The Mental Status Examination

1. The Mental Status Examination Michael Blumenfield, M.D. Professor of Psychiatry, Medicine & Surgery Department of Psychiatry New York Medical College Valhalla, New York

2. Mental Status Examination • A systematic organization and documentation of the quality of mental functioning at the time of the interview.

3. Mental Status Examination • Much of information is obtained informally during other parts of the interview. • It is usually necessary to ask the patient some formal questions to evaluate all the categories of the examination

4. Categories of Mental Status Examination (can be broken down in different ways) • Appearance & Behavior • Thought (Form & Content) • Mood & Affect • Memory & Intellectual Functioning • Insight & Judgment

5. Appearance & Behavior • attractiveness vs unattractiveness • healthy vs sickly • older vs younger ( than stated age) • angry, puzzled, frightened, ill-at-ease, apathetic, contemptuous, etc.

6. Appearance & Behavior • Mannerisms,gestures,combativeness,psychomotor retardation ,rigidity, twitching, handwringing,pacing • Suspiciousness, cooperative seductiveness,laughing, joking, seriousness,dramatic flair , etc.

7. Behavior & ApperanceClinicalExamples: • People with psychois such as schizophrenia may be poorly groomed or dressed in bizarre manner • Depressed person may show decreased psychomotor activivity , handwringing • Swollen neck may be evidence of hypothyroidism and perspiration may be evidence of hyperthyroidism both of which can have mental status findings • Confused behavior can point to cognitive deficits

8. Thought - Form • Formal Thought Disorder - Is speech logical, coherent, relevant? • Loose Associations - thoughts unrelated and patient unaware of this • tangentiality,circumstantiality ,derailment,evasiveness,blocking • Flight of Ideas- jumping from idea to idea but with understandable but often tenuous associations • pressured speech, overinclusiveness , “clang” associations • Other Unusual Speech • echolalia- patient mimics words back to interviewer • neologisms-patient makes up new words • perserveration-needless repetition of the same thought or phrase

10. Thought- Form ClinicalExamples: • Loosening of Association(LOA) with tangentiality or derailment is characteristic of schizophrenia as are blocking neologisms and echolalia when they occur • Flight of Ideas(FOI) frequently occurs with pressure of speech and with overinclusiveness which is characteristic of mania but can be seen in drug intoxication • Perseveration is found in dementia and is indicative of memory difficulties

11. Thought- Content

12. Thought - Content • Refers to what the patient thinks and talks about • Hallucinations- Totally imagined sensory perceptions • auditory , visual, olfactory, tactile, • can be accusatory, threatening or commanding • Illusions - Misinterpretation of of sensory stimuli • Delusions- Fixed false beliefs not congruent with patient’s culture • Obsessions - recurrent persistent unwanted thoughts, impulses, images • Compulsions-need to do repetitive,purposeless behavior to ward off unwanted happenings • Phobias- intense unreasonable fear leading avoidance of feared object • Depersonalization-the feeling that one has changed in a bizarre way • Rerealization- the feeling that the environment has changed • Déjà Vu- sense of familiarity with a new perception • Suicidal & Violence Towards Others - see mood for suicidal ideation

13. Thought - Content • Delusions • Bizarre, confused delusions • Persecutory delusions • Grandiose delusions • Delusions of influence-patient believes that he can control events through telepathy • Delusions of reference-patient is convinced that there are special meaning to events and actions which are directed specifically towards himself • Delusions of thought broadcasting- the belief that others can hear the patient’s thoughts • Delusions of thought insertions-the belief that someone else’s thoughts have been inserted into the patient’s mind

14. Thought- ContentClinicalExamples: • Delusions that are understandable and fit with content are more likely to be related to depression ie, patient believes that he or she has cancer or is persecuted because he or she is a bad person • Delusions that are not understandable and are bizarre are more likely to be due to schizophrenia ie. Patient believes that he or she has superhuman powers or believes their thoughts can be read by others or others are inserting their thoughts into their mind • Visual Hallucinations - are more common in organic disorders particularly with delirium ,can occur with psychedelic drugs and less likely with schizophrenia • Auditory Hallucinations- Most common with schizophrenia but can occur with alcoholic hallucinosis and affective disorders • Olfactory Hallucinations- Associated with temporal lobe seizures • Tactile Hallucinations- (including formications-which is sensation of insects crawling under or in skin ) can occur in drug intoxication, delirium tremens and sometimes schizophrenia

15. Thought - Content • Ability to Think abstractly vs Concrete Thinking • Similarities: What do the following have in common? • Chair and desk? • Apple and pear? • Poem and statue? • Proverbs: What do people mean when they say…..? • Don’t cry over spilled milk • A rolling stone gathers no moss • When the cat’s away the mice will play

16. Thought- Content ClinicalExamples: • You must take into account a person’s intelligence when evaluating the ability to abstract • Concrete thinking especially when it is bizarre suggests a psychotic disorder such as schizophrenia • Inability to abstract especially if the answers are vague suggests that the patient is failing and it could be due to delirium or early dementia.

17. Let’s Go To The Video Tape !!!

18. Mood and Affect • Mood refers to the patient’s words describing his/her internal emotional state • sad, depressed,gloomy • happy,euphoric,ecstatic • angry,irritable ,anxious)

19. Mood and Affect • Affect is the externally observed emotion • appropriate vs inappropriate to reported mood , content of thought and situation • flat, blunted , contricted or full range • labile, intense

20. Mood and Affect • When evaluating depression it is customary to ask about vegetative symptoms • sleep- falling asleep,staying asleep and early morning awakenings • (also a good time to ask about dreams ) • appetite- change in appetite and weight change

21. Mood and AffectSuicidal Ideation • When evaluating depression it is often a smooth transition to ask about suicidal ideation • It is myth to believe that asking about suicidal ideation will give the patient the idea of doing it • Failure to evaluate for suicidal ideation is a very serious omission

22. Mood & Affect- ClinicalExamples: • Inappropriate and flat affects are often associated with schizophrenia • Labile mood and labile affect are often seen in patients with disorders which are charcterized by damaged brain function • Extreme distress or pain described with an indifferent affect is called “ la belle indifference” and is associated with conversion disorder • The clinicians own emotional response to the mood and affective response of the patient can be a good indication of the underlying condition • ie. If examiner does not feel some sadness during report of extremely depressed mood, there is something wrong with affect of patient which may be indicative a conditon other than major depression • ie.If examiner finds one self smiling and almost laughing as patient reports material, the underlying mood may be mania or hypomania

23. Let’s Go To The Video Tape !!!

24. Memory and Intellectual Functioning • Orientation • Time- disoriented if more than one day off of the week and more than several days off date or the wrong year (except around the New Year ) • Place- disoriented if gives wrong hospital,wrong city , wrong setting • Person- if doesn’t know who they are

25. Memory • Immediate- serial 7s, alternative can be to ask how many nickels in $1.10. Spell WORLD backwards (also tests attention , concentration and intellect) • Short-term- recalling 3 objects 5 minutes later • Recent-recalling events of past week or month • Remote- recalling a famous news event of many years ago or naming their first grade teacher

26. Intellectual Functioning • Must interpret with understanding of patient’s educational, cooperativeness and mood state • Ask questions which are appropriate for specific individual, if not sure ask person’s interest • Examples : • Name the past 6 presidents? • What does the heart do? • How far is it from New York to San Francisco? • What happens to a caterpillar ? • Math questions noted above also test intellectual function

27. Memory & Intellectual Functioning -Clinical Examples • Disorientation for time and place are usually due to delirium but can occur with severe dementia • Disorientation for person is unusal even in dementia and malingering should be suspected. Rare case of dissociative state is possible • Disturbances of attention, concentration, immediate and short-term memory is usually due to delirium and can be characterized by fluctuations • Recent memory is more severly impaired than remote memory in dementia and persist when there is no delirium

28. Let’s Go To The Video Tape !!!

29. Insight • Insight: The patient knows that he or she was or has a psychiatric illness . If hallucinating, the patient knows that he/she’s mind is playing tricks on him/her

30. Judgment • An estimate of the patient’s real life problem solving skills.Is the patient realistic about limitations and life circumstances? It is a complex mental functioning • Examples of Questions to Evaluate Judgment • What would you do if you found a self addressed envelope? • What will you do when you leave the hospital ?

31. Insight & Judgment--Clinical Examples • Insight is often lacking with schizophrenia and other psychotic states but not this is not always the case. Similarly patient’s with organic impairment such as delirium and dementia will have absent or diminished insight. • Insight can be described on a relative scale with terms such as absent, limited, poor fair and good • The term insight is used in somewhat different manner when discussing patient’s without major psychiatric disorder in regard to their ability to accept , understand and utilize interpretation of behavior and unconscious dynamics • Judgement is regularly impaired in dementia, delirium and psychosis including schizophrenia as well as at times with mental retardation • Assessment of judgement helps determine the patient’s capacity for independent functioning • When mental illness is shown to impair a patient’s judgment so he/she is not capable of signing a consent form or handling finances , a court will declare a patient as “ incompetent” for that task

32. Example of Poor Judgment

33. The Mental Status Examination Michael Blumenfield, M.D Professor of Psychiatry, Medicine & Surgery Department of Psychiatry New York Medical College Valhalla, New York