Dr Joel Zugai's Lecture- Mental Status Examination (Audio Recorded) PDF

Aims Today’s lecture is focused on the mental status examination (MSE). We will be covering:  How to perform a mental health assessment in consideration of contemporary values;  Foundational features and techniques;  Common terms and language.  What is the MSE? The mental status examinati...

Aims Today’s lecture is focused on the mental status examination (MSE). We will be covering:  How to perform a mental health assessment in consideration of contemporary values;  Foundational features and techniques;  Common terms and language.  What is the MSE? The mental status examination (MSE) is the standardised format for documenting our observations of mental health consumers. The MSE format provides insight into the operation of mental health consumers’ minds. Aims to (objectively) uncover the subjective experience of the consumer and to determine the current mental state (focused on a particular moment in time).  Why have formalised means of assessment?  We need a standardised, routine approach to assessment so that professionals and consumers can work collaboratively with the greatest effect and efficiency. Standardised instruments and approaches ensure that assessments are thorough, accurate, and readily shared within the multidisciplinary team.  The formulaic structure of the MSE also prompts us to explore and consider multiple facets of the consumers’ mind. When and where do nurses conduct the MSE? Answer: Anywhere, anytime.  In the inpatient setting, the MSE is largely integrated into routine nursing interactions/conversations (observations of behaviour, appearance, mood, etc).  In the outpatient setting, the information that informs an MSE can only be gained from the brief interactions that are shared between nurse and consumer.  What do we get from the MSE? An effective, well documented MSE provides:  A comprehensive assessment of a person’s emotional, behavioural, cognitive & functional wellbeing.  A means to gauge the mental health of the person (what the person is experiencing & how these experiences affect them).  Information for shared clinical decision making.  Ongoing MSEs establish a baseline of expectations around an individual’s mental state. The Components of the MSE  Components of MSE  Appearance  Cognition &  Behaviour intellectual  Mood/Affect functioning  Insight & judgement  Speech  Risks  Thought form  Thought content  Perception  Appearance How does the person look/appear? Observe & document (no judgement or labels) -Distinctive features (scars, tattoos, wounds…) -Clothing (appropriateness to climate, social appropriateness) -Hygiene and grooming (clean, unkempt, disheveled, body odor…) -Build / body type (slight, medium, obese…) Concerning features of appearance Behaviour What is the person doing? (behaviour & attitude) -Cooperativeness, rapport developed, engagement with interview, response and interaction with health professional. -Body language & gestures, eye contact, posture.. -Psychomotor activity  hyperactivity - pacing, restless, psychomotor agitation  hypoactivity - slow reactions, psychomotor retardation -Compulsive behaviours -Bizarre behaviour (include descriptions) Behaviour Not all behaviours are obvious or intentional. https://www.youtube.com/watch?v=4ALy6I1J1uo Play from 0 – 2:00 Movements, such as those depicted in the video, should be documented, as they are indicative of mental state, and may be diagnostically relevant. As pictured in the next slide, some behaviours are intentional, and are more obvious.....  Smashed Perspex Broken Chairs Broken Table Affect & Mood What can you observe about the person’s emotional state & how does the person feel? Affect -The outward expression of emotion, observable by others. It manifests in facial expression, voice tone, body language and posture. Affect & Mood Mood - a term that describes a pervasive and sustained emotional state, subjectively experienced and described by the individual. It ‘colours’ the individual’s perception of the world -Generally, one has a broad range of affect that changes over time and in response to environmental changes. -Consumers can be asked to rate their mood on a scale of 1 to 10 where 1 is the lowest it has ever been, 10 the highest -Terms to describe mood & affect include: dysphoric, flat, elevated, depressed, anxious, labile, restricted, euthymic  Speech How is the person talking?  Consider quantity, quality, rate, volume and tone -Quantity: (increased) talkative, pressure of speech or (decreased) poverty of speech, monosyllabic, mute -Quality: slurred, mumbled, stuttering, whispered(even singing!) -Rate: pressured, rapid, slow -Volume: loud, quiet, whispered -Tone: monotone, deep, regular  Thought Form How are the persons thoughts constructed? How does the person put his/her ideas together - assessed through persons behavior, speech & expression of ideas. Consider: -Amount of thought & rate of production: poverty of ideas, thought blocking, flight of ideas, slow thinking -Continuity of ideas: ability to connect ideas/maintain logical order & flow. may not be able to stick to topic of conversation… -Disturbances in language: using words that do not exist, conversations don’t make sense, disorganization. -Direction: Is the language goal directed, or circumstantial & tangential. Features of Pathological Thought Form:  Derailment (Loosening of associations): Loss in the usual structure of thinking, ideas shift from subject to subject in an unrelated or loosely related way. "I think someone's infiltrated my copies of the cases. We've got to case the joint. I don't believe in joints, but they do hold your body together."  Tangentiality: Gives irrelevant or oblique replies to questions, might refer to the topic but not a complete answer. “Did you take medication, today?” “Medication is a tool of the devil, and we need to be careful about the supernatural. Supernatural is my favourite TV show! When will I get my T.V!?”  Thought blocking: Thoughts become absent for a few seconds unrelated to distraction or anxiety, and can not be retrieved.  Flight of ideas: Person’s ideas are too rapid for them to express, speech is fragmented & incoherent. The person is also difficult to interrupt. Features of Pathological Thought Form:  Circumstantiality: Speech is indirect & long winded, unnecessary details are provided, and the goal of the interaction is met in delayed form.  Poverty of Speech: Restriction in the amount of spontaneous speech, replies tend to be brief.  Word Salad: The expression of seemingly random words in an unintelligible sequence.  Neologisms: Made up words. Thought Disorder- Interview with Sandra  https://search.informit.org/do/10.3316/802963-21 3vid-id817735-29913318 Watch the following video. -Make note of how Sandra responds to questions, and her overall engagement in the interview. -Make note of the language that Dr. Cross uses to describe Sandra’s behaviour.  Thought Content What is the person actually thinking (ideas/beliefs) about? What is the person actually thinking about. What themes are coming up in their speech? Consider  Delusions  Suicidal/homicidal ideation/intent/plan - risk assessment  Preoccupations - persistent/repetitive topics  Obsessions  Phobias Delusions  Fixed, false, ideas, not in keeping with the individual’s cultural/religious beliefs, that can not be changed with reasoning.  Are examples of thought content disturbance, observed in people with psychotic conditions are usually categorised according to their content -somatic, nihilistic, grandiose, and persecutory.  They may also be considered in terms of their congruence with the person’s mood.  Delusions of control/passivity - the belief that one’s feelings are not one’s own but controlled by an external force  Ideas of reference - a person or object has particular significance or relevance to the person eg: a media presenter, a song on the radio, bill boards, number plates.  Perceptual Disturbance How does the person experience the world around them? Does the person hear voices, or strange or unusual sounds? -Observed by behavioural cues and/or person relating their experience. -Sensory misinterpretations or distortions. -Perceptions may be heightened (or dulled), so noises, colours and the environment seem more intense or vivid (how does the person experience/sense themselves in relation to the world around). -Depersonalisation and derealisation may occur. Hallucinations  A sensory perception that seems real but occurs in the absence of external stimuli and can involve any of the 5 senses (visual, tactile, olfactory, gustatory, auditory)  Auditory hallucinations are more commonly experienced in schizophrenia, particularly ‘voices’, but sounds, such as laughter, whispering, banging or music may also be heard  Auditory hallucinations can involve one or more voices, including ones commentating, commanding or conversing with each other  Auditory Hallucinations are the most common type of hallucination Cognition, Orientation & Sensorium Is the person alert and oriented to time & place, are they aware of their surroundings, are they able to concentrate?  Ascertains basic brain process and cognitive state (thinking) & functioning  Assessment of consciousness, orientation, memory, concentration, attention, capacity to read and write, visuo- spatial ability and abstraction  Brief initial assessment, if some dysfunction is suspected may require specific cognitive assessment  The Mini-Mental State Examination commonly used for screening cognitive function  Orientation – understanding of time, place & person  Levels of consciousness/alertness - alert, clouding, fluctuating, delirium, stupor, drowsy, etc.  Abstract thinking -the ability to understand concepts & juggle more than one idea at a time (similarities/differences between an apple and an orange or the meaning of a proverb ‘people in glass houses shouldn’t throw stones’ – need to consider the age, and linguistic/cultural background of the consumer)  Memory - immediate/recent/remote  remote eg childhood  recent past eg news in the last few months  recent eg what was eaten for breakfast that day  recall eg immediately repeat the names of 3 objects back to interviewer, then again after 5 & 15 min intervals Case study-Miriam Merten  The death of Miriam Merten in care is a reminder of our responsibility towards monitoring cognition.  https://www.youtube.com/watch?v=g1cT7gkL2-g Insight and Judgement  How aware is the person of his/her situation? Consider the person’s degree of awareness and understanding of the origin of their problem/symptoms and its meaning -Partial – e.g aware of a problem(s) but believes it originates with another who is considered responsible for it -Absent - no awareness that a problem of a psychological nature exists nor originates within the self Complete/true - the individual has awareness & understanding of his/her illness  acknowledgement of a possible MH problem  attributing the symptoms experienced to the illness  understanding possible treatment options & a willingness to engage in treatment  Judgement Is the person able to make safe judgements?  The extent that symptoms are influencing the persons behaviour and decisions  The persons ability to act safely & with understanding of the possible consequences of their actions  Significant in the context of safety & wellbeing Risks What kind of risks is the consumer vulnerable to? We must be thoughtful about the risks that a mentally ill person is subject to, and we must also consider how we can protect these people we are responsible for. Risks may involve: Suicide, self-harm, absconding, reputation, sexual exploitation, falls, etc. Clinical Formulation What do we get from the MSE?: -We learn a lot about the consumer. -Information gathered is readily shared with other team members. -With a baseline and ongoing assessments, development and progress can be monitored. -The findings from the MSE are used to inform nursing actions taken. -The nature & severity of symptoms & any risk issues are identifiable. -With findings from the MSE, we have both a subjective impression of the consumer as a person and a set of objective data about the consumer, also an understanding of their perceptions of current problems and how these relate to life history Clinical formulation is the process of bringing this information to develop an individualised explanatory account of the consumer