Mental state assessment

1. Mental state assessment Dr hab. med. Wiktor Drózdz

2. Basic contradiction during psychiatric examination need to obtain data necessary for diagnosis and intervention need to establish interpersonal relationship with a patient OR • Patients do not always cooperate • Open refusal to comply during examination of mental state • Problem of „shame cooperation”

3. Mental state examination • Crucial circumstances: • conversation in a quiet room with no other persons • TIME • Format: interview + observation of behavior • Additional information: • Medical documents • General medical examination • Lab tests • Inteview with near relative, friend or somebody who has observed patient (hospital staff)

4. Five Phases of the Psychiatric Interview • Phase 1: Warm-up and Chief Complaint • Phase 2: The Diagnostic Decision Loop • Phase 3: History and Database • Phase 4: Diagnosing and Feedback • Phase 5: Treatment Plan and Prognosis

5. Mental state examination aspects that must be considered • Reason for examination • Current mental health problem and course of the problem • Somatic interview • Interview toward substance abuse/other forms of addiction • Interview concerning past psychosocial development • Interview concerning past social functiong • Interview concerning past school/occupational functiong • Family interview • Current general medical sufferings • General medical examination • Examination of current mental state • Current level of functiong in social roles • Lab tests performed lately • Impressions from the examination

6. Openers • Opening questions or statements target a problem of varying scope. • Narrow scope: “What troubles bring you here to see me?” • The interviewer expects a prioritized brief list of difficulties. • Problem: The patient rambles. • Solution: The interviewer narrows the scope of the question or curbs the response. For instance (if patient cooperates): • P: (Responds with a long list of events that went wrong in his or her life). • I: Just tell me what problem has troubled you most during the last 3 days. • P: That I can't sleep. • Broad scope: “Give me a sense of how your life is going.”

7. Continuation • The interviewer tends to the patient's talk by raising eyebrows or uttering hmmms to signal to the patient nonverbally to continue. If his or her nonverbal signals get ignored the interviewer may use short tracking phrases, such as • “And?” • “Then what?” • “How is that?” • “That's interesting,” “ • “Really?” • “Oh, no!” to reward the patient with his or her attention and to encourage the patient to continue.

8. Five Ws of interviewing • What? • When? • Where? • Who? • Why?

9. Cues in psychiatric examination • Verbal • Vocabulary • Fluency? • Narration: structuralised? informative? • Non-verbal • eye contact • facial expression • gesticulation, body language • cadence, intonation • dress code

10. Methods to gain information • Conversation • Additional sources of information • Application of structuralised tools • Application of medical tests: EEG, MRI, urine test for psychoactive compounds, MDD Score(?) • Cooperation with other physicians/health care workers • Examination of medicated/intoxicated patient and/or under constraint (i.e. in emergency) • General medical examination

11. Some suggestions concerning interview • Decrease patient’s anxiety, create feeling of comfort • Decrease your own anxiety • Be patient, be commiserate and consolate • Things to be avoided: • Confrontation/argument • Medical jargon, scientific jargon, sophisticated terminology, weird sentences • Jokes (but sense of humour is OK) • Extract the time as much as possible • Learn from patients • Create adequate type of conversation

12. O C E T • Observation • Exploration • Conversation • Testing

13. Mental state assessment • Appearance, attitude & behavior • Cognitive status: awareness, memory, attention, IQ • Disorders of perception • Thought disorders • Obsessions and compulsions • Speech disorders • Mood, affect and emotions • Psychophysiological (vegetative) symptoms • Stressful life situations • Suicide risk assessment

14. 1. Appearance (O) • Well-groomed? dowdy? • Reek of sweat? of alcohol? • Needle marks? • Scars (on forearm, wrist)? • Inappropriate attire? • Missing eyelashes, eyebrows, hair? • Bitten-off nails? • Reddened, chapped hands? • Excessive piercing or tattoos?

15. 1. Patient attitude • Cooperative? Frank? • Eye contact: appropriate? • Withdrawn? Defensive? • Anxious? • Hostile? Angry? • Too friendly? Evasive? • Suspicious? Distrustful?Seductive? • Claim? • Apathetic?

16. 1. Insight & criticism • Slight awareness? • Blames others? • Complete denial? Level of cooperation: • Withdrawn? • Guarded? • Passive? • Acting Out? • Oppositional? • Hostile?

17. 1. Insight & criticism • awareness of morbid change in oneself and a correct attitude to this change including a realization that it indicates for a mental disorder • Is the patient aware of phenomena that others have observed? • If so, does he recognize the phenomena as abnormal? • If so, does he/she consider that they are caused by mental illness? • If so, does he/she think that treatment is needed? • degree of insight indicates whether a patient is likely to comply with treatment.

18. 1. Insight & criticism • ANOSOGNOSIA present in: • Psychosis • Dementia • Mania • Dependence • Anorexia

19. 1. Motor activity • Slowed • Restless • Agitated

20. Rigidity Tremor Tics (motor, vocal) Restless fidgeting, mannerisms Choreatic, athetotic movements Buccolingual movements Catalepsy Opposing movements Echopraxia Pseudoaphonia, pseudoparalysis, pseudoseizures Avoidance of touching Apraxia Seizures Cataplexy Micrographia Stereotypical movements Picking 1. Psychomotor disturbances (O, C, T)

21. 1. Dangerous? • DANGER TO OTHERS: • Violent temper • Threatens others • Physical abuser • Hostile • Assaultive • Homicidal ideation,homicidal threats,homicide attempt • DANGER TO SELF: • Self-injury • Self-mutilation

22. 2. Consciousness (O, T) • Consciousness - awareness of the self and the environment. Orientation: • personal • external (time, place, situation) • Hyperalertness? • Lethargy? Stupor?Coma?

23. 2. Confusion & delirium • Confusion- an inability to think clearly. It occurs in states of impaired consciousness but may occur when consciousness is normal. • Clouding of conciousness? • Delirium? • Confused: periodically? permanently?

24. 2. Stupor • the patient is immobile, mute, and unresponsive but appears to be fully conscious (eyes are usually open and follow external objects),reflexes are also normal and resting posture is maintained

25. 2. Memory • Immediate memory - the retention of information over a short period measured in minutes. • Recent memory- events that took place in last few days. • Long term memory - events over longer periods of time. • Ecmnesia? • Hypermnesia? • Confabulation- reporting memories as current events, or fulfilling memory gaps with description of events that never took place. It is characteristic for amnestic syndrome. • Criticism toward memory dysfunctions preserved?

26. 2. Attention Concentration: ability to focus the attention • Impaired concentration may be present in a wide variety of psychiatric disorders i.e. depression, mania, anxiety, schizophrenia and delirium • It is crucial symptom of ADHD

27. 2. Cognitive functions assessment • Digit Span (forward and reverse): • “I will recite a series of numbers to you, and then I will ask you to repeat them to me, first forwardand then backwards.” [Begin with 3 numbers – not consecutive numbers, and advance to 7-8 numbered sequence.] • Spelling Backwards: • “Spell the word ‘world.’ Now spell the word ‘world’ backwards.” • Calculations: • (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep subtracting 7 from that number asfar as you can go.” • (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3 from that number as far as you can go.” [Monitor for speed, accuracy, effort required, and monitor patient reactions to the request] • “Add these numbers: (15 + 12 + 7)” • “Multiply these numbers: (25 x 6)”

28. 2. IQ • Approximate assessment of intellect important in patients with intellectual disability • Mild • Moderate • Severe

29. 3. Disorders of perception • Illusions:perception of a real object or event, which is misinterpreted. May be present in delirium • Hallucinations: sensory perceptions occuring without external stimuli • Auditory, visual, tactile, olfactory, gustatory • Complexity: elementary or complex • Pseudohallucitations: identified in patient’s psychic space. Real hallucinations: identified in external space

30. 3. Disorders of perception • The most common hallucination are auditory hallucinations, usually in the form of voices. • Voices talking to each other about the patient, and voices commenting about the patient‘s ongoing acting or thinking, are considered to be typical to schizophrenia (third-person hallucination). • Voices which anticipate, speak or repeat (echo of thoughts) the patient’s thoughts also suggest schizophrenia.

31. 3. Disorders of perception- examples • „I can see a snake in the corner”- in fact it is a length of rope. Illusion • „I can hear some people talking with each other about my very private affairs just outside of the room”– other people in the same room hear nothing. Auditory hallucination (third-person)

32. 4. Thinking (C, E, T) • Linear, logical? • Goal-directed?

33. 4. Thought disorders • PACING: • increased? decreased? • CONTENT: • FORM: • Coherent thinking? • Incoherent? loosening of associations, lack of consistency, chaotic

34. 4. Thought disorders • Disorders of content of thinking (adequacy): delusion- a belief that is firmly held on inadequate grounds, it could not be affected by rational argument or evidence to the contrary, and is not a conventional belief that the person might be expected to hold given his/her educational, cultural and religious background. Briefly- a false unshakable belief hold against the evidence

35. 4. Thought disorders • Delusional moodis preceding unclear convictionthat some as yet unidentified change or event is about to take place, then the delusion follows, and the delusion is perceived like explaining of this mood. • Delusional perceptionis the attaching the new significance to a familiar percept without any rational reason. • Delusional memoryis a delusional interpretation attached to past event.

36. 4. Thought disorders: types of delusions Paranoid (bizarre) persecutory delusion of reference delusion of control thoughts insertion thoughts withdrawal thoughts broadcasting delusions of marital infidelity Affective (mood congruent & coherent) Depressive: guilt, punishment, catastrophic, hypochondric, Maniacal: grandiosity, charismatic, exceptional abilities/features

37. 4. Thought disorders: paranoid • The most common theme of delusion is persecution • The patient believes/is sure that some persons or organizations are trying to inflict harm on the patient, damage his/her reputation, or make him/her insane.

38. 4. Thought disorders: paranoid • Delusion of reference • the unwarranted idea based upon a trivial occurrence (e.g.the person at the next table looked at the patient) that a person is talking about you,watching you, or noticing you (the belief continues in spite of no evidence supporting the belief) • the idea that objects, events or people have a personal significance for and association with the patient (usually of very strong intensity) but in fact these events, objects or people (also: messages in TV, internet, news) have in common with the patient

39. 4. Thought disorders: paranoid • Delusion of control: beliefs that patient’s actions, movements or thoughts are controlled by an external agency, people or power and not driven by himself/herself • Delusion of possession of thoughts:i.e. thoughts insertion (thoughts are not the patient’s own but implanted from outside), thoughts withdrawal and thoughts broadcasting (due to lack of normal convictions that thoughts are private and cannot be shared unwillingly)

40. 4. Thought disorders: paranoid • Thought insertion – insertion of a thought into one’s mind by an outside agent • Thought withdrawal – having one’s thought withdrawn from one’s mind • Thought broadcasting – being able to broadcast one’s thoughts

41. 4. Thought disorders: maniacal delusions • Grandiose delusions: beliefs of exaggerated self-importance • Charismatic delusions: beliefs of kind of mission, special task and exceptional abilities to do this • Delusion of power: the patient is sure to have extraordinary strengths and capacities and therefore does not need to care for money, rules, other people etc.

42. 4. Thought disorders: depressive delusions • Guilty delusions: beliefs of deep, unbearable sinfulness • Punishment delusions: beliefs of penalty which is impossible to avoid because of great fault (without real reason) • Catastrophic delusions: beliefs that everything has gone wrong and there is no future due to lack of money, house, family etc. • Hypochondric delusions: beliefs of serious (even fatal) illness without evidence of disease

43. 4. Thought disorders • Overvalued idea: an acceptable comprehensible idea pursued by the patient beyond the bounds of reason. • The content of the overvalued idea is usually understandable and acceptable considering the person’s background • Hypochondria: preoccupation with (usually exagerrated or unreal) problems associated with organism and health

44. 4. Thought disorders • In pressure of thought: occurs in mania, ideas arise in unusual variety and abundance , thought pass through the mind rapidly. • In poverty of thought which occurs in depression, the patient has few thoughts and these lack variety and richness , thoughts seem to move slowly through the mind. • In thought block the stream of thoughts is interrupted suddenly, and the patient feels that his mind has gone blank. It suggests schizophrenia

45. 4. Formal thought abnormalities • Paralogy: ignoring rules of logic and common sense • Metonyms (paraphasia): words used in a new, private and unconventional way • Ambivalency • Catathymia • Evasive, racing thinking, flight of ideas • Blocking • Perseveration: persistent and inappropriate repetition of the same thought content

46. 4. Formal thought disorders • Loose associations, incoherent thinking, derailment (ideas slip off thetrack and onto another one that is obliquely related): a loss of the normal structure of thinking; thinking (constantly) missing the point and senseless; rules of syntax and grammar are ignored • Example: „My friend has an electric-radio receiver, but he never told me where it is. In fact, I have been to nuclear power plant, and there is nothing dangerous” • Circumstantiality (inclusion of too many trivial details, seriously indirect) • Tangentiality (oblique or irrelevant answers)

47. 4. Thought disorders • Derealization: feeling that the world surrounding is unreal/substantially changed in some alien way • Depersonalization: feeling that the body and/or personal identity is unreal/substantially changed/lost both may be associated with anxiety or psychosis

48. Examples of questions about thought disorders • “What’s been on your mind lately?” • “Do you find yourself ruminating about things?” • “Are there thoughts or images that appear really difficult if getting out of your head?” • “Are you worried/scared/frightened about something or sb?” • “Do you have beliefs that are not shared by others?” • “Do you ever feel detached/removed/changed/different from others around you?” • “Do things seem unnatural/unreal to you?”

49. Examples of questions about thought disorders & hallucinations • “Do you think someone or some group intend to harm you in some way?” • [In response to something the patient says] “What do you think they meant by that?” • “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into your head? Doesit ever seem like your own thoughts are broadcast out loud?” • “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile) things that arenot really there, such as voices or visions?” (Hallucinations are false perceptions) • “Do you sometimes think that real things around you, such as muffled noises or shadows may denote something special?” (Illusions are misinterpreted perceptions)

50. 5. Obsessions & compulsions • Obsessions: recurrent persistent thoughts, impulses, or images that enter the mind despite efforts to exclude them. Obsessions are regarded as untrue, useless, or senseless. • The characteristic feature of obsessions is the subjective sense of a struggle, the patient resists the obsession, which nevertheless intrudes into awareness. • There may be obsessional thoughts, ruminations, impulses or doubts