ul><li>Mimics neurologic disorder in which psychological factors are etiologic, patients may not realize stress factor </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sx: HA, pain, paralysis </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Hypochondria </li></ul></ul></ul><ul><ul><ul><ul><li>Preoccupation with idea of having a serious Dz </li></ul></ul></ul></ul><ul><ul><ul><li>Body dysmorphic disorder </li></ul></ul></ul><ul><ul><ul><ul><li>Preoccupation with imagined or exaggerated defect in physical appearance </li></ul></ul></ul></ul>
  53. 53. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Other Somatoform-like Disorders </li></ul></ul><ul><ul><ul><li>Factitous disorder </li></ul></ul></ul><ul><ul><ul><ul><li>Intentional production or feigning of physical signs without external reinforcers </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Munchausen syndrome; inflict physical harm on themselves or inflict / provoke symptoms in a child </li></ul></ul></ul></ul><ul><ul><ul><li>Malingering </li></ul></ul></ul><ul><ul><ul><ul><li>Intentional production or feigning of physical signs with external reinforcers /gain clearly present </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Most common Opt Presentation: 6 - 8 yo Fe wanting glasses </li></ul></ul></ul></ul>
  54. 54. Abnormal Mental Status: <ul><li>Other Somatoform-like Disorders </li></ul><ul><ul><li>Dissociative disorder </li></ul></ul><ul><ul><ul><li>Disruptions of consciousness, memory, identity or perception judged to be due to psychological factors </li></ul></ul></ul><ul><ul><ul><ul><li>Dissociative amnesia </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Unable to remember traumatic events </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Dissociative fugue </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Acting in complex ways, travel with out memory of </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Dissociative identity </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>AKA: multiple personality disorder </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Switching from one coherent personality to another </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Depersonalization disorder </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Recurrent episodes of feeling outside of ones body </li></ul></ul></ul></ul></ul>
  55. 55. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Character Disorders </li></ul></ul><ul><ul><ul><li>AKA: “personality disorders” “difficult patients” </li></ul></ul></ul><ul><ul><ul><li>6% of population </li></ul></ul></ul><ul><ul><ul><ul><li>Assoc with alcohol & substance abuse (30-59%) </li></ul></ul></ul></ul><ul><ul><ul><li>Dysfunctional interpersonal coping skills </li></ul></ul></ul><ul><ul><ul><li>Early onset, not due to substance abuse, long term </li></ul></ul></ul><ul><ul><ul><ul><li>Behavioral traits formed in early childhood </li></ul></ul></ul></ul><ul><ul><ul><ul><li>30% sexual abused </li></ul></ul></ul></ul><ul><ul><ul><li>Impulsive </li></ul></ul></ul><ul><ul><ul><ul><li>50% attempt suicide or self mutilation </li></ul></ul></ul></ul>
  56. 56. Abnormal Mental Status: <ul><li>Types of Character Disorders </li></ul><ul><ul><ul><li>Paranoid - distrust & suspicious </li></ul></ul></ul><ul><ul><ul><li>Schizoid – detached, restricted range of emotions </li></ul></ul></ul><ul><ul><ul><li>Schizotypal – eccentric with cognitive distortions </li></ul></ul></ul><ul><ul><ul><li>Antisocial – disregard for others, no remorse </li></ul></ul></ul><ul><ul><ul><li>Borderline – instability in relations & self-image </li></ul></ul></ul><ul><ul><ul><li>Histrionic – emotional overreactions, theatrical </li></ul></ul></ul><ul><ul><ul><li>Narcissistic – grandiosity, need for admiration </li></ul></ul></ul><ul><ul><ul><li>Avoidant – social inhibition, hypersensitivity </li></ul></ul></ul><ul><ul><ul><li>Dependant – submission, clinging behavior </li></ul></ul></ul><ul><ul><ul><li>Obsessive-compulsive –rigid, detailed, repetitive </li></ul></ul></ul>
  57. 57. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Disorders of Mood </li></ul></ul><ul><ul><ul><ul><li>30% of pop </li></ul></ul></ul></ul><ul><ul><ul><li>Major depressive episode </li></ul></ul></ul><ul><ul><ul><li>Manic episode </li></ul></ul></ul><ul><ul><ul><li>Mixed episode </li></ul></ul></ul><ul><ul><ul><li>Hypomanic episode </li></ul></ul></ul><ul><ul><ul><li>Bipolar I and II </li></ul></ul></ul><ul><ul><ul><li>Dysthymic and Cyclothymic disorders </li></ul></ul></ul>
  58. 58. Abnormal Mental Status: <ul><li>Disorders of Mood </li></ul><ul><ul><ul><li>Major depressive episode </li></ul></ul></ul><ul><ul><ul><ul><li>10 to 15% of pop </li></ul></ul></ul></ul><ul><ul><ul><ul><li>More common in females 2:1 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Peck onset; 30 to 40 yo, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>13% of postpartum Fe, 5% of adolescents, 30 - 40% in elderly </li></ul></ul></ul></ul><ul><ul><ul><ul><li>20 - 40% in pts with comorbid medical Dz </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Genetic links </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>2-3X risk with Dx 1° relatives </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>50% in twins </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Relapse > 60% </li></ul></ul></ul></ul>
  59. 59. Abnormal Mental Status: <ul><li>Disorders of Mood </li></ul><ul><ul><li>Major depressive episode </li></ul></ul><ul><ul><ul><li>Diagnosis </li></ul></ul></ul><ul><ul><ul><ul><li>Must have a change from their normal state with either: </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Depressed mood most of the day nearly every day </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sig wt gain or loss, change in appetite nearly every day </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Plus: 3 or 4 of the following nearly every day </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Insomnia, agitation, fatigue, feeling of worthlessness or guilt, loss of concentration, recurrent thoughts of death or suicide </li></ul></ul></ul></ul></ul>
  60. 60. Abnormal Mental Status: <ul><li>Disorders of Mood </li></ul><ul><ul><ul><li>Manic episode </li></ul></ul></ul><ul><ul><ul><ul><li>Dx period of persistently elevated, expansive or irritable mood X 1week with 3 of the following Sx </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Inflated self-esteem or grandiosity </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Decreased need for sleep (< 3 hrs) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>More talkative than usual or pressure to keep talking </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Flight of ideas or racing thoughts </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Distractibility </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Increased agitation </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Excessive involvement in high-risk activities </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Severe enough to impair function </li></ul></ul></ul></ul>
  61. 61. Abnormal Mental Status: <ul><li>Disorders of Mood </li></ul><ul><ul><ul><li>Mixed episode </li></ul></ul></ul><ul><ul><ul><ul><li>Having both major and manic depressive episodes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Each episode last at least a week each </li></ul></ul></ul></ul><ul><ul><ul><li>Hypomanic episode </li></ul></ul></ul><ul><ul><ul><ul><li>The mood and Sx similar to a manic episode </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Less impairing, do not require hospitalization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>No hallucination or delusions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sx are shorter, minimum in duration - min 4 days </li></ul></ul></ul></ul>
  62. 62. Abnormal Mental Status: <ul><li>Disorders of Mood </li></ul><ul><ul><ul><li>Bipolar Disorders </li></ul></ul></ul><ul><ul><ul><ul><li>Gen pop ≈ 2%, genetic linked Pos Hx 5-10% risk, Male /Female 1:1, rapid cycling freq in females </li></ul></ul></ul></ul><ul><ul><ul><li>Bipolar I </li></ul></ul></ul><ul><ul><ul><ul><li>Includes one or more manic or mixed episodes, accompanied by major depressive episodes </li></ul></ul></ul></ul><ul><ul><ul><li>Bipolar II </li></ul></ul></ul><ul><ul><ul><ul><li>Includes one or more major depressive episodes accompanied by at least one hypomanic episodes </li></ul></ul></ul></ul>
  63. 63. Abnormal Mental Status: <ul><li>Disorders of Mood </li></ul><ul><ul><ul><li>Dysthymic disorders </li></ul></ul></ul><ul><ul><ul><ul><li>Minor depressed mood & Sx for most of the day, for more days than not, over at least 2 years </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Freedom from Sx last no more than 2 months at a time </li></ul></ul></ul></ul><ul><ul><ul><li>Cyclothymic disorders </li></ul></ul></ul><ul><ul><ul><ul><li>Noted for numerous periods of hypomanic and minor depressive symptoms that last for at least 2 years </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Freedom from Sx last no more than 2 months at a time </li></ul></ul></ul></ul>
  64. 64. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Anxiety Disorders </li></ul></ul><ul><ul><ul><li>Panic disorder </li></ul></ul></ul><ul><ul><ul><li>Agoraphobia </li></ul></ul></ul><ul><ul><ul><li>Phobias </li></ul></ul></ul><ul><ul><ul><li>Social phobia </li></ul></ul></ul><ul><ul><ul><li>Obsessive-compulsive disorder </li></ul></ul></ul><ul><ul><ul><li>Acute Stress disorder </li></ul></ul></ul><ul><ul><ul><li>Posttraumatic Stress disorder </li></ul></ul></ul><ul><ul><ul><li>General Anxiety disorder </li></ul></ul></ul>
  65. 65. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Psychotic Disorders </li></ul></ul><ul><ul><ul><li>Schizophrenia </li></ul></ul></ul><ul><ul><ul><li>Schizophreniform Disorder </li></ul></ul></ul><ul><ul><ul><li>Schizoaffective Disorder </li></ul></ul></ul><ul><ul><ul><li>Delusional Disorder </li></ul></ul></ul><ul><ul><ul><li>Brief Psychotic Disorder </li></ul></ul></ul><ul><ul><ul><li>Substance-induced Psychotic Disorder </li></ul></ul></ul>
  66. 66. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Temporal lobe epilepsy </li></ul></ul><ul><ul><ul><li>Abnormal electrical discharge most often 2° to old temporal lobe trauma </li></ul></ul></ul><ul><ul><ul><li>Most common in the elderly </li></ul></ul></ul><ul><ul><ul><li>Must DDx from other Disorders </li></ul></ul></ul><ul><ul><ul><li>Sx: sudden unprovoked change in behavior </li></ul></ul></ul><ul><ul><ul><ul><li>Temporal pattern of “spells” </li></ul></ul></ul></ul><ul><ul><ul><ul><li>“ Aura” ; feeling or sensation (odor) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Automatisms; lip smacking, eye blinking, pilling </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Change in level of consciousness </li></ul></ul></ul></ul>
  67. 67. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Dementias & Alzheimer’s </li></ul></ul><ul><ul><ul><li>Dementia – 30% of those > 85yo </li></ul></ul></ul><ul><ul><ul><ul><li>Alzheimer’s (AD) – 70% of Dementias </li></ul></ul></ul></ul><ul><ul><ul><li>Vascular Dementia </li></ul></ul></ul><ul><ul><ul><li>Parkinson’s – Lewy Body Dz </li></ul></ul></ul><ul><ul><ul><ul><li>Parkinson’s Plus – with dementia </li></ul></ul></ul></ul><ul><ul><ul><li>Hydrocephlic Dementia </li></ul></ul></ul><ul><ul><ul><li>Delirium </li></ul></ul></ul><ul><ul><ul><li>Metabolic & Hematologic Disorders </li></ul></ul></ul>
  68. 68. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Dementias & Alzheimer’s </li></ul></ul><ul><ul><ul><li>Dementia – 30% of pop> 85yo </li></ul></ul></ul><ul><ul><ul><ul><li>Alzheimer’s (AD) – 70% of Dementias </li></ul></ul></ul></ul><ul><ul><ul><li>Early onset vs late onset </li></ul></ul></ul><ul><ul><ul><ul><li>Early onset – 30- 60yo rare 2%, genetic #21 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Late onset - >65yo common 98% </li></ul></ul></ul></ul><ul><ul><ul><li>Clinical presentation: </li></ul></ul></ul><ul><ul><ul><ul><li>Gradually progressive decline in multiple functions; memory, orientation, judgment, insight, language </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Depression frequently early </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Psychosis, agitation, behavioral disinhibition late </li></ul></ul></ul></ul>
  69. 69. Abnormal Mental Status: <ul><li>Types of Dementias </li></ul><ul><ul><ul><li>Vascular Dementia – </li></ul></ul></ul><ul><ul><ul><ul><li>10% of dementias, 2° strokes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Onset after CVD Sx stepwise </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Early incontinence, gait disturbances, flatted affect </li></ul></ul></ul></ul><ul><ul><ul><li>Parkinson’s – Lewy Body Dz </li></ul></ul></ul><ul><ul><ul><ul><li>2 nd most common dementias </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Parkinson’s – brain stem findings of Lewy bodies </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Slow movement, tremors, rigidity, balance problems </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Parkinson’s Plus – with dementia, diffuse Lewy bodies </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Above Sx and visual hallucinations, cognitive fluctuations </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Death ≈ 1 year after Dx </li></ul></ul></ul></ul></ul>
  70. 70. Abnormal Mental Status: <ul><li>Types of Dementias </li></ul><ul><ul><ul><li>Hydrocephalic Dementia </li></ul></ul></ul><ul><ul><ul><ul><li>Late onset hydrocephalic > 85 yo </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sx: motor slowing, impaired affect & mood, gait instability, urinary incontinence </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gait is wide with shuffling walk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sx evolve slowly over weeks </li></ul></ul></ul></ul><ul><ul><ul><li>Delirium </li></ul></ul></ul><ul><ul><ul><ul><li>AKA: Acute confusional state, toxic encephalopathy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Acute onset, hours to days, fluctuates </li></ul></ul></ul></ul><ul><ul><ul><ul><li>2° to medical condition; 10% of hospitalized pts </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Drugs, anesthesia, infections, stress, endocrine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Sx: disorientation, excitement, defective perceptions with illusions and hallucinations </li></ul></ul></ul></ul>
  71. 71. Abnormal Mental Status: <ul><li>Types of Disorders </li></ul><ul><ul><li>Substance-Related disorders </li></ul></ul><ul><ul><li>15% of pop, males > females, Onset 25 -30 yo </li></ul></ul><ul><ul><li>Types </li></ul></ul><ul><ul><ul><li>Sedatives: alcohol, barbiturates, benzodiazepines </li></ul></ul></ul><ul><ul><ul><ul><li>Sx: acute lethargy, disorientation stupor, memory loss, apathy </li></ul></ul></ul></ul><ul><ul><ul><li>Hallucinogens:cannabis, opioids, mescaline, phencyclidine </li></ul></ul></ul><ul><ul><ul><ul><li>Sx: defective perceptions with illusions and hallucinations </li></ul></ul></ul></ul><ul><ul><ul><li>Stimulants: amphetamine, caffeine, cocaine </li></ul></ul></ul><ul><ul><ul><ul><li>Sx: agitation and paranoia </li></ul></ul></ul></ul><ul><ul><ul><li>Substance-induced Psychotic Disorder </li></ul></ul></ul><ul><ul><ul><ul><li>Sx can be induced with intoxication or withdrawal </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>More common with alcohol, cocaine and opioids </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Sx: Delusions & hallucinations, seizures </li></ul></ul></ul></ul>
  72. 72. Mental Status <ul><li>Reference & readings </li></ul><ul><li>Bates’ Guide to Physical Examination and History Taking , 7th Ed. (Red) Lippincott, </li></ul><ul><ul><li>Chap 3; pgs 107-122 & 123-127 </li></ul></ul><ul><li>Or </li></ul><ul><li>Bates’ Guide to Physical Examination and History Taking 8th or 9 th Ed. (both black) </li></ul><ul><ul><li>Chap 16 </li></ul></ul>

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