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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 MENTAL
STATUS EXAMINATION
    Appearance and Behavior
    Motor activity
    Speech
    Mood
    Affect
    Thought process
    Thought content
    Perceptual disturbances
    Cognition
    Abstract thinking
    Insight
    Judgment
APPEARANCE AND BEHAVIOR:WHAT DO
YOU 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/drug
de-addiction.
Bright/ Colorful clothes- Mania
Stooped posture,hunched,leaning forward- Depression
Sitting on the edge of the seat, gripping the arms of the chair- Anxiety
Facial 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 exophthalmos
Eye 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.
Speech
Rate: normal, very slow, rapid, pressure of speech
Flow: spontaneous, hesitant, slurring, stuttering, speaks
only on question, muttering, mute
Volume: audible, excessive loud, abnormally soft
Amount: Normal, abundant, scanty
Tone: normal fluctuations, monotonous
Coherence: coherent, incoherent
Relevance: relevant, irrelevant
Disorders of Speech:-
Aphonia: fails to produce any vol. of sound, e.g. in laryngeal
or vocal cord disorder. If despite this he/she is able to cough
normally, probably hysterical.
Slow speech: may be a feature of psychomotor retardation.
Fast speech: normal anxiety but may indicate Mania or
Schizophrenia
Pressure of speech: rapid speech that is increased in
amount and difficult to interrupt. Seen in Mania
Poverty of speech: restriction in amount of speech, replies
may be monosyllabic
Poverty of content of speech: speech is adequate in amount
but covers little information due to vagueness, emptiness
stereotyped phrases.
Echolalia: repetition of sentence just uttered by the examiner.
Palilalia: repetition of only last uttered word or phrase said by the
examiner.
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 are


1. Circumstantial: When thinking proceeds slowly with
many unnecessary detail but eventually get to the
point. Goal is never completely lost. It can occur in
context of learning disability and in individual with
obsessional personality traits,schizophrenia, dementia,
and anxiety disorders.
 2. Tangential: Move from thought to thought that
relate in some way but never get to the point.e.g. In
Psychosis 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. When
clearly present, it highly suggests Schizophrenia.
4. Perseveration: Inappropriate repetition of words or
phrases. It is common in generalized & local disorders of
brain, when present provide strong support for such a
diagnosis. 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 are


1. Loosening of association: Illogical shifting between
unrelated topics. It is a hallmark feature of
Schizophrenia.
2. Derailment : Gradual or sudden deviation in train of
thought without blocking.
3. Word Salad: Extreme version of LOA in which
changes in topics are so extreme and the associations so
loose that the resulting speech is completely incoherent .
4. Stereotypes: Constant repetition of a phrase(or
behavior) in many different settings, irrespective of
context.
3. Verbigeration: Disappearance of understandable
speech replaced by strings of incoherent utterance
.
4. Metonyms: are word approximation e.g. paper skate for
pen
5. Clang association: words are chosen or repeated based on
similar sounds, instead of semantic meaning.
Seen in mania
6. Neologism : It refers to the new word formation by the
patient 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 is
out of keeping with the patient’s social, cultural, and
educational 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 following
distinction b/w delusion and overvalued ideas –

1. Delusional individuals are less likely to identify what
might modify their belief, less preoccupied and less
concerned about others’ reactions than those with
overvalued ideas.
2. Delusions are less plausible and their onset less likely
to appear reasonable.
3. Delusions are more likely to have abrupt onset and
overvalued ideas have gradual onset.
4. Conviction and insight were similar in both groups.
5. Belief , conviction and insight may be an inadequate
basis for separating delusion from overvalued ideas.
Abrupt onset, implausible content, and relative
indifference to the opinions of others may be better
distinguishing 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 impulse

4. 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. mental
process 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 environment
o 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
          contact
Disorders:- 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 or
learned 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 storage
at will(recall).
Impairment
Effort 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 months
3. Recent memory: past few days or breakfast, lunch
 or dinner
4. Remote memory: childhood datas, important events
 known to have occurred when patient was younger or
 free of illness, personal matters, neutral materials

5. 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 looking
objects (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 to
illustrate the meaning) or overtly abstract(giving
generalized explanation); appropriate
 Insight : Degree of awareness and understanding
 the patient has that he/she is ill
Grades :-.
1. complete denial of illness
2. slight awareness of being ill but denying it at the
    same time
3. awareness of being sick but blaming it on others,
   external factors, or medical or unknown organic
   factors
4. Awareness that illness is due to something unknown
     in the patient
5. 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 patient's 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
THANK YOU

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Mental status examination

  • 1. MENTAL STATUS EXAMINATION Dr. Vijit Jaiswal Junior Resident Deptt. of Psychiatry
  • 2. 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.
  • 3. 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
  • 4. 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!
  • 5. COMPONENTS OF THE MENTAL STATUS EXAMINATION  Appearance and Behavior  Motor activity  Speech  Mood  Affect  Thought process  Thought content  Perceptual disturbances  Cognition  Abstract thinking  Insight  Judgment
  • 6. APPEARANCE AND BEHAVIOR:WHAT DO YOU 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.
  • 7. Examples: General self neglect- chronic schizophrenia, dementia, alcohol/drug de-addiction. Bright/ Colorful clothes- Mania Stooped posture,hunched,leaning forward- Depression Sitting on the edge of the seat, gripping the arms of the chair- Anxiety Facial 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 exophthalmos Eye contact: Reduced in Depression,Unsettled in Autistic disorder or social Anxiety, may appear staring in Parkinsonism/Drug side effects.
  • 8. 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.
  • 9. Speech Rate: normal, very slow, rapid, pressure of speech Flow: spontaneous, hesitant, slurring, stuttering, speaks only on question, muttering, mute Volume: audible, excessive loud, abnormally soft Amount: Normal, abundant, scanty Tone: normal fluctuations, monotonous Coherence: coherent, incoherent Relevance: relevant, irrelevant
  • 10. Disorders of Speech:- Aphonia: fails to produce any vol. of sound, e.g. in laryngeal or vocal cord disorder. If despite this he/she is able to cough normally, probably hysterical. Slow speech: may be a feature of psychomotor retardation. Fast speech: normal anxiety but may indicate Mania or Schizophrenia Pressure of speech: rapid speech that is increased in amount and difficult to interrupt. Seen in Mania Poverty of speech: restriction in amount of speech, replies may be monosyllabic Poverty of content of speech: speech is adequate in amount but covers little information due to vagueness, emptiness stereotyped phrases. Echolalia: repetition of sentence just uttered by the examiner. Palilalia: repetition of only last uttered word or phrase said by the examiner.
  • 11. 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
  • 12. 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.
  • 13. 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
  • 14. b). Continuity of thoughts – abnormalities seen are 1. Circumstantial: When thinking proceeds slowly with many unnecessary detail but eventually get to the point. Goal is never completely lost. It can occur in context of learning disability and in individual with obsessional personality traits,schizophrenia, dementia, and anxiety disorders. 2. Tangential: Move from thought to thought that relate in some way but never get to the point.e.g. In Psychosis and Dementia
  • 15. 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. When clearly present, it highly suggests Schizophrenia. 4. Perseveration: Inappropriate repetition of words or phrases. It is common in generalized & local disorders of brain, when present provide strong support for such a diagnosis. Also seen in OCD & Psychosis.
  • 16. 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.
  • 17. Formal thought disorder - abnormalities seen are 1. Loosening of association: Illogical shifting between unrelated topics. It is a hallmark feature of Schizophrenia. 2. Derailment : Gradual or sudden deviation in train of thought without blocking. 3. Word Salad: Extreme version of LOA in which changes in topics are so extreme and the associations so loose that the resulting speech is completely incoherent . 4. Stereotypes: Constant repetition of a phrase(or behavior) in many different settings, irrespective of context. 3. Verbigeration: Disappearance of understandable speech replaced by strings of incoherent utterance
  • 18. . 4. Metonyms: are word approximation e.g. paper skate for pen 5. Clang association: words are chosen or repeated based on similar sounds, instead of semantic meaning. Seen in mania 6. Neologism : It refers to the new word formation by the patient or ordinary word that are used in new way. Seen in Schizophrenia.
  • 19. 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).
  • 20. 2. Delusions: False, firm (fixed), unshakable belief that is out of keeping with the patient’s social, cultural, and educational 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
  • 21. Richard & Richard, 2010, provided the following distinction b/w delusion and overvalued ideas – 1. Delusional individuals are less likely to identify what might modify their belief, less preoccupied and less concerned about others’ reactions than those with overvalued ideas. 2. Delusions are less plausible and their onset less likely to appear reasonable. 3. Delusions are more likely to have abrupt onset and overvalued ideas have gradual onset. 4. Conviction and insight were similar in both groups. 5. Belief , conviction and insight may be an inadequate basis for separating delusion from overvalued ideas. Abrupt onset, implausible content, and relative indifference to the opinions of others may be better distinguishing feature.
  • 22. 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 impulse 4. 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.
  • 23. Perceptions: Process of transferring physical stimulation into psychological information i.e. mental process by which sensory stimuli are brought to awareness.
  • 24. 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.
  • 25. o Derealization: Feelings the outer environment feels unreal and detached from environment o 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.
  • 26.  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 contact Disorders:- 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
  • 27. 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
  • 28.  Memory: It is a process whereby what is experienced or learned 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 storage at will(recall). Impairment Effort 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
  • 29. 2.Recent past memory: past few months 3. Recent memory: past few days or breakfast, lunch or dinner 4. Remote memory: childhood datas, important events known to have occurred when patient was younger or free of illness, personal matters, neutral materials 5. Working memory : Immediate + recent memory
  • 30. 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
  • 31. Abstract thinking • Manner in which patient conceptualizes or handles his/ her ideas.  To test we may ask 1. Similarities and differences b/w similar looking objects (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 to illustrate the meaning) or overtly abstract(giving generalized explanation); appropriate
  • 32.  Insight : Degree of awareness and understanding the patient has that he/she is ill Grades :-. 1. complete denial of illness 2. slight awareness of being ill but denying it at the same time 3. awareness of being sick but blaming it on others, external factors, or medical or unknown organic factors 4. Awareness that illness is due to something unknown in the patient 5. 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.
  • 33. 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.
  • 34.  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 patient's 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
  • 35.  Bibliography 1.C.T.P. 2.Synopsis of Psychiatry 3.Fish’s clinical psychopathology