Week 2: Mental state examination

Question 1

What is the purpose of a mental state exam?

Answer 1

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

Question 2

What are the differences between a history and MSE?

Answer 2

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

Question 3

What is the structure of the MSE?

Answer 3

Appearance and behaviour

Speech

Mood and affect

Thought (form and content)

Perception

Cognition

Insight

Question 4

What elements of appearance and behaviour should be commented on?

Answer 4

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

Question 5

What elements of speech should you look out for in an MSE?

Answer 5

Rate (slow/ fast/ pressured)

Volume

Tone and rhythm (monotonous)

Spontaneity (poverty of speech)

Fluency (dysphasia, dysarthria, stuttering?)

Question 6

What is the definition of mood?

What is the nature of a mood?

Answer 6

mood = sustained emotional experience over a period of time

Nature can by euthymic (normal), depressed, anxious, irritable, elated

Question 7

What is the definition of affect?

What elements of affect should you comment on?

Answer 7

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

Question 8

How is thought form assessed?

What does thought form refer to?

Answer 8

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?

Question 9

What are key terms of thought disorders?

Answer 9

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

Question 10

What are key aspects of thought content?

Answer 10

• Suicidal thoughts
• Violent/ homicidal thoughts
• Abnormal beliefs –> delusions, overvalued ideas
• Obsessional thoughts

Question 11

Define delusion

Answer 11

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

Question 12

Define overvalued idea

Answer 12

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

Question 13

Define obessive thoughts

Answer 13

Recurrent, intrusive unpleasant thought.

The patient knows that the thought makes no sense and struggles to resist it.

Question 14

What are different types of delusion?

Answer 14

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

Question 15

What are three types of delusion defined by content?

Answer 15

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

Question 16

How can the content of delusions differ?

Answer 16

• 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

Question 17

Define hallucination

Answer 17

Hallucination = sensory perception in the absence of an external stimulus, which the patient believes is a real perception

Question 18

Define pseudo hallucination

Answer 18

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

Question 19

Define illusion

Answer 19

Illusion –> misinterpretation of an external stimulus e.g. mistaking a shadow for a person

Question 20

When are hallucinations normal?

What perception modalities can be involved in hallucination?

Answer 20

It is normal to hallucinate when falling asleep (hypnagogic hallucinations) or waking up (hypnopompic hallucinations)

Perception modality:

auditory/ visual/ gustatory/ olfactory/ somatic/ tactile

Question 21

What are key terms to know with auditory hallucinations?

Answer 21

• Elemental hallucinations –>
• First person hallucination –> thought echo
• Second person hallucination –> command hallucination
• Third person hallucination –> running commentary

Question 22

How would you ask a patient about their perceptions?

Answer 22

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?

Question 23

What is cognition?

What tools can you use?

Answer 23

Orientation to time, place and person

Use a formal cognitive testing tool e.g. MMSE

Question 24

What is insight in the psychiatric patient?

How do we assess insight?

Answer 24

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?