Ppt05

Chapter 5
Behavior and Mental Status
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Mental Status and
Behavior History Taking
• Unlike most organ systems, mental status and
behavior are not areas you can inspect, percuss, or
palpate
• As you talk to a patient, you will quickly begin to
discern the patient’s level of alertness, mood,
orientation, attention, and memory
• As you continue talking with a patient in depth, you
will begin to learn about his insight, judgment, and
any thought disorder or disorder of perception

Mental Status and Behavior Terminology
• To appreciate the differences in mental status and
behavior, you must learn the terminology
– Level of consciousness: how aware the person is of
his environment
– Attention: the ability to focus or concentrate
o Alert: the patient is awake and aware
o Lethargic: you must speak to the patient in a
loud forceful manner to get a response
o Obtunded: you must shake a patient to get a
response
o Stuporous: the patient is unarousable except
by painful stimuli (sternal rub)
o Coma: Copyright the © 2014 patient Wolters Kluwer Health is completely | Lippincott Williams & Wilkins
unarousable

(cont.)
• Memory: the process of recording and retrieving
information
– Short-term memory covers events or memories
that occurred minutes to days before
– Long-term memory covers events or memories
that occurred months to years before
• Orientation: aware of person (who they are), place
(where they are), and time (when is it); this
requires memory Copyright © 2014 and Wolters Kluwer attention
Health | Lippincott Williams & Wilkins

(cont.)
• Perceptions: awareness of the objects in the environment
to the five senses and their interrelationships
• Thought processes: the logic, coherence, and relevance
of a patient’s thoughts as they lead to thoughts and
goals; HOW people think
• Insight: awareness that thought, symptoms, or behaviors
are normal or abnormal; e.g., distinguishing that a
daydream or hallucination is not real
• Judgment: process of comparing and evaluating different
possible courses of action

(cont.)
• Affect: the observable mood of a person expressed
through facial expression, body movements, and voice
• Mood: the sustained emotion of the patient
– Euthymic: normal
– Dysthymic: depressed
– Manic: elated
• Language: the complex symbolic system for
expressing written and verbal thoughts, emotion,
attention, and memory
• Higher cognitive functions: level of intelligence
assessed by vocabulary, knowledge base, calculations,
and abstract thinking

Mental Status Examination
• Consists of the following components:
– Appearance and behavior
– Speech and language
– Mood
– Thoughts and perceptions
– Cognitive function: memory, attention,
information and vocabulary, calculations,
abstract thinking, and constructional ability

Appearance and Behavior
• Assess the level of consciousness
– Is the patient awake and alert?
– Does the patient understand your questions?
– Does the patient respond appropriately and
reasonably quickly or lose track of the topic and
fall silent or even asleep?
• If the patient does not respond to your questions,
escalate the stimulus in steps:
– Speak to the patient by name and in a loud voice
– Gently shake the patient

Appearance and Behavior (cont.)
• Posture and motor behavior
– Does the patient lie in bed or prefer to walk around?
– Is the patient sitting or lying comfortably?
– Is the patient agitated with repetitive movements?
• Assess the patient’s dress, grooming, and personal
hygiene
– Generally, grooming and hygiene deteriorate in
depression or schizophrenia
• Assess the patient’s facial expressions
– A flat affect (lack of facial movement) can be seen
due to a physical reason such as Parkinson’s disease
or a psychological reason such as profound
depression

Appearance and Behavior (cont.)
• Assess the patient’s manner, affect, and relationship
to people and things
– Does the affect reflect the mood?
– Is the affect stable or labile (mood changing from
happiness to tears and back quickly)?
– Does the patient seem to see or hear things you
do not?

Speech and Language
• Quantity: Is the patient talkative or silent?
• Rate: Is the speech fast or slow?
• Loud: Is speech loud or soft?
• Articulation of words: Does the patient speak
clearly and distinctly? Is there nasal quality to
the speech?

Speech and Language (cont.)
• Fluency: involves the rate, flow, and melody of speech
– Hesitancies in speech (as seen in patients with
aphasia from strokes)
– Monotone inflections (schizophrenia or severe
depression)
– Circumlocutions: words or phrases are substituted
for the word a person cannot remember; e.g., “the
thing you block out your writing with” for an eraser
– Paraphasias: words are malformed (“I write with a
den”), wrong (“I write with a branch”), or invented
(“I write with a dar”)

Assessing Mood
• Use open-ended questions
– “How do you feel about that?”
– “How are you feeling?”
• How long has the patient’s mood been this way
• How good or bad has the patient felt
• Sometimes you have to ask friends or family of
the patient to help you assess the patient’s mood
• Do not be afraid to ask the patient about thoughts
of self-harm or suicide

Thought and Perceptions:
Thought Processes
• Assess thought processes: logic, relevance, organization,
and coherence
• Abnormalities in the thought process
– Circumstantiality: speech characterized by indirection
and delay due to the patient’s excessive use of details
that have no connection to the point
– Derailment: speech in which a person shifts topics
with no apparent relation between the topics
– Flight of ideas: accelerated change of topics in a very
fast but generally coherent manner
– Neologisms: invented or distorted words

Thought Processes (cont.)
• Incoherence: speech that is incomprehensible
because it is illogical
• Blocking: sudden interruption of speech, before the
completion of an idea, occurs in normal people
• Confabulation: fabrication of facts to hide memory
impairment
• Perseveration: persistent repetition of words or
ideas
• Echolalia: repetition of the words or phrases of
others
• Clanging: choosing a word on the basis of sound
rather than meaning

Thought Content
• Assess thought content during the interview by following
appropriate leads as they occur
• Abnormalities of thought content
– Compulsions: repetitive behaviors that a person feels
driven to perform to prevent or produce some future
state of affairs
– Obsessions: recurrent, uncontrollable thoughts,
images, or impulses that a patient considers
unacceptable
– Phobias: persistent fear of a stimuli the patient feels
is irrational (spiders, snakes, the dark)
– Anxiety: apprehension or fear that may be focused
(phobia) or free floating (general sense of dread)

Thought Content (cont.)
• Abnormal thought content continued
– Delusions: false, fixed beliefs that are not shared by other
members of the person’s culture
o Delusion of persecution, grandeur, or jealousy
o Delusion of reference: a person believes an outside
event or object has an unusual personal reference to
them; i.e., a comet passing earth means the patient
should buy a car
o Delusion of being controlled by outside forces
o Somatic delusion: believing one has a disease or defect
that he does not
o Systematized delusion: a single delusion with many
elaborations around a single theme all systematized into
a complex network; i.e., the KGB is after the patient

Question
• Is the following statement true or false?
When assessing the patient’s thought content, it is
important to always follow specific questions to
keep the patient on task.

Answer
False.
When assessing the patient’s thought content,
follow appropriate leads as they occur rather
than using stereotyped lists of specific
questions.

Thought and Perceptions: Perceptions
• Inquire about false perceptions
– Do you hear voices other people don’t hear?
– Do you see things other people don’t see?
– Do you know things other people don’t know?
• Abnormalities of perception
– Illusions: misinterpretations of real stimuli; e.g., the postman
leaves mail, therefore there is a plot to poison the patient
– Hallucinations: a subjective external stimuli the patient hears or
sees that others do not hear or see and that the patient may
not recognize as false; these can be auditory, visual, olfactory,
gustatory, or tactile
o Abe Lincoln speaks to the patient from the back of a penny
o Do not include false perceptions associated with
dreaming/falling asleep

Question
Which of the following is true about hallucinations?
a. Experiences may or may not be recognized by
the person as false
b. Hallucinations may be auditory, visual, olfactory,
gustatory, tactile, or somatic
c. Do not include false perceptions associated with
dreaming and falling asleep
d. All of the above

Answer
d. All of the above
– Experiences may or may not be recognized by
the person as false
– Hallucinations may be auditory, visual, olfactory,
gustatory, tactile, or somatic
– Do not include false perceptions associated with
dreaming and falling asleep

Insight and Judgment
• Ask the patient about the reasons behind his clinic
or hospital visit; patients with psychological
disorders often lack insight into their disease
• You can usually assess judgment by noting the
patients’ responses to stressors on their
relationships, job, and finances

Cognitive Functions
• Assess orientation to person, place, and time
• Assess attention
– Digital span: give the patient a string of numbers to
recite back to you
– Serial 7s: ask the patient to subtract serial “7s” from 100
– Spelling backward: ask the patient to spell W-O-R-L-D
backwards
• Assess remote memory by asking about past historical
events
• Assess recent memory by asking about something recent
(weather, national event, etc.)
• Assess new learning ability by giving the patient three or four
words to remember; then ask him to repeat the words after
several minutes

Higher Cognitive Functions
• Through your conversation, you can often assess the
patient’s higher cognitive functions
• Information and vocabulary
• Calculating ability: ask the patient to perform more
difficult calculations such as making change (e.g., if you
had a dollar’s worth of nickels and someone needed 65
cents how many nickels would you have left?)
• Abstract thinking
– Interpreting proverbs: “A stitch in time saves nine”
– Similarity exercises: What do a ball and an orange
have in common?

Higher Cognitive Functions (cont.)
• Constructional ability
– Ask a patient to copy a geometric figure onto a
sheet of paper
– Ask a patient to draw a clock
face indicating 5:00

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