Download Mental status examination and symptoms in psychiatry

Mental status examination
and symptoms in psychiatry
İpek Sönmez, MD
Department of Psychiatry
What is
MSE?
• Mental status examination (MSE) can be considered
as a “review of psychiatric symptoms”
• It begins as soon as the patient is in view glance
• Observation at the beginning of the interview reveals
information: grooming, hygiene, behavior, gait etc.
• History taking = learning the psychiatric symptoms of
the patients
All of the components can not be measured precisely
• MSE is called “brain stethoscope”
MSE (main components)
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General appearance
Cooperation and reliability
Speech
Affect/mood
Cognitive functions
Behavior
Appearance
Diagnostic significance of observations
with regard to appearance
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Trichotillomania
Anorexia Nervosa
Major Depressive Episode
Schizophrenia (Sch)
Manic episode
Cooperation and reliability
• Eye contact
– Continuous/good/intermittent/fleeting/
absent
• Attitude/demeanor
• Attentiveness to the interview
• Level of conciousness
Diagnostic significance of cooperation and
reliability
• Paranoid sch or par. personality
disorder
• Manic/hypomanic episode
• Major depressive episode
• Dementias
Speech
speech
language
Thought process
Speech/language/thought process
• Speech: verbal expression, consisting utterances,
words, phrases and sentences
• Language: communication of comprehensible ideas
• Language can be conveyed by means other than
speech (posture, gestures, fascial expressions, action
and sign “body” language)
• Language consists of ideas that convey meaning and
are properly produced
• Thought process: production and organization of the
thought
• Thought is inferred from speech and language
(including writing)
Other qualities of speech
• Accent/dialect: regional and cultural
differences in pronunciation
• Amount of speech:
– “normal” amount of speech; spontaneous
speech
– anxious patients provide a lot of detail
– conversely other patients provide sparse
answers
Amount of speech can be
increased in...
• Mania (“pressured” speech)
• Anxiety disorders
• Obsessive compulsive personalities
(needless detail)
• Fluent aphasias
Terms used to describe increased amount
of speech: verbose, logorrhea, talkative
etc.
Amount of speech can be
decreased in...
• Depression
• Sch
• Catatonia
• Avoidant, schizoid personalities
• Dementia (can be verbose in early stages)
• Delirium (hypoactive subtype)
Terms used to describe decreased amount of
speech: paucity of speech, impoverished etc.
• Mutism: totally absence of speech
Affect and
mood
Affect and Mood
• Affect (visible objective manifestations of
emotional state): Moment to moment variation
in emotion
It can be modulated by both internal and
external events
• Mood (internal, subjective emotional state):
pervasive emotional tone throughout the
interview
Less connected to internal or external stimuli
Diagnostic significance of affective and
mood changes
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Sch/blunted
Manic episode/elevated
Major depressive episode/depressed
Anxiety disorders/anxious
– Panic disorder
– Generalized anxiety disorder
– Simple and social phobic disorders
Several types of
affect
Various aspects of affect
1. Type or quality
happiness, sadness, fear/anxiety, surprise,
shame, anger, interest, disgust, contentment
2. Range:
“Normal” affective tone consist of a
combination of the above emotional qualities
Narrow range (1 or 2 emotional state: mania)
Wide range (several emotions are expressed:
borderline P.D.)
3. Degree (intensity/amplitude)
Low intensity (flattened/ blunted): Sch, dementia
Normal: adequate
High intensity (exaggerated): mania/depression
4. Stability (duration of an affective response; shifts
appropriate to the context of interview)
Labile: Affective changes occur rapidly and frequently
Mania: Vary rapidly e.g. from elation to irritable affect
Borderline personality: affective instability
5. Appropriateness is the degree to which visible
emotions match thought content
Inappropriate affect: Sch
Mood
Type or quality
• Depressed: Major depressive episode
• Euphoric: Manic episode of BP
• Angry/Irritable: mania, paranoid states
• Anxious: Panic disorder, generalized
anxiety disorder, phobic disorders
manic
Patterns of mood disturbances
Bipolar disorder
euthymia: normal mood changes
Major depression
Cognitive functions (CF)
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Level of conciousness
Orientation
Memory
Attention and concentration
Intelligence
Perception
Language
Judgement
Abstraction
Thought (process and content)
Reality testing
Level of conciousness
• To be aware of one self and the environment
• Degree of alertness is the first cognitive
function to be assesed and is essential for
higher mental abilities to be intact
• Unless patients are awake and capable of
language the remainder of CF can not be
examined
• Level of conciousness decrease in delirium
(toxic-organic etiology)
• In most of the functional psychiatric
disorders it is not impaired
Orientation
• To recognize the time, place and person
• Orientation is tested according to
– Time (time of day, day of week, date, month, year, season)
– Place (hospital, clinic, floor level, town, city, country)
– Person (identity of person and recognition of family members,
friends)
• Disorientation is seen in organic disorders, dementia,
delirium
• Ask such questions...
– When did the patient come to the hospital? With whom? Where
is he now? What is the date of the day, what time of day it is;
morning, noon, evening, night? etc
Attention
• Attention: The ability to direct mental energy
A conscious, willfull focusing of cognitive process
while excluding competing stimuli
• Concentration: Sustained focus of attention for a
period of time
• Digit span: The number of figures patient can recall
both forwards and backwards; tell the patient to
repeat a list of numbers
• Serial seven substractions: Start with the number
100 and substract 7, then again and again...: Test for
concentration
• Decrease in attention: Depression, anxious patients,
sch, dementia
• Spontaneous attention is increased in mania,
concentration is impaired; dystractibility
Memory
• Registration (immediate) memory:
instantaneous recall of new information;
dependent on alertness and adequate
concentration
• Short-term (recent) memory: has a capacity
of 7 items in 20 seconds; is also used to
denote events that occured in the past few
hours
• Long-term (remote) memory; delayed recall:
no demonstrable limits of storage, quite
stable over time
Memory examination
• The most commonly used test is word recall
• Patient is given 3-4 words and asked to repeat
them afterwards (immediate) and then recall
them after 5 minutes (short-term)
• Words should be unrelated to each other and
not be in the room (such as : green, honesty,
postcard)
• Long-term memory: questions which you can
verify the answer (events days, years ago)
Amnesia is the inability to recall learned
material or past experiences in a person
who has no impairment of attention
• Retrograde amnesia: loss of memories
that were made prior to an event (e.g.
accident)
• Anterograde amnesia: inability to make
memories after the occurence of an
event
retrograde amnesia
event
anterograde amnesia
time
Diagnostic significance of
memory disturbances
• Depressed, anxious patients can be assessed
as if they have memory disturbances
• They should be facilitated to focus their
attention
• Dementia, head injury: Memory impairment
• Korsakoff syndrome- anterograde amnesia
• Confabulation (falsification of memory):
“invention of stories” to fill in memory gaps in
Korsakoff syndrome
Estimation of intelligence
Intelligence: a group of mental abilities
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The assimilation and recall of factual information
Logical reasoning
Problem-solving skills
The use of abstraction, generalization and symbolization
Integration of parts into a whole
I.Q. = mental age
100
chronological age
It can be assesed by standardized tests if necessary. 70 > MR
In interviews by:
– Degree of insight, judgement and abstract thinking
– Fund of knowledge
– Vocabulary (considered the best single indicator)
– Level of education, vocation, interests, hobbies
Perception:
• An object in the environment cause a sensation;
upon interpretation by the brain, it becomes a
perception
Various aspects of perception
• Hallucinations
• Illusions
• Disturbances of self and environment
– Depersonalization
– Derealization
• Disturbances of experience
– Deja vu
– Jamais vu
A visual
hallucination
Hallucinations
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Hallucination: perceptions that occur when
there is no actual stimulus present
Occur in all sensory modalities (sight/visual,
sound/auditory, smell/olfactory,
taste/gustatory, touch/somatic)
Can be simple or complex
Seem as vivid as real experiences, beyond the
will or control, intrusive
Occur simultaneously with real stimuli
“Internal experiences attributed to external
sources”
Type of hallucinations/diagnostic
significance
• Auditory hall.: most comon type of hallucination in
psych. dis. /most commonly reported in psychotic
illness, particularly sch
• Command hallucinations: instructed by a voice to
perform an act
• Schnederian
– Voices arguing or discussing: 2 or more voices
speak about the patient in the third person
– Voices giving a running commentary: comments
center on an activity of patient
• Visual hall.: next most prevalent type, mostly
accompany auditory type
Type of hallucinations/diagnostic
significance
• Olfactory hall.: less common, common smells (foul);
burning rubber, rotting garbage, strong body odors
– Psychotic disorders
– Patients with psychotic disorder and TLE-particularly in
uncinate seizures
• Gustatory hall.: least common, similar conditions with
olfactory hall.
• Somatic hall.: common in psychotic conditions, TLE
– Tactile: e.g. Formification: ants or other insects crawling on
the skin
– Kinesthetic hall.: moving body parts such as joint position,
body rotation
– Cenesthetic or visceral hall.: involving internal organs
• Tactile in delirium tremens
Illusions/diagnostic significance
Illusion: misperception of an existing stimulus
Actual percepts are exaggerated, distorted
or altered so that they appear as something
different to the patient
• When walking alone at night one may see a
menacing figure in the shadows
• The spots on the wall can be perceived as
insects in delirious patients
• Schizotypal personality disorder
Derealization/depersonalization
Depersonalization: a change in the perception of self,
causing the individual to feel as if he or she has
become unreal
• Leaving one’s body or somehow being outside of one’s
self; “watching myself in a movie”
• Body or parts of it is changing in size etc.
Derealization: a change in the awareness or the
perception of the external world
• Environment becoming strange, unfamiliar
• “World is like a movie theather, or not real, or has
changed somehow”
• Common among psychologically healthy people
• In sch, in severe anxiety disorders; panic
Disturbances of experience
• deja- vu: “already seen or experienced”
– A feeling of familiarity to situations that are
novel
• jamais-vu: “never seen or experienced”
– Applied to situations that are familiar but strike
the person as something they have not
experienced
• “Normal”, TLE, sch
• “Identifying paramnesias”: patients may not
be able to accurately recall if an event
occured or not (as it may have happened in a
dream and the person can’t be certain)
Abstract Thinking
• The ability to deal with concepts
• In first years of childhood: concrete
thinking
• Abstract thinking develops by time:
concepts, generalizations, symbols
• Disturbed in schizophrenia, organic
brain syndrome
Abstract thinking
• Patients have difficulty in understanding
symbolic conversations, generalizations
• They have difficulty in interpreting jokes,
proverbs etc.
• Ask similarities, differences and meanings of
proverbs during examination
‘How are an apple and an orange like?’
‘What are the similarities between a chair and
desk?
‘Time is money’
Reality Testing
• Objective evaluation of the world
• The ability to differentiate what is real
and what is unreal (dreams, thoughts,
wishes, impulses, fears, feelings).
• The ability to differentiate
‘thought’ and ‘action’
‘fantasy’ and ‘fact’
Reality Testing
• Children may consider their fantasies,
wishes as ‘real’.
• Everybody may wish to be very
beautiful, very clever
• ‘I am the most beautiful/clever in the
world, everybody is in love with me’
Impairment of reality testing
• Hallucinations
• Delusions
(Pscyhosis)
Judgement
• The ability to recognize the true relation of
ideas; capacity to make correct conclusions
from experience
• Does the patient understand the outcome of
his behavior?
• Can the patient predict what he would do in
imaginary situations?
Example: What would the patient do if he
smelled smoke in a crowded movie theater?
Poor Judgement
• In psychotic disorders, dementia,
delirium
• A patient with dementia selling all of his
goods at one day without any reason
Insight
• Patient’s degree of awareness and
understanding about being ill.
• Patients may exhibit a complete denial
of their illness or may have some
awareness but blame on an external
factor.
THOUGHT
• Thought process
• Thought content
Thought Process
• Refers to the way in which ideas are
produced and organized.
• The way the person puts together the
ideas and associations
• Assessment of how patients are
communicating
• Thought can not be assessed directly, it
is inferred from speech
Thought Process
• Goal directedness
• Tightness of associations between
words, phrases, sentences
• Rate, pressure
• Idiosyncrasy of word usage
Disorders of thought process
• The degree of connection and flow of
thought are disrupted in many
psychiatric illness
• The way ideas are linked together is as
important as its content
Disorders of thought process
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Circumstantiality
Tangentiality
Flight of ideas
Loose associations
Thought derailment
Incoherence
Word salad
Thought blocking
Disturbances in thought
process
• Circumstantiality
-Patient responds the question with an
excessive amount of (needless) detail
but eventually reaches the point
-There is a delay in answering the
original question because of
overinclusion of details and
parenthetical remarks.
-Present in schizophrenia
Circumstantiality
Disturbances in thought
process
• Tangentiality:
-Inability to have goal directed associations of
thought
-Speaker never gets from point to desired goal
-In response to a question, the patient gives a
reply that is appropriate to the general topic
without actually answering the question
Doctor: ‘ Have you had any trouble sleeping lately?’
Patient: ‘I usually sleep in my bed, but now I am
sleeping in sofa’
Tangentiality
Disturbances in thought
process
• Flight of ideas:
-A rapid shifting from one topic to
another
-Often expressed through rapid,
pressured speech
-Speech remains logical, connections
between ideas are still recognizable
-Seen in manic patients
Flight of ideas
Disturbances in thought
process
• Loosening of associations:
-No logical connection between ideas
and sentences
-The words make sentences but
sentences don’t make sense!
- In schizophrenia
1:Goal directed thought
2: Circumstantiality
3:Tangentiality
4:Flight of ideas
5: Loosening of associations
Disturbances in thought
process
• Word salad:
• Extreme form of loosened associations
• Mixture of words and phrases that lack
comprehensive meaning
• Incoherence
• In schizophrenia with severe course
Disturbances in thought
process
• Thought Blocking:
- A sudden involuntary disruption of
thought or a break in the flow of ideas.
-Patient becomes silent and may
indicate an inability to recall what was
being said.
-In schizophrenia
Disturbances in thought
process
• Clang associations:
-Thoughts are associated by the sounds of
words rather than by the meaning
-Most commonly by rhyming the last word in a
sentence.
-Most common in mania, but can also be seen
in schizophrenia
‘I have to go, you know
To and fro before the snow starts to blow’
Disturbances in thought
process
• Neologism: The invention of new words
or phrases or the use of conventional
words in idiosyncratic ways
Thought Content
Thought Content
• Content refers to what a person is
actually thinking about: ideas, beliefs
etc.
• Disturbances in content of thought:
delusions, obsessions, suicidal th. etc
Disorder of thought content
Delusion:
• A delusion is a fixed, false belief that :
- is inconsistent with cultural norms
-is inappropriate for person’s level of
education
- is based on incorrect inference of external
reality
-can not be corrected by reasoning
• In schizophrenia, mania, delusional disorder,
dementia etc
DELUSIONS:
• Grandiose delusions: Belief that one has
great wealth, fame, power, abilities etc.
‘ I am the president’
• Persecutory (paranoid) delusions: Belief
that he is being harrassed, persecuted by
others, irrational, excessive suspicousness
‘They will poison me’
• Delusions of jealousy: pathological jealousy
about the lover or spouse
‘my wife is unfaithful to me’
DELUSIONS:
• Reference delusions: Behavior of others
refers to him
‘They are talking about me’
DELUSIONS:
• Delusion of control: Person’s will, thoughts, or
feelings are being controlled by external
forces.
• Thought insertion: Thoughts are implanted in
a person’s mind by other forces
• Thought withdrawal: Thoughts are being
removed from a person’s mind by other
forces
• Thought broadcasting: Thoughts are being
broadcasted to the world by TV, radio etc.
DELUSIONS:
• Self-accusatory delusions: False feeling of
guilt
• Nihilistic delusions: self, others and the world
is coming to an end, loss of organs etc.
• Somatic delusions: ‘I have cancer’
• Depersonalization delusions: ‘my hands are
getting bigger’
• Derealization delusions: ‘ environment has
changed’
Disorders of Thought Content:
Obsessions
• A thought, impulse or image that is:
-Recurrent and persistent
-Unwanted (ego-dystonic)
-Not able to be controlled by person’s will
-Recognized as absurd and irrational
-Resisted by the patient
-Accompanied by anxiety
Disorders of Thought Content:
Obsessions
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Contamination
Pathological doubt
Need for symmetry
Aggressive, sexual, religious
Disorders of Thought Content:
Suicide
• Don’t forget to ask about suicidal
thoughts
• Frequently in depression and
schizophrenia
Behavior
Behavior, energy level, motivations, activities
• Decrease in behavior: Decreased activity,
slowing in movements, catatonia
• Increase in behavior: Aggression, excitation,
agitation
• Disorders in behavior: compulsions,
sterotypy, mannerisms, echomimi, echopraxy,
disorganized behavior.
Behavior
• Psychomotor retardation: Slowing and
decrease in speech, thought and
behavior
• Psychomotor acceleration: Increase in
speech, thought and behavior
Behavior: Catatonia
• Patients keep the same position without
moving for a long time.
• Mostly seen in a subtype of schizophrenia
• Negativism: Motiveless resistance to all
attempts to be moved or to all instructions
• Catatonic excitation: Patient may suddenly
become excited, agitated
• Catatonic stupor: Marked decrease in
reactivity to environment and reduction of
spontaneous movements and activity.
Behavior: Catatonia
• Catalepsy:General term for an immobile
position that is constantly maintained
We can give a position to the patient
and it is maintained: Waxy flexibility
• Echopraxia: pathological imitation of
movements
Catatonia
Behavior: Compulsion
• Compulsions are repetetive behaviors or
mental acts that the person feels driven
to perform in response to an obsession
• The behaviors or mental acts are aimed
at reducing the distress
• Behaviors are not related with the
obsession in a realistic way or they are
excessive
Behavior: Compulsion
• Patient thinks that these behaviors are
excessive and unreasonable
• The compulsions are time consuming
• Checking, washing, counting, praying etc.
Behavior
• Stereotypy:
Repetitive fixed pattern of physical
action or speech
• Mannerisms:
Habitual gestures, movements
Thanks for your attention