Week 2: Mental state examination Flashcards
What is the purpose of a mental state exam?
1) Your observation of the patient’s mental experiences and behaviours at that period of time
2) Structured description of signs and symptoms
Note –> not the same as MMSE
What are the differences between a history and MSE?
History in patients own words, MSE uses medical teminology and pt’s description.
History is patient led, MSE doctor led
History includes only symptoms, MSE includes both symptoms and signs
History is subjective whereas MSE is both subjective and objective
History can include whole life, MSE only includes now
History is longitudinal, wheras MSE is cross sectional
What is the structure of the MSE?
Appearance and behaviour
Speech
Mood and affect
Thought (form and content)
Perception
Cognition
Insight
What elements of appearance and behaviour should be commented on?
Physical state –> Rapport, are they calm/ anxious/ guarded/distracted/ disinhibited? Psychomotor –> agitation, retardation? Abnormal movements? (tremors/ tics?)
Dress –> app. and cleanliness
Self care and hygiene
Evidence of injury or self harm
Facial expression
Eye contact
What elements of speech should you look out for in an MSE?
Rate (slow/ fast/ pressured)
Volume
Tone and rhythm (monotonous)
Spontaneity (poverty of speech)
Fluency (dysphasia, dysarthria, stuttering?)
What is the definition of mood?
What is the nature of a mood?
mood = sustained emotional experience over a period of time
Nature can by euthymic (normal), depressed, anxious, irritable, elated
What is the definition of affect?
What elements of affect should you comment on?
Affect = emotional state prevailing at a given moment
“transient ebb and flow of emotion in response to stimuli”
mood vs affect = climate vs weather
Comment on 1) congruity with patients mood
2) range/ intensity of affect (normal and reactive or blunted/ flattened?)
Stability of affect
How is thought form assessed?
What does thought form refer to?
Thought form is assessed objectively by speech
Thought form refers to pattern of thinking
How thoughts are organised and expressed
Amount of thought -> increased or decreased
Thought flow –> logical or disordered?
What are key terms of thought disorders?
1) Circumstantial thinking –> inability to answer a question without giving excessive, unnecessary detail. Differs from tangential thinking, in that the person does eventually return to the original point.
2) tangentiality –>communication disorder in which the train of thought of the speaker wanders and shows a lack of focus, never returning to the initial topic of the conversation.
3) Flight of ideas –> person rapidly shifts between conversation topics, making his or her speech challenging or even impossible to follow
4) Loosening of associations (poorly, unrelated concepts)
5) Word salad –> confused or unintelligible mixture of seemingly random words and phrases
6) Neologisms –>newly coined word or expression.
7) Thought blocking –> During thought blocking, a person stops speaking suddenly and without explanation in the middle of a sentence
What are key aspects of thought content?
- Suicidal thoughts
- Violent/ homicidal thoughts
- Abnormal beliefs –> delusions, overvalued ideas
- Obsessional thoughts
Define delusion
Delusion = a false and firmly held belief that is out of keeping w the patient’s educational, cultural and social background. It is held with unshakable conviction and cannot be altered by rational argument
Define overvalued idea
overvalued idea = non delusional, non obessional belief that nevertheless preoccupies the patient and dominates their thinking.
Plausible belief arrived at logically but held with undue importance and causes distress to patient or those around them.
No majr abnormality in reasoning and not viewed as abnormal by the patient
Define obessive thoughts
Recurrent, intrusive unpleasant thought.
The patient knows that the thought makes no sense and struggles to resist it.
What are different types of delusion?
Primary vs secondary delusion:
Primary –> Delusion occurs separate to psychopathological disorder
Secondary –> false belief that is understandable in patients circumstances, pervasive mood state or because of cultural content.
Delusions can be congruent or incongruent:
Conguent –>‘delusions of guilt, worthlessness, bodily disease, or impending disaster’
Inconguent –> mood-incongruentpsychotic symptoms are characterized by ‘persecutory or self-referential delusions and hallucinations without an affective content
Delusions can be bizarre or non bizarre
Bizarre –> compleley implausible
Non bizarre –> belief of something occuring that isn’t completely implausible
What are three types of delusion defined by content?
Persecutory delusion = The individual thinks that harm is occurring, or is going to occur.
Grandiose delusion = ver-inflated sense of worth, power, knowledge, or identity. The person might believe he or she has a great talent or has made an important discovery.
Nihilistic = the delusion that things (or everything, including the self) do not exist; a sense that everything is unreal
How can the content of delusions differ?
- Delusions of reference –> individual experiencing innocuous events or mere coincidences and believing they have strong personal significance
- Delusional perception –> true perception to which patient attaches false meaning
- Delusions of control/ passivity phenomenon –> According to the patient’s narrative, his thoughts, emotions, perceptions or actions are under the control of a different agent
- Delusions of thought control/ interference:
- Thought insertion
- Thought broadcast
- Thought withdrawal
Define hallucination
Hallucination = sensory perception in the absence of an external stimulus, which the patient believes is a real perception
Define pseudo hallucination
Pseudo hallucination –> does not have the same sense of reality as hallucinations and occurs as part of ones subjective internal expereince not from the external world
e.g. “a voice inside my head”
not under concious control, patients may be aware that they are not real
Define illusion
Illusion –> misinterpretation of an external stimulus e.g. mistaking a shadow for a person
When are hallucinations normal?
What perception modalities can be involved in hallucination?
It is normal to hallucinate when falling asleep (hypnagogic hallucinations) or waking up (hypnopompic hallucinations)
Perception modality:
auditory/ visual/ gustatory/ olfactory/ somatic/ tactile
What are key terms to know with auditory hallucinations?
- Elemental hallucinations –>
- First person hallucination –> thought echo
- Second person hallucination –> command hallucination
- Third person hallucination –> running commentary
How would you ask a patient about their perceptions?
I want to ask you about some experiences that some people have, but can find difficult to talk about. These are questions I ask everyone.
Have you ever had the experience that you were unreal or that the world has become unreal?
have you ever had the experience of hearing noises or voices when there was no one about to explain it?
do you ever hear voices commenting on what you are doing? or discussing you between themselves? or repeating your own thoughts back to you?
have you had any visions?
do you ever notice smells or tastes other people arent bothered by?
What is cognition?
What tools can you use?
Orientation to time, place and person
Use a formal cognitive testing tool e.g. MMSE
What is insight in the psychiatric patient?
How do we assess insight?
Does the person recognise that they are ill or what they are experiencing is abnormal?
What do they think is the cause of their problems?
Do they recognise they need help or treatment?
