Mental status exam

Question 1

 The ______ is an essential part of every psychiatric patient’s clinical evaluation
 You do part of one every time you talk to someone
 describes the patient’s present state, not his or her past history of symptoms

Answer 1

mental status examination (MSE)

Question 2

Steps to performing a mini mental exam

Answer 2

1. Appearance, Attitude, and Behavior
2. Speech
3. Mood and Affect
4. Thought Form/Process and Content
5. Perception
6. Sensorium/ Cognition
7. Insight
8. Judgment

Question 3

A Snake Moves Toward Prey Silently In Jungles

Answer 3

1. Appearance, Attitude, and Behavior
2. Speech
3. Mood and Affect
4. Thought Form/Process and Content
5. Perception
6. Sensorium/ Cognition
7. Insight
8. Judgment

Question 4

How do we describe appearance, behavior, attitude?

Answer 4

overall apperance, look for abnormalities

attitude: towards examiner; friendly or hostile
behavior: moving around, attentive, rocking, weeping

Question 5

How would you describe the Speech aspect of pt when doing the MME

Answer 5

QUALITIES, not content: rate, rhythm, volume and tone

Question 6

____ describes the patient’s subjective, internal state of feeling
____ describes the patients objective, external appearance of feeling.

Answer 6

Mood

Affect

Question 7

What is the relationship between mood and affect?

Answer 7

Mood and affect are normally congruent, but may be incongruent in some psychiatric syndromes (e.g. patient with schizophrenia is laughing uncontrollably, but feels sad)

Question 8

____is appropriate when it “fits” with the patient’s situation and feelings.

Answer 8

Affect
*Patients with psychotic disorders often have inappropriate affect (e.g., laughing when discussing recent death of mother). Comment on range, intensity and appropriateness

Question 9

describes how the patient is thinking. Normal thought form is often described as “logical, linear, and goal-oriented

Answer 9

 Thought form (or process)

Question 10

Among the many abnormalities of thought form seen in psychiatric patients are:
 _____ – mind frequently goes blank
 ______ – very little thought occurring
 _______ – takes a long time to get to the point
 ________ – logical, but never gets to the point

Answer 10

Thought blocking
Poverty of thought
Circumstantiality
Tangentiality

Question 11

___________ – logical connections between thoughts breaks down
 ___________ – thoughts are expressed through sounds (e.g. rhyming) rather than meaning
 _______ – new words or phrases are invented

Answer 11

Loose associations (a.k.a. derailment)

Clang associations

Neologisms

Question 12

 _______ – being stuck on a single thought
 ________ – rapid jumping from thought to thought, often seen in mania
 Normal thought form is often documented as “logical, linear, and goal-oriented”

Answer 12

Perseveration

Flight of ideas

Question 13

refers to what the patient is thinking
 Abnormal thought content needs to be explored and
documented

Answer 13

 Thought content

Question 14

 _______– fixed, false beliefs impervious to disproof or argument. Many types (grandeur, persecution, somatic, paranoid, etc.)
 _______ – belief that TV, radio, etc. are talking to or about patient
 _______ – belief that another person or force is controlling some aspect of patients thoughts or behavior

Answer 14

Delusions

Ideas of reference

Ideas of Influence

Question 15

_______ – upsetting, unstoppable thoughts
_________ – irresistible urge to act on
obsessional thoughts
_______ – irrational, troublesome fears

Answer 15

Obsessions
Compulsions
Phobias

Question 16

 ___________ – consuming bodily concerns w/o medical cause, but not delusional
 ___________ – always inquire and document in careful detail, intervene if necessary
 __________ – inquire and document in careful detail, intervene if necessary

Answer 16

Hypochondriacal symptoms

Thoughts of suicide

Thoughts of violence

Question 17

Describe hallucinations and when you see them

Answer 17

 Hallucinations are the most common type of perceptual disturbance, and are often seen in schizophrenia
 Hallucinations are sensory perceptions in any modality (auditory, visual, tactile, olfactory, gustatory) that are internally generated. To patients, they are as real as the externally-generated perceptions everyone experiences

Question 18

______ are misinterpretations of externally-generated perceptions, often vague

Answer 18

Illusions

Question 19

 Other perceptual disturbances include depersonalization, derealization, tunnel vision,::::

Answer 19

 The absence of hallucinations should be confirmed and documented in any psychiatric evaluation
 When present, hallucinations should be described in detail. “Hears voices” is not adequate

Question 20

How do you describe Sensorium/ Cognitive Assessment

Answer 20

describes patient’s state of awareness and cognitive abilities, including:
 Alertness – may be somnolent, obtunded, clouded, fluctuating, etc.
 Orientation – to person, place, time, situation
 Concentration – serial 7s or 3s, reverse spellings
 Memory – immediate (retention and recall), recent, long-term
 Calculation – everyday money questions work well
 Fund of knowledge – e.g., geography, current events

Question 21

More ways to assess for Sensorium

Answer 21

 Abstract reasoning – e.g. interpretation of proverbs, similarities
 Reading – doctor writes “close your eyes”, then patient reads and does it
 Writing – patient is asked to write a complete sentence
 Visuospatial ability – patient is asked to draw a clock face, interlocking pentagons, or a cube
 Estimated intelligence – e.g. “above/below/about average”

Question 22

 A one-page, structured instrument that covers most of the previous “Sensorium” items
 A numeric score is generated (30 points = no gross cognitive deficits)
 Can be done in about 10 minutes, depending on patient

Answer 22

The Folstein Mini-Mental Status Exam (MMSE)

Question 23

What’s the focus of MMSE

Answer 23

 Emphasis is on cognition: a delirious patient will likely score low, but a psychotic patient may (or may not) do well
 Is a relatively objective way of monitoring cognitive changes

Question 24

is a broad term that can describe a patient’s capacity for self-reflection, awareness of illness, understanding of his or her present situation, etc.
is often lacking in patients with chronic psychotic disorders (e.g. schizophrenia), delirium, or severe personality disorders

Answer 24

 Insight

Question 25

refers to a patient’s capacity to make reasonable decisions

 can be temporarily impaired (e.g., intoxication) or chronically impaired (e.g., dementia)

Answer 25

 Judgment

Question 26

Assessing Judgement

Answer 26

 Questions to assess judgment can be asked in the MSE (e.g., “What would you do if you found a stamped, addressed letter on the ground next to a mailbox?”), but judgment or lack thereof is often evident in the patient’s recent behavior

Question 27

Key for MSE

Answer 27

 A thorough and well-documented MSE is a critical part of a psychiatric evaluation (you want the reader to be able to know exactly how the patient was)
 Pertinent negatives (e.g. psychotic symptoms, suicidal/violent thoughts or impulses) are very important
 Don’t confuse the MSE (present mental state) with the HPI (recent symptoms, behaviors, and events)
 Find an organizational format you like for the MSE, learn it well, and stick with it

Question 28

Clinical Disorders with symptoms

Answer 28

 Axis I

Question 29

Personality Disorders and Mental Retardation

Answer 29

 Axis II

Question 30

General Medical Conditions

Answer 30

 Axis III