psychiatric interview and mental status exam

Question 1

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

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

-Essentially is “physical exam” for psychiatry
-Allows clinician to examine pt and their current mental status
-Allows a baseline evaluation of mental status -> allows to notice any changes going forward
-Best to engage pt in a conversational approach
-Provides info on functional status of pt at a given point in time
-Along with psychiatric hx serves as a basis for dx and psychodynamic understanding
-May be used to help localize neurologic deficits

Question 5

MSE process

Answer 5

-a way of organizing data and suggests areas to investigate
-There are different formats for organizing an MSE, but the essential info that needs to be gathered is contained in all formats, e.g.,

-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
-cognitive function- memory

-insight and judgement
-insight- do they know whats happening, can they make appropriate decisions
-capacity -> can the person tell you the consequences of their actions

Question 6

competency vs capacity

Answer 6

-competency- legal
-capacity- medical

Question 7

things to observe during MSE

Answer 7

-manner 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
-voluntary and autonomic reactions- tremor, drooling

Question 8

optimizing the psychiatric interview

Answer 8

-make pt comfortable and secure
-allow pt to talk freely and frankly
-pt trust, security about confidentiality
-direct discussion along pertinent and relevant lines for dx and tx
-technique is learned through continued practice and experience
-setting
-distance
-no inturruptions
-introduce self and establish pt identity
-non-judgemental
-be responsive to variations in pts affect
-eye contact
-dont take too many notes
-allow silence
-avoid rapid questions
-inquire why pt may have a emotional reaction to a situation out of context
-allow pt to interrupt
-avoid psychiatric jargon
-encourage pt to talk about themself rather than others
-positive or negative reactions may be a matter of transference

Question 9

eliciting data

Answer 9

-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
-Note pt’s ability to deal with more pointed questions

Question 10

medical hx

Answer 10

-may be difficult and undesirable to separate medical and psychiatric hx in strict fashion from MSE
-is there underlying condition and delirium
-are they taking steroids
-are they on meds/changing meds
-hx of suicide attempts

Question 11

psychiatric hx

Answer 11

-Recent medications
-Substance abuse
-Suicidal or homicidal ideation
-Unusual behavior

-Past psychiatric problems or hospitalizations and tx
-FH
-Prenatal, birth, childhood, adolescence
-School record

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

Question 12

leads

Answer 12

-explore leads through HPI/past illnesses
-symptomatology like:
-delusions
-hallucinations
-obsessions- thought
-compulsions- action
-phobias
-orientation difficulty
-intellectual deficits
-affective disturbance
-interpersonal relationships

Question 13

MSE: appearance, attitude, behavior/psychomotor activity

Answer 13

-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 14

MSE: speech

Answer 14

-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 15

MSE: mood and affect

Answer 15

-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 16

MSE: mood and affect: assessment of suicidality

Answer 16

-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 17

what is the extent of the pts thinking and behavior related to suicide

Answer 17

-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 18

Does pt have sociodemographic and historical risk factors for completed suicide?

Answer 18

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

Question 19

Does the patient have a severe psychiatric disorder associated with completed suicide?

Answer 19

-Major depressive disorder
-Schizophrenia
-Bipolar mood disorder
-Panic disorder
-Active alcohol or drug dependence
-Personality disorder with Axis 1 comorbidity
-N.B. Recently placed on antidepressant medication

Question 20

mood and affect: assessment of homicidality

Answer 20

-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 21

MSE: thought and language: production of thought

Answer 21

-refers to abundance of though as evidenced by interactional capacity

Question 22

MSE: thought and language: disorders of production of thought

Answer 22

-Paucity of ideas aka poverty of thought: characterized by a decrease in apparent ability or interest in interacting with others or the environment
-Flight of ideas (thought’s race ahead of pts ability to communicate them)
-Rapid or slow thinking
-Does pt speak spontaneously or only when questions are asked?

Question 23

MSE: thought and language: form of thought or thought processes

Answer 23

-how thoughts are connected or associated
-Normal thinking is goal directed and sequential thoughts have logical connections—train of thought can be followed

Question 24

MSE: thought and language: disorders of thought processing (incoherent speech)

Answer 24

-circumstantiality- talking in circles, dont answer the question
-tangentiality- tangents,
-loosening of associations
-“world salad”- making up new words
-neologisms- making up new words
-echolalia- repeating back what they say

Question 25

MSE: thought and language: disorder of thought content

Answer 25

-1. PREOCCUPATIONS
-phobias- irrational, pathological dread of a particular stimulus or situation that results in marked anxiety and avoidance of situation
-Obsessions: disturbing, persistent, and usually intrusive thoughts, feelings, or impulses that cannot be eliminated from consciousness
-Compulsions: irresistible urges to perform meaningless, often ritualistic motor acts.

-2. DELCUSIONS- paranoia
-Fixed, false beliefs that have no basis in reality, are not generally held by one’s culture, and from which the patient will not be dissuaded, evidence to the contrary
-Can be mood congruent or not.
-Delusions of grandeur
-Delusions of reference—unrelated events apply to oneself
-Delusions of control, e.g.,
-1. Thought insertion or withdrawal
-2. Thought broadcasting- controlling other people with your thoughts
-3. Made feeling, drives, or volitional acts
-4. Somatic passivity

Question 26

MSE: perceptions (perceptual disturbances)

Answer 26

-disordered processing of sensory information (and distortions of reality)
-Hallucinations: perceptions that occur in the absence of actual stimuli
-Auditory
-Visual
-Olfactory
-Gustatory

-Illusions are misinterpretations of existing stimuli
-Delusions (previously defined)
-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

-Depersonalization- Detachment from self
-Derealization - Detachment from environment- victims usually

Question 27

MSE: cognitive function

Answer 27

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

Question 28

MSE: cognitive function: level of consciousness

Answer 28

-pts ability to respond to environmental stimuli
-Extremes are coma and hyperalertness
-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 29

MSE: cognitive function: orientation

Answer 29

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

Question 30

MSE: cognitive function: concentration (attention)

Answer 30

-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 31

MSE: cognitive function: memory

Answer 31

-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
-Confabulation

Question 32

MSE: cognitive function: intelligence

Answer 32

-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, e.g.,
-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 33

MSE: insight and judgement

Answer 33

-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?
-Can test, e.g., what patient would do if he found a stamp, addressed letter in the street or a medication that was lost

-To test for insight can 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?