psychiatric history and mental status examinaiton

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