Download Mental State Examination

Mental State Examination
Dr Sati Sembhi
Consultant Psychiatrist, Suffolk
18th August 2009
What is the MSE
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“Here and now” record of presentation
History will give clue as to likely symptoms
Systematic
Until more experienced carry out full mental
state
• Be observant but also learn the terminology to
describe symptoms/signs
• Use conventional headings to structure
examination – other colleagues and examiners
will expect it
MSE
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Appearance and Behaviour
Speech
Mood
Affect
Thought
Perception
Cognition
Insight
Appearance and Behaviour
• Describe what you see.
• General appearance and behaviour. Striking physical
features. Posture.
• Physique, clothing, cleanliness, self-care, posture
• Eye contact, rapport
• Motor activity: agitation, retardation, stuperose (akinesic
and mute), abnormal movements (tic, tardive dyskinesia,
chorea, stereotypy, catatonic features), mannerism,
restlessness
• Tearfulness
• Distractibility
• Disinhibition
• Appears to hear voices, preoccupied.
Speech
• Rate: slow in depression; pressure of speech in mania.
• Quantity: reduced (poverty) in depression and chronic
schizophrenia; flight of ideas in mania
• Volume
• Pattern: spontaneous, coherence, rationality,
circumstantial (trivial detail eg obsessional traits),
perseveration
• Neologisms, puns, clang associations (word that sounds
the same).
• Formal thought disorder: loosening of associations;
knight’s move thinking, word salad (schizophrenia)
• Thought blocking: arrest of train of thought leading to
blank. Different to losing train of thought
Mood
• Patient description: Sad, happy, top of the world,
worried
• Accompanying symptoms
Depression: early morning wakening, diurnal
variation, anhedonia, loss of appetite, loss of
weight, fatigue, loss of concentration.
Hopelessness,
Suicidal thoughts, plans, intent
Anxiety: palpitations, dry mouth, sweating, tremor
Elation: Overactivity, excessive self-confidence,
reduced sleep, distractibility, increased libido
Affect
• Your objective description of emotion
• Depressed, anxious, fearful, irritable,
suspicious, perplexed, elated, angry
• Fluctuations: reactivity, lability (mania),
blunting (chronic schizophrenia)
• Consistent with thoughts/behaviour?
Incongruity seen in schizophrenia
Thought Content (1)
• Preoccupations: thoughts that recur frequently
but can be put out of mind
• Obsessional thoughts/compulsive rituals.
Obsessional thoughts are ideas, images,
impulses that repeatedly enter mind in
stereotyped form, seen as senseless,
distressing, recognised as own thought even if
repugnant. Compulsions are obsessional motor
acts, often resulting from obsession, may be
attempt to “neutralise” obsession.
• “Do you have to keep on repeating the same
action which most people would only do once?”
Thought Content (2)
Delusion is a false, unshakeable, belief that is out of
keeping with the patient’s social and cultural
background.
Primary Delusion:
used to be thought diagnostic of schizophrenia.
• delusional mood: something going on but not sure what
it is
• delusional perception: attribution of new meaning to
normally perceived object eg traffic light change means
chosen to be Messiah.
• sudden delusional idea (autochthonous delusion):
sudden arrival of fully formed delusion, like a “brainwave”
Thought Content (3)
• Secondary Delusion: explains another
experience eg to explain auditory
hallucinations
• Mood Congruent
• Content: persecution, infidelity, grandiose,
hypochondriacal, love, guilt, nihilistic,
poverty, reference, infestation.
Thought Content (4)
• Thought Interference - “loss of boundary with outside
world”, usually found in schizophrenia
Thought withdrawl: thoughts taken away (link with thought block)
Thought insertion: another agency’s thoughts implanted
Thought broadcasting: thought’s leaking, escaping, other people know what
thinking in unison (not thought echo)
• Passivity – humans usually experience actions, thoughts,
feelings as under their control but may (usually in schizophrenia)
experience them as being under control of another agency
Derealisation and
Depersonalisation
• Depersonalisation - feeling unreal
and unable to feel emotion; “as if cut off
from world” “watching self”
• Derealisation – feeling world is unreal
• Can occur in healthy people if tired
• Occurs in anxiety, depression,
schizophrenia, TLE
• Unpleasant and very distressing
Perception (1)
• Illusion - Misperception of stimulus
• Hallucination – Perception experienced in
the absence of an external stimulus to the
corresponding sense organ.
• Can occur in any sensory modality:
auditory, visual, olfactory, gustatory, tactile,
deep sensation
Perception (2)
• Visual: more likely in organic conditions
• Gustatory: unpleasant taste. In schizophrenia,
TLE. May lead to delusion is being poisoned
• Olfactory: Schizophrenia, organic, TLE. May
believe result of gas being pumped into dwelling
• Tactile: touched, pricked, insects crawling on
skin (formication, drug withdrawal/cocaine
addiction)
• Deep Sensation: often in schizophrenia. May be
sexual.
Auditory Hallucinations
• May be noises, whispers, partially organised
• 2nd person voices: depression
Characteristic, but not diagnostic of schizophrenia:
• 3rd person discussing
• Running commentary
• Thought echo (echo de pensee,
gedankenlautwerden)
Cognition
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Orientation – time, place and person
Attention – digit span
Concentration – serial 7’s, WORLD
STM – name and address recall after 3 mins
LTM - history
General knowledge and intelligence – from
interview and PM, events
• Can use screening instruments: MMSE or ACE
Insight
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Awareness of abnormal state of mind
Understanding of cause
Understanding of benefits of treatment
Awareness of effects of not having
treatment