Mental status examination

Mental status examination

1. MENTAL STATUS EXAMINATION Mrs.D.Meba Sahaya Sweety M.Sc Nursing GIMSAR

2. INTRODUCTION The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes the mental state and behaviours of the person being seen. It includes both objective observations of the clinician and subjective descriptions given by the patient . It includes descriptions of the patient's appearance and general behaviour, level of consciousness and attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight, the reaction evoked in the examiner, and, finally, higher cognitive abilities.

3. DEFINITION The mental status examination (MSE) is an assessment procedure It is a semi-structured interviewing used to organize clinical observations pertaining to mental condition Mental status is the total expression of a person’s emotional responses, mood, cognitive function, and personality It is a standardised format in which the clinician records the psychiatric signs and symptoms present at the time of interview .

4. PURPOSE OF MSE The purpose of the MSE is To obtain a comprehensive cross-sectional description of the patient's mental state. To allows the clinician to make an accurate  diagnosis  and  formulation , which are required for coherent treatment planning. It is used to diagnose the general cerebral functioning It is to evaluate, quantitatively and qualitatively, a range of mental functions and behaviours at a specific point in time.

5. COMPONENTS OF MSE   Appearance & behaviour   Psychomotor activity Speech Mood Affect Thought 7.Perception 8. Cognitive function (Attention , Sustained Attention & Concentration , Memory,Intelligence ) 9. Insight 10.Judgement

6. 1. APPEARANCE & BEHAVIOUR 1. Attitude 2. General appearance & grooming 3. Facial expression 4. Posture 5. Gait & carriage 6. Body build 7. Rapport  8. Mode of Entry 9.Cooperativeness

7. 1.Cooperative 2. Friendly 3. Trustful 4. Purposefulness 5. Attentive 6. Interested 7. Seductive 7. Seductive 8. Hostile 9. Contentious 10. Playful 11. Defensive 12. Guarded 1. APPEARANCE & BEHAVIOUR 1. ATTITUDE

8. 2. GENERAL APPEARANCE & GROOMING Appearance: looking one's age older/younger Level of grooming: normal/ shabbily dressed/ overdressed/ idiosyncratically dressed Level of cleanliness: adequate/ inadequate/ overtly clean Level of consciousness : fully conscious and alert/ drowsy / stuporous / comatosed 1. APPEARANCE & BEHAVIOUR

9. 3. FACIAL EXPRESSION 1. Appropriate or not 2. Is it changed with subject or not. 3. Look:- a) Attentive b) Apathetic-in chronic schizophrenia c) Indifferent-in severely depressive 1. APPEARANCE & BEHAVIOUR

10. 4 . EXPRESSION :- a) Elation b) Fears -Mild Anxiety or Apprehension , Crying, Perplexed or Frightened. c) Anger d) Sad - Omega sign & Veraguth’s folds in Depressed patients. 1. APPEARANCE & BEHAVIOUR 3. FACIAL EXPRESSION

11. e) Blank - in schizophrenic patients. f) Eye to eye contact:- maintained/ difficult/not maintained ( maintain gaze in anxious patients , Void gaze in schizophrenic pts , excessive scanning ) 1. APPEARANCE & BEHAVIOUR 3. FACIAL EXPRESSION

12. 4. POSTURE 1. Relaxed – In obsessive 2. Guarded - in paranoid patients. 3. Limp and sprawled out in chair. 4. Sitting at edge of chair in schizophrenic patients. 1. APPEARANCE & BEHAVIOUR

13. 5. GAIT & CARRIAGE Gesturing:- normal/ exaggerated/ odd Carriage – Does patient carry himself erect or bends down. Gait types:- 1. Normal 2. Brisk 3. Slow- in depressed patient. 4. Desultory-in schizophrenic patients. 5. Dilatory-in manic patients. 6. Unsteady – in organic brain disorders. 1. APPEARANCE & BEHAVIOUR

14. 6. BODY BUILD 1. ASTHENIC - Person narrows in length with narrow swallow thorax with narrow sub costal angle . 2. PYKNIC - Person with large body cavities relatively short limbs and large sub costal angle with rounded head and short fat neck. 3. ATHLETIC - Persons with wide shoulders and narrow hips and well developed bones and muscles 1. APPEARANCE & BEHAVIOUR

15. 7. RAPPORT  Rapport: spontaneous/ difficult/not established 8.MODE OF ENTRY Mode of entry : came willingly/ persuaded/ brought using physical force 1. APPEARANCE & BEHAVIOUR

16. 9.COOPERATIVENESS Cooperativeness: normal/more than so/less than 1. APPEARANCE & BEHAVIOUR

17. Quantity And Quality 2. PSYCHOMOTOR ACTIVITY 1.Quantity:- a. Normal b. Agitation-severe anxiety associated with motor restlessness. c. Retardation:-abnormal physical &/or psychological slowing as a part of any psychiatric illness. Ranges from lack of expression, slow movements , mutism to stupor .

18. 2.Quality:- Facial movements in oral dyskinesia Tremors Tics 2. PSYCHOMOTOR ACTIVITY Mannerism Posturing Rigidity Waxy flexibility Perseveration

19. Stereotypy Gesture Grimace Restlessness 2. PSYCHOMOTOR ACTIVITY Automatic obedience Echolalia Echopraxia Negativism compulsion 2.Quality:-

20. Tics:- Def:- short sudden repetitive, rapid movements of small muscles usually of face & neck. Types of tics:- 1.Simple motor tics 2. Simple vocal tics 3. Complex vocal ti cs 2. PSYCHOMOTOR ACTIVITY

21. Posturing: normal posture/ catatonic posture Def.:- Voluntary assumption of inappropriate or bizarre posture 2. PSYCHOMOTOR ACTIVITY

22. Rigidity:- Def:- Assumption of rigid posture against all attempts to move.  Waxy flexibility:- Def:- Waxy flexibility is a decreased response to stimuli and a tendency to remain in an immobile posture. Attempts to reposition the patient are met by "slight, even resistance", and after being repositioned, the patient will typically remain in the new position 2. PSYCHOMOTOR ACTIVITY

23. Perseveration:- Def:- persistent induced repetition of words, ideas, subject Mannerism:- Def:-unusually performed goal directed , semi-purposive repetitive verbal/motor actions.  2. PSYCHOMOTOR ACTIVITY

24. Stereotypy:- Def.:-repetitive, spontaneous non goal directed movement which is carried out in uniform way. Types:-verbal & motor Gesture:- Def.:-a mode of non verbal communication in which information is conveyed by movement of hand, arm, parts of body. 2. PSYCHOMOTOR ACTIVITY

25. Grimace:- Def:- Specific facial expression which is non goal directed & spontaneous Restlessness:- Def:-persistent and generalised diffuse increase in body movements and inability to relax. Automatic obedience:- Phenomenon of undue compliance with instructions  2. PSYCHOMOTOR ACTIVITY

26. Echolalia:- Def.:-repetition of a part of sentence or whole sentence told to patient . Echopraxia :- Def:-automatic imitation of another persons movements like clapping , snapping fingers 2. PSYCHOMOTOR ACTIVITY

27. Negativism:- Purposeless resistance to all external suggestions or advice. 2. PSYCHOMOTOR ACTIVITY

28. Initiation Reaction time Rate Productivity Volume Tone 3. SPEECH Relevance Stream Coherence Others

29. Initiation: spontaneous / speaks when spoken to/ minimal/ mute Reaction time : normal/ delayed/ shortened/ difficult to assess 3. SPEECH

30. Rate: normal/ slow/ rapid Productivity: monosyllabic/ elaborate replies/ pressured Volume: normal/ increased/ decreased 3. SPEECH

31. Tone: normal variation/monotonous Relevance: fully relevant/ sometimes off target/ irrelevant Stream : normal/ circumstantial/ tangential Coherence: fully coherent/loosening of associations 3. SPEECH

32. Others: rhyming/punning/echolalia perseveration/neologism/ Verbigeration Punning:- the humorous use of a word or phrase so as to emphasize or suggest its different meanings or applications Neologism:- coining new words or use words in inappropriate way Verbigeration - a manifestation of stereotype consisting of morbid repetition of words , phrases sentence.   3. SPEECH

33. Subjective Objective Range Reactivity Appropriateness Congruity liability 4.MOOD

34.  Objective- depressed,euphoric,elated,blunted , flat,Dysphoric ,   Irritable mood, Exaltation, Ecstasy, Expansive mood 4.MOOD

35. Elation:- mood consisting of feeling of joy, euphoria, triumph and intense self satisfaction or optimism associated with increased psychomotor activity.  Euphoric:-  excitement and intense feelings of well-being and happiness. 4.MOOD

36.   . Dysphoric :- unpleasant, uncomfortable and dissatisfied mood with an admixture of sadness, anxiety and irritability.  Irritable mood:- state in which one is easily annoyed and provoked to anger.  4.MOOD

37. Ecstasy:- a state of extreme happiness, especially when feeling pleasure: Exaltation:- feeling of intense elation and delusion of grandeur Expansive mood:- expression of feelings without restraint, frequently with an overestimation of their significance and importance. 4.MOOD

38.   Range- wide , restricted(over a course of time , horizontal-happy-sad-angry-placid- fearful). Reactivity -present/absent(in response to stimulus, longitudinal)  4.MOOD

39. Athenic - joy,hate,anger Asthenic - fear, sadness, anxiety, shame Flat - near or absolute absence of any signs of affective expression Blunt -significant reduction in intensity of emotional expression  Constricted- reduction in intensity of emotion that is less severe than that of blunted affect. 5.AFFECT

40. 6. Restricted -mild reduction in range and intensity of emotional expression. 7. Inappropriate 8. Incongruent- discordance between affective expression and content of speech/ideation. 9. Labile affect:- abrupt,rapid,unstable changes in emotions unrelated to external stimuli 10. Affective incontinence- inability to control the affect 5.AFFECT

41. Disorder of form of thought Disorders of stream of thought  Disorders of possession of thought  Content of thought 6.THOUGHT

42. Disorder of form of thought   1 . Asyndesis orDerailment : lack of adequate connections between successive thoughts  Loosening of association simply means that the patient's thoughts are unrelated. • Seen mostly in mania or schizophrenia.  • How did you bruise your arm? • I woke up in the morning, I washed my face and I applied some make up on..then I tried to create some cute style with my hair and then I opened the door and walked out to the parking and opened the door of the car and sat in the car and I started driving while listening to some jazz music and then when I got out of the car I entered the building and hit my arm with the door. 6.THOUGHT

43. 2. Metonyms -imprecise approximations in which a substitute term is used instead of amore exact one or It is a  figure of speech  in which a thing or concept is referred to by the name of something closely associated with that thing or concept "the  White House " or " The Pentagon " are used to refer to the U.S. presidential staff or the military leadership, respectively. Disorder of form of thought 6.THOUGHT

44. 3 . Over inclusion-   Overinclusive thinking is usually conceptualized (form a concept or idea of something) as the inability to preserve conceptual boundaries and identified as a cognitive characteristic of individuals with schizotypy who show an over-responsiveness to associative or irrelevant aspects of words and extraneous stimuli . People with OT tend to have a broader conceptual boundary. For example, when answering the questions in categorization tasks, such as “Are feet vehicles?”, people with OT tend to think of feet as vehicles based on the fact that feet transport people and items from one place to another just like vehicles. However, people without OT would not place feet in the vehicle category because they believe that wheels are the necessary features of vehicles  6.THOUGHT Disorder of form of thought

45.  1. Disorders of tempo:-( the abnormality in the speed of the production of one's thoughts .) a) Retarded thinking:- slowing down of thought /flow of thought Associated features:- lack of attention & concentration, inability to make decisions, no clarity in thinking, dull fuzziness in head. seen in depression and in manic stupor. 6.THOUGHT Disorder of Stream of thought

46. b . Flight of ideas :- fragmented ideas; frequent shifts in conversation topics Most commonly seen in manic episodes, bipolar disorder and manic phases of schizophrenia. For example ✦ I went to the market. I should read that book. ✦ When did you buy this dress? It's a lovely evening. ✦ I should go for a walk. I feel like having a chocolate. ✦ I need to study for the examination. That movie has received very good reviews. Disorder of Stream of thought 6.THOUGHT

47. c . Circumstantiality -  Using of excessive details which distract from the central theme of a conversation. (unnecessary details and irrelevant remarks cause a delay in getting to the point.) • The disorder is often associated with schizophrenia and obsessive-compulsive disorder. • Why do people comb their hair? • "Because it makes a light in life, my box is broken help me blue elephant. Isn't banana brave? I like electrons, hello please !" 6.THOUGHT Disorder of Stream of thought

48. d. Tangentiality - final goal is not reached and patient losses track of original question For example, in answer to the question "Where are you from?", the person answers "My dog is from England. They have good fish and chips there. Fish breathe through gills." e . Incoherence- pattern of speech that is essentially incomprehensibe Speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish. • a listener is unable to understand the meaning or purpose of the phrase. • It mostly appears in people with dementia and schizophrenia. 6.THOUGHT Disorder of Stream of thought

49. 2. Disorder of continuity a. Perseveration-  Persistent repetition of words or ideas even when another person attempts to change the topic.e.g . "It's great to be here in Nevada, Nevada, Nevada, Nevada, Nevada." This may also involve repeatedly giving the same answer to different questions. e.g. "Is your name Mary?" "Yes." "Are you in the hospital?" "Yes." "Are you a table?" "Yes."  6.THOUGHT Disorder of Stream of thought

50. b. Thought block- interruption of train of speech before a thought or idea has been completed. schizophrenic patient’s speech is suddenly interrupted/comes to a halt; he then goes on talking about something else after so many seconds; patient may complain that his/her mind is empty during discrete periods; unable to recover what has just been said c. Echolalia   - Echoing of another's speech [41]  that may only be committed once, or may be continuous in repetition. This may involve repeating only the last few words or last word of the examiner's sentences. This can be a symptom of Tourette's Syndrome, e.g. "What would you like for dinner?", "That's a good question. That's a good question. That's a good question. That's a good question." 6.THOUGHT Disorder of Stream of thought

51. Disorder of possession of thought  Thought alienation:- patient has experience that his thoughts are under control of an outside agency or that others are participating in his thinking. Thought insertion :- Patients belief that one's thoughts are not one's own, but rather belong to someone else and have been inserted into one's mind. Thought broadcasting:- Patient belief that others can hear or are aware of one's thoughts 6.THOUGHT

52. Obsession - a persistent thought, idea, or image that is  intrusive ( unwelcome , involuntary thought, image, or unpleasant )  or inappropriate, and is distressing or upsetting Compulsion:- def. – a disorder in which a person feels compelled to perform certain stereotyped actions repeatedly to alleviate persistent fears or intrusive thoughts, typically resulting in severe disruption of daily life. Rumination:- involves negative thought patterns that are immersive or repetitive . Or The process of continuously thinking about the same thoughts, 6.THOUGHT Disorder of possession of thought

53. Disorder of Content of thought 6.THOUGHT  1. Obsession 2. Compulsion 3. Ideas of hopelessness- an attitude characterized by an untoward and unfavourable expectations from self & environment. 4. Ideas of worthlessness:- Feeling that one is good for nothing and cannot tackle problems of life with due skill it is frequent underestimation of one’s talent, knowledge and capabilities.

54. 5. Suicidal ideas 6. Homicidal ideas 7. Depersonalization :-  experience a persistent or recurring feeling of being outside of your body 9. Derealization :- a feeling that one's surroundings are not real, especially as a symptom of mental disturbance. 6.THOUGHT Disorder of Content of thought

55. 10. Idea of reference the incorrect idea that the words and actions of others refer to one's self , belief that innocuous or coincident events experienced have strong personal significance) or influence (belief that other people or external agents are covertly exerting powers over oneself), persecutory ideas   11. Delusion ( something that is falsely or delusively believed  ) Erotomanic /Grandiose/ Jealous/ Persecutory/ Somatic / Paranoia/Negation Or Nihilistic   6.THOUGHT Disorder of Content of thought

56. Erotomanic : patient belief that someone is in love with oneself Grandiose: belief that one is the greatest, strongest, fastest, richest, and/or most intelligent person ever Persecutory: belief that the person, or someone to whom the person is close, is being malevolently treated in some way), 6.THOUGHT Disorder of Content of thought

57. Somatic: A somatic delusion is a false belief that a person's internal or external bodily functions are abnormal. This belief may also extend to viewing one's physical appearance as very irregular. Also known as monosymptomatic hypochondriacal psychosis, this condition is a very rare form of a delusion . Jealous :   delusional jealousy, is a psychological disorder in which a person is preoccupied with the thought that their  spouse  or  sexual partner  is being unfaithful without having any real proof, [1]  along with socially unacceptable or abnormal behaviour related to these thoughts 6.THOUGHT Disorder of Content of thought

58. Paranoia : Paranoid delusions, also known as persecutory delusions, are fears, anxieties, and suspicions centered on perceived victimization or unwarranted feelings of being threatened by external forces such as individuals or government authorities.   Paranoia/Negation Or Nihilistic  : a  depressive delusion that the self, part of the self, part of the body, other persons, or the whole world has ceased to exist . 6.THOUGHT Disorder of Content of thought

59. 1. Illusion- misinterpretation of perception 2. Hallucinations:- perception occurring without external stimulation 7 .PERCEPTION

60. 1. Illusion-   is a distortion of the senses, which can reveal how the human brain normally organizes and interprets sensory stimulation. Optical illusions, Auditory illusions and Tactile illusions. 7 .PERCEPTION 2 . Hallucination - A hallucination is a  perception  in the absence of external  stimulus  that has qualities of real perceptions Auditory Visual Olfactory Gustatory Tactile

61. Attention Sustained Attention Or Concentration Memory Intelligence Abstraction 7. COGNITIVE FUNCTION

62. Attention Def:- It is patients ability to attend to specific stimulus without being distracted by extraneous internal or external stimuli  Attention :- normally aroused/ aroused with difficulty / digit forward /digit backward 7. COGNITIVE FUNCTION

63. Def:- It is ability to maintain attention to a specific stimulus over an extended period Concentration :- normally sustained/ sustained with difficulty / distractible100-7/40-3/ 20-1/Name of months(backwards)/Name of weekdays (backwards)   7. COGNITIVE FUNCTION Sustained Attention

64. Def:- It is a general term for mental process that allows the individual to store memory for later recall.  Memory :- 1,Immediate:- ( Digit repetition test) 8. COGNITIVE FUNCTION Memory

65. 2) Recent: (recent happenings - last meal, visitors etc)/verbal recall - 3 unrelated objects /5 unrelated objects, or imaginary/address of 5 items 3) Remote: personal events/impersonal events/illness-related events 8. COGNITIVE FUNCTION Memory

66. General fund of information:   Questions presented in increasing difficulty . Arithmetic ability: mental arithmetic /written sums 8. COGNITIVE FUNCTION Intelligence

67. Abstraction Abstraction :- (the   cognitive  process of isolating, or “abstracting,” a common feature or relationship observed in a number of things, or the product of such a process.) Normal / concrete/interpretation of proverbs/Similarities between paired objects 8. COGNITIVE FUNCTION

68. Awareness of abnormal behaviour /experience:- yes / maybe / no Attribution to physical causes:- yes / maybe / no Recognition of personal responsibility:- yes /maybe / no Willingness to take treatment: yes /maybe /no 9 . INSIGHT

69.   Social Judgement:- It is a more complex function that includes basic knowledge of social situations, knowledge of socially appropriate responses in such situations and ability to apply the correct response personally when faced with a actual social situation It can assess by history from informants who have witnessed the patients actual performance in dealing with day to day events. 10. JUDGEMENT

70. Personal Judgement The individuals personal expectations/plans/attitudes are assessed. Personal: intact / impaired Social: intact / impaired Test: intact / impaired 10. JUDGEMENT