Week 1 - A - Mental State Examination (A+B, Speech, M+A, Thoughts, Perception, Cognition, Insight - & Qs in Past Psychiatric history

Question 1

What are the things you assess for in a mental state examination?

Answer 1

• 1. Appearance and behaviour
• 2. Speech
• 3. Mood and affect
• 4. Thoughts
• 5. Perception
• 6. Cognition
• 7. Insight

Could get asked to watch a mental state examination and then describe it in osces so important to understand these

Question 2

State the different areas of the mental state examination? Give examples of things you are looking for under the category of appearance/behaviour?

Answer 2

• 1. Appearance + Behaviour
• 2. Speech
• 3. Mood and affect
• 4. Thoughts
• 5. Perception
• 6. Cognition
• 7. Insight

Under appearance + behaviour:

Appearance - age, sex, well groomed, appropriate clothing, posture smell, look at gait, tremor, any signs of self harm, any involuntary movements

Behaviour - is there eye contact, looking around, rapport developed, agitiation

Question 3

What involuntary movements that are a side effect of anti-psychotics may be seen in appearance in the appearance part of the mental state examination?

Answer 3

This could be tardive dyskinesia (tardive means delayed onset) - usually due to chronic exposure to dopamine antagonistis eg anti psychotics - this is seen as repetitive involuntary movements- causes lip smacking, grimacing, sticking tongue out

Can also get acute dystonia - prolonged muscular contractions causing repetitive movements - presents hours to days after beginning anti-psychotics

Question 4

What are the three signs of acute dystonia? What is given for the treatment of acute dystonia?

Answer 4

In acute dystonia, usually get

• Torticollis - head pulled back
• Trismus - oromandibular spasm and/or
• Oculogyric crisis - eyes drawn up

IV cholinergics should cause the symptoms of acute dystonia to disappear however

Question 5

Name the different parts examined in the mental state examiantion? What are you looking for on speech?

Answer 5

• 1. Appearance + behaviour
• 2. Speech
• 3. Mood + affect
• 4. Thoughts
• 5. Perception
• 6. Cognition
• 7. Insight Speech

The rate of the speech, rythym, tone

Is it pressured speech - person speaking very very quickly feeling almost like they are trying to force their words out

Poverty of speech - cant think of the words

Staccato speech - rhythm– pronunciation of every syllable being overly pronounced

Question 6

When rating the patients speech Can rate it under Rate/quantity of speech Tone/volume of speech Fluency and rhythm of speech What words can fit into these categories for describing the patients speech?

Answer 6

Rate/quantity of speech - is it pressured or poverty of speech

Tone/volume of speech - is it monotonous or shy or loud

Fluency and rhythm of speech - is it staccato speech, or fluent speech

Question 7

What are the different parts of the mental state examination? What is the difference between mood and affect?

Answer 7

• 1. Appearance + behaviour
• 2. Speech
• 3. Mood and affect
• 4. Thoughts
• 5. Perception
• 6. Cognition
• 7. Insight

Mood is the way you have been feeling over a long period of time

Affect is usually short lived and is their current emotion / reaction what is happening ie they say they are feeling suicidal (have been for a while and are not happy - mood) but appear to be cracking jokes (their affect) - doesnt really add up

Question 8

How would you examine the mood and affect part of the mental state examination?

Answer 8

Ask them how they are feeling at the given moment

It is important to ask if they are feeling like self harming or are feeling suicidal

If they have had these thoughts, check whether it is planned or impulsive - this moves on to the next part of the mental state examiantion

Question 9

How would you rate the patients mood and affect? Can be rated under the mood state Can be rated under * Quality of affect * Range/intensity of affect

Answer 9

Mood state - low/depressed/anxious/elated/manic

Quality of affect - is the patient positive/euphoric or negative

Range of affect (ie range of emotion) - might be reactive, flattened (reduced repsonse) or blunted affect (not really any response)

Question 10

If the affect matches the mood, what is this known as? If the affect doesn’t match the mood, what is this known as?

Answer 10

Affect matches the mood - mood congruent

Affect doesn’t match the mood - mood incongruent

Question 11

What part of the mental state examination comes after mood and affect? What two main things are being assessed here? (also a third thing if you can remember)

Answer 11

Thoughts comes next

• Thought form
• Thought content

Also thought possession

Question 12

What is the difference between thought form and content?

Answer 12

Thought form is the way the infromation comes out, ie is it relevant and are the thoughts coming at rapid speed

Thought content - this is the things they are actually thinking, are they obsessive or suicidal thoughts, is there any delusions

Question 13

What is a delusion?

Answer 13

Delusions are fixed beliefs that cannot be shaken despite logical argument and are inappropriate to the patients socio-economical background

Question 14

What are the different ways to talk to an examiner about the patients thought form and their thought content?

Answer 14

Thought form -

Say whether the thoughts are coming out at rapid speed or normal whether you ask a question and they answer and then go off in a huge tangent - tangential thought, incoherenet tho

Thought content -

is the patient experiencing delusions - where they have a fixed belief that cannot be shaken, whether they have any suicidal thoughts or homicidal/violent thoughts

Question 15

What are the different types of thought possession?

Answer 15

Thought insertion - people are putting these thoughts into his head and they are not his own

Thought withdrawal - people are taking the thoughts out of their head

Thought broadcasting - whether everybody can hear there thoughts

Question 16

The next part of the mental state examination is perception Can examine the patient for hallucinations and illusions here What is the difference between hallucinations and illusions?

Answer 16

Hallucinations are perceptions in the absence of an external stimulus - eg there is someone behind you watching me

Illusions are the misinterpretation or misidentification of a stimulus eg nurse taking routine bloods is trying to posion you

Question 17

What sort of hallucinations are the most common?

Answer 17

Audiotry hallucinations are the most common type eg you can hear voices speaking to you

Followed by visual hallucinations - where you can see the people

Question 18

What important questions should you ask a patient with auditory hallucinations (voices)?

Answer 18

Ask the patient how many voices they are? What they are saying? Whether or not they are listening to the hallucinations?

Question 19

How would you assess cognitive function?

Answer 19

Ask the person where they know where they are, what day it is, who the prime minister is?

Can use addebrookes to further assess cognition

Question 20

What does insight in a patient refer to in the mental state examination?

Answer 20

Insight ie are they aware why they are hear and how do they feel the talk went

Question 21

What are the different parts of the mental state examination? What is a good opening sentence for a psychiatric history?

Answer 21

Different parts -

• Appearance + behaviour
• Speech
• Mood and affect (range of emiotion and long time mood)
• Thoughts (form, content, possession) (Delusion)
• Perceptions(hallucinations and illusions)
• Congition
• Insight

During this consultation I am going to be asking you some personal questions, they all do serve a purpose but please let me know if they make you feel uncomfortable.

Question 22

Past psychiatric history questions?

Answer 22

Have you ever been treated for a psychiatric illness - if so, when How long for, what drugs were you on?

Question 23

What are the important areas to cover in a drug history?

Answer 23

Prescription drugs Over the counter meds Illicit drugs Alcohol use Smoking Compliance

Question 24

Key questions to ask in personal/social history?

Answer 24

Home arrangements- whats it like at home?

Relationships- have you got any family? Are you in a relationship? How is that going?

Occupation- do you have a job? If they are steady enough to hold down a job then they are immediately at less risk.

Childhood- what was your childhood like?-really important for patients with personality disorders.

Hobbies- what do you do for fun?

Financial situation

Sexual history and psychosexual history

Children/marital status- are there people relying on this person?

Have you ever been involved with the police? Has any of your family ever been involved with the police?

Question 25

Why is family history important?

Answer 25

Psychiatric illnesses tend to run in families

Ask about substance abuse whilst during pregnancy and prematurity

Question 26

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Answer 26

Ask about the psychiatric history after the history of presenting complaint but before the past medical history

* Ask about past diagnosis/diagnoses

* Timescales and the symptoms in previous episodes

* Also the effect on function & their previous contacts

* Ask if there were&hospital admissions or detentions

Basically Can combined the past psych (so meds, drugs, social, personal, family) as part of the normal history as these are asked anyway