Mental State Examination Flashcards
Components of exam mneumonic:
ASEPTIC?
What is an MSE?
Appearance and behaviour
Speech
Emotion (mood)
Perception
Thought
Insight
Cognition
An examination of the patient’s mental state at the time you see them.
Appearance and behaviour:
What to look out for in appearance? - 4
What to look for in behaviour? - 5
What comment can you use for someone who is healthy?
Overall impression Physical condition - overweight/underweight Suitability of dressing Cleanliness ---- Appropriateness of behaviour (e.g. aggressive, agitated, over-familiar) Eye contact Distractibility Abnormal involuntary movement Rapport -----
‘They were casually dressed, well-kept, calm and had good eye contact. Rapport was easily established.’
Appearance and behaviour -Abnormal Behaviour:
- What is too much? - 2
- What is too little? - 3
Disinhibition and overfamiliarity
Withdrawn
Poor eye contact
Poor rapport
Appearance and behaviour:
Signs of anxious behaviour?
- general
- hands
- feet
- the way they sit in chair?
Signs of depressed mood?
- posture
- eyes
- lips
- affect
Fidgeting, trembling Nail biting Shuffling feet Squirming in the chair Sits on edge of chair ----- Hunched, self hugged posture Little eye contact Downcast eyes - tears Biting or licking lips Slow thought, speech and movement -
Appearance and behaviour - abnormal movements:
What may cause motor slowing (psychomotor retardation? - 2
What is tardive dyskinesia and what may cause it? How does the person present?
Depression
Schizophrenia
Side effect of antipsychotics
Schizophrenia
Grimacing and movements of the tongue
Appearance and behaviour - abnormal movements:
What can cause parkinsonism’s such as a mask like appearance on their face?
What is Catatonia and what is it a sign of?
Side effect of antipsychotics - may also have reduced arm swing and stooping
Stuporous catatonia is characterized by immobility during which patients may show reduced responsiveness to the environment (stupor), rigid poses (posturing), an inability to speak (mutism), and waxy flexibility (in which they maintain positions after being placed in them by someone else).
Schizophrenia
Appearance and behaviour - Social behaviour:
- What is disinhibition?
- What is overfamiliarity?
A diminution or loss of the normal control exerted by the cerebral cortex, resulting in poorly controlled or poorly restrained emotions or actions. (Swearing in dementia)
Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
Speech:
What are you looking at in their speech? - 5
Comment for normal speech
Rate Quantity Volume Tone Articulation (smooth/dysarthria/stammer)
‘Speech is of a normal quantity, rate, volume and tone, and is fluent and smooth.’
Speech - Rate and quantity:
What is pressured speech and what patient is it seen in? - 2
Speech in depression - 2
Slowing of speech means…
What causes latency of speech?
What is circumstantiality & tangentiality?
Fast (high rate and quantity) and uninterruptible speech - Mania and schizophrenia
Low quantity and tone
Psychomotor slowing
Cognitive problems such as thought blocking, depression or thought disorders.
When the focus of a conversation drifts, but often comes back to the point – patient often derails, adding irrelevant details to the conversation - schizo
The tendency to speak about topics unrelated to the main topic of discussion - Schizophrenia
Speech - Content:
What are neologisms and what do the indicate?
What does incoherent speech mean?
What is echolalia and what causes this?
What is clanging associations and what causes it?
A newly coined word or expression made up by them - Seen in schizophrenia and neurological diseases
Disordered thoughts - hard to distinguish from disordered thoughts
Repeating words another person has spoken - schizophrenia and dementia
Grouping of words that are usually rhyming words even though they don’t have any logical reason to be grouped together. - Psychosis, bipolar disorder or schizophrenia.
Speech - Flow:
How does thought blocking present?
What is a ‘Knight’s move’ (flight of ideas) in psych?
Person stops speaking suddenly and without explanation in the middle of a sentence.
A complete loosening of associations where there is no logical link between one idea and the next - bipolar disorder
Emotion (Mood):
Depression - what may you see?
Anxiety - what may you see?
Suicidal
Tearful
Lethargy
Self-loathing, failure, worthlessness
Fearful
Restless
Obsessive
Irritable
Emotion (Mood):
What does grandiose mean in someone who is manic?
An unrealistic sense of superiority, characterized by a sustained view of one’s self as better than other people, which is expressed by disdainfully viewing them as inferior.
Emotion (Mood):
Define:
- Dysphoric
- Euphoric
- Euphoric
What is objective vs subjective?
Normal mood
Elevated mood
Low mood
What you observe vs what the patient tells you they feel
Emotion (Mood) - AFFECT:
3 ways to describe affect?
What does incongruous mean and think of an example?
What is labile mood?
What is flattening? Who does it happen in? - 2
Example for someone who is normal
Reactive
Blunted
Labile
Flat
A mismatch between experienced emotion and its expression - ‘they seem happy while describing traumatic events.’
Unstable display of emotion - happy one minute then sad the next
A severe reduction in emotional expressiveness - depression and schizo
“The patient was subjectively and objectively euphoric, with reactive affect”
Perceptions - Hallucinations:
Define hallucinations?
2 types and what type of disease they are seen in?
What 2 ways can the voices be?
What type of auditory hallucination is seen in schizo?
How may the patient describe the voices?
Sensation without stimulus
Auditory (psych) and Visual (neurological)
The patient’s voice or another’s
3rd person - anothers
Persecutory
Sinister
Pleasant
Perceptions - Visual Hallucinations:
What do they see in a simple H?
What do they see in a complex H?
What does hypnopompic H mean?
What does hypnogogic H mean?
Flashes of light
People, objects and animals
On waking
Just before going to sleep
Perceptions - Hallucinations:
Olfactory H - what is it?
Gustatory H - what is it?
Tactile H - what is it and what can cause it?
Unpleasant smell though not always
Unpleasant taste
Feeling of insects crawlings on or under the skin - Alcohol withdrawal and cocaine-induced psychosis
Perceptions:
What are illusions and give an example?
What is depersonalisation?
What is derealisation and what disorder is it seen in?
Misinterpretation of an external stimulus
‘Hearing whispers in the rustling of leaves’
Out of body feeling
The world feels unreal - PTSD
Thoughts:
3 aspects of thought
Form
Flow
Content
Thoughts - Content:
What is hypochondriasis?
What are obsessions?
What are overvalued ideas?
What are delusions?
Preoccupations or worries
Recurrent, distressing and egodystonic thoughts
Mild delusions which they sort of know are untrue but can’t shake
False beliefs unchanged by evidence, which are culturally incongruent.
Thoughts - Content:
Delusional perceptions? Give an example?
Other thoughts which should always be asked about?
Example of a way to divulge into these thoughts?
Delusion arising from false interpretation of real perception.
‘Shopkeeper giving you change is a spy delivering message’
Thoughts of suicide, self-harm or harm to others.
‘Has there ever been times when you’ve thought something strange was going on?’
Thoughts - Content - Persecutory delusions:
Q’s you can use to explore
Why should you ask if they have identified s specific person?
What can give you an indication of how severe it is?
Is there anything worrying you at the moment particularly regarding other people?
Do you feel others are up to no good?
A person may be in danger
Carrying weapons
Installing home security
Thoughts - Content - Delusion of reference:
What is the less severe form of this?
Q’s used
Thoughts - Content - Grandiose:
Q’s used
Ideas of reference
Do you feel you have any special talents that other people don’t?
Do you feel you have a special relationship with God?
Thoughts - Content - Interference or alienation:
3 types
Broadcasting
Insertion - is anyone putting thoughts into your head?
Removal of thoughts - may feel as though there is a gap
Thoughts - Content:
Define delusions of passivity?
Define nihilistic delusions?
Define hypochondrial delusions
What is magical thinking?
2 other delusions that you might see in
depression?
Beliefs that your own thoughts/feelings/actions are controlled by others
Rejection of all religious and moral principles - belief that life is meaningless
The belief that they are ill when evidence suggests otherwise
The belief that one’s ideas,thoughts, actions, words, or use of symbols can influence the course of events in the material world.
Delusions of worthlessness and guilt
Thoughts - Form and flow:
What is flight of ideas? What patient is it seen in?
A person rapidly shifts between conversation topics, making his or her speech challenging or even impossible to follow.
Mania
Thoughts - Form and flow:
What is circumstantiality? What causes this?
What is tangentiality?
Define:
- Poverty of thought
- Thought blocking
- Pressure of thought
Doesn’t get to the point - schizo - also seen in mania and OCD
Going off-topic
Flow reduced - schizophrenia - also seen in depression and dementia
Lose the train of thought
Rapid rate and quantity
Thoughts - Form and flow:
Loosening of associations - Define:
- Derailment (knights move)
- Thought blocking
- Word salad
What can you say if normal?
Where they jump from thought to another
Lose the train of thought - stop mid-sentence
An unintelligible mix of words.
No formal thought disorder
Cognitive Testing:
Simple test q’s
2 other tests MMSE AND MoCA.
What do they stand for?
Evaluation of orientation in person, place and time i.e. their name, where they are and time
Mini-Mental State Exam
Montreal Cognitive Assessment
Cognitive Testing:
MMSE - what score indicates:
- mild impairment
- moderate impairment
- severe impairment
What is a more detailed test that can be used? - ACE-R
<26
<20
<10
Addenbrooke’s Cognition Examination Revised
Cognitive Testing:
How may you test attention and concentration?
How may you test memory:
- Short term
- Long term
- Remote
- Grasp on life
Months of the year backwards
Subtract 7 from 100 and keep going
Retain and recall 3 objects or a 5 part name and address - assesses both immediate and delayed recall
Ask about news events of the last wk or so
DOB of children, historical events
Name the prime minister
Insight:
3 parts they need to grasp
Q’s used?
Knows the experiences are:
- abnormal
- due to disease
- can be medicated
Why do you think this is happening to you?
This must be awful. is it making you feel unwell?
Would you be willing to try some medication?
Do you ever feel like your mind plays tricks on you?
Formulation:
How do you split the factors in regards to the person?
What 3 ways can they be grouped?
What can the management plan be split into?
Biological
Psychological - how the person feels
Social
Predisposing
Precipitating
Perpetuating
Short and long term
Confidentiality:
When can it be broken? - 2
Who can you consult if you are unsure?
Where disclosure will prevent a serious crime (risk of serious harm or death)
A patient who continues to drive, against medical advice - contact DVLA
Consult a professional body (BMA or you protection organization) and/or senior colleague.
