Examining Mental Status of a Psychiatric Patients | Essay | Psychology

In this essay we will discuss about the mental status examination of psychiatric patients.

In contrast to the psychiatric history which is a record of the patient over the course of his or her entire life, the mental status examination is an evalua­tion of all the areas of mental functioning of the patient at one patient in time.

It serves the same function for a psychiatrist as the physical exami­nation does for the primary care physician.

 An out­line of the components parts of the mental status examination is given below (Table 4.3):

A. Appearance and Behaviour of Psychiatric Patients:

(a) Attitude:

Describe the manner in which the Patients relates to the examiner i.e,:

a) Cooperative

b) Alternative

c) Contentious

d) Defensive

e) Trustful

f) Seductive

g) Ingratiating

h) Friendly (Frank)

i) Interested

j) Playful

k) Guarded

l) Purposefulness

m) Hostile

n) Evasive

It is possible to empathize with the patient or not (“Empathy” is defined as the ability to identify with the patient in order to recognize and identify the mental state (i.e., feelings, emotions, passions, sufferings, torments etc.) of the patient; Schizo­phrenic patients may be difficult to be empathized (and there is a feeling in the therapist that he is talking to the patient as if through a wall i.e., ‘Praecox feeling’.

Level of rapport:

Level of rapport (“Rapport” is a conscious feeling of accord, sympathy, trust and mutual responsiveness between one person and another; rapport may be easily established (e.g., with a depressive) or with difficulty (e.g., with a deluded patient) or cannot be established (e.g., Negativistic patient) or can be established without effort (e.g., due to disinhibition in Mania).

(b) General appearance and grooming:

Appearance includes apparent age, obvious physical stigmata, general state of physical health and overt emotional displays.

a) Dressed with neatness

b) Clothes neatness appropriate to season

c) Hair/nails

d) Concern about appearance

e) Clothes clean and good

N.B. 1:

Schizophrenic and organic patients may be dirty and disheveled, being both aware of and unconcerned about appearance. Manic patients are the most colourful and bizarre in appearance and clothing etc.

N.B. 2:

Current social trends must be respected when assessing appearance e.g., covering face with a part of saree, dyed hair, pins through the earlobe or nasal septum, hands covered with jewellery may be acceptable in some subcultures,

(c) Facial expression:

i. It is appropriate or not (Schizophrenic patients may have inappropriate or incon­gruous expression).

ii. Is it changed with subject or not.

iii. Look:

Look attentive, apathetic (e.g., in chronic schizophrenic) indifferent (e.g., in severely depressive).

iv. Expression:

Expression elation (mild pleasure, appropriate smile or uncontrolled laughter). Fears (mild anxiety or apprehension, crying, Perplexed or frightened). Anger (Frowning, scorn, rage or fury). Sad (depressed patients may show ‘Omega Sign’ a furrowed brow caused by sustained contraction of the corrugaror muscle and ‘ Veraguth folds’ – an upward, inward peaking of the upper eyelids). Blank (e.g., in Schizophrenic patients, there is no facial expression at all).

v. Eye to Eye contact :

Maintains Gaze (e.g., anxious patients). Avoids gaze (e.g., in schizophrenic patients). Excessive scanning (e.g., manic patients).

(d) Posture:

i. Relaxed (e.g., Obsessive):

Guarded (e.g., in Paranoid patients), Limp and Sprawled out in Chair, Sitting at the edge of the chair (e.g., in schizophrenic patients), Unsteady (e.g., in patients with organic brain disorders) Poorly coordinated (e.g., in schizophrenic patients).

(e) Body build:

a) Asthenic (Leptosomatic or ectomorph) i.e.,:

Persons with narrow in length with narrow, shallow thorax with narrow subcostal angle. The persons are believed to be more prone to schizophrenia.

b) Pyknic type (Endomorphic) i.e.,:

Persons with large body cavities, relatively short limbs and large subcostal angle with rounded head and short, fat neck. These persons are believed to be more prone to manic depressive psychosis.

c) Athletic type (Mesmorphic):

Persons with wide shoulders and narrow hips and well developed bones and muscles. These persons are believed to be more prone to drug dependence, etc.

(f) Psychomotor activity:

i. Appropriateness:

Appropriate to situation or not.

ii. Quantity:

Normal, increased (e.g., in mania, agitation, Hyperkinetic syndrome, drug induced akathesia manifested as foot tapping, scalp rubbing, hand wringing, pacing, alternatively sitting and standing and picking at clothing or bed linens. Decreased (e.g., in severe depression, parkinsonism, some schizophrenic patients expressed as excessive speech latency or stupor (mute, immobile, unresponsive to givorous painful stimuli).

iii. Quality:

Facial movements e.g., in oral dyskinesia, tremors in hands or body e.g., in anxiety neurosis or neuroleptic induced.

iv. Mannerisms i.e.,:

Mannerisms odd, repetitive movements, may be a part of a goal directed activity (e.g., in normal persons, manics).

v. Stereotypies i.e.,:

Stereotypies Motor or verbal repetition without any discernible goal e.g., in schizophrenics.

vi. Automatic obedience:

Automatic obedience a type of catatonic behaviour when verbal instructions are overridden by tactile or visual stimuli e.g., the patient shakes hands with the examiner, contrary to the firm verbal instructions whenever the examiner’s right hand is extended e.g., in schizophrenic patients.

vii: Mitmachen:

Mitmachen despite instructions to be contrary, the patient will allow a body part to be put into any position without resistance to the light pressure, then returns the body part to the original position when the examiner releases it.

viii. Echopraxia e.g.,:

Echopraxia in Catatonic schizo­phrenics Automatic copying of the examiner’s movements or postures e.g., in catatonic schizophrenia.

ix. Echolalia:

Echolalia Automatic repetition of the examiner’s utterances e.g., in catatonic schizophrenic patients.

x. Catalepsy:

Catalepsy prolonged sustaining of an awkward posture or position e.g., schizophrenic patients.

xi. Cerea Flexibilitas or waxy flexibility:

Cerea Flexibilitas or waxy flexibility if the examiner encounters plastic resistance like bending of a wax rod when moving the patient’s arm, which will then be maintained in an odd position e.g., in Catatonic schizophrenic.

xii. Cogwheel or Lead pipe rigidity, (e.g., inparkinsonism).

xiii Compulsions are obsessional motor acts (e.g., in obsessive compulsive disorder).

(g) Voice and speech:

i. Intensity:

Audible, excessively loud (e.g., in excited manic or schizophrenic), Soft (e.g., withdrawn depressives).

ii. Pitch:

Monotonous (e.g., retarded patients), Abnormal changes (e.g., in manic patients).

iii. Speech:

Slow (e.g., in depressives), Rapid (e.g., manic patient), Pressure (i.e., difficult to be interrupted e.g., in mania).

iv. Ease of Speech:

Under much pleasure, hesitatingly (e.g., in manic patients).

v. Spontaneity:

Spontaneous, (e.g., manic) Only when asked (e.g., obsessive patients), Mute (e.g., schizophrenic).

vi. Productivity:

Usual verbal productivity, Garrulous or laccnic (e.g., manic patients).

vii. Relevance:

Relevant, Flighty (e.g., manic patients), Distractible (e.g., mania).

viii. Manner:

Excessively formal (e.g., Paranoid patients), Relaxed, Inappropriately familiar (e.g., mania).

ix. Deviation:

Neologism (coining of new words or used words in an appropriate way), Echolalia (Automatic repetition of the examiner’s utterances) e.g., in schizo­phrenia. Clang Association (Speech in which sounds rather than meaningful conceptual relationships govern words choice) e.g., mania. Verbigeration (a manifestation of stereotypy consisting of morbid repetition of words, phrases or sentences also called cataphasia) e.g., in schizophrenia.

x. Reaction time:

Appropriate, Inappropriately slow (e.g., depression), Inappropriately fast (e.g., mania anxiety states).

xi. Vocabulary and Diction:

Were vocabulary and diction consistent with social and educational background (may be inconsistent in schizophrenic patients e.g., hebephrenice schizophrenics may talk like a child).

B. Mood and Affect of Psychiatric Patients:

Mood is a sustained subjective feeling state, which can be described by qualities such as happiness, sadness, worry, anxiety, irritability, anger, detachment and indifference. It is assessed by combining observations of behaviour and appearance particularly facial expression and posture, with what the patient tells you about what he is feeling (i.e., a subjective phenomenon).

Aspects of affect:

i. Appropriateness (Quality):

It refers to affective display to the content of speech and thought. Inappropriate affect is characteristic of schizophrenia (where it is also known as incongruous affect). Affect may be inappropriate and labile in pseudobulbar palsy in which the patients laugh while describing depression or cry while claiming to be happy. Affect may be shallow and inappropriate infrontal lobe lesions).

ii. Intensity (Quantity):

Normal, Increased as in vituperative, infective speech with dogmatic insistence regarding self- convictions e.g., in mania. Decreased when the patients appear shallow and vacuous with little conviction in their statements e.g., in schizophrenia.

iii. Type:

Elated (e.g., in mania), Sad (e.g., in depression), Fear (e.g., in Phobia), Anger (e.g., in schizophrenia), Anxious (e.g., in anxiety neurosis), Irritable (e.g., in Hypomania), Blunting (affects are diminished in intensity and constricted to a narrow neutral range) e.g., in schizophrenia, Flat (No effective response at all) e.g., in schizophrenia.

N.B.:

Motor dysprosody following lesions in anterior right cerebral hemosphere strikes with monotonous sparse speech without affective colouring.

i. Range:

Constricted (when a spectrum of moods not elicitable) e.g., in depression. Expanded (e.g., excess of joyfulness or sadness are seen) e.g., in mania.

ii. Stability:

Stable (e.g., in depression). Lability (e.g., in ununderstable, rapid changeability) e.g., in organic mental disorders. Lability with inappropriateness e.g., in Pseudobulbar palsy. Relatedness (ability to establish rapport and interpersonal connectedness).

C. Perception of Psychiatric Patients:

Any sensory modality may be affected with mi­nor or severe perceptual disorders:

(a) Illusions:

Illusions are misinterpretations of perceptions (e.g., shadows are mistaken for frightening figures). Disorders of the intensity or quality of stimuli may occur as in hyperacousis, or there may be distorted visual perceptions (i.e., dymegalopsia) e.g., micropsia (decreased size), macropsia (increased size). Illusions may occur in normal individuals (e.g., on falling asleep (hypnagogic) or arising (hypnopompic) or when the person is fatigued or frightened) or in organic mental disorders.

(b) Hallucinations:

Perceptions occurring without external stimulation. Hallucinations may depend on type of sensory system affected e.g., auditory, visual, olfactory, gustatory, tactile. Pseudohallucinations. Hallucinations accompanied by the insight that they are unreal (e.g., may occur in drug (LSD, alcohol) induced states etc.

i. Elementary hallucinations:

Consists of flashes of light, noises or sound that are not formed into a coherent organization.

ii. Functional hallucinations:

Occur only when there is a concurrent real perception in the same sensory modality (e.g., hearing voices only when the water tap is on).

iii. Autoscopic hallucinations:

A visual hallucination of patients themselves.

iv. Extracampine hallucinations:

When occurring outside of a known sensory field (e.g., seeing objects through a solid wall).

v. Kinaesthetic hallucinations:

Feeling movement when none occurs e.g., out of body experiences.

vi. Hypnagogic hallucinations:

Hypnagogic hallucinations which occur when falling asleep.

vii. Hypnopompic hallucinations:

Hypnopompic hallucinations which occur when awakening.

(c) Depersonalization and derealization:

Depersonalization and derealization are alterations in the perception of one’s reality.

i. Depersonalization:

The patient feels detached and views himself or herself as strange and unreal. (It is an “as if” phenomenon and patient is not fully convinced) e.g., a patient perceives that his face is distorted or his hands have become long. It may be seen in depression, anxiety disorders, organic states.

ii. Derealization:

It involves a similar alteration in the sense of reality of the outside world. (Familiar objects or places may seem altered in size and shape),

(d) Other abnormal perceptions:

i. Deja vu:

Feeling of familiarity with unfamiliar things.

ii. Deja pense:

A patient’s feeling, verging on certainty that he has already thought of the matter.

iii. Deja enterndu:

The feeling that one had at some prior time heard or perceived what one is hearing in the present.

iv. Deja raconte:

A forgotten experience, particularly from the distant past, is recalled and the individual feels as if he had known all the time that the experience had been told to him.

v. Deja eprouve:

The feeling that an act or experience in which the subject has never in fact engaged, has already been carried out by him.

vi. Deja fait:

What is happening to the patient now has happened to him before.

vii. Jamais vu:

An erroneous feeling or conviction that one has never seen anything like that before (i.e., Feeling of unfamiliarity).

D. Thinking Pattern of Psychiatric Patients:

The pattern of a patient’s speech allows the examiner to note the quality of the thought process including its flow, logic and associations. Normal thinking is initiated by a problem, goal directed (controlled) and lead to logical conclusions.

Abnormalities in thinking process include:

(a) Stream:

It includes:

Disorders of tempo:

Flight of ideas (Rapid speech with quick changes of ideas) that may be associated by chance factors such as by the sound of the words but which can usually be understood, e.g., See the king is standing, king, king, sing, sing, bird on the wing, wing, wing) e.g., in mania (in hypomania, there is ordered flight of ideas, i.e., despite many irrelevances, the patient is able to return to the task in hand. It is also called Prolixity).

i. Inhibition or retardation:

Thoughts are slowed down and the number of ideas and mental images which present themselves are decreased, e.g., in depression, stupor.

ii. Circumstantiality:

Thinking proceeding slowly with many unnecessary trivial details but finally the goal is reached e.g., in mania, organic mental disorders, schizophrenia.

iii. Tangentiality:

It differs from circumstan­tiality that the final goal is not reached and the patient loses track of the original question.

iv. Incoherence:

Marked degree of loosening of associations in which the patient shifts ideas from one to another with no logical connection, accompanied by a lack of awareness on the part of the patient that ideas are not connected, the examiner cannot understand the talk. It is seen in schizo­phrenia.

Disorders of continuity:

i. Perseveration:

Mental operations tend to persist beyond the point at which they are relevant, e.g., repetition of the same words or phrases over and over again despite the interviewer’s direction to stop.

ii. Blocking:

Occurs when the thinking process stops altogether. It occurs in schizophrenia and anxiety states, the patients may not start with the same topic again.

iii. Echolalia:

Repetition of the interviewer’s words, like a parrot.

(b) Possession and control:

i. Obsessions:

Persistent occurrence of ideas, thoughts, images, impulses or phobias, the patient recognizes that the ideas do not make sense and are his own (i.e., arises from inside) but occurring against his will.

ii. Phobias:

Persistent, excessive, irrational fear about a real or an imaginary object, place or a situation.

iii. Thought alienation:

The patient has the experience that his thoughts are under the control of an outside agency or that others are participating in his thinking. It may be insertion (thoughts are inserted by someone), withdrawal (A foreign influence has withdrawn his thoughts) or broadcasting (the patient thinks that others can read his thoughts or everyone else is thinking in unison with him) e.g., in schizophrenia.

iv. Suicidal/homicidal thoughts.

(c) Content:

i. Primary delusions:

Fixed unshakable false beliefs, which are against one’s sociocultural and educational background, and they cannot be explained on the basis of reality. The patients lack insight into it. They are different from ideas (when the patient is not fully convinced), overvalued ideas (which are part of a patient’s personality) and superstitions (shared by a community). Primary delusions can be.

a. Delusional mood:

Patient thinks that something is going on around him which concerns him but he does not know what it is. It may change into delusional perception or sudden delusional idea.

b. Delusional perception:

Giving a new meaning usually in the sense of self- reference, to a normal perceived object. It cannot be understood from one’s affective states or previous attitudes e.g., patient hears the stairs creak and knows that this is a detective spying on him.

c. Sudden delusional ideas:

A sudden revelation or well-formed ideas appear in the thinking, e.g., a patient says that he is of royal descent because he remembers when he was taken to a military parade as a little boy, the king saluted him.

ii. Secondary Delusions:

They arise from some other morbid experience, e.g., delusions, e.g.,

The patient unconsciously thinks ‘I love him -I do not love him -I hate him – he hates me”.

iii. Content of Delusions: Delusions of:

a) Persecution (the others are against him or he is conspired upon)

b) Self-reference (the others talk about him).

c) Innocence (opposition in nature but apparently related to the delusion of influence; there is firmly held belief in self-justification or acquittal noted in some individual accused of crime, coward or unacceptable behaviour. It almost always coexist with delusion of persecution).

d) Grandiosity (in relation of one’s worth, power or knowledge)

e) III health or Somatic function (that some part of the body is not functioning normally e.g., delusions of incurable disease).

f) Guilt (self-reproachful and self-critical thoughts blaming the patient himself)

g) Nihilism (the patient denies the existence of this body, his mind or the world around)

h) Poverty (Patient is convinced that he is impoverished)

i) Love or erotomania (Patient is convinced that some person is in love with him although the alleged lover may never have spoken to him).

j) Jealousy or infidelity (Others e.g., spouse hates him or is unfaithful to him).

(d) Form of thinking:

It consists of disorders of conceptual or abstract form (also called Formal thought disorder) e.g., in Schizophrenic or coarse brain disease.

These can be in the form of:

i. Given by Cameron:

a. Asyndesis:

Lack of adequate connections between successive thoughts. The patient uses clusters of more or less related thoughts in place of well-knit sequences.

b. Metonyms:

Imprecise expressions or use of substitute term or phrase instead of more exact one (e.g., for a pen ‘writing stick’).

c. Interpenetration of themes:

The patient’s e.g., schizophrenic’s speech contains elements which belong to the task in hand interspersed with a stream of phantasy which he cannot understand.

d. Over inclusion:

Inability to maintain the boundaries of the problem and to restrict operations within their correct limits. The patient shifts from one hypothesis to another.

ii. Given by Goldstein:

In schizophrenia and organic mental disorders, there is a loss of abstract attitude i.e., thinking becomes concrete (patient is unable to free himself from the superficial concrete aspects of thinking).

iii. Given by Schneider:

He said that normal thinking has constancy (persistence of a complete thought), organization (relatedness to consciousness) and continuity (i.e., sudden ideas or fears are arranged in order in the whole content).

The disorder of form of thinking in schizophrenia has:

a) Derailment:

Derailment the thought slides on to a subsidiary thought.

b) Substitution:

Substitution a major thought is replaced by a subsidiary one.

c) Omission :

Omission senseless omission of a thought or part of it.

d) Fusion:

Fusion heterogenous elements of thoughts are interwoven.

e) Drivelling:

Drivelling Disorganized intermixture of constituent parts of one complete thought.

f) Desultary:

Drivelling thinking (speech is grammatically and syntactically correct but sudden ideas force their way in from time to time).

N.B:

Always record a sample of Patient Talk (in verbatim) reflecting various types of disorders of thinking,

E. Judgement Patterns of Psychiatric Patients:

Judgement it is the capacity to draw direct conclusions from the material acquired by experience. It is impaired in psychoses.

i. Test Judgement (Patient’s prediction of what he or she would do in imaginary situations):

The type of judgement is assessed by giving a patient a particular situation and judging his response, e.g., Asking a patient, “Suppose, the room in which you are sitting catches fire, what will you do? A patient with suicidal tendencies may say “I would like to die” or a patient with delusions of grandiosity may say “the fire can do no harm to me.”

ii. Social Judgement (Subtle manifestations of behaviour that are harmful to the patient and contrary to acceptable behaviour in the culture):

This can be assessed from the history by noting his attitude towards social, financial, domestic or ethical problems. A patient with abnormal abusive violent behaviour obviously has impaired judgement.

Judgement should always be tested at the time of discharge from the hospital by asking him, what does he propose to do when he is discharged from the ward. A deluded patient with incomplete improvement may say, “I will take revenge on that person.”

F. Insight of Psychiatric Patients:

It refers to subjective awareness of the pathological nature of psychiatric symptoms and behavioural disturbances. Lack of insight is characteristic of psychoses.

The level of insight will be:

(a) complete denial of illness (insight absent).

(b) slight awareness of being sick and needing help but denying it at the same time.

(c) awareness of being sick.

(d) awareness that illness is due to something unknown in patient.

(e) Intellectual insight:

Admission that patient is ill and that symptoms or failures in social adjustment are due to patient’s own particular irrational feelings or disturbances without applying that knowledge to future experiences.

(f) True emotional insight:

Emotional awareness of the motives and feelings within patients and the important people in his or her life.

N.B. Anosognosia:

The denial of illness (or lack of insight). It is seen in right parietal lobe lesions.

Anosodiaphoria:

Indifference to the disability e.g., in brain lesions.

la belle indifference:

A calm mental attitude or indifference towards any disability e.g., in hysteria.

G. Sensorium and Cognition Power of of Psychiatric Patients:

(a) Consciousness:

Awareness of facts and the content to mental phenomenon and degree of reactivity of the environment. Conscious­ness may be clouded e.g., in organic mental disorder. Somnolence e.g., in drug intoxica­tions. Stupor (Unconscious but responds to painful stimuli). Coma (Unconscious and unresponsive) e.g., in hypoglycemia.

i. Alertness:

Fully aware of and responsive to the environment.

ii. Fugue:

Fugue Patient suddenly leaves his previous activity and begins to wonder or goes on a journey with subsequent amnesia e.g., in epilepsy, hysteria, organic mental disorders.

(b) Orientation:

Awareness about time, place and person. When it is impaired, it is usually in the order of time, then place and then person and when it is regained it is in the reverse order).

i. In time :

It is tested by asking time of day, day of week, date and year. It may be: Does the patient know his duration of hospitalization? Impaired in delirium, dementia etc.

ii. In place:

Does patient know where he or she is? Asking the address of patient’s house or office.

iii. In person:

Does patient know who the examinee is, the names and relations of the familiar attendants to him.

(c) Attention and concentration:

Conscious and willful focusing of mental energy on one object or one component of a complex experience.

i. Active attention (concentration):

The amount effort the patient exerts to solve a problem. It is tested by asking the patient to solve certain problems, (e.g., keep on subtracting seven from 100 or 4 times 5 or months of the year backwards). It may be disturbed in mania, anxiety states, depression and those with impaired reasoning (formal thought disorder).

ii. Passive attention:

The attention, which the environment draws, and the patient pays very little effort e.g., a shop on fire, an accident. It may be disturbed in organic mental disorders.

(d) Memory:

The ability, process or act of remembering or recalling and especially the ability to reproduce what has been learned or experienced.

The memory can be:

i. Remote memory:

The ability to recall information what was experienced in the distant past. It is tested by asking the childhood data, important events known to have occurred when the patient was younger or free of illness, personal matters. Take into account the patient’s age and normal intelligence and which for gaps of knowledge, confabulation or perseveration.

ii. Recent past memory:

The past few months.

iii. Recent memory:

The past few days, recall of what was done yesterday, the day before, what was eaten for breakfast, lunch, dinner etc.

iv. Immediate retention and recall:

The, ability to register information. Ability to repeat 5-6 figures after examiner dictates them – first forward and then backward, then after a few minutes interruption. The examiner may show 4-5 objects (known to patient) after asking him to remember and then recall after 4-5 minutes. The memory may be impaired in organic mental disorders (dementia) or amnesia (organic and psychogenic).

(e) Abstraction (abstract thinking):

It is determined by asking the meaning of common (prevalent in a culture) idioms, proverbs and similarities and differences between objects in the same class, e.g., similarities and differences between “ball and orange” “fly and aeroplane” etc. Simple questions should be asked first to reduce performance anxiety.

Abstraction does not develop fully until early adolescence, is closely linked to educational accomplishment, and may appear impaired if the person is not fluent in language used. Concreteness indicates thinking that is determined by, and not precede beyond some immediate experience or attribute. Abstraction is impaired in schizophrenia, mental retardation etc.

(f) General Intelligence:

It can be gauged by patient’s vocabularies, complexity of concepts they use and progressively more difficult questions about current events.

Previous levels can be assessed from education and work history.

Present levels can be assessed by history, simple tasks and clinical impression.

N.B.:

Apraxia is the inability to perform a skilled act without basic disturbances of strength, coordination or sensation. In ideational apraxia patients cannot perform on command acts that can be performed spontaneously and in constructional apraxia, there is difficulty in copying simple figures.

(g) Attitudes and beliefs:

It is important to note patient’s attitudes and beliefs towards.

I. The illness

II. The consequences of and limitations imposed by the illness.

III. Any help offered.

(h) Impulse control and frustration tolerance:

Record the patient’s ability to control the expression of aggressive, hostile, fearful, affectionate, sexual and/or appetitive impulses in situation where the expression would be maladaptive. The mode of impulsive of dyscontrol may be either verbal or behavioural and may range from the utterance of a socially unacceptable comment to violent outbursts which endanger lives.