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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) • • • • • • General appearance Cooperation and reliability Speech Affect/mood Cognitive functions Behavior Appearance Diagnostic significance of observations with regard to appearance • • • • • 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 • • • • 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) • • • • • • • • • • • 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 • • • • • 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 • • • • 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 • • • • • • • • 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 • • • • 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