Mental State Examination PDF

**Mental State Examination** [Components of the Mental Status Exam] - General Appearance and behavior - Talk - Mood - Thought content. - Perception - Orientation - Memory - Attention and concentration. - Intelligence - Insight/Judgment ➤ **Appearance** - Build, pos...

**Mental State Examination** [Components of the Mental Status Exam] - General Appearance and behavior - Talk - Mood - Thought content. - Perception - Orientation - Memory - Attention and concentration. - Intelligence - Insight/Judgment ➤ **Appearance** - Build, posture, dress grooming الهيئة (care for one\'s personal appearance, hygiene, and clothing), prominent physical abnormalities. - Looks healthy or sick. - **Signs of anxiety**; wet hands, perspiring, tense posture, wide eyes. - **Level of alertness**: Somnolent, alert. - **Attitude toward the examiner**: Cooperative, uncooperative. ➤ **Behavior** - **Stereotypy:** repetition of speech or action without significance - **Mannerism:** repetition of normal movement that appear to have some significance e.g. exaggerated shaking hands. - **Perseveration:** repetition of the same act in spite of the desire to stop. - **Echolalia**: (imitation of words) - **Echopraxia**: (imitation of action). - **Negativism, resistance and rigidity:** resist all efforts to be moved. - **Catatonic symptoms (catatonic schizophrenia or brain pathology):** - [**Catatonic excitement**:] agitated purposeless motor activity uninfluenced by external stimuli - **[Catatonic Posturing (waxy flexibility, cerea flexibility, catalepsy):]** abnormal posture for a long time without fatigue. - **[Catatonic stupor:]** markedly slowed motor activity to the point of immobility and seeming unaware of the surroundings - **[Catatonic rigidity:]** resist all efforts to be moved, **➤ Speech: Stream** 1. **Hurried stream:** a. **Pressure of speech** b. **Circumstantiality:** excessive unnecessary details but get to the point c. **Tangential**: Move from thought to thought that relate in some way but never get to the point d. **Flights of ideas:** change of stream from one idea to another. 2. **Slow stream:** a. Poverty of thought: little or absent thought. b. Thought block: sudden stopping of the stream of talk. **➤ Speech: Expression** a. Loosening of association b. Incoherence: severe degree of loosening of association. c. Word salad: extreme incoherence. d. Neologism: new language formed by the patient **➤ Mood** - Is sustained emotional tone reported by the patient and observed by others. - Affect is a transient emotional experience. Comment on: depth, intensity, duration, fluctuations Mood 1. **Increased intensity of emotions** - **[Increased sadness]** - **Depression**: undue sadness - **Irritable mood:** easy provocation - **Anhedonia**: loss of interest and withdrawal from all regular pleasurable activities - **Greif or bereavement**: sadness appropriate to real loss - **[Increased happiness]** - **Euphoria**: sense of wellbeing - **Elation**: undue happiness, triumph, satisfaction or optimism - **Exaltation**: happiness with grandeur - **Ecstasy**: extreme happiness with mystical coloring and rapture نشوة - **[Increased fear]** - **Anxiety**: fear on anticipation of danger which may external or internal - **Fear**: of real danger - **Panic**: acute episodic anxiety with feeling of dread and autonomic discharge 2. **Decreased intensity of emotions** - **Flat affect:** absence of any signs of affective expression, voice monotonous, face immobile. - **Apathy:** absence of emotions associated with detachment and indifference - **Indifference:** calm or lack of concern about one\'s disability 3. **Abnormal emotions** - **Incongruity:** disharmony between affect and thought content. - **Ambivalence**: two contradictory emotions at the same time toward the same person. - **Emotional** **liability**: emotions swing from one extreme to the other (in pseudo bulbar palsy) **➤ Disorders of thought** - **Disorders of stream** - **Disorders of form** - **Disorders of content** - **Disorders of possession** - **[Disorders of content]** 1. **[Delusions]** - Fixed, false beliefs firmly held in, not corrected by logic. - Not accepted by patient education and culture - **Delusions of persecution:** people intend to harm me. - **Delusions of reference:** people\'s talk refers to me. - **Delusions of grandeur**: I\'m a great person, a prophet. - **Delusions of influence**: some power control the patient. - **Hypochondriacal delusions:** I have serious illness, a snake in my stomach. - **Nihilistic delusions**: I\'m not living, a dead body without soul - **Self-blame delusions**: God will never forgive me. - **Poverty delusions:** I lost everything; money, position or possessions. 2. **[obsessions]** - Compulsion to repeat thought or action, the patient tries to resist but he can\'t get rid of it. - **Recurrent obsessions, compulsion, or both** - **Obsessions**: thoughts, images, impulses That are persistent, markedly distressing - **Compulsion**: repetitive behaviors performed in response to an obsession. - **Thought withdrawal**: thoughts are withdrawn from his mind. - **Thought insertion**: someone puts thoughts in his mind. - **Thought broadcasting**: his thoughts are known to others **➤ Perception** **Illusions**: False Perception of the environment **Hallucinations**: False Perception without sensory stimulus e.g. hearing a voice that doesn\'t exist. **[Causes of hallucinations]** 1. **Normal** (**hypnagogic**: states between sleeping and waking and **hypnopompic**: awakening from sleep**).** 2. **Pathological**: Organic or psychogenic: A. **Organic**: - Toxic substance: endogenous or exogenous - Brain lesions and epilepsy B. **Psychogenic**: As Depression or Schizophrenia **[Types of hallucinations:]** 1. Auditory hallucinations 2. Visual hallucinations 3. Gustatory hallucinations 4. Olfactory hallucinations 5. Tactile hallucinations - as noise, music, voice. - Commenting or commanding. - 3rd person hallucination (talk to one another referring to the patient. - 2nd person hallucinations appear to address the patient. - as flashes of light, faces, persons - occur in hysteria, depression, schizophrenia. - They always raise the possibility of organic disorder. - Unpleasant smell or tastes, in temporal lobe epilepsy, schizophrenia or severe depression. - Sensation of insects moving under the skin occur in cocaine abusers. **➤ Orientation** - Time, place and person - Orientation is affected in organic brain syndrome **➤ Memory** - Immediate, short and long term - **Immediate**: repeat 6 digits forwards then backwards - **Short term**: mention what he ate in breakfast or last evening - **Long term**: Information about childhood then verified 1. **[Decreased or lost: ]** - **[(amnesia) which may be:]** - **Anterograde**: inability to learn new information. - **Retrograde**: amnesia for past events - **Circumscribed**: a gap in memory 2. **[Increased]**: - (**hypermnesia**) may be normal or occur in hypomania and paranoia 3. **[Distortion of memory (Paramnesia):]** - **Confabulation**: to fill a gap in his memory by false details. - **Falsification**: to add false details to his normal memory. - **Déjà** **vu**: disorder of recognition in which new situation is regarded as a previous experience. - **Jamais** **vu**: feeling of strangeness of familiar situation. **➤ Attention and concentration** - Serial 7(100-7) - Months of year - Days of the week **➤ INSIGHT AND JUDGEMENT** - **Insight**: is the patient\'s realization of his illness. - **[The patient should recognize that]:** -He is ill. -His illness is psychiatric in nature -He should seek medical help -He should cooperate with the given treatment. - **Judgement**: the ability to grasp the meaning of the situation and to react appropriately. **Remember to always do a** **PHYSICAL EXAMINATION** **[General observations]**: - Vital signs: HR, BP, RR, Temp - Autonomic arousal, tremor, sweating etc. **[Important features]**: - scars, tattoos, signs of liver disease, signs of thyroid or Cushing\'s disease, etc. - Specific CVS, RS, GI, and CNS examination findings and important negative findings **Psychosis** **It is a group of mental illnesses characterized by the Following:** - Impaired reality testing (touch with reality) - Impaired insight - Personality deterioration - In many cases necessitates hospitalization - In many cases delusions and Hallucinations **Schizophrenia** - [**The schizophrenic disorders:** ] - Are characterized in general by distortions of Thinking and perception, and affects that are Inappropriate or blunted. - Clear consciousness and Intellectual capacity are usually maintained. - **[Incidence]**: 1% of population and begins mainly in young age (mostly around 16 to 25 years). - **[Risk Factors/Etiology:]** - Men have an earlier onset, usually at age 15-25. - Many theories have evolved regarding the cause of schizophrenia. - Schizophrenia has been associated with high levels of dopamine and abnormalities in serotonin. - Because there is an increase in the number of schizophrenics born in the winter and early spring, many believe it may be viral in origin. - **[Prevalence]** - General population\...\...\...\...\...\...\.....1% - One schizophrenic parent......... 12% - Monozygotic twin\...\...\...\...\...\...\...\.... 47% - Two schizophrenic parents...\...\... 40% - Dizygotic twin\...\...\...\...\...\...\...\...\...\... 12% - First-degree relative\...............\....12% - Second-degree relative\...\...\...\...\... 5-6% - **[Course]**: - Continuous without temporary improvement or episodic with progressive (or stable) deficit or episodic with complete or incomplete remission. - **[Stages]**: - Prodromal phase, active phase, residual phase. - **[Diagnostic manuals:]** - ICD-10 (International Classification of Disease\", WHO) and DSM-IV (Diagnostic and Statistical Manual\", APA) - **[Negative schizophrenia]**: - alogia, avolition, anhidonia, apathy, asociality, attentional deficits. - **[Positive schizophrenia]**: - delusions, hallucinations, excitement and gitation. - **[Catatonic symptoms:]** - (stupor, stereotypy, mannerism, echolalia, echopraxia, waxy flexibility, posturing, negativism). - **[Clinical picture]**: - Positive or negative symptoms or mix of both - 6 months duration (including prodrom, active and residual phases) - socio-occupational impairment. - **[Etiology:]** - **The etiology and pathogenesis of schizophrenia is not known.** - **It is accepted, that it is multifactorial** - **[internal factors]** genetic, inborn, biochemical, - **[external factors]** trauma, infection of CNS, stress. - Role of dopamine hyperactivity and frontal lobe hypoactivity. - **[Types]**: - **paranoid** (persecutory delusions), - **catatonic** (stupor, stereotypy, mannerism, echolalia, echopraxia, waxy flexibility, posturing, negativism), - **disorganized** (disorganized behavior and speech) - **Simple** (social withdrawal and avolition). - **[Treatment]**: - Anti-psychotic medications - ECT - Therapeutic relationship - **[Hospitalization:]** - Is usually recommended for either stabilization or Safety of the patient. - If you decide to use Medications, antipsychotic medications are most Indicated to help control both positive and negative Symptoms. - If no response, consider using clozapine After other medications have failed. - The suggested psychotherapy will be supportive Psychotherapy with the primary aim of having the Patient understand that the therapist is trustworthy And has an understanding of the patient, no matter How bizarre. **Other psychotic disorders:** - Brief psychotic disorder - Schizo-affective disorders - Delusional disorders - Drug-induced psychotic disorders. - Psychotic disorders due to general medical Conditions. **Brief psychotic disorders Presenting** - **[Symptoms:]** - Hallucinations - Delusions - Disorganized speech - Grossly disorganized or catatonic behavior - Symptoms more than one day but less than 30 - **[Risk Factors:]** Seen most frequently in the low socioeconomic Status as well as in those who have preexisting personality disorders or the presence of Psychological stressors. - **[Treatment:]** - Hospitalization is warranted if the patient is acutely Psychotic, to assure the safety of her/himself or of Others. - Pharmacotherapy will include both antipsychotics and benzodiazepines. - The benzodiazepines may be used for short term Treatment of psychotic symptoms. **Schizophreniform Disorder** - **[Risk Factors/Etiology:]** Suicide is a risk factor given that the patient is likely to have a depressive episode after the psychotic Symptoms resolve. - **[Presenting Symptoms]** - Hallucinations - Delusions - Disorganized speech - Grossly disorganized or catatonic behavior - **[Negative symptoms]** - Social and/or occupational dysfunction - Symptoms are present more than one month but Less than 6 months - Most of the patients return to their baseline level of Functioning - **[Treatment]**: - Must assess whether the patient needs Hospitalization, to assure safety of patient and/or Others. - Antipsychotic medication is indicated for a 3-6 Month course. - Individual psychotherapy may be indicated to help the patient assimilate the psychotic experience into His/her life. **ACUTE STRESS DISORDER/POST-TRAUMATIC** **Schizoaffective Disorder** - **[Presenting Symptoms:]** - Uninterrupted period of symptoms meeting criteria for major depressive episode, manic episode, or Mixed episode - Symptoms for schizophrenia - Delusions or hallucinations for at least 2 weeks in The absence of mood symptoms - **[Prognosis]**: - Better prognosis than patients with schizophrenia. - Worse prognosis than patients with affective Disorders. - **[Treatment]**: - First determine if hospitalization is necessary. - Use Antidepressant medications and/or anticonvulsants to control the mood symptoms. - If not effective, Consider antipsychotics to help control the ongoing Symptoms. **Delusional Disorder** - **[Risk Factors/Etiology:]** - Mean age of onset is about age 40. - Seen more commonly in women, and most are Married and employed. - Has been associated with low socioeconomic status As well as recent immigration. - Can usually see Conditions in limbic system or basal ganglia, if Medical causes are determined to be the cause of The delusions. - **[Presenting Symptoms]** - Non bizarre delusions for at least 1 month - No impairment in level of functioning - The patients are usually reliable unless it is in Relationship to their delusions. - **[Types]**: - include erotomanic, jealous, grandiose, somatic, Mixed, unspecified. - **[Treatment]**: - Outpatient treatment is usually preferred, but the Patient may need hospitalization while you rule out medical causes. - **Pharmacotherapy**: consists of antipsychotic Medications, but studies indicate that many patients Do not respond to treatment. - **Individual psychotherapy**: is recommended, having the patient trust the physician to point out how the Delusions interfere with normal life. **Personality disorders (PDs)** - **[Personality disorders (PDs)]** - are characterized by personality patterns that are pervasive, inflexible, and maladaptive. - **[There are 3 clusters:]** - **[Cluster A]**: Peculiar thought processes, inappropriate affect. - **[Cluster B]**: Mood lability, dissociative symptoms, preoccupation with rejection. - **[Cluster C:]** Anxiety, preoccupation with criticism or rigidity - **[Risk Factors/Etiology]**: - PDs are the product of the interaction of inborn temperament and subsequent developmental environment. - Risk factors include innate temperamental difficulties, such as irritability; adverse environmental events, such as child neglect or abuse; and personality disorders in parents. - **[Prevalence]**: - All are relatively common. - More males have antisocial and narcissistic PDs, - more females have borderline and histrionic PDs. - **[Onset]**: Usually not diagnosed until late adolescence or early adulthood - **[Course]**: - Usually very chronic over decades without treatment. - Symptoms of paranoid, schizoid, and narcissistic PD often worsen with age; symptoms of antisocial and borderline PD often ameliorate. - **[Key Symptoms]**: - Long pattern of difficult interpersonal relationships, problems adapting to stress, failure to achieve goals, chronic unhappiness, low self-esteem. - **[Associated Diagnoses]**: Mood disorders - **[Treatment]**: - Psychotherapy is the mainstay of treatment. - Intensive and long-term psychodynamic and cognitive therapy are treatments of choice for most PDs. - Use of mood stabilizers and antidepressants is sometimes useful for Cluster B PDs. - **[Differential Diagnosis]**: - Major rule-outs are mood disorders, personality change due to a general medical condition, and adjustment disorders. **Cluster A** **[Paranoid PD]**: - **Distrust and suspiciousness**. - Individuals are mistrustful and suspicious of the motivations and actions of others and are often secretive and isolated. - They are emotionally cold and odd. **[Schizoid PD:]** - **Detachment and restricted emotionality.** - Individuals are emotionally distant. - They are disinterested in others and indifferent to praise or criticism. - Associated features include social drifting and dysphoria. **[Schizotypal PD:]** - **Discomfort with social relationships; thought distortion; eccentricity.** - Individuals are socially isolated and uncomfortable with others. - Unlike Schizoid PD, they have peculiar patterns of thinking, including ideas of reference and persecution, odd preoccupations, and odd speech and affect. - DSM-5 includes this PD in both psychotic disorders and personality disorders. **Cluster B** **[Histrionic PD:]** - colorful, exaggerated behavior and excitable, - shallow expression of emotions; - uses physical appearance to draw attention to self; - sexually seductive; - and is uncomfortable in situations where he or she is not the center of attention. **[Borderline PD:]** **Usually characterized by** - an unstable affect, mood swings, marked impulsivity, unstable relationships, recurrent suicidal behaviors, chronic feelings of emptiness or boredom, identity disturbance, and inappropriate anger. - If stressed, may become psychotic. - Main defense mechanism is splitting. **[Antisocial PD:]** **Usually characterized by** - continuous antisocial or criminal acts, inability to conform to social rules, impulsivity, disregard for the rights of others, aggressiveness, lack of remorse, and deceitfulness. - These have occurred since the age of 15, and the individual is at least 18 years of age. **[Narcissistic PD:]** **Usually characterized by** - a sense of self-importance, grandiosity, and preoccupation with fantasies of success. - This person believes s/he is special, requires excessive admiration, reacts with rage when criticized, lacks empathy, is envious of others, and is interpersonally exploitative. **Cluster C** **[Avoidant PD:]** - Individuals have social inhibition, feelings of inadequacy, and hypersensitivity to criticism. - They shy away from work or social relationships because of fears of rejection that are based on feelings of inadequacy. - They feel lonely and substandard and are preoccupied with rejection. **[Dependent PD:]** - Submissive and clinging behavior related to a need to be taken care of. - Individuals are consumed with the need to be taken care of. - They have clinging behavior and worry unrealistically about abandonment. - They feel inadequate and helpless and avoid disagreements with others. - They usually focus dependency on a family member or spouse. - And desperately seek a substitute should this person become unavailable. - [Associated features include] self-doubt, excessive humility, poor independent functioning, mood disorders, anxiety disorders, adjustment disorder, and other PDs. **[Obsessive-Compulsive PD:]** - Individuals are preoccupied with orderliness, perfectionism, and control. - They are often consumed by the details of everything and lose their sense of overall goals. - They are strict and perfectionistic, over conscientious, and inflexible. - They may be obsessed with work and productivity and are hesitant to delegate tasks to others. - [Other traits include] being miserly and unable to give up possessions. - This PD should not be confused with OCD, a separate disorder. - [Associated features include] indecisiveness, dysphoria, anger, social inhibition, and difficult interpersonal relationships.