psychiatric history and mental status examinaiton
DESCRIPTION
Psychiatric History & Mental status examinationTRANSCRIPT
LOGO
Psychiatric History & MSE
Bivin JB
Department of Psychiatric Nursing
Mar Baselios College Of Nursing
History and MSE
Most important diagnostic tools
To obtain information to make an accurate diagnosis
From the time patient enters the interview room till he/she leaves the room
History & MSE
Rapport
A relationship of mutual understanding or trust
and agreement between people
Basic principles of History taking
• Introduce yourself
• Explain the purpose and approx how long it will take
• Ask Open Ended Questions
• Allow the patient to Explain Things In his/her Own Words
• Encourage the patient to Elaborate and Explain
• Avoid Interrupting
• Guide the Interview As Necessary
• Avoid Asking “Why?” Questions
• Listen and Observe For Cues
• You might need an informant
History
Demographic data
Name
Sex
race
Locality
marital status
Occupation
Religious belief
living circumstance
History
Chief complaints
Patient's problem or reason for the visit
Recorded as the patient's own words
Ask leading questions such as
• "What brings you here today?“
• “How can I help you?”
History of present illness
main part of the interview
gather basic information of specific symptoms
Include both pertinent positives and negatives
Record important life events
Different approaches may be needed
depending on the circumstances
• Emergency department consult
• Routine Out patient evaluation
Onset
Abrupt
Acute
Insidious
Course
Continuous
Episodic
Remittent
Precipitating factor
A failed romance A death in
the family
Serious
illnesses
Failure in
exams
Problems in
relationships
Important
Obtain a clear chronological account of symptoms ( e.g. depression, psychosis) &
the effects of these symptoms on behaviour
Past history
Psychiatric & Medical History
Life chart
Family history
3 generation Genogram
Family history of Psychiatric illness
Family history of Medical illness
Living situation
Interpersonal issues
Personal history
Birth & early development
Disorders during childhood
Schooling and occupation
Menstrual history
Marital history
Premorbid personality
Social relations
Mood
Attitude towards work and responsibility
Response to criticisms and praise
Leisure activities and hobbies
Questions for PMP assessment
• Before all this happened, how would you describe yourself?
• How would other people describe you?
• When you find yourself in difficult situations, how do you cope?
• What sort of things do you like to do to relax?
• Do you have any hobbies?
• Do you like to be around other people or do you prefer your own company?
• Are you religious?
• Do you have any ambitions or plans?
Alcohol & drug history
Do you smoke? How many? Since when?
Do you take a drink?
How much do you drink?
Have you been drinking any more or less
than normal recently?
Have you ever taken drugs?
Forensic history
Have you ever been in trouble with the police, or been convicted of anything?
***
LOGO
Mental Status Examination
Definition
• Cross-section of the patients’ psychological life and sum total of nurses’ observations & impression of that moment.
• Some part of the MSE are through simple observation
• Others requires asking specific questions
• MSE is the evaluation of the patients’ present status
Descriptive Vs. Psychodyanamic
Descriptive
• Karl Jaspers
• Method of describing subjective experience & pt behavior
• Atheoretical
• Not rest on any particular explanation for the cause of the abnormal status
• Close-observation & empathetic exploration of the subjective experience (Phenomenology)
Psychodyanamic
• Sigmund Freud
• Assessing the behavioral changes by explaining the psychological process which is unaware to the pt
• Psychoanalysis/Hypnotherapy/Dream analysis
Mental status examination
General appearance & behavior
Psychomotor activity
Speech
Thought
Mood
Perception
Cognitive functions
General appearence
Attitude toward the interview situation
Consciousness
Orientation
Cooperativenes
Rapport and attitude toward the interviewer
Dress
Attention Span
Catatonic signs
Clinical implications
• Dilated pupil: Drug intoxication
• Pupil constriction: Narcotic misuse/dependance
• Gaze shift/stooped posture: Depression
• Unusual attire/colourful dress: Mania
• Over familiarity: Mania
• Seductive: Histrionic PD
Psychomotor activity
Goal directed activity
• Decreased
• Normal
• Increased
Level of activity: Lethargic, tense, restless,
agitated
Type: Grimaces, Tics, Tremors
Unusual gestures
Disorders of motor activities
Tics:
Rapid irregular movements involving groups of facial
or limb muscles
Mannerisms
Abnormal & occasional bizarre performance of a
voluntary, goal-directed activity
Stereotypy
A negative & bizarre performance; Not goal-directed
Catalepsy
General term for an immobile position that is
constantly maintained
Posturing
Assumption of various abnormal bodily positions for a
long time (Psychological pillow)
Negativism
Patient resists carrying out the examiners’
instructions & his attempts to move or direct
the limbs
Catatonia
Syndrome characterized by cataleptic
posturing, stereotypy, mutism, stupor,
negativism, automatic obedience, echolalia &
echopraxia.
1. Excitement & 2. Retardation
Echopraxia
Imitation of another persons movements
Ambitendency
Series of uncertain, incomplete movements
carried out when a voluntary action is
anticipated
Abulia
Reduced impulses to act or think; associated
with indifferences about the consequences of
action
Akinesia: Inability to move
Akathisia: inability to seat/stand still
Clinical implications
Excessive body movement (PM Agitation)
Anxiety, mania, stimulant abuse
Psychomotor retardation
Depression, organicity, catatonic F20, drug-
induced stupor
Tics/grimaces
S/E of Psychotropic Medications
Repeated movements OCD
Picking up of dirt from clothes:
Delirium, Drug-toxicities
Speech
Tone
Tempo
Volume
Reaction time
Coherent
Relevant
Sample of
Speech:…………………………………………
……………………………………………………
Disorders of speech
Pressure of speech
Rapid speech that is increased in amount &
difficult to interpret
Poverty of speech
Restriction in the amount of speech
Dysprosody: Loss of normal speech melody
Dysarthria: Difficulty in articulation
Cluttering: erratic & Dysrythmic speech
Stuttering
Frequent repetition/ prolongation of a
sound/syllable leading to markedly impaired
speech fluency
Clinical implications
Speech expressive problems
Brain involvement, developmental problems,
Eg: ELD
Pressure of speech
Mania
Mutism/Alogia
Depressive Sx/Catatonic F20
Thought
Form
Stream
Posession
Content
Delusion
Overvalued idea
Depressive cognition
Suicidal idea
Disorders of form of thought
Derailment: Thoughts slides on to a subsidiary content
Substitution: Major thought is substituted by a subsidiary one
Omission: Senseless omission of a thought or a part of it.
Fusion: Heterogenous elements of thoughts are intervowen with each other
Driveling: Distorted intermixture of constituent part of one complex thought
Evident through neologism, word salad etc
Disorders of stream of thought
1- Pressure of thought
2- Poverty of thought: A slowing down of the
thinking process which hampers the formation of associations & may prevent the patient from reaching the original goal of his thoughts.
3-Thought blocking: The patient experiences
a sudden break in the chain of thought (Schizophrenia).
4-Flight of ideas: A series of thoughts
verbalized rapidly with abrupt shifts of subject matter with logical sequence. (Mania as well as in organic mental disorders)
5- Loosening of associations: A disorder of
thinking & speech in which ideas shift from one subject to another with remote or no apparent reasons. (F20)
6- Perseveration: Repetitive behavior or
repetitive expression of a particular word, phrase, or concept during the course of speech.
7- Circumstantiality: The determining
tendency is maintained but the patient can reach the goal only after having exhaustively explored all unnecessary associations arising in his mind.
8-Tangentiality: expressions or responses
characterized by a tendency to digress from an original topic of conversation, in which a common word connects two unrelated thoughts.
Clinical implications
Circumstantiality:
Defensiveness, paranoid thinking
Schizophrenia/psychotic disorders
Loosening of association
Schizophrenia/psychotic disorders
Perseveration
Brain damage
Word salad
Severe form of thought disintegration
Chronic psychotic illness
Disorders of Content of thought
Delusion
False unshakable belief, which is out of
keeping
Overvalued ideas
Ideas which are reasonable & understandable
in themselves but which come to
unreasonably dominate the patient's life.
Depressive cognition
Suicidal idea
Types of delusions
1. Delusions of persecution: being followed, harassed, threatened, or plotted against.
2. Delusions of grandeur: being influential and important, perhaps having occult powers, or actually being some powerful figure out of history (Napoleonic complex).
3. Delusions of reference: external events or “portents” have personal significance, such as special messages or commands.
Continues
4- Delusions of love characterized by the patient's conviction that another person is in love with him or her .
5- Delusions of guilt :A delusional belief that one has committed a crime or other reprehensible act. (psychotic Depression)
6- Delusions of control: The core feature is the delusional belief that one is no longer in sole control of one's own body.
Continues.
7- Hypochondriacal delusions founded on the conviction of having a serious disease.
8- Delusional jealousy: A delusional belief that one's partner is being unfaithful (Othello syndrome)
9- Delusional misidentification: A delusional belief that certain individuals are not who they externally appear to be.
The delusion may be that familiar people have been replaced with outwardly identical strangers (Capgras syndrome) or that strangers are (really) familiar people (Fraegoli syndrome).
Continues.
10- Delusions of thought interference:. A group of delusions which are considered first-rank symptoms of schizophrenia. They are thought insertion, thought withdrawal, and
thought broadcasting
11-Nihilistic delusion: A delusional belief that
the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless. A feature of psychotic depressive illness
Mood Vs. Affect
Mood Affect
Subjective Objective (noted by the examiner)
Pervasive & sustained emotion, it is not influenced by will, & is strongly related to values
Subjective & immediate experience associated to ideas or mental representations of objects
Sadness, aggression, joyous etc
Classified as blunted, flattened, broad, labile, appropriate & congruent
Disorders of emotions
Alexithymia:
Inability/difficulty in describing or being aware
of ones emotion/mood (depression,
substance abuse, PTSD)
Anhedonia:
Loss of interest in, and withdrawal from all
regular & pleasurable activities (Depression)
Anxiety:
Feeling of apprehension caused by
anticipation of danger, which may be internal
or external
Bereavement
Feelings of grief or desolation, especially at
the death or loss of a loved one.
Blunted affect
Severe reduction in the intensity of
externalized feeling tone (F20)
Elation:
Mood consists of feelings of joy, euphoria,
and intense optimism (mania)
Flat affect
Absence/nearly absence of any signs of
affective expression
Irritability:
Abnormal excessive excitability, with easily
triggered anger, annoyance and impatience
Melencholia:
Severe depressive state
Clinical implications
Euphoria, elation, exaltaion, ectacy:
Mania
Anxious/restlessness:
Depression/anxiety
Sad, irritable, angry/depressed:
Depression
Shallow, blunted, indifferent, restricted inappropriate:
Schizophrenia
Anhedonia:
F20, Depression
Perception
Perception
Complex process Of screening of physical
signals by sense organs by processing these
data to represent reality.
Imagery:
Awareness of a percept that has been
generated within the mind. Imagery can be
called up and terminated by an effort of
will(voluntary).
Disorders of perception
Illusion
Misperceptions of external stimuli (anxiety
and delirium)
Hallucination
A true hallucination will be perceived as in
external space, distinct from imagined
images, outside conscious control, and as
possessing relative permanence
Types of hallucinations
Auditory hallucinations—false perceptions of sounds
(second person, third person)
Gustatory hallucinations—false perceptions of taste.
Olfactory hallucinations—false perceptions of smell.
Visual hallucinations—false visual perceptions with eyes open in a lighted environment.
Tactile hallucinations—false sensations of touch. (Formication)
Hypnagogic Vs. hypnopompic hallucinations (Pseudo AH)
Autoscopic hallucination:
Experience of seeing ones own body
projected in to external space, usually in front
of oneself, for short periods (NDE)
Reflex hallucination:
A stimulus in one sensory modality results in
hallucination in another…..music-----visual
hallucination
Clinical implications
Any form of hallucinations:
Schizophrenia (72% AH), affective disorders, and
organic mental disorders.
Visual hallucinations
Suggestive of organic mental disorders but are seen
in functional disorders.
Gustatory, olfactory, and tactile hallucinations
Strongly suggest organic mental disorders.
Tactile hallucinations
Common in drug and alcohol withdrawal and
intoxication states.
Cognitive functions
Consciousness and Orientation 1
Attention and Concentration 2
Memory 3
4
Judgement 5
6
Intelligence
Insight
Insight
Insight
Patients awareness of his disability & need for
help
Clinical grading of Insight
1. Completed denial of illness
2. Slight awareness of being sick & needing
help but denying at the same time
3. Awareness of being sick, but attributed to
external/physical cause
4. Awareness of being sick due to something
unknown in self
5. Intellectual insight:
• Awareness of being ill & that the Sx/failures in
social adjustments are due to own particular
irrational feelings/thoughts yet does not apply
this knowledge to the current/future experience
6. True emotional insight
• It is different from the intellectual insight in that
awareness leads to significant basic change in
the future behavior personally
Multiaxial format in DSM -IV
Axis I- All clinical disorders
Axis II - MR, personality disorder
Axis III - General Medical Conditions
Axis IV - Psychosocial Stressors
Axis V - Global Assessment of Functioning
Diagnostic Clusters under ICD-10
F00-09 Organic including symptomatic, mental dis
F10-19 Mental & Behavioral dis. Due to psychoactive substance use
F20-29 Schizophrenia, schizotypal & delusional dis.
F30-39 Mood (Affective) disorders
F40-49 Neurotic-stress related & Somatoform dis.
F50-59 Behavioral syndromes associated with physiological disturbances & physical factors
F60-69 Dis. of adult personality & behavior
F70-79 Mental retardation
F80-89 Disorders of psychological development
F90-98 Behavioral & emotional dis. with onset usually occurring in childhood and adolescence
Fuerther readings
1. Kaplan & Saddocks’ Synopsis of Psychiatry