Mental State Examination

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Mental state Examination

• Appearance and behavior• Speech• Mood• Thoughts• Perceptions• Cognition• Insight

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Appearance and Behaviour

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Appearance and Behaviour

• General appearance• Facial expressions• Posture• Movements• Social Behaviour

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General appearance

• Physique (the shape and size of a person’s body)• Hair• Make up• Clothing

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General appearance

• Self neglected• Dirty unkempt appearance• Stained, crumpled clothing• Suggests – alcoholism, drug addiction, dementia,

or schizophrenia

• Wight loss• Physical disorders –

• cancer, hyperthyroidism• Psychological disorders –

• anorexia nervosa, depressive disorders• Social Problems

• Financial difficulty, homelessness

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Facial Expression

• Depression• Turning down of corners of mouth• Vertical furrows in the brows

• Anxiety • Horizontal furrows on the brow• Wide palpebral fissures• Dilated pupils

• Parkinsonism Syndrome• Unchanging ‘wooden’ expressions

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Posture

• Depression• Shoulders hunched• With head and eyes down casted

• Anxiety• Sits upright• With the head erect• Hands gripping the chair

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Movements

• Manic • Over reactive, restless• More rapidly from place to place and task to task

• Depressed• Inactive and move slowly

• Stupor – when depressed patient become completely immobile and mute

• Anxious or agitated• Restless, sometimes tremours• Involuntary movements

• Tics, characiform movements, dystonia, tardive dyskinesia

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Movements

Tics Choreiform Dystonia

Irregular Brief Muscle spasm

Repeated movements

Involuntary Movements

Often painful

Involving group of muscles

Coordinated but purposeless

May lead to contortions

Grimacing or movements of the arm

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Social Behaviour

• Disinhibited

• SIGNS OF IMPENDING VIOLANCE• Restlessness• Sweating• Clenched fists or pointed fingures• Intrusions into the interviewer’s ‘personal

space’• Raised voice

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Speech

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Speech

• Quantity • ↓ in depressed• ↑ in Manic

• Rate • Pressure of speech – copious rapid speech which is hard to

interrupt

• Spontaneity• Long answer latency – depressed and intoxicated

• Volume • Quite – depressed• Loud - Manic

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Speech

• Abnormalities of the continuity of speech• Any sudden interruptions• Rapid shifts of topics• Lack of logical tread

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Mood

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Mood

• Subjective mood

• Objective Mood• Predominant mood• Constancy• Congruity

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Subjective Mood

• Ask the patient • What is your mood just now?• Recent days

• If depressed• A feeling of being ready to cry• Lack of interest and enjoyment and pessimistic thoughts • Thoughts of suicide

• If Anxious • Palpitations• Dry mouth• Tremor • Sweating

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Objective Mood

• Nature of mood/ moods• What is the mood or moods appear to

predominate within the interview?

• Depression• Elation• Anger• Anxiety• Suspicious• Perplexity• Unremarkable mood

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Objective Mood

• Constancy of mood• If normal spectrum is enhanced

• Emotional liability• Such as in dementia, mania, after a stroke

• When it is extreme• Emotional incontinence

• When it is decreased• Reduced activity, blunting, flattening

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Objective Mood

• Congruity of mood• Normally out mod, thoughts and perceptions

are closely associated and fit together logically.

• In schizophrenia – incongruity of mood• Person appears cheerful while describing sad

events

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Thoughts

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Thoughts

• Stream

• Form

• Content • Pre-occupations• Morbid thoughts, including suicidality• Delusions and overvalued ideas• Obsessional symptoms

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Abnormalities of Thoughts

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Abnormality of the

Steam of thought

Form of thought

Content of thought

It’s amount andspeed

The ways in which thought are linked together

Pre-occupationsMorbid thoughtsDelusionsOvervalued ideasObsessional and compulsive symptoms

Abnormalities of STREAM of Thoughts

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Abnormality of stream of thought

Pressure of thought

Poverty of thought

Blocking of thoughts

• Unusually rapid, abundant and varied

• Characteristic of mania

• But can occur in schizophrenia

• Unusually slow, few and unvaried

• Characteristic of severe depression

• Can occurs in schizophrenia

• Suddenly empty of thoughts• Schizophrenia

Abnormalities of FORM of Thoughts

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Abnormality of form of thought

Flight of ideas Loosening of associations Perseverations

• Characteristic in mania

• Sometimes links may be difficult to follow

• RHYME• PUNS• DISTRACTION

• Lacking logical association – Knight’s move thinking

• Mostly occur in schizophrenia

• Persistent & inappropriate repetition of the samesequence of thought.

Pre-occupations

• Thoughts that recur frequently but can be put out of mind by an effort of will

• Common in• Depressive disorders

• About suicide• Anxiety disorders • Sexual diorders

• Hx taking ask• “ what sort of things do you worry about?”• “What sort of thoughts occupy on your mind”

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Morbid thoughts

• These are particularly associate with specific illness, through either their nature• Suicidality

• Ask about feelings of depression and then hopelessness before• Moving on to ‘passive’ suicidal ideas • Asking about ‘active’ suicidal ideas

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Delusions

• Is a belief that is held firmly • but on inadequate grounds, • is not affected by rational argument or

evidence to the country.• And it is not conventional belief that the

person might be expected to hold given • his cultural background and level of

education

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Delusions

Primary

• One that occurs suddenly without any other abnormal mental even leading to it.

• Rare

• When occur- strongly suggest schizophrenia

Secondary

• Arise from previous abnormal idea or experience• Hallucinations• Mood • Another delusion

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Other mental phenomena related to delusions• Delusional mood

• In explicable feeling of apprehension that is followed before long by a delusion that explains it.

• Delusional Perception• Misinterpretation of the significance of

something perceived normally

• Delusional memory• Retrospective delusional misinterpretation of

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Shared delusions / folie à deux

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Delusional themes

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Persecutory (Paranoid) Schizophrenia , organic diorders, depression

Delusions of reference Schizophrenia

Grandiose and expansive delusions

Mania, Schizophrenia

Delusions of guilt & worthlessness

Severe Depressive disorders

Nihilistic delusions Severe Depressive diorders

Hypochondriacal delusions

Delusions of jealousy

Sexual or amorous delusions

Religious delusions

Delusion of control Schizophrenia

Delusions concerning the possession of thoughts

• Delusion of thought insertion

• Delusion of thought withdrawal

• Delusion of thought broadcasting

Persecutory delusions

• Ideas that people or organizations are trying to inflict harm on the patient, • damage his reputation, • or make him insane.

• Sometimes normal in some people

• Common in schizophrenia • Occur in organic states and severe

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Delusions of Reference

• Concerned with the idea that objects, events or the actions of other people have a special significance for the patient.

• Ex:• A remark heard on television is believed to be

directed specifically to the patient, or a gesture by a stranger is believed to convey something about the patient

• Associate with schizophrenia

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Grandiose & Expansive delusions • Beliefs of exaggerated self-importance

• Occur in mania & sometimes in schizophrenia

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Delusions of guilt and worthlessness• Beliefs that the person has done

something shameful or sinful.

• Usually concerns innocent errors

• Most often in severe depressive disorders

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Nihilistic Delusions

• Beliefs that the patient’s career is finished, • that he is about to die or • has no money, or • that the world is doomed

• Common in severe depressive disorders

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Hypochondriacal Delusions

• False beliefs about the presence of disease.• Common among elderly

• Related dysmorphophobic delusions – concerned with the appearance of parts of the body

• Severe depressive & schizophrenia

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Delusions of jealousy

• Common among men

• ‘Morbid (pathological) jealousy’ • May lead to dangerously aggressive behavior

towards the person who is believed to be unfaithful

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Sexual or amorous delusions• Common among women

• They believe that she is loved by a man who has never spoken to her & who is inaccessible

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Religious Delusions

• May be concerned with guilt or with special powers.

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Delusions of Control

• Beliefs that personal actions, impulses or thoughts are controlled by an outside agency.

• This has to be distinguished

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Delusions concerning the possession of thoughts• Delusions of thought insertion

• Some of the person’s thoughts have been implanted by an outside agency

• Delusion of thought withdrawal• Some of their thoughts have been taken away

• Delusions of thought broadcasting• Some of their thoughts are known to other

people through telepathy, radio, or some other unusual way

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Overvalued ideas

• Isolated,• Preoccupying, and• Strongly held belief,• That dominates a person’s life and• May affect his or her own actions,• But which (unlike a delusion) has been

derived through normal mental processes.

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Overvalued ideas

• Example • Someone whose parents developed cancer

within a short time of one another may be convinced that cancer is contagious, despite having been presented many times with evidence to the country.

• Difficult to differentiate from delusions• Main difference – assess the way, how the

idea developed

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Obsessional and compulsive symptoms

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Perceptions

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Perceptions

• Perception• Process of becoming aware of what is presented

to the body through the sense organs.• These perceptions are experienced as real and

are real.

• Imagery• An experience originating within the mind that

usually lacks the sense of reality that is part of perception

• It differs from perception• It can be initiated and terminated at will

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Perceptions

Abnormalities of

perception

Changes in intensity

Changes in quality Illusion Hallucination

s

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Delusional Perceptions

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• It is a disorder of thinking

Changes in intensity of perception

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• In mania -• Perception seems more intense• Eg

• Colours – seen as very bright• Sound of pin drop – very loud

• In depression • Opposite of previous

Changes in quality of perception

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• In schizophrenia • Perceptions are distorted or unpleasant

Illusions

• Misperception of a real stimulus

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Illusions

Sensory impairment Inattention

Impaired consciousne

ss

Emotional arousal

At dusk or dawn,Pt is visually impaired

Delirium Usually fear

Hallucinations

• Is a perception, • experienced in the absence of an

external stimulus • to the corresponding sense organ

• It has 2 qualities that distinguish it from imagery• It is experienced as a true perception• It seems to come from outside the head

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Hypnagogic Hallucinations

• Healthy people experience hallucinations, • especially when falling asleep

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Hypnopompic Hallucinations • Healthy people experience hallucinations, • especially when waking up

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Modalities of Hallucinations

Hallucinations

Auditory Visual Smell and taste Tactile Deep

sensation

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Auditory Hallucinations

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• Second person hallucination• Address the patient as ‘you’

• Third person hallucinations• Others talks about the patient “he”/”she”

• Thought echo• Repeat what he has just been thinking

Visual Hallucinations

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• Simple, flashes of light

• Experienced as normal in size

• Associated particularly with organic mental disorders

Hallucinations of deep sensations

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• Viscera being pulled or distended

• As a sexual stimulation

• May be associated with delusional interpretation

Diagnostic association of hallucinations

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• Occurs in• Organic disorders• Severe affective disorders• Schizophrenia

• Visual hallucinations • Organic psychiatric disorders• Severe mood disorders• Schizophrenia

• Hallucinations of taste, smell and deep sensation• Schizophrenia

Hallucinations

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• Command hallucinations• Can indicate a high risk of harm to self or

other

Cognition

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Cognition

• Assessment of • Consciousness• Orientation• Attention• Concentration• Memory• Language• Visuospatial functioning

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Consciousness

• Awareness of self and the environment

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consciousness

Clouding of consciousnes

sStupor Confusion

State of drowsiness with,incomplete reaction to stimuli, impaired attention, concentration, and memory , slow, muddled thinking

Person is mute, immobile,& unresponsive, but appears conscious bcoz the eyes are open and follow objects

Muddled thinkingAcute – deliriumChronic – dementia

Orientation

• Assessed by asking about awareness of• Time• Place• Person

• Disorientation • Indicates impairment of consciousness• Impairment of new learning

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Attention and concentration • Attention

• Ability to focus on the matter in hand

• Concentration • Ability to sustain that focus

• Both can be impaired in• Anxiety disorders• Depressive disorders• Mania• Schizophrenia • Organic disorders

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Attention and concentration • ‘Serial 7s test’• Subtract 7 from 100 and then to take 7 from

the remainder repeatedly until it is less than 7

• Say months of the year in reverse order• Naming the days and week in reverse

order

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Memory

Memory

Immediate memory

Recent memory

Long-term memory

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Memory- Immediate memory• ‘Digit span test’• assessed by asking patients to repeat

sequences of digits • immediately after • they have been spoken slowly enough for

them to register the digits

• Start with 4 digits then increase the number..

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Memory- recent memory

• Ask the patient to remember one name and address• Ask it later

• Score out of 6

• 0,1,2 – abnormal• 5-6 score - normal

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Memory- long-term memory• Asking to recall personal events or well

known public events

• Personal events• Birth dates

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Amnesia Amnesia

Anterograde Retrograde Jamais vu Confabulation

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Occurs after a period of unconsciousnessImpairment of memory for events between the ending of complete unconsciousness & the restoration of full consciousness

Loss of memory for the events before the onset of unconscious Occurs after head injury and ECT

Failure to recognize events that have been encountered before

Déjà vuRecognition of events as familiar when they never been encountered

Reporting as ‘memory’ of events that did not take place at time of questioning

Language Language

Naming Verbal instruction

Written instructions

Writing a sentence

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Insight

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Insight

• The extent to which the patient’s view of their • symptoms, illness, prognosis, and treatment

is • identical to that of their healthcare

professional

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Insight

• awareness of oneself as presenting phenomena that other people consider abnormal (e.g. being unusually active and elated);

• recognition that these phenomena are abnormal (versus, for example, being a desirable mental state, of which other people are jealous);

• acceptance that these abnormal phenomena are caused by mental illness (versus, for example, being excited about and energized by a new project or idea, or having a physical illness);

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Insight

• awareness that treatment is required (versus treatment being unnecessary and undesirable);

• acceptance of the professional’s specific treatment recommendations (e.g. admission to hospital and sedative medication).

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Thank You!!!

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