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Mental State Examination

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by

Richard Duffy

on 13 September 2013

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Transcript of Mental State Examination

Mental State Examination
Appearance
Behaviour
Speech
Affect and Mood
Thoughts
Cognitive assessment
Perceptions
Dress
Self care
Cleanliness
Signs of IVDU
Tattoos
BMI
Ethnicity
General appearance
Psychomotor activity
Retardation or Stupor
EPSE
Poverty
Increased motor activity agitation or hyperactivity
Mannerisms
Tremor
Stereotyped movements
Sympathetic activity
Sweating
Restlessness
Hyper vigilance
Tension
Spontaneity
Quantity
Speed
Volume
Fluency- stammer
Aphasia
Dysarthria
Speech Form
Speech Content
Punning
Idiosyncratic use
Neologisms (a completely new word the derivation of which cannot be understood)
Clang associations
Perseveration
Manic speech and thoughts
Disorganized thinking
Catatonia
Schizophrenia
Depression
Mania
Insight
Not a binary outcome
Do you think something is wrong?
Could id be due to an illness?
Could it be a psychological illness?
Does you think you need help?
Will you take treatment?
General attitude to the illness?
Psychiatric History Taking
Presenting complaint
Past Psychiatric History
Past medical &
surgical History

Medication
Background: Age, marital status, occupation, physical health
Relationship: how they get on, frequency of contact
Psychiatric illness: in close and extended family
Genogram
Family History
Social history
Personal History
&
Mild
Serious
Illness
Attended GP
Taken medication
Self harm
Attended psychologist/ psychotherapist
Substance misuse
Attended psychiatry (treating teams)
Admitted to a
Day hospital
Prior medications
Admitted
Involuntary admissions
ECT
Seclusion
CMH
Risk
Full details of any illness including treatment
Consider organic differential
Axis I: Clinical Disorders
Axis II: Personality Disorders
Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Environmental
Problems
Axis V: Global Assessment of Functioning
DSM IV
AXIAL CLASSIFICATION
The history of the presenting complaint - precipitants, onset, duration, severity, impact, elevating and exasperation factors

Big five demographic details
Reason for referral
Referral source
Expected outcome
Same level as the doctor, to one side
Appropriate distance
Ideally the chairs should be fixed to the floor and the doctor should be seated nearest to the exit
Ensure no potential weapons in the room
Inform colleague that the interview is taking place
Panic buttons and personal alarms
SEATING ARRANGEMENTS

Introductions
Explain the purpose & estimated length of the interview
Explain the need to take notes
Reassure about confidentiality
Flight of ideas: thoughts follow each other rapidly & the connections between successive thoughts are understandable
Retardation: Thinking is slowed down. Experienced as difficulty making decisions and concentrating
Thought blocking: The complete interruption of speech before a thought or idea has been completely expressed
Perseveration: the adherence of an individual to the same concepts and words beyond the point at which they are relevant
Circumstantiality: Speech is very indirect and delayed in reaching its goal due to the inclusion of details

Thought alienation: characterized by the experience of one’s thoughts being alien, not originating from one’s own mind, and not being under voluntary control

3 forms described by Schneider and included as first rank symptoms for the diagnosis of schizophrenia. These are

Thought broadcasting (diffusion of thought)
Thought insertion
Thought withdrawal (interruption of thought)
Irritability, distractibility and apathy, over familiarity, sexual inappropriateness, suspicious, social withdrawal, no eye contact, Perplexity, aggression and violence
Echolalia : repetition of the examiners speech
Depression: sad, despondent, dejected
Elation: happy, cheerful, overactive
Emotional lability: rapid changes of mood from one extreme to the other
Euphoria: excessive & unreasonable cheerfulness
Ecstasy: state of extreme well-being
Apathy: Absence of feeling plus anergia
Affective blunting: lack of emotional sensitivity
Anxiety: subjective experience of fear
Depersonalization: a feeling of change involving the inner and/or outer worlds associated with an uncomfortable sense of unfamiliarity (seen in phobic disorders)
Irritability: Reduced control over temper

Defined as abnormalities of thought expressed in language

Includes incoherence, neologism, poverty of speech, poverty of the content of speech, tangentiality, circumstantiality
Delusions: A delusion is a false unshakeable idea or belief that is out of keeping with the patient’s social or cultural background
Overvalued ideas: are isolated, preoccupying beliefs, accompanied by a strong affective response
Disorders of thought content
Disorders of the control of thinking
Formal thought disorder (FTD)
Hallucinations: A hallucination is defined as a percept-like experience in the absence of an external stimulus (Slade 1976). Include auditory, visual, bodily senses (somatic), gustatory, olfactory hallucinations
Sensory distortions: mispreceptions of actual stimuli
Illusions (completion, affective, paredolic)
Distortions of magnitude (micropsia, hyperacusis)


Descriptive psychopathology is a method of precisely describing and categorizing abnormal experiences as described by psychiatric patients and observed in their behaviour
Collateral Information
Verbal - Family, friends, Social workers, teacher
Written- Hospital notes discharge letters, GP, school
Consent
Introduction
Functions of interview: History, MSE, Rapport, Motivation, Treatment, Education
The clinician should be:
Non-judgemental and sensitive
Empathic and respectful
Aware of own preconceptions and bias
Record the patient’s words verbatim - “I feel miserable. Completely hopeless”
Attended ED
Head injury
Epilepsy
Cardiovascular disease
Infectious disease
Chronic illness
Important illnesses
Current medication and allergies
Some important examples
Thyroid hormone
Corticosteroids
Warfarin
Anti retrovirals
Opiates
Benzodiazepines
L-Dopa
NSAID
ACE Inhibitors
Why ?
Premorbid Personality
"Before you became unwell what were you like?"
Friends
Close friends they can confide in
How often they saw them
Character
How would you describe your self?
How would others describe you
Patient, dependent, trusting, perfectionistic, quick-tempered, obcessionality, rigidity, impulsivity
Interests
Club or society membership
Religious practice
Spirituality
Hobbies
Free time
Future plans
Big five personality traits
OCEAN

Openness (inventive/curious vs. consistent/cautious)
Conscientiousness (efficient/organized vs. easy-going/careless)
Extraversion (outgoing/energetic vs. solitary/reserved)
Agreeableness (friendly/compassionate vs. cold/unkind)
Neuroticism (sensitive/nervous vs. secure/confident)
Usual mood: cheerful or despondent, optimistic or pessimistic, stable or emotional
Life course model of illness vs. adult risk factor model
Dutch famine
Migration studies
Gestational and delivery factors
Conception to birth
Problems during pregnancy
Gestational age at delivery
Complications with delivery
Method of delivery
Early life
Developmental milestones
Relationship with care giver
Early traumatic events
Illnesses
Primary care giver
CSA
Education
Primary and secondary school - when finished
Suspended or expelled
Bullied or bully
Truancy
Friends
Academic achievement
Subjects
University
Occupational
First job
Jobs
Current job - enjoyable problems
Periods of unemployment
Reasons for leaving jobs
Forensic
Arrested/Cautioned
Court appearance
Prison sentence (how many, what for)
Crime not convicted for
Cases pending
Psychosexual history
Current partner and current difficulties
Previous partners
Age at first relationship
Orientation - do not assume heterosexual
Unwanted sexual experiences
Children, conceptions and terminations
Accommodation
Income
Social support
Substance misuse
Biological
Psychological
Social
Predisposing
Perpetuating
Precipitating
Genetic causes
Birth trauma
Head injury
Medical condition
Ongoing medical condition
Functional impairment
Non adherence
Ankastic personality
Physical or sexual abuse
Children under 3 in the home
No work outside the home
No confiding relationship
Break down of a relationship
Loss of a job
Low mood
Feelings of hoplessness
Cognitive errors
Chronic social difficulties
Drug abuse
Cognitive errors
Psychological slowing
Poor coping skills
Formulation
Psychopathology
False perceptions: in which non-existent objects are perceived
Hallucinations
Types of Hallucinations
Sensory modilaties - visual, auditory, olfactory, gustatory, touch (haptiv, hygric, thermic kinaesthetic, formication)
Extracampine
Elemental
Hypno
GO
gic, hypnopompic (
GO
ing
to sleep and waking up)
Functional (same modality)
Reflex (different modality)
Autoscopy
Multimodal hallucinations
Mood Vs. Affect
Mood is subjective and constant over time
Affect id more changeable and objective
Mood is Climate (MC)
Affect is weather
Types of Affect
Character, Congruency, Range....
Depression: low mood, anhedonia (lacking enjoyment, anergia (low energy, Feelings of guilt, worthlessness, hopelessness. Biological features
Euthymic: normal
Mania: Irritability, expansiveness, grandiosity and overactivity. Pressured speect and flight of ideas
How is your mood at the moment?
How has it been over the last few weeks?
Out of ten, 1 being...?
Catatonic symptoms including posturing, mutism, mannerisms and automatic obedience
Examples
Orientation - person, place, time
MMSE
ACE (Addenbroke's Cognitive assessment)
Frontal lobe assessment
Frontal lobe assessment
Letter and category fluency
Go no Go
Luria
Cognitive estimated
Proverb Interpretation - over literal
Similarities and dissimilarities
Primitive reflexes
Orbitofrontal Syndrome
Lack of warmth and empathy
Disinhibition
Stereotyped
Peserveration
Thought Disorders
Abnormal thought content
Neurotic Disorders
Anxiety/Phobias
Obsessions
Hypochondriasis/Somatisation
Preoccupations
Depersonalisation/Derealisation
Flashbacks
Psychotic disorders
Mannerisms: unusual, repetitive goal directed movements
Stereotypies: unusual, repetitive non-goal directed movements
Echopraxia: the patient repeats the actions of the examiner
Disorders of thought form and flow (FTD)
Control of thinking
Obsessions: These are recurrent ideas, thoughts, impulses or images that are recognized as being intrusive and senseless but are recognized as the person’s own thoughts. Compulsions include actions or cognitions such as praying or counting
Examples
Basic info
Intro
Attitude
Common Affective states
Formal though disorder
Hallucinations
Dr Richard Duffy MRCPsych
Special lecturer in psychiatry
Driving
Persecutory
Guilt
Nihilistic
Grandiose
Delusional Jealousy
Misidentification
Reference
Dysmorophobia
Hypochondriasis
Erotomanic
Types of delusions
Full transcript