Psychological medicine

Mental State Examination

  • This is NOT an assessment of cognitive function (the mini-mental state is about cognitive function, but is just part of a description of mental state)
  • Appearance and Behaviour
  • General appearance: physique, hair, make-up, tattoos, scars, clothing (self neglect, incongruous dress, weight loss)
  • Facial expression: suggestion of depression, anxiety, physical disorder (eg parkinsonian syndrome)
  • Posture
  • Movements: mood and involuntary movements (tics, dystonia, akathisia, tardive dyskinesia, parkinsonism), psychomotor agitation (eg how long to answer a question) 
  • Social behaviour: over familiar, disinhibited, withdrawn, preoccupied, co-operative or not, bizarre behaviour
  • Speech
    • Rate – fast/slow, Quantity – a lot/little, Loudness – loud/soft
    • Spontaneity, Continuity, Articulation, Prosody, Pressure
  • Mood: Prevailing mood at the time. The patient‟s subjective experience, what they report. Note fluctuations (eg diurnal variation in depression is common)
  • Affect
  • Refers to the objective appearance of emotions observed during the interview: anger, anxiety, elation, irritability, depressed, etc
  • Quality, intensity, stability, range
  • Variations: labile, restricted, blunted, flattened, inappropriate, fluctuating
  • Appropriateness: congruous with thinking or not
  • Thought Form
    • May be best demonstrated by direct quote
    • Is there a logical connection between ideas or not – from an opening statement through to a goal
    • Then define type, eg:
      • Loosened associations
      • Flight of ideas
      • Derailment
      • Thought block (just stops)
      • Tangential (talks at great length but never gets to the point)
      • Interpenetration of themes (rapid change to something completely different)
  • Thought Content
    • Depersonalisation: feeling detached from oneself, feeling unreal (often with anxiety)
    • Derealisation: feelings of unreality of the external world 
  • Spectrum: ideas ® concerns ® preoccupations ® overvalued ideas ® obsessions ® delusion. Note different levels of conviction: 
    • Over-valued idea: I think it but accept that others don‟t
    • Obsessional: I know it‟s not true but I can‟t get it out of my head 
    • Delusional: I think that, and everyone else thinks that, and I don‟t believe them if they say they don‟t 
  • Obsessional phenomena (see Topic: History Taking in Anxiety Disorders)
  • Delusions: 
    • Evaluating delusions: Describe unusual statement, experience or event, decide if it is false, is there any cultural determination, classify it
    • Passivity phenomena/control:
      • Thought insertion: reports „alien‟ thoughts
      • Thought broadcast: thoughts transmitted to other people
      • Thoughts spoken aloud: feels as if thoughts are audible to others
      • Thought echo: involuntary repetition of thoughts
    • Delusional mood
    • Delusional perception: perception + delusional interpretation
    • Paranoid delusions: Is anyone trying to harm you?
  • Referential delusions: have you noticed anything (eg on TV) that refers to you
  • Grandiose delusions, sexual delusions
  • Delusions of guilt, hypochondriasis, nihilism 
  • Delusions of misidentification and misrepresentation: refers to the belief that people have been replaced by impostors

Suicidal and homicidal ideation

  • Always screen all psychiatric patients for suicide
  • Definitions:
    • Attempted suicide: self-inflicted harm intended to cause death
    • Parasuicide: Act intended to communicate distress not intended to cause death

Suicide History

  • Overview:
    • Establish and maintain rapport
    • Evaluate for:
      • Suicidal thinking
      • Suicidal intent
      • Suicidal plans
      • Future orientation
      • Relevant mental status: including mood, drugs/alcohol, labile, impulsiveness, insight, etc
    • Assessment of risk factors
  • Ideation questions:
    • Do you see a future for yourself?
    • Do you think a lot about death?
    • Have you ever considered harming yourself/wanted to end your life?
    • What specifically have you thought about this? When did you start thinking this way?
    • Have you talked to anyone about this?
    • Do you want to die – or do you want others to realise how bad things are for you?
    • Have you thought of a plan to kill yourself?
    • Do you have the means?
    • What has stopped you so far?
    • Have you thought about the effect your death would have on family and friends?
    • How do you feel about accepting help?
    • How does talking about this make you feel? 
    • If can‟t ask the question directly, then „what do you think about suicide‟, „what would you do if it got that bad‟, „how bad does it get… have you ever felt so bad that you wanted to end your life‟ 
    • Have you thought of hurting anyone else
  • Past Suicide attempt(s):
    • What did you do?
    • When did you start thinking about suicide?  Why did you think that?
    • When did you plan to do something? (ie was it impulsive or planned)
  • When did you start to action the plan?  What triggered that (what was the final straw)?
  • Did you leave a note/say goodbye/wind up your affairs?
  • What stopped you going through with it?
  • How did you get to be in hospital?
  • Are you surprised to be alive? (ie did they genuinely think it was going to kill them)
  • Has anything changed in the things that made you try?
  • What did you feel about getting help? 
  • Perceptual Phenomena
    • Illusions: misrepresentation of external environment – transformation without perception
    • Hallucinations: 
      • External perception without any external stimulus. Hearing voices inside your head is not an hallucination – they should hear them as coming from outside their head
      • Can be auditory, visual, olfactory, tactile or taste 
      • If auditory, clarify characteristics: sounds or voices, one or more voices, talk to you or to each other, give commands, do you recognise them, believe them
  • Cognition
    • Is defined by how we assess it!
    • Can test with Mental Status tests, etc 
    • Observe alertness, attention and concentration (serial sevens, spell „world‟ backwards, days or months backwards), orientation (time, place and person), memory, executive function, localised functions 
    • Testing memory: short term – recollection at 5 minutes, recent memory – events over past several days (adapt to patient‟s interests), remote memory – personal events, birth date, sequence of events [NB – this classification is really an artefact – it doesn‟t correlate with how memory works]
  • Language: word finding, comprehension, reading, writing
  • Calculation: needed for getting change, paying bills
  • Visuospacial: dressing, finding way around, neglect, problem for driving
  • Visual perception: can‟t recognise what they see 
  • Personality change: usually exaggerates or ameliorates premorbid state: motivation, spontaneity, persistence, care, social conduct, quality of relationship, aggression
  • Problem solving ability 
  • Consider in the context of ADLs (Activities of Daily Living) and Instrumental ADLs (eg using phone) 
  • If confused may need to interview an informant
  • Patient will usually water down symptoms
  • Intelligence: Vocabulary, previous and current performance
  • Insight and Judgement
    • Awareness of their own mental condition, do they recognise the reasons for their difficulties
    • Full, partial, limited, grossly impaired
    • Base around 4 questions:
      • Are they aware of the phenomena others have observed
      • If so, do they recognise them as abnormal
      • If so, do they consider they are caused by mental illness
      • If so, do they need treatment
  • Rapport
    • Sense of empathy, emotional response of interviewer to patient and patient to interviewer
    • Good, superficial, none 
    • Easy to overestimate: key test is would they do something you asked if they didn‟t want to. Can you predict future relationship