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Mental State Examination
This document provides an overview of the components of a mental state examination, including appearance and behavior, speech, mood, thoughts, perceptions, cognition, and insight. It describes how to assess each component and what abnormal findings may indicate for conditions like depression, mania, schizophrenia, and other psychological disorders. Key areas covered include appearance, facial expressions, posture, movements, speech patterns, subjective and objective mood, thought content and form, perceptions like hallucinations and illusions, attention, memory, and orientation.
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Mental State Examination
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- 2. Mental state Examination •Appearance and behavior • Speech • Mood • Thoughts • Perceptions • Cognition • Insight JMJ 2
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- 5. Appearance and Behaviour •General appearance • Facial expressions • Posture • Movements • Social Behaviour JMJ 5
- 6. General appearance • Physique(the shape and size of a person’s body) • Hair • Make up • Clothing JMJ 6
- 7. General appearance • Selfneglected • Dirty unkempt appearance • Stained, crumpled clothing • Suggests – alcoholism, drug addiction, dementia, or schizophrenia • Wight loss • Physical disorders – • cancer, hyperthyroidism • Psychological disorders – • anorexia nervosa, depressive disorders • Social Problems • Financial difficulty, homelessness JMJ 7
- 8. Facial Expression • Depression •Turning down of corners of mouth • Vertical furrows in the brows • Anxiety • Horizontal furrows on the brow • Wide palpebral fissures • Dilated pupils • Parkinsonism Syndrome • Unchanging ‘wooden’ expressions JMJ 8
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- 10. Posture • Depression • Shouldershunched • With head and eyes down casted • Anxiety • Sits upright • With the head erect • Hands gripping the chair JMJ 10
- 11. Movements • Manic • Overreactive, restless • More rapidly from place to place and task to task • Depressed • Inactive and move slowly • Stupor – when depressed patient become completely immobile and mute • Anxious or agitated • Restless, sometimes tremours • Involuntary movements • Tics, characiform movements, dystonia, tardive dyskinesia JMJ 11
- 12. Movements Tics Choreiform Dystonia IrregularBrief Muscle spasm Repeated movements Involuntary Movements Often painful Involving group of muscles Coordinated but purposeless May lead to contortions Grimacing or movements of the arm JMJ 12
- 13. Social Behaviour • Disinhibited •SIGNS OF IMPENDING VIOLANCE • Restlessness • Sweating • Clenched fists or pointed fingures • Intrusions into the interviewer’s ‘personal space’ • Raised voice JMJ 13
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- 15. Speech • Quantity • ↓in depressed • ↑ in Manic • Rate • Pressure of speech – copious rapid speech which is hard to interrupt • Spontaneity • Long answer latency – depressed and intoxicated • Volume • Quite – depressed • Loud - Manic JMJ 15
- 16. Speech • Abnormalities ofthe continuity of speech • Any sudden interruptions • Rapid shifts of topics • Lack of logical tread JMJ 16
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- 18. Mood • Subjective mood •Objective Mood • Predominant mood • Constancy • Congruity JMJ 18
- 19. Subjective Mood • Askthe patient • What is your mood just now? • Recent days • If depressed • A feeling of being ready to cry • Lack of interest and enjoyment and pessimistic thoughts • Thoughts of suicide • If Anxious • Palpitations • Dry mouth • Tremor • Sweating JMJ 19
- 20. Objective Mood • Natureof mood/ moods • What is the mood or moods appear to predominate within the interview? • Depression • Elation • Anger • Anxiety • Suspicious • Perplexity • Unremarkable mood JMJ 20
- 21. Objective Mood • Constancyof mood • If normal spectrum is enhanced • Emotional liability • Such as in dementia, mania, after a stroke • When it is extreme • Emotional incontinence • When it is decreased • Reduced activity, blunting, flattening JMJ 21
- 22. Objective Mood • Congruityof mood • Normally out mod, thoughts and perceptions are closely associated and fit together logically. • In schizophrenia – incongruity of mood • Person appears cheerful while describing sad events JMJ 22
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- 24. Thoughts • Stream • Form •Content • Pre-occupations • Morbid thoughts, including suicidality • Delusions and overvalued ideas • Obsessional symptoms JMJ 24
- 25. Abnormalities of Thoughts JMJ25 Abnormality of the Steam of thought Form of thought Content of thought It’s amount and speed The ways in which thought are linked together Pre-occupations Morbid thoughts Delusions Overvalued ideas Obsessional and compulsive symptoms
- 26. Abnormalities of STREAMof Thoughts JMJ 26 Abnormality of stream of thought Pressure of thought Poverty of thought Blocking of thoughts • Unusually rapid, abundant and varied • Characteristic of mania • But can occur in schizophrenia • Unusually slow, few and unvaried • Characteristic of severe depression • Can occurs in schizophrenia • Suddenly empty of thoughts • Schizophrenia
- 27. Abnormalities of FORMof Thoughts JMJ 27 Abnormality of form of thought Flight of ideas Loosening of associations Perseverations • Characteristic in mania • Sometimes links may be difficult to follow • RHYME • PUNS • DISTRACTION • Lacking logical association – Knight’s move thinking • Mostly occur in schizophrenia • Persistent & inappropriate repetition of the same sequence of thought.
- 28. Pre-occupations • Thoughts thatrecur frequently but can be put out of mind by an effort of will • Common in • Depressive disorders • About suicide • Anxiety disorders • Sexual diorders • Hx taking ask • “ what sort of things do you worry about?” • “What sort of thoughts occupy on your mind” JMJ 28
- 29. Morbid thoughts • Theseare particularly associate with specific illness, through either their nature • Suicidality • Ask about feelings of depression and then hopelessness before • Moving on to ‘passive’ suicidal ideas • Asking about ‘active’ suicidal ideas JMJ 29
- 30. Delusions • Is abelief that is held firmly • but on inadequate grounds, • is not affected by rational argument or evidence to the country. • And it is not conventional belief that the person might be expected to hold given • his cultural background and level of education JMJ 30
- 31. Delusions Primary • One thatoccurs suddenly without any other abnormal mental even leading to it. • Rare • When occur- strongly suggest schizophrenia Secondary • Arise from previous abnormal idea or experience • Hallucinations • Mood • Another delusion JMJ 31
- 32. Other mental phenomena relatedto delusions • Delusional mood • In explicable feeling of apprehension that is followed before long by a delusion that explains it. • Delusional Perception • Misinterpretation of the significance of something perceived normally • Delusional memory • Retrospective delusional misinterpretation of memories of actual events JMJ 32
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- 34. Shared delusions /folie à deux JMJ 34
- 35. Delusional themes JMJ 35 Persecutory(Paranoid) Schizophrenia , organic diorders, depression Delusions of reference Schizophrenia Grandiose and expansive delusions Mania, Schizophrenia Delusions of guilt & worthlessness Severe Depressive disorders Nihilistic delusions Severe Depressive diorders Hypochondriacal delusions Delusions of jealousy Sexual or amorous delusions Religious delusions Delusion of control Schizophrenia Delusions concerning the possession of thoughts • Delusion of thought insertion • Delusion of thought withdrawal • Delusion of thought broadcasting
- 36. Persecutory delusions • Ideasthat people or organizations are trying to inflict harm on the patient, • damage his reputation, • or make him insane. • Sometimes normal in some people • Common in schizophrenia • Occur in organic states and severe depressive disorders JMJ 36
- 37. Delusions of Reference •Concerned with the idea that objects, events or the actions of other people have a special significance for the patient. • Ex: • A remark heard on television is believed to be directed specifically to the patient, or a gesture by a stranger is believed to convey something about the patient • Associate with schizophrenia JMJ 37
- 38. Grandiose & Expansive delusions •Beliefs of exaggerated self-importance • Occur in mania & sometimes in schizophrenia JMJ 38
- 39. Delusions of guiltand worthlessness • Beliefs that the person has done something shameful or sinful. • Usually concerns innocent errors • Most often in severe depressive disorders JMJ 39
- 40. Nihilistic Delusions • Beliefsthat the patient’s career is finished, • that he is about to die or • has no money, or • that the world is doomed • Common in severe depressive disorders JMJ 40
- 41. Hypochondriacal Delusions • Falsebeliefs about the presence of disease. • Common among elderly • Related dysmorphophobic delusions – concerned with the appearance of parts of the body • Severe depressive & schizophrenia JMJ 41
- 42. Delusions of jealousy •Common among men • ‘Morbid (pathological) jealousy’ • May lead to dangerously aggressive behavior towards the person who is believed to be unfaithful JMJ 42
- 43. Sexual or amorousdelusions • Common among women • They believe that she is loved by a man who has never spoken to her & who is inaccessible JMJ 43
- 44. Religious Delusions • Maybe concerned with guilt or with special powers. JMJ 44
- 45. Delusions of Control •Beliefs that personal actions, impulses or thoughts are controlled by an outside agency. • This has to be distinguished JMJ 45
- 46. Delusions concerning the possessionof thoughts • Delusions of thought insertion • Some of the person’s thoughts have been implanted by an outside agency • Delusion of thought withdrawal • Some of their thoughts have been taken away • Delusions of thought broadcasting • Some of their thoughts are known to other people through telepathy, radio, or some other unusual way JMJ 46
- 47. Overvalued ideas • Isolated, •Preoccupying, and • Strongly held belief, • That dominates a person’s life and • May affect his or her own actions, • But which (unlike a delusion) has been derived through normal mental processes. JMJ 47
- 48. Overvalued ideas • Example •Someone whose parents developed cancer within a short time of one another may be convinced that cancer is contagious, despite having been presented many times with evidence to the country. • Difficult to differentiate from delusions • Main difference – assess the way, how the idea developed JMJ 48
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- 51. Perceptions • Perception • Processof becoming aware of what is presented to the body through the sense organs. • These perceptions are experienced as real and are real. • Imagery • An experience originating within the mind that usually lacks the sense of reality that is part of perception • It differs from perception • It can be initiated and terminated at will JMJ 51
- 52. Perceptions Abnormalities of perception Changes in intensity Changesin quality Illusion Hallucinations JMJ 52
- 53. Delusional Perceptions JMJ 53 •It is a disorder of thinking
- 54. Changes in intensityof perception JMJ 54 • In mania - • Perception seems more intense • Eg • Colours – seen as very bright • Sound of pin drop – very loud • In depression • Opposite of previous
- 55. Changes in qualityof perception JMJ 55 • In schizophrenia • Perceptions are distorted or unpleasant
- 56. Illusions • Misperception ofa real stimulus JMJ 56 Illusions Sensory impairment Inattention Impaired consciousness Emotional arousal At dusk or dawn, Pt is visually impaired Delirium Usually fear
- 57. Hallucinations • Is aperception, • experienced in the absence of an external stimulus • to the corresponding sense organ • It has 2 qualities that distinguish it from imagery • It is experienced as a true perception • It seems to come from outside the head JMJ 57
- 58. Hypnagogic Hallucinations • Healthypeople experience hallucinations, • especially when falling asleep JMJ 58
- 59. Hypnopompic Hallucinations • Healthypeople experience hallucinations, • especially when waking up JMJ 59
- 60. Modalities of Hallucinations Hallucinations AuditoryVisual Smell and taste Tactile Deep sensation JMJ 60
- 61. Auditory Hallucinations JMJ 61 •Second person hallucination • Address the patient as ‘you’ • Third person hallucinations • Others talks about the patient “he”/”she” • Thought echo • Repeat what he has just been thinking
- 62. Visual Hallucinations JMJ 62 •Simple, flashes of light • Experienced as normal in size • Associated particularly with organic mental disorders
- 63. Hallucinations of deep sensations JMJ63 • Viscera being pulled or distended • As a sexual stimulation • May be associated with delusional interpretation
- 64. Diagnostic association of hallucinations JMJ64 • Occurs in • Organic disorders • Severe affective disorders • Schizophrenia • Visual hallucinations • Organic psychiatric disorders • Severe mood disorders • Schizophrenia • Hallucinations of taste, smell and deep sensation • Schizophrenia
- 65. Hallucinations JMJ 65 • Commandhallucinations • Can indicate a high risk of harm to self or other
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- 67. Cognition • Assessment of •Consciousness • Orientation • Attention • Concentration • Memory • Language • Visuospatial functioning JMJ 67
- 68. Consciousness • Awareness ofself and the environment JMJ 68 consciousness Clouding of consciousness Stupor Confusion State of drowsiness with, incomplete reaction to stimuli, impaired attention, concentration, and memory , slow, muddled thinking Person is mute, immobile, & unresponsive, but appears conscious bcoz the eyes are open and follow objects Muddled thinking Acute – delirium Chronic – dementia
- 69. Orientation • Assessed byasking about awareness of • Time • Place • Person • Disorientation • Indicates impairment of consciousness • Impairment of new learning JMJ 69
- 70. Attention and concentration •Attention • Ability to focus on the matter in hand • Concentration • Ability to sustain that focus • Both can be impaired in • Anxiety disorders • Depressive disorders • Mania • Schizophrenia • Organic disorders JMJ 70
- 71. Attention and concentration •‘Serial 7s test’ • Subtract 7 from 100 and then to take 7 from the remainder repeatedly until it is less than 7 • Say months of the year in reverse order • Naming the days and week in reverse order JMJ 71
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- 73. Memory- Immediate memory •‘Digit span test’ • assessed by asking patients to repeat sequences of digits • immediately after • they have been spoken slowly enough for them to register the digits • Start with 4 digits then increase the number.. JMJ 73
- 74. Memory- recent memory •Ask the patient to remember one name and address • Ask it later • Score out of 6 • 0,1,2 – abnormal • 5-6 score - normal JMJ 74
- 75. Memory- long-term memory •Asking to recall personal events or well known public events • Personal events • Birth dates JMJ 75
- 76. Amnesia Amnesia Anterograde Retrograde Jamaisvu Confabulation JMJ 76 Occurs after a period of unconsciousness Impairment of memory for events between the ending of complete unconsciousness & the restoration of full consciousness Loss of memory for the events before the onset of unconscious Occurs after head injury and ECT Failure to recognize events that have been encountered before Déjà vu Recognition of events as familiar when they never been encountered Reporting as ‘memory’ of events that did not take place at time of questioning
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- 79. Insight • The extentto which the patient’s view of their • symptoms, illness, prognosis, and treatment is • identical to that of their healthcare professional JMJ 79
- 80. Insight • awareness ofoneself as presenting phenomena that other people consider abnormal (e.g. being unusually active and elated); • recognition that these phenomena are abnormal (versus, for example, being a desirable mental state, of which other people are jealous); • acceptance that these abnormal phenomena are caused by mental illness (versus, for example, being excited about and energized by a new project or idea, or having a physical illness); JMJ 80
- 81. Insight • awareness thattreatment is required (versus treatment being unnecessary and undesirable); • acceptance of the professional’s specific treatment recommendations (e.g. admission to hospital and sedative medication). JMJ 81
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