Group 1 Mental Status Examination
Group 1 Mental Status Examination
Group 1 Mental Status Examination
Status
Examination
Signs and Symptoms
Group 1 Members:
Abittor, Portia
Adhikari, Sanju
Alam, Md Farhan
Appoy, Ivy Grace
Bollaram, Sathish
Calugay, Von Alfredo
Kintali, Chakradhar
Yadav, Pankaj
I. Introduction
❖ Mental status is the total expression of persons emotional responses, mood,
cognitive function and personality.
❖ The mental status examination (MSE) is the psychiatric equivalent of the physical
examination in the rest of medicine. The MSE explores all the areas of mental
functioning and denotes evidence of signs and symptoms of mental illnesses
❖ The MSE gives the clinician a snapshot of the patient’s mental status at the time
of the interview and is useful for subsequent visits to compare and monitor
changes over time
II.4. Mood
❖ Traditionally, mood is defined as the patient’s internal and sustained emotional
state
II.5. Affect
❖ It is the expression of mood or what the patient’s mood appears to be to the
clinician. Affect is often described with the following elements: quality, quantity,
range, appropriateness, and congruence. Terms used to describe the quality (or
tone) of a patient’s affect include dysphoric, happy, euthymic, irritable, angry,
agitated, tearful, sobbing, and flat
❖ Affect can also be congruent or incongruent with the patient’s described mood or
thought content. A patient may report feeling depressed or describe a depressive
theme but do so with laughter, smiling, and no suggestion of sadness
❖ Questions that can be helpful include, “Do you ever feel like someone is following
you or out to get you?” and “Do you feel like the TV or radio has a special
message for you?” An affirmative answer to the latter question indicates an “idea
of reference.” Paranoia can be closely related to delusional material and can
range from “soft” paranoia, such as general suspiciousness, to more severe
forms that impact daily functioning. Questions that elicit paranoia can include
asking about the patient worrying about cameras, microphones, or the
government
❖ The circumstantial patient over includes details and material that is not directly
relevant to the subject or an answer to the question but does eventually return to
address the subject or answer the question
❖ Tangential thought process may at first appear similar, 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. 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
II.7.a. Formal thoughts disorders
▪ Circumstantiality- Overinclusion of trivial or irrelevant details that impede the
sense of getting to the point
▪ Clang association- Thoughts are associated by the sound of words rather than
by their meaning (e.g., through rhyming or assonance)
▪ Derailment- (synonymous with loose associations). A breakdown in both the
logical connection between ideas and the overall sense of goal directedness. The
words make sentences, but the sentences do not make sense
▪ Flight of ideas- The invention of new words or phrases or the use of
conventional words in idiosyncratic ways
▪ Neologism- The invention of new words or phrases or the use of conventional
words in idiosyncratic ways
▪ Perseveration- Repetition of out of context words, phrases, or ideas
▪ Tangentiality- In response to a question, the patient gives a reply that is
appropriate to the general topic without actually answering the question.
Example: Doctor: “Have you had any trouble sleeping lately?”
Patient: “I usually sleep in my bed, but now I’m sleeping on the sofa.”
▪ Thought blocking- A sudden disruption of thought or a break in the flow of ideas
II.8. Perceptual Disturbances
❖ Hallucinations are perceptions in the absence of stimuli to account for them.
Auditory hallucinations are the hallucinations most frequently encountered in the
psychiatric setting. Other hallucinations can include visual, tactile, olfactory, and
gustatory (taste). In the North American culture, non-auditory hallucinations are
often clues that there is a neurological, medical, or substance withdrawal issue
rather than a primary psychiatric issue. In other cultures, visual hallucinations
have been reported to be the most common form of hallucinations in
schizophrenia
❖ Derealization is a mental state where you feel detached from your surroundings.
People and objects around you may seem unreal. Even so, you're aware that this
altered state isn't normal. More than half of all people may have this
disconnection from reality once in their lifetime
II.9. Cognition
❖ The elements of cognitive functioning that should be assessed are alertness,
orientation, concentration, memory (both short and long term), calculation, fund
of knowledge, abstract reasoning, insight, and judgment
❖ A general sense of intellectual level and how much schooling the patient has had
can help distinguish intelligence and educational issues versus cognitive
impairment that might be seen in delirium or dementia
II.11. Insight
❖ Insight, in the psychiatric evaluation, refers to the patient’s understanding of how
he or she is feeling, presenting, and functioning as well as the potential causes of
his or her psychiatric presentation or Psychiatric form of awareness of illness. It
refers to the capability of psychiatric patients to recognise and accept that they
are suffering from a mental illness
❖ The amount of insight is not an indicator of the severity of the illness. A person
with psychosis may have good insight, while a person with a mild anxiety
disorder may have little or no insight
II.12. Judgement
❖ Judgment refers to the person’s capacity to make good decisions and act on
them. The level of judgment may or may not correlate to the level of insight. A
patient may have no insight into his or her illness but have good judgment
❖ For example, “What would you do if you found a stamped envelope on the
sidewalk?” It is better to use real situations from the patient’s own experience to
test judgment. The important issues in assessing judgment include whether a
patient is doing things that are dangerous or going to get him or her into trouble
and whether the patient is able to effectively participate in his or her own care.
III. Common Questions for Psychiatric History and Mental Status
Topic Questions Comments and Clinical
Hints
Identifying data Be direct in obtaining If patient cannot
identifying data. Request cooperate, get information
specific answers from family member of
friend; if referred by a
physician, obtain medical
record
Chief complaint (CC) Why are you going to see Records answers
a psychiatrist? What verbatim; a bizarre
brought you to the complaint points to
hospital? What seems to psychotic process
be the problem?
History of present illness When did you first notice Record in patient’s own
(HOP) something happening to words as much as
you? Were you upset possible. Get history of
about anything when previous hospitalizations
symptoms began? Did and treatment. Sudden
they begin suddenly or onset of symptoms may
gradually? indicate drug-induced
disorder
Previous psychiatric and Did you ever lose Ascertain extent of illness,
medical disorders consciousness? Have a treatment, medications,
seizure? outcomes, hospitals,
doctors. Determine
whether illness serves
some additional purposes
(secondary gain)
Personal history Do you know anything Older mothers (>35) have
about your birth? If so, high risk for Down
from whom? How old was syndrome babies; older
your mother when you father (>45) may contribute
were born? Your father damaged sperm,
producing deficits including
schizophrenia
Childhood Toilet training? Bed- Separation anxiety and
wetting? Sex play with school phobia are
peers? What is your associated with adult
childhood memory depression; enuresis is
associated with fine
setting. Childhood
memories before age of 3
are usually imagined, not
real
Adolescence Adolescents may refuse to Poor school performance
answer questions, but they is a sensitive indicator of
should be asked. Adults emotional disorder.
may distort memories of Schizophrenia begins in
emotionally charged late adolescence
experiences. Sexual
molestation?
Adulthood Open-ended questions are Depending on the chief
preferrable. Tell me about complaint, some areas
your marriage. Be require more detail injury.
nonjudgmental: What role Manic patients frequently
does religion play in your go into debt or are
life, if any? What is your promiscuous. Overvalued
sexual preference in a religious ideas are
partner? associated with paranoid
personality disorder
Sexual history Are there or have there Be nonjudgmental. Asking
been any problems or when masturbation began
concerns about your sex is a better approach than
life? How did you learn asking do you or did you
about sex? Has there been ever masturbate
any change in your sex
drive?
Family history Have any members in your Genetic loading in anxiety,
family been depressed? depression, schizophrenia.
Alcoholic? In a mental Get medication history of
hospital? Describe your family (medications
living conditions. Did you effective in family
have your own room? members for similar
disorders may be effective
in patient).
General appearance Introduce yourself and Unkempt and disheveled in
direct patient to take a cognition disorder, pinpoint
seat. In the hospital, bring pupils in narcotic addiction,
your chair to bedside; do withdrawal and stooped
not sit on the bed posture in depression
Motoric behavior Have you been more Fixed posturing, old
active than usual? Less behavior in schizophrenia.
active? You may ask about Hyperactive with stimulant
obvious mannerisms, such (cocaine) abuse and in
as, “I notice that your hand mania. Psychomotor
still shakes, can you tell retardation in depression;
me about this?” Stay tremors with anxiety or
aware of smells, such as medication side effect
alcoholism/ketoacidosis (lithium). Eye contact in
schizophrenia. Scanning of
environment in paranoid
states
Attitude during interview You may comment about
attitude: “You may seem Suspiciousness in
irritated about something, paranoia, seductive in
is that an accurate hysteria; apathetic in
observation?” conversion disorder (la
belle indifference); punning
(witzelsucht) jn frontal lobe
syndromes
Mood How do you feel? How are Suicidal ideas in 25% of
your spirits? Do you have depressive; elation in
thoughts that is not worth mania. Early morning
living or that you want to awakening in depression;
harm yourself? Do you decreased need for sleep
have plans to take your in mania
own life? Do you want to
die? Has there been a
change in your sleep
habits?
Affect Observe nonverbal signs Change in affect usual with
of emotion, body schizophrenia: loss of
movement, facies, rhythm prosody in cognitive
of voice (prosody). disorder, catatonia. Do not
Laughing when talking confuse medication
about sad subjects, such adverse effect with flat
as death, is inappropriate affect
Speech Ask patient to say Manic patients show
“Methodist Episcopalian” to pressured speech; paucity
test for dysarthria of speech in depression;
uneven or slurred in
speech in cognitive
disorders
Perceptual disorders Do you ever see things or Visual hallucination
hear voices? Do you have suggest schizophrenia.
strange experiences as Tactile hallucination
you fall asleep or upon suggests cocainism,
awakening? Has the world delirium tremens (DTs).
changed in any way? Do Olfactory hallucination
you have strange smells? common in temporal lobe
epilepsy
Thought content Do you feel people want to Are delusions congruent
harm you? Do you have with mood (grandiose
special powers? Is anyone delusions with elated
trying to influence you? Do mood) or incongruent?
you have strange body Mood-incongruent
sensations? Are there delusions point to
thoughts that you can’t get schizophrenia. Illusions are
out of your mind? Do you common in delirium
think about the end of the Thought insertion is
world? Can people read characteristic of
your mind? Do you ever schizophrenia
feel the TV Is talking to
you? Ask about fantasies
and dreams
Thought process Ask meaning of proverbs Loose associations point to
to test abstraction, such schizophrenia; flight of
as, “People in glass ideas to mania; inability to
houses shout not throw abstract to schizophrenia,
stones.” Concrete answers brain damage
deal with universal themes
or moral issues. Ask
similarity between bird and
butterfly (both alive), bread
and cake (both food)
Sensorium What place is this? What is Delirium or dementia
today’s date? Do you know shows clouded or
who am I? wandering sensorium.
Orientation to person
remains intact longer than
orientation to time or place
Remote memory (long- Where were you born? Patients with dementia of
term memory) Where did you go to the Alzheimer’s type retain
school? Date of marriage? remote memory longer
Birthdays of children? than recent memory. Gaps
What were last week’s in memory may be
newspaper headlines? localized or filled in with
confabulatory details.
Hypermnesia is seen in
paranoid personality
Immediate memory (very Ask patient to repeat six Loss of memory occurs
short-term memory) digits forward, then with cognitive, dissociative,
backwards (normal or conversion disorder.
responses). Ask patient to Anxiety can impair
try to remember three immediate retention and
nonrelated items; test recent memory.
patient after 5 minutes Anterograde memory loss
(amnesia) occurs after
taking certain drugs, such
as benzodiazepines.
Retrograde memory loss
occurs after head trauma
Concentration and Ask patient to count from 1 Rule out medical cause for
calculation to 20 rapidly; do simple any defects vs anxiety or
calculations (2 x 4, 4 x 9); depression
do serial 7 test (i.e., (pseudodementia). Make
subtract 7 from 100 and tests congruent with
keep subtracting 7). How educational level of patient
many nickels in $1.35?
Judgement What is the thing to do if Impaired in brain disease,
you find an envelop in the schizophrenia, borderline
street that is sealed, intellectual functioning,
stamped and addressed? intoxification
Insight level Do you think you have a Impaired in delirium,
problem? Do you need dementia, frontal lobe
treatments? What are your syndrome, psychosis,
plans for the future? borderline intellectual
functioning
Reference: Sadock & Kaplan (2010). Kaplan and Sadock’s Pocket Handbook of
Clinical Psychiatry. Philadelphia: Lippincott Williams & Wilkins.