psych interview and mental status exam

Question 1

what is DSM?

Answer 1

-dx manual used by counselors, psychologist and psychiatrists
-help guide dx decision making
-only classification system addressing mental disorders in current widespread use in most professional settings
-currently on version 5 rn

Question 2

hx of dsm

Answer 2

-1st version of 1952 and had 60 disorders
-1st and 2nd edition (1968) based on psychoanalytic traditions
-3rd version in favor of biomedical model (1980(
-DSM-3-R (1987) changed dx criteria for several mental illness
-DSM-4 (1994) had a interim text revision called DSM-4-TR (2000) before it has now taken shape as a DSM-5 (2013)

Question 3

structure of DSM-5: section 1-3

Answer 3

-section 1- includes intro and instructions on how to use the new version
-section 2- covers the dx categories
-section 3- includes conditions that need additional research, a glossary of term, and other important information

Question 4

purpose of mental status exam

Answer 4

• the “physical exam” for psychiatry
  -Allows the clinician to examine the patient and their current mental status
  -Allows a baseline evaluation of mental status thus enabling the clinician to notice any changes going forward
  -Best to engage patient in a conversational approach
  -Provides information on the functional status of a patient at a given point in time
  -Along with the psychiatric history serves as a basis for diagnosis and psychodynamic understanding
  -May be used to help localize neurologic deficits

Question 5

MSE: what are the essential information that needs to be gathered

Answer 5

-appearance, attitude, behavior
-speech: fast (mania, bipolar)
-mood and affect: (mood comes from pts mouth, affect is how they look)
-thought and language: concrete thoughts dont make sense
-perceptions: hallucinations, delusions -> might need meds before therapy here
-cognitive function: Do they understand what you are saying
-insight and judgement

Question 6

MSE: while context is important, examiner must also be attuned to what

Answer 6

-manner in which information is presented: going off on tangents
-quality (quantity) of speech- slow or fast
-use of language
-non-verbal forms of communication: psychomotor retardation if no movement / psychomotor aggravation is restless
-emotional reactions: resilience - Greater with attributing to external factors
-voluntary and autonomic reactions: tremor, drooling

Question 7

Insight vs judgement ; capacity vs competency

Answer 7

insight: do you know what is going on, they understand their medical condition

Judgement: can they make the appropriate decision

Capacity (medical) eval:
- is the pt able to tell you the consequences of their actions?
- Pt could exhibit poor judgment but understand consequences -> they have capacity

Competency
- legal term determined by judge or law officer

Question 8

mood vs affect, congruent and incongruent

Answer 8

Mood: pt telling you how they feel

Affect: how pt LOOKS

Congruent: mood is happy and they look happy (affect)

Incongruent: mood doesn’t match how they look -> ask more questions

Question 9

optimizing the psychiatric interview

Answer 9

-make pt comfortable and secure
-allow pt to talk freely and frankly
-allow pt to trust you, security about confidentiality
-direct discussion along pertinent and relevant lines for dx and tx
-optimize the physical setting and make personal distance
-no interruptions during interview
-introduce self and establish pt identity
-non-judgemental: dont censor pts thoughts or feelings
-be responsive to variations in pts affect
-eye contact but dont stare
-dont take too many notes
-allow silences/pauses
-avoid rapid questions
- if emotional reaction seems out of context with the situation: inquire why they are reacting that way
-allow pt to interrupt: might be something important
-avoid psychiatric jargon
-encourage pt to talk about themself rather than others: “you are my primary concern/interest”
-positive or negative reactions may be a matter of transference: pt might project their feelings of past relationships onto us

Question 10

start of mental status exam: introductions

Answer 10

-Identify self and ask pt identifying info
-Chief complaint

HPI:
-present illness and current symptoms with pertinent data on setting in which they began
-Onset, duration, course, precipitants, aggravating/alleviating factors
-Proceed from general to specific, e.g., if pt uses general terms like “nervousness or “nervous breakdown” ask what he means; How do you feel? -> what does your boss do to stress you out?
-Note pt’s ability to deal with more pointed questions

Question 11

mental status exam: medical history and what is particularly pertinent to psychiatric hx

Answer 11

-may be difficult and undesirable to separate medical and psychiatric hx in strict fashion from MSE

particularly important
-is there underlying condition and delirium
-are they taking steroids (affects mood)
-are they on meds/changing meds
- substance abuse? (weed to help with pain)
-hx of suicide attempts
- unusual behavior

Question 12

3 reasons to involuntarily Hospitalize:

Answer 12

Homicidal: want to hurt someone

Suicidal

Gravely disabled: cannot function on their own, need help with ADL

Question 13

psychiatric hx important topics: medical, childhood and adule

Answer 13

Medical:
-Past psychiatric problems or hospitalizations and tx
-FHx

Prenatal, birth, childhood, adolescence: School record

Adult:
-Education
-Occupational
-Interpersonal/Social - Difficulty with law, Marital stability/concerns
-Military
-Sexual

Question 14

MSE: eliciting data with sympatomatology

Answer 14

Symptomatology: collection of sx associated with a particular disease, disorder, or condition

-delusions: Fixed, false beliefs.
-hallucinations: sensory disturbances without an external stimulus
-obsessions: thought
-compulsions: repetitive actions to reduce anxiety or prevent a feared event
-phobias
-orientation difficulty
-intellectual deficits
-affective disturbance: Emotional instability or inappropriate affect
-interpersonal relationships

Question 15

MSE: what is the first thing to look at

Answer 15

1) appearance, attitude, behavior/psychomotor activity

APPEARANCE/HYGIENE:
-well-nourished, neat, clean, alert, worried, sad, happy, in pain, slovenly, dirty, unkempt, pungent body odor, poor eye contact

ATTITUDE TOWARDS EXAMINER:
-Friendly, cooperative, guarded, suspicious, flattering, ingratiating, seductive, hostile, threatening, competitive

BEHAVIOR AND PSYCHOMOTOR ACTIVITY:
- Indifferent, frank, evasive, dramatic, posture (erect, slouched, stooped), gait, gestures, tics, rigidity, tremors, picking at body, underactive, hyperactive

Question 16

MSE: speech

Answer 16

-Helps us to appreciate difficulties with thought processes
-Volume, coherence, speed, quantity
-Soft, loud, stuttering, hesitant, rapid, slow, slurred, monotonous, mumbled, vocabulary, whispered, over or under talkative
-make sure there isnt a hearing problem

Question 17

MSE: mood and affect

Answer 17

MOOD
-how the pt says they are feeling
-Pervasive and sustained emotion; prevailing subjective state
-Look at depth, intensity, duration, fluctuations
-ex. sundowning at night -> do meds at a certain time
-Descriptors: happy, sad, terrified, depressed, anxious, angry, guilty, sensual, anhedonic, silly

AFFECT
-Refers to how pts mood (inner experiences) is expressed
-Full, appropriate, inappropriate, blunted (flat), labile, shallow, restricted
-Is emotional expression aligning to content?
-Does affect vary appropriately with content of pts thought?
-Appropriate: Bright when discussing a relative; sad when discussing death of friend
-Inappropriate: Grinning while discussing a tragic accident
-Blunted (flat): Affect can be static regardless of environmental stimuli (occurs in some pts with schizophrenia)

Question 18

MSE: mood and affect - assessment of suicidality main questions/considerations

Answer 18

-what is extent of pts thinking and behavior related to suicide
-Does pt have sociodemographic and historical risk factors for completed suicide?
-Does pt have a severe psychiatric disorder associated with completed suicide?

Question 19

MSE: suicidality assessment: what is the extent of the pts thinking and behavior related to suicide? what is the spectrum

Answer 19

-Passive death wish (not taking meds) vs. desire to kill self (plan)
-Hopelessness about situation and future
-Specific plan to commit suicide
-Means to commit suicide by plan
-Lethality of suicide plan
-Arrangements made to accommodate completed suicide
-Suicide note

Question 20

MSE: suicidality assessment: sociodemographic and historical risk factors for completed suicide

Answer 20

-Hx of aggressive and violent behavior
-FHx of suicide
-Hx of prior suicide attempts
-Male gender
-White race
-Single, divorced, widowed or recently separated

Highest risk: over 65 male white, single, divorced
Lower risk: AA female over 65

Question 21

MSE: suicidality assessment: psychiatric disorders associated with completed suicide

Answer 21

-Major depressive disorder
-Schizophrenia
-Bipolar mood disorder
-Panic disorder
-Active alcohol or drug dependence
-Personality disorder with Axis 1 comorbidity
-pt recently placed on antidepressant medication

Question 22

MSE: mood and affect - assessment of homicidality

Answer 22

Does pt have thoughts of hurting others?
-What have these thoughts been?
-How far has planning progressed?
-Has the pt been violent before?
-Toward whom?
-What were the circumstances and consequences?
-Possess weapons or has access to them
-Where are weapons stored?
-Ever been incarcerated for violence?
-Were drugs or alcohol involved?
-Does pt feel in control of impulses at the current time?

Question 23

MSE: thought and language: production of thought definition and disorders of production of though

Answer 23

Production of Thought:
- the abundance/quantity and flow of thoughts a person has, and how these thoughts are expressed during interactions
- rapid or slow thinking
- does the pt speak spontaneously (healthy) or only when questions are asked? (slow thinking or depression)

increased production:
- flight of ideas: thought’s race ahead of pts ability to communicate them (seen in mania)

decreased production:
- “poverty of thought”: paucity of ideas, fewer thoughts, lack spontaneity, or are not interested in engaging

Question 24

MSE: thought and language: form of thought/ thought processes; what is normal

Answer 24

Refers to how thoughts are connected or associated

Normal thinking:
- goal directed and sequential thoughts have logical connections
- train of thought can be followed

Question 25

thought and language: Disorders of Thought Processing: incoherent speech categories and adjectives

Answer 25

Circumstantiality: Excessive detail in responses, “talking in circles”

Tangentiality: going on tangents

Loosening of Associations:
- Lack of logical connection between thoughts

Word Salad: Incoherent, disorganized speech

Neologisms:
- Made-up words that may have meaning only to the patient

Echolalia:
- Repetition of another person’s words

Question 26

thought and language: disorder of thought content - what two main categories

Answer 26

1) preoccupations:
- phobias
-obsessions
- compulsions

2) delusions:
- fixed, false beliefs that are not shared by others in the individual’s culture or reality

Question 27

Disorders of Thought Content: preoccupations what are the three main ones

Answer 27

Phobias:
- An irrational and pathological fear
- The fear is so severe that it causes marked anxiety and avoidance behaviors

Obsessions:
- Persistent, disturbing, and intrusive thoughts, urges, or impulses that are difficult to suppress and cause distress.

Compulsions:
- Repetitive, ritualistic behaviors or mental acts that the individual feels compelled to perform to REDUCE anxiety
- pt may know the behaviors are unreasonable
- often ritualistic motor acts

Question 30

Disorders of Thought Content: delusions - common types

Answer 30

Delusions: fixed, false beliefs that are not shared by others in the individual’s culture or reality
- can be be mood congruent or not

Common delusions:
- of grandeur: pt has extraordinary abilities, wealth, or importance
- of reference: unrelated events apply to oneself
- control: external forces are controlling one’s thoughts, feelings, or actions

ex of delusions of control:
- Thought insertion or withdrawal: Belief that thoughts are being placed into or removed from one’s mind by an external source.
Thought broadcasting: Belief that one’s thoughts are being broadcasted to others.
Made feelings, drives, or volitional acts: Belief that one’s feelings, desires, or actions are being controlled or initiated by external forces.
Somatic passivity: Belief that external forces are influencing bodily sensations or functions.

Question 31

MSE: perceptions (perceptual disturbances) types

Answer 31

Def: disordered processing of sensory information (and distortions of reality)

Hallucinations: perceptions that occur in the absence of actual stimuli; auditory, visual, olfactory, gustatory

Illusions: misinterpretations of existing stimuli

Delusions: fixed, false beliefs that are not shared by others in the individual’s culture or reality

Depersonalization: Detachment from self

Derealization: Detachment from environment- victims usually

Question 32

delusions and paranoia

Answer 32

Delusions: fixed false beliefs

-Paranoid delusions may be highly systematized or bizarre
-Paranoia as an isolated symptom is not diagnostic.
-Must consider the nature, duration, and severity of the paranoia in context of pts hx that relates it to one particular dx or another

Question 33

MSE: cognitive function overview

Answer 33

-level of consciousness
-orientation
-concentration
-memory
-intelligence

Question 34

MSE: cognitive function: level of consciousness definition and spectrum

Answer 34

-pts ability to respond to environmental stimuli
-Extremes are coma and hyperalertness

spectrum:
-Alert: normal wakefulness and awareness
-Lethargic: pt has tendency to drift into a state of unconsciousness if left alone, but easily aroused to verbal stimuli
-Stupor: need for continual stimulation to maintain consciousness
-Coma: characterized by unconsciousness and the lack of response to any stimuli

Question 35

MSE: cognitive function: orientation

Answer 35

assesses pts awareness of:
-Identity (Person)
-Time (day of week, month, exact day of month, year, time of day)
-Place
-Situation

Question 36

MSE: cognitive function: concentration (attention)

Answer 36

-pts ability to direct and sustain attention
-Serial 7s or 3s (counting backward from 100)
-Repeat strands of numbers forward (average normal is seven digits) or in reverse (average normal five digits)
-Multiplication
-Number of nickels in $1.35
-Failure is 2 unsuccessful attempts to respond at the same number
-Impairment is usually recognized by pts inability to respond to your request consistently and coherently

Question 37

MSE: cognitive function: memory

Answer 37

ability to retrieve and recite info previously stored and to form new memories

-Remote memory: childhood event, milestones, personal matters, neutral material
-Recent memory: Events of past few months, then past few days, food eaten yesterday or today
-Immediate retention/recall: Repeat 6 figures provided by examiner—first forward, then backward, then after a few minutes; Name 3 objects, have pt repeat, then ask patient to recall after 5 minutes
-MMSE (mini-mental status exam): screens for many of the cognitive components of the MSE; Scores < 24/30 are suggestive of cognitive difficulties
-Note effect of defect in memory on pt and mechanisms pt uses to cope with defect such as denial
and confabulation (filling in memory gaps)

Question 38

MSE: cognitive function: intelligence overview

Answer 38

-observations about general education level and ability to learn, integrate, and process new information
-Do not confuse formal education with intelligence
-Make sure questions have relevance to pts level of education and cultural background
-Is pt functioning at level of education?
-Accurately assess pts intelligence level requires formal psychological testing

assessed by asking questions like:
-Who were the past four Presidents of U.S.?
-Difference between idleness and laziness?
-Math questions

Abstract Thinking: ability to make valid generalizations
-What does the phrase “You can lead a horse to water but you can’t make him drink” mean to you?
-Answers can be literal, concrete, personalized, or bizarre and essentially miss the point.

Question 39

MSE: insight and judgement overview

Answer 39

Insight: awareness of factors influencing one’s situation
-assess pts appreciation that an illness/difficulty is occurring, recognition of its impact on functional ability, and awareness of the need to take steps to correct it.
-Helpful to think about insight in terms of complete denial of illness, slight awareness, intellectual insight, true emotional insight
-Capacity for self-observation and demonstrations of empathy are also indicative of insight

Judgment: ability to manage day-to-day activities, handle finances, and avoid danger
-Insight must be present before options and priorities can be weighted and appropriate judgment exercised
-Does pt understand consequences of behavior that are harmful to him or contrary to accepted behavior in the culture?

Question 40

MSE: insight and judgement - how to test

Answer 40

Insight - directly ask patient:
-Do you think that you have a problem?
-Do you need treatment?
-What are your plans for the future?
-Should also look at the circumstance that led to patient’s receiving psychiatric attention. Did patient voluntarily seek help or was he walking in the snow with shorts and no socks or shoes on?

Judgment:
- what patient would do if he found a stamp, addressed letter in the street or a medication that was lost