mental state exam-part one
TRANSCRIPT
DEFINITION
A structural way of observing and describing a patient’s state of mind
Part of the clinical examination
Standard format in which psychiatric signs and symptoms are recorded at the time of the interview.
Cross sectional description of patient’s state of mind
Evaluation of patient’s thinking at a point in time.
Provides information of patients thinking, reasoning, feeling, behavior etc.
Examiner interprets the meaning of of the patient’s communication- verbal and non-verbal
Based on this the diagnostic formulation and treatment planning is done
Helps examiner comprehend patient’s experiences through his own description
OUTLINE Appearance, Attitude, Behavior, and Social Interaction
Motor activity
Mood
Affect
Speech
Thought
Intelligence
Judgment and impulse control
Insight
APPEARENCE
Appearance provides many clues to patient’s mental state.
The following can be noted on careful observation
Physical health and hygiene
Self care and grooming
Comfortable or restless
Gait and posture
Intoxication
ATTITUDE
How the person relates to the examiner and the interview situation
Maybe summarized in one or several words such as-guarded, suspicious, hostile, friendly, manipulative, seductive, cooperative, threatening etc.
Interested/ Disinterested/ Apathetic
Eye Contact- initiated/ not initiated/ maintained/ not maintained
Attention – aroused/not aroused/ sustained/not sustained
Reflects upon the patient’s ability to function and relate
BEHAVIOUR
Social and n0n verbal
Hallucinating behavior- inappropriate smiling, muttering, gesticulations
Compulsions
Conversion episodes
Motor behavior- stereotypies( repeated non goal directed) mannerism( goal directed) posturing, other catatonic signs
RAPPORT Foundation of assessment
Important to note if rapport has been established or not
Establish rapport by:
Welcoming the patient, state purpose of the meeting, maintaining privacy
Provide comfort, calming and respectful demeanor, encourage open communication
Acknowledge and validate the patient’s distress/concerns
MOOD
Pervasive feeling tone which is sustained and colors the total experience of the person
Subjective
In answer to the question- how do you feel
Described in the patients words
Euthymic, relaxed, happy , worried, angry, fearful, depressed,
AFFECT
Outward objective expression of the emotional expression of the emotional experience at a given time
No question asked
Interpreted by the examiner
Judged based on – 1)quality 2) congruency 3)appropriateness 4)stability (stable or labile) 5)intensity 6)range (normal, restricted, blunted or flat)
SPEECH
Elements in evaluation include-
Quantity - Mute, talkative, articulate
Rate- normally responsive, rapid or slow.
Tone and volume- loud, whispered, mumbled
Flow and rhythm- spontaneous, stilted
Quality- slurred or stuttering
ABNORMAL SPEECH
Pressure of speech- difficult to stop the patient from talking
Flight of ideas- chance connections between ideas
Proxility- similar to flight of ideas but less in severity. Seen in hypomania
Thought block- sudden cessation of chain of thought and previous thought cant be remembered
THOUGHT PROCESS
Thought process describes how the thoughts are formulated, organized and expressed.
A patient may have normal thought content but abnormal process and vice versa
Normal thought process is describes as linear, organized and goal directed.
DISORDERS OF THOUGHT PROCESS
Circumstantiality
Tangentiality
Loose associations
Verbigeration
Word salad
Neologism
Clang association
Echolalia
Normal thought
I was home
I felt some chest pain
So I called my son And he called an ambulance
And I now am here
circumstanstiality
I was homeI felt some chest pain
So I told my son
And now I am here
The circumstantial patient over-includes details and
material that is not directly relevant to the subject or
answer to the question but does eventually return to
address the subject or answer the question. Typically the
examiner can follow a circumstantial train of thought,
seeing connections between the sequential statements.
tangentiality
I was homeNow I am here
I felt some chest pain
So I told my son
Tangential thought process may at
first appear similar to
circumstanstiality, but the patient
never returns to the original point or
question. The tangential thoughts
are seen as irrelevant and related in a minor, insignificant manner.
Loose thoughts or associations differ from circumstantial and tangential thoughts in that with loose thoughts it is difficult or impossible to see the connections between the sequential content.
Perseveration is the tendency to focus on a specific idea or content without the ability to move on to other topics. The perseverative patient will repeatedly come back to the same topic despite the interviewer's attempts to change the subject.
Neologisms refer to a new word or condensed combination of several words that is not a true word and is not readily understandable although sometimes the intended meaning or partial meaning may be apparent.
Word salad is speech characterized by confused, and often repetitious, language with no apparent meaning or relationship attached to it.
THOUGHT CONTENT
Thought content is essentially what thoughts are occurring to the patient. This is inferred by what the patient spontaneously expresses, as well as responses to specific questions aimed at eliciting particular pathology.
OBSESSIONS
Obsessional thoughts are unwelcome and repetitive thoughts that intrude into the patient's consciousness. They are generally ego-alien and resisted by the patient.
Compulsions are repetitive, ritualized behaviors that patients feel compelled to perform to avoid an increase in anxiety or some dreaded outcome.
DELUSIONS
Delusions are false, fixed ideas that are not culturally sanctioned and persist in spite of evidence to the contrary.
can be divided into bizarre and nonbizarre(nonbizarre delusions refer to thought content that is not true but is not out of the realm of possibility).
Common delusions that have recognition in the DSM-IV-TR as types of delusional disorder include grandiose, erotomanic, jealous, somatic, and persecutory.
SUICIDE AND HOMICIDE
Simply asking if someone is suicidal or homicidal is not adequate.
One must get a sense of ideation, intent, plan, and preparation.
Other variables that can be useful in the assessment of both suicidal and homicidal thoughts and impulses include whether there is a contingency involved (if this happens then I will commit suicide), whether the thoughts are new or chronic, and what prevents the patient from acting on them.