By Salina Chan, R32013

Psychiatric Diagnosis

Components of an accurate psychiatric diagnosis

1. History – HPI and especially past psychiatric history

2. Collateral

3. Psychiatric interview

4. Mental Status Exam

5. Biological workup

What is the Mental Status Exam (MSE)?

The MSE is a set of standardized observations and questions designed to evaluate 5 basic elements:1. Sensorium2. Perception3. Thinking4. Feeling5. Behaviour

What is the Mental Status Exam (MSE)?

Integral part of any clinical interview, not just in the psychiatric context

Records only observed behaviour, cognitive abilities and inner experience during the interview

Partly integrated into the history

To help provide info re: diagnosis, help formulate txn plan, and follow a patient’s clinical course

Essential to a complete psych assessment

Helpful Determinants of

Diagnosis1. Reasons for referral

2. Previous personality/level of functioning

3. Thought disorder on the MSE

4. Previous psych d/o

5. Testing for organic conditions

6. Personality testing

7. Insight & judgment on MSE

8. Appearance & behaviour on MSE

9. Affect & mood on MSE

10. Physical Exam

MSE Menomic

A = Appearance

S = Speech

E = Emotion

P = Perception

T = Thought form and thought content

I = Insight and judgment

C = Cognition

50% of the MSE is FREE

Free Parameters

Level of Consciousness

Appearance

Behavior

Cooperation

Reliability

Affect

Thought form

Parameters to ask about

Orientation

Cognitive functions

Suicidal/homicidal thoughts

Knowledge base

Perception

Mood

Thought content

A

Appearance General appearance

Behaviour

Motor disturbances

Internal state

Cooperation, reliability, accessibility

For your exam: describe from outside then go inward

Appearance Gender & Cultural background

Actual and apparent age

Attire

Grooming and hygiene

Body habitus

Physical abnormalities & assistive devices

Jewelry & cosmetics

Other notable Features

Appearance 77 yo white Caucasian M who looked his

stated age, thin and tall, with neatly groomed beard, dressed casually and, walked with a cane and an antalgic gait

34 yo Asian female who looked younger than her stated age, average body size, dressed provocatively, wearing colourful makeup applied in excess, with a number of rings adorned on her fingers, with tattoo along the right side of her neck

Behaviour General Observations

Activity level Habits &

mannerisms Psychomotor

agitation, restlessness or retardation

Specific Movement Abnormalties Akathisia Automatisms Catatonia Choreoathetoid

mvmts Compulsions Dystonia & EPS Tardive Dyskinesia Tremors Negative Symptoms

Behaviour Pt sat comfortably in the room with his

arms folded across his chest and absent-mindedly figeted with the zipper of his jacket.

Cooperation & Reliability

Eye Contact

Attitude/Demeanor

Attentiveness to the I/V

LOC

Affect

Secondary Gain

Malingering

Factitious d/o

S

Speech Primary language d/o

E.g. aphasia, dystarhria, anomia, apraxia

Quality of speech Accent, dialect,

amount (), articulation, modulation

Quantity of speech

Prosody Pitch/intonation/

musicality Spontaneity/latency Rhythm/cadence Stress/inflection

Volume

E

Mood & Affect

Affect & Mood Mood

The person’s internal feeling state, subjective “emotional background”

Affect Visible, external, or objective manifestation of

emotional state “emotional foreground”

Affect & MoodAffect

Type/Quality

Range/Variability

Degree/Intensity

Stability/Mobility

Appropriateness

Congruence

Mood

TypeQuality

Reactivty

Intensity

Stability/Duration

Pattern

P

Perception Hallucinations

Illusions

Disturbances of self & environment Depersonalization Derealization

Disturbances of experiences Deja vu Jamais vu

Disturbances of Quality of size Micropsia Macropsia Dysmegalopsia

Disturbances in intensity of perception Hyperacusis Visual

hyperaesthesia

T

Thought Form/Process

Describes the way in which ideas are produced and organized

An assessment of how patients are communicating Degree of connection b/t ideas Flow of thought

Assessed via speech, writing and behaviour

Thought FormLogical and goal-oriented?

Tangential or Circumstantial?

Flight of Ideas?

Loosening of Associations?

Designed to show thoughts of persecution

Thought Content What the patient talks about

Delusions = fixed, false belief Lots of different ones!

Overvalued Idea = preoccupy patient’s thinking and alter behaviour Less firmly held – pt can admit not true Content less absurd & Not systematized

Obsessions = Thoughts/impulses/images that are recurrent, unwanted, not controllable, recognized as irrationa

Thought Content Phobias = marked, persistent fears that are

excessive, with anxiety

Thoughts of suicide and homicide. Be direct and specific when asking Suicide assessment lecture

I

Insight & Judgment

Insight

Awareness of having illness

Understanding of factors contributing to illness

Appreciation that various signs and symptoms part of disease

Awareness of illness impacts on other ppl and society

Acknowledgment of need for txn

Judgment

1. Appraising the situation

2. Surveying the alternatives

3. Weighing the alternatives

4. Deliberating about selection

5. Making a commitment to a choice

C

Sensirium & Cognitive

LOC and attentiveness

Orientation x 3

Attention

Concentration

Memory

Knowledge

Intelligence

Capacity for abstract thinking

Examples Catatonia:

http://www.youtube.com/watch?v=_s1lzxHRO4U&list=PLB917B13752F820BE&index=24

Pressured Speech: http://www.youtube.com/watch?v=F_YPZt7CuNY&list=PLB917B13752F820BE&index=16

Thought Block http://www.youtube.com/watch?v=0u9d96b-Tyc&list=PLB917B13752F820BE&in

dex=6

Delusion http://www.youtube.com/watch?

v=Gc2Nox6PMnc&list=PLB917B13752F820BE&index=7&ytsession=v_3GrpGVjj4SZQikefVmIwQM3XDixgmygOKTnNMFPF8U3b9mP0Rhpm8KNWmuRRAIEmGzO3q7MnFfwhhwSzSaCdwdRAh8Q6SOLbrnLYz55bdDdSrGVc_jA7k1q4MZ2MR2Z7YN4hYQII4EeeMYhFa99GHdynP62Qai9rNUAVjYpEXKIq83rtLJEFIjtc58SYPmJ0D9kHZEun5FZalQsGSw5woaoPvtU8FmcZnny-S3jfw_R_oVmcfHXY3Mmo7l0hTnPdBhubWfENumayfjnzJbX3LLF2OMVMUnfgbBSfsAy_PraWyJMcW-8t-fN_PVGCrHWdB8scm4ETqkDr1KgCg4gaP7czlWq_zh4tEX-IoFuIPYt06Szua9SxEC8-of_f0I97iQ9IOcU4Crv7tM5S7eNLSy4Xw2gBqn299ZtKhgv5DwWnay2eANL3fNxr5L3aaZS_VGX-3NyFA6PHZ-itMqjQLhgEYfMc4iwYRixaPjUrQRJoCtObxUCPxjv-s1oUtn2NsNzF0xx9n4BfSYEsKmpFrBA_UEdjZKt8-aZ6G-hXMdSwP0B-XqxBBL0Jq_GNcPaiJgX7focwLskatuUhXRNNkn-giq5JzJvsm2uZscogg