[01.32] Mental Status Examination (TG01-CG10) (V2) - Margerie Zia Majarais.pdf

Mental Status Examination Module 01: Principles & Perspectives II Joan Mae G. Perez-Rifareal, MD, DPBP, FPPA | Asynchronous II. COMPONENTS OF THE MSE TABLE OF CONTENTS I. MENTAL STATUS EXAMINATION........................................................1 A. PURPOSE OF CONDUCTING A THOROUGH MSE.........

Mental Status Examination Module 01: Principles & Perspectives II Joan Mae G. Perez-Rifareal, MD, DPBP, FPPA | Asynchronous II. COMPONENTS OF THE MSE TABLE OF CONTENTS I. MENTAL STATUS EXAMINATION........................................................1 A. PURPOSE OF CONDUCTING A THOROUGH MSE..........................1 II. COMPONENTS OF THE MSE............................................................. 1 A. GENERAL DESCRIPTION................................................................1 B. MOOD AND AFFECT..................................................................... 1 C. SPEECH......................................................................................... 2 D. PERCEPTION.................................................................................2 E. THOUGHT CONTENT AND PROCESS.............................................3 F. COGNITION...................................................................................4 G. IMPULSIVITY................................................................................ 4 H. JUDGMENT AND INSIGHT ........................................................... 4 III. MSE DEMONSTRATION...................................................................5 QUESTIONS......................................................................................... 6 ANSWER KEY.......................................................................................6 RATIONALE..........................................................................................6 1. General description ○ Appearance ○ Behavior ○ Attitude towards the examiner 2. Mood and Affect 3. Speech 4. Perception 5. Thought content/process 6. Cognition 7. Impulsivity 8. Judgment and Insight Take Note! ● When performing the MSE, avoid using judgmental terms and use objective descriptions LEARNING OBJECTIVES A. GENERAL DESCRIPTION 1. To discuss the significance of the MSE in the overall assessment of patients 2. To identify parts of the MSE 3. To correlate the different aspects of the MSE with particular medical disorders 4. To practice the skill of doing a thorough MSE APPEARANCE I. MENTAL STATUS EXAMINATION (MSE) ● A systematic format for recording findings about thinking (thoughts), feeling (emotions), and behavior (actions) ● Assesses the mental and psychological function at a particular time ○ MSE is dynamic because it changes from minute to minute or from day to day ● Based on the examiner’s observation ● Placed in the context of the patient’s history ● Begins the instant the examiner sees the patient A. PURPOSE OF CONDUCTING A THOROUGH MSE ● Assists in diagnosis ○ Is it a medical, neurological, or a surgical problem? ○ Is there a presence of psychosis? ○ Is the patient suffering from both medical and psychiatric disorders? ● Assess organicity ○ Is the medical problem due to something organic? ● Assess threat to self or others ○ For those with suicidal or self-harm thoughts, or homicidal plans ● Assist in decision-making in regard to the management of patients ● Evaluate progress through therapy ● Determines prognosis ● Necessary skill to become competent evaluators of patients YL6:01.32 ● Assess the patient’s appearance the moment they enter the examination room ○ Posture, poise, clothing, grooming ▸ E.g., healthy, ill, at ease, unkempt BEHAVIOR AND PSYCHOMOTOR ACTIVITY ● Assess the patient’s mannerisms ○ Observe for tics, gestures, twitches, agitation, combativeness, rigidity, gait, purposeless activity, and slowing of body movements ATTITUDE TOWARDS THE EXAMINER ● Assess the patient’s attitude ○ Cooperative, friendly, attentive, interested, frank, seductive, and playful ○ Some may be hostile, guarded, and evasive B. MOOD AND AFFECT ● Mood involves asking the patient questions while affect involves observing their facial expression ○ Look for the appropriateness between mood and affect MOOD ● The pervasive and sustained emotion that colors the person’s perception of the world ● Guide questions for assessing mood include: ○ Does the patient voluntarily share their feelings? ○ Is the patient depressed, anxious, euphoric, empty, guilty, frightened? ▸ E.g., “How are you feeling today?” or “Ano po ang nararamdaman niyo ngayong araw na ito?” ● May be labile or fluctuating ○ E.g., Patient’s mood changes from happy to depressed TG01: Alvarez, Balayan, Bantayan, Cosico, Escalante, Majarais, Manlutac, Ozaeta, Rivera, Roque, Santiago CG10: Beltran, Bugtas, Castro, Co, Figueroa, Laroga, S. Lim, Reyes, S. So, Te, Valencia, Vallar 1 AFFECT ● Inferred from the patient’s facial expression ● Guidelines for assessing affect include: ○ Is the patient’s affect congruent or incongruent with their mood? ▸ E.g., Patient may say that they are happy but their affect is constricted or blunted ○ Is the patient’s affect within normal range, constricted, blunted or flat? ● Ranges of affect include: ○ Normal ▸ E.g., Happy, able to smile and laugh ○ Constricted ▸ Facial expressions are controlled ○ Blunted ○ Flat ▸ More severe ▸ E.g., Monotonous voice, immobile face, no sign of expression Answers: 1T, 2F, 3 attitude towards the examiner D. PERCEPTION ● How we perceive or understand our environment using our 5 senses PERCEPTUAL DISTURBANCES ● Hallucinations ○ False sensory perception with no external stimuli ○ Seeing or hearing something that is not there ● Illusions ○ Misperception or misinterpretation of real external sensory stimuli ○ There is a source of stimuli but individual perceives it differently ● Depersonalization ○ The individual feels unreal, strange, and unfamiliar ○ The patient feels they are “not there” ○ The patient feels they are experiencing something different from reality ● Derealization ○ The patient feels the environment is unreal ○ The patient asks: “Is this really me?” ASSESSMENT FOR HALLUCINATIONS Figure 1. Ranges of affect C. SPEECH ● Quantity ○ Is the patient talkative? ○ Does the patient have poverty of speech? ○ Is the patient silent? ○ Does the patient speak one-worded or one-phrase responses? ○ Is the patient not able to talk in complete sentences? ● Quality ○ Is the patient pressured to talk? ○ Is the patient monotonous? ○ Is the patient loud? ○ Is the patient mumbling? ○ Is the patient comprehensible? ● Impairments in speech ○ Is the patient stuttering? ● Spontaneity ○ Is the patient spontaneous or not? ○ Does the patient need to be encouraged for them to talk to you? Active Recall Box 1. T/F: Mood involves asking the patient questions while affect involves observing their facial expression 2. T/F: Cooperative, friendly, attentive, interested, frank, seductive, and playful are words used to describe a patient’s behavior 3. The general description of the MSE involves assessing the appearance, behavior, and _______? YL6:01.32 Mental Status Examination ● Describe the sensory modality ○ Auditory: “May naririnig po ba kayo na kayo lang ang nakakarinig?” ○ Visual: “May nakikita po ba kayo na kayo lang ang nakakakita?” ○ Tactile: “May nararamdaman po ba kayo na kayo lang ang nakakaramdam?” ○ Olfactory: “May naaamoy po ba kayo na kayo lang ang nakakaamoy?” ● Identify the circumstances of the occurrence ○ Is it hypnagogic or hypnopompic? ▸ Considered normal and not pathognomonic of any psychiatric disorder ○ Is it postictal (after a seizure)? ○ Is it stress or anxiety-related? ● Describe the hallucinatory content ○ Did the patient mention seeing aliens? ○ Did the patient mention hearing voices talking to each other? ○ Did the patient mention hearing about a running commentary on what they are doing? ● These assessments can lead us to an assessment of either a primary psychiatric disorder or something medical Common Causes of Hallucinations ● Auditory ○ Can be a sign of a psychotic disorder ○ E.g., Voices talking despite being alone in a room ● Visual ○ Usually due to: ▸ Drug use ▸ Substances of abuse ○ E.g., Seeing bizarre things ● Tactile ○ Causes: ▸ Cocaine intoxication ▸ Alcohol detoxification ○ E.g., Formication: feeling of bugs crawling under the skin ● Olfactory 2 ○ Smelling something that is not there ○ Causes: ▸ Complex partial seizures (temporal) ▸ Seizure disorders Take Note! ● Dr. Perez-Rifareal mentioned in the lecture that Formication will appear in the exam. E. THOUGHT CONTENT AND PROCESS ● Thought Content: “Ano ang nilalaman ng iniisip?” ● Thought Process: How we are able to process our thoughts, if there are any derailments, etc. THOUGHT CONTENT ● Answers the question “What are you thinking about?” ● What to look out for: ○ Delusions ○ Preoccupations ○ Obsessions and compulsions ○ Phobias ○ Suicidal or homicidal thoughts and ideas ○ Ideas of reference ○ Poverty of content ○ Circumstantial ▸ Patient is able to answer the question but after going through irrelevant data before this person is finally able to go back to the original question ○ Looseness of Association ▸ Patient is unable to go back to the central idea of the question ▸ Logical flow of thought and coherence is lost ▸ Derailment ▸ E.g., derailment of thought process in sentence construction skills ○ Neologism ▸ Coming up with non-existent words or those that are not in the dictionary ○ Clang association ▸ Tendency to use words which have a clang or that are rhyming ○ Thought blocking ▸ Unable to give an answer ▸ Suddenly freezing and not able to respond Delusions ● ● ● ● False belief Fixed and difficult to challenge Based on incorrect inference about external reality Firmly held despite objective and obvious contradictory proof or evidence ● Firmly held despite the fact that other members of the culture or religion do not share the belief ● Types of Delusion: ○ Delusion of Control ▸ False belief that a person’s will, thoughts, or feelings are being controlled by external forces ▸ E.g., Belief that an alien is controlling their thoughts or is controlling them ○ Delusion of Grandeur ▸ Exaggerated conception of one’s importance, power, or identity ▸ E.g., “I am president”, “I am married to someone important” ○ Delusion of Infidelity ▸ Also called pathological jealousy ▸ False belief that one’s lover is unfaithful ○ Delusion of Persecution ▸ Most common delusion ▸ False belief of being harassed or persecuted ▸ E.g., Belief that they are being followed, paranoia THOUGHT PROCESS ● Pertains to how we are able to process our thoughts ● Answers the question “How is the patient processing thoughts?” ● Observe for the following when assessing for thought processes: ○ Normal ▸ Patient gives a coherent answer ○ Tangential ▸ Patient gives an answer that is really far off ▸ It does not answer the question that we asked YL6:01.32 Mental Status Examination Figure 2. Thought processes Practice giving the MSE for the patient in the video from Dr. Perez-Rifareal ● Give the MSE for the patient in the video: ○ General description ○ Mood and affect ○ Speech ○ Perceptual disturbances (e.g., hallucinations or illusions) ○ Thought content (e.g., delusions, preoccupations, or obsessions) ○ Thought process ● To access the video: Canvas > P&P Module > Modules > “Others” sub-module > Mental Status Examination Active Recall Box 4. T/F: Delusion of infidelity is the most common type of delusion. 5. T/F: Tangential thought process is when a patient is unable to go back to the central idea. Answers: 4F, 5F 3 F. COGNITION OTHER COGNITIVE TESTS ● Important to assess ● Looks at possible organic brain problems ○ Gives an idea if patient is suffering from any other medical problems and not really a primary psychiatric condition ● It tests the following: ○ Intelligence ○ Memory ○ Abstract ○ Thinking ○ Judgment ○ Insight ● Abstract Thinking ○ Different from concrete thinking ▸ Concrete thinking is very specific ○ Relative ▸ E.g., Checking if the patient is able to enumerate the differences or similarities between 2 objects ● Information and Intelligence ○ Checking for fund of information ○ E.g., Ask the patient to enumerate the last 5 presidents of the Philippines ● Be mindful of the educational level and economic status of the patient ● Ask the patient to interpret/understand proverbs ○ Ask them to interpret “Aanhin pa ang damo, kung patay na ang kabayo” CONSCIOUSNESS ● Take note if the patient in the clinic is: ○ Awake ○ Somnolence ○ Stuporous ○ Coma ORIENTATION ● Check for orientation to time, place, and person MEMORY ● Immediate Memory ○ Includes immediate recall and retention ▸ For example: ask patient to say “bola, mangga, puno” and then ask the patient to repeat the three words after 3-5 minutes ▸ Sometimes, we can ask to repeat the figures after examiners dictates them forward then backwards ● Recent Memory ○ Memory of the past few days ▸ Example: “Ano ang kinain mo kanina?” or “ Ano ang kinain mo kahapon?” ● Recent Past Memory ○ Memory of events in the past few months ● Remote Memory ○ Childhood date ○ Important events that occurred when the patient was younger such as: growing up years, happy memories with the family, years when patient was free of illness or younger CONCENTRATION AND ATTENTION SPAN ● Ask patient to do Serial 7’s ○ Instruct patient to start counting from 100 and deduct 7 each time ○ Tests for the ability of the patient to concentrate and focus. Give attention to the task at hand ○ Needs to be based on educational attainment ○ Another test is to ask the patient to spell the word “WORLD” or “KOPRA” ▸ Forwards and backwards ○ Ask the patient to name 5 things that start with a specific letter ▸ E.g., “Give 5 things that start with the letter X” READING AND WRITING ● Ask the patient to read and write ○ E.g., write "close your eyes" on a paper then ask the patient to read and do what is written on the paper ● Ask the patient to write a simple but complete sentence ● This checks if their cognitive processes are intact or affected YL6:01.32 Mental Status Examination G. IMPULSIVITY ● Is the patient able to control sexual, aggressive, homicidal, or other impulses? ○ Do they have full control over actions and emotions? ○ Critical to ascertain potential dangers to others ○ Can be estimated from recent history and observed behaviors ● Useful in assessing potential danger to oneself or others ● Estimated from recent history and observed behaviors H. JUDGMENT AND INSIGHT JUDGMENT ● Seeks to answer the question, “Can the patient predict what he can do in imaginary situations?” ● The ability to predict the outcome in any situation ○ Can you come up with good decisions or appropriate responses, given the possible repercussions of your actions? ● Is the judgment good? Is it poor? Is it impaired? [Example] Test for Judgment ● What would you do if, while watching a movie in a cinema, someone suddenly shouts, “FIRE!!!”? INSIGHT ● Patient’s degree of awareness and understanding about his mental and emotional state, about being ill Intellectual Insight ● Admission of illness without applying this knowledge to future experiences ○ E.g., the patient knows that he needs to take medications for his illness, but he won't adhere to it because he thinks he doesn’t need it True Emotional Insight ● Emotional awareness of the motives and feelings within the patient which can lead to basic changes in behavior Practice Identification from Dr. Perez-Rifareal Identify the symptom present in the patient for the following situations: 1. A person is convinced that he has special powers and believes that he is someone famous 4 2. You hear people talking next to you when there is no one in your house 3. A boy hears voices in the sound of running water 4. A girl thinks that aliens control her thoughts and that she has no control over them 5. A child perceives tree branches at night as if they are goblins Identify the thought process present in the patient for the following situations: 6. Q: How old was your mother when she died? A: A lot of accidents happen every day. Too many people die in accidents. My mother was 58 when she died in a car accident. 7. Q: Where are you from? A: My dog is from England. They have good fish and chips there. Fish breath through gills. 8. Q: How do you interpret the proverb, “Don’t cry over spilt milk?” A: I believe you should release the tension now of all milk on the ground. You know you hold it inside and you could explode a lot. I think you should release yourself after all that milk is on the ground. Answers: 1 Delusion of grandeur, 2 Auditory hallucination, 3 Illusion, 4 Delusion of control, 5 Illusion, 6 Circumstantial thought process, 7 Looseness of association of thought process, 8 Impaired abstract thinking Active Recall Box ● ● ● ● ● 6. T/F: Evaluating the thought process involves asking the question “what are you thinking about?” 7. T/F: Abstract thinking is both specific and relative. Answers: 6F, 7F ● Take Note! ● The following part is a demonstration of how to conduct the MSE with the questions the physician used for testing each domain of the exam ● III. MSE DEMONSTRATION ● Start ○ “I’m going to ask you some simple questions that are going to test your memory and your thinking” ● Alertness and Attention ○ “Can you please tell me the months of the year starting from January?” ○ “Now can you say them backwards please?” ● Orientation ○ “Can you tell me your full name please?” ○ “What year is it right now?” ○ “And what month is it?” ○ “And what is today’s date?” ○ “And where are we right now?” ● Recent memory ○ “I’m going to give you three words to remember, and I’m going to test you on those words in about five minutes.” ▸ Use a timer after giving the three words to ensure that you remember to ask the patient to recall the words after a fixed interval YL6:01.32 Mental Status Examination ● ● ● ● ○ Please remember hat, chair, and Chicago. Can you say those back to me now please? ▸ Set the timer and give other tests to distract the patient so that they do not rehearse during the interval ○ When the timer goes off ▸ “Do you remember those words I asked you before?” Remote Memory ○ “Can you please tell me the name of the president?” ▸ “And before that?” ▸ Continue asking the patient the previous presidents until they can no longer recall Language: Spontaneous Speech ○ “Can you tell me what it was like when you were growing up in the place that you grew up?” Language: Comprehension ○ “Close your eyes please” ○ “Open your eyes” ○ “Stick out your tongue” ○ “Point to the door” ○ “Point to the floor” ○ “Point to the source of illumination in this room” ○ Make sure the patient finishes performing each task before giving the next instruction Language: Naming ○ “I’m going to ask you to name a few things. Can you please tell me what this is called?” ▸ Present common everyday objects to the patient and ask them to name them ▸ E.g., watch, parts of the watch, neck tie, parts of the tie Language: Repetition ○ “Please listen closely and repeat exactly what I say.” ▸ “House” ▸ “Hospital” ▸ “Today is a nice day” ▸ “No ifs, ands, or buts” Language: Reading ○ A newspaper or magazine can be a useful tool for evaluating reading, face, and picture recognition, and visual neglect ○ To test reading, ask the patient to read individual words, headlines, and complete paragraphs aloud, and then test for comprehension Language: Writing ○ “Can you please write your name?” ○ “Can you please write a sentence?” Calculations ○ “Can you please tell me what 5 minus 2 is?” ○ “What’s 2 times 4” ○ “And here’s a hard one, what’s 54 divided by 3”? Right-left Orientation and Finger Recognition ○ “Can you touch your right ear with your left thumb?” Praxis ○ “Can you show me how you would brush your teeth ○ please?” ○ “Can you show me how you would comb your hair?” ○ “Can you show me how you would throw a baseball?” ○ “Can you show me how you would strike a match and blow it out?” ○ “Can you show me how you would open a can of soda and take a drink?” Neglect and Constructions ○ “Can you please draw the face of a clock filling up the whole page? Please draw in all the numbers.” ○ “Can you please divide this line right in half?” 5 ● ● ● ● ● ● ● ○ “Can you please cross out all the lines on this page with a single mark on each line?” Constructions ○ “Can you please copy this picture right next to it?” Grasp Reflex ○ “I’m just going to test your hands for a minute here.” ○ Move your hand distally across the palm of the patient Manual Sequencing Task ○ “Can you please make a fist, tap your hand on your thigh like this?” ▸ Sequence ⎻ Fist ⎻ Medial part of the hand/side of pinky finger ⎻ Palm ○ “Repeat that sequence over and over again as fast as you can.” Written Sequencing Task ○ “Can you please copy this sequence and continue the same sequence to the end of the page?” Auditory Go-No-Go ○ “Take your hands and rest them on your thighs. When you hear one tap, I want you to please pick up your right index finger once and put it right back down again.” ○ “Now when you hear two taps, please don’t move your index finger.” ○ Mix up one tap and two taps Logic and Abstraction ○ “Can you tell me how an apple and a banana are alike?” ¨ ○ “Can you tell me how a car and a boat are alike?” ○ “If Mary is taller than Jane, and Jane is taller than Anne, who’s the tallest?” Delusions, Hallucinations, Mood, and Affect ○ The patient should be assessed for auditory, visual, and other hallucinations, as well as for delusional thought processes ○ Mood and affect should also be assessed, through specific questions, as well as through nonverbal cues and social interactions occurring throughout the patient interview QUICK REVIEW QUESTIONS 1. Which of the following is not true regarding the Mental Status Examination? A. It is a systematic format for recording findings about thinking, feeling, and behavior B. It is based on the examiner’s observation C. It begins after the interview D. It is placed in the context of the patient’s history 2. Winnie Ping hired a private investigator to follow her husband, Phil Pines, because she suspects that he’s cheating on her with her nemesis, Jenny Bithen. Despite the lack of evidence, she continues to rant about it to her best friend Valerie Padin. What does Winnie have? A. Delusion of Control B. Delusion of Grandeur C. Delusion of Infidelity D. Delusion of Persecution 3. Regarding thought processes, _____ is when a patient uses non-existent words whereas _____ is when a patient goes through irrelevant data before going back to the original question. YL6:01.32 Mental Status Examination A. Neologism; circumstantial B. Circumstantial; neologism C. Neologism; thought blocking D. Circumstantial; thought blocking 4. T/F: Thought content asks how a patient thinks and thought process asks what a patient thinks. 5. If the doctor asks the patient to describe how an apple and banana are alike, what is this testing in the Mental Status Examination? A. Constructions B. Logic and Abstraction C. Neglect and Constructions D. Alertness and Attention 6. Which of the following responses show poor judgment when the patient is asked “What would you do if you found a wallet with P25,000 cash on the passenger seat of the taxi?” A. “I will sing along to the bridge of “Cruel Summer” playing on the radio because I love that song.” B. “I will check if there are IDs in the wallet and attempt to contact whoever left it.” C. “I will keep the P25,000 and leave the wallet.” D. “I don’t know.” 7. A test for a patient's concentration and attention span. A. Serial 7 B. Thought process test C. Grasp reflex D. Sequencing task 8. T/F: Recent memory is tested by asking a patient to repeat words mentioned by the examiner just 3-5mins after. 9. It seeks to answer the question, “Can the patient predict what to do in imaginary situations?” A. Insight B. Judgment C. Abstract thinking D. Impulsivity E. NOTA 10. Observing tics, gestures, twitches, agitation, and combativeness is assessing the patient’s _____. A. Attitude B. Mannerisms C. Appearance D. Mood and affect ANSWER KEY 1C, 2C, 3A, 4F, 5B, 6D, 7A, 8F, 9B, 10B RATIONALE 1. C. It begins after the interview. MSE begins the instant the examiner sees the patient. 2. C. Delusion of Infidelity. Winnie has a delusion of infidelity, or pathological jealousy, which is the false belief that one’s lover is unfaithful. 3. A. Neologism; circumstantial. Regarding thought processes, neologism is when a patient uses non-existent words whereas circumstantial is when a patient goes through irrelevant data before going back to the original question. Thought blocking is when a patient is unable to give an answer and does not respond. 4. F. Thought content asks what a patient thinks and thought process asks how a patient thinks. 6 5. B. Logic and Abstractions. The example described in the question will assess the logic and abstraction abilities of the patient. Constructions, neglect and construction, as well as alertness and attention are all assessed with different questions. 6. D. “I don’t know.”. Judgment is the ability to predict what a person would do in imaginary situations. All other choices give a prediction except D. This is the best answer. 7. A. Serial 7. Instructing patients to start counting from 100 and deduct 7 each time is a test for concentration and attention span, which is called Serial 7. 8. F. Recent memory is asking for events in the past few days. The description pertains to immediate memory in which the patient is tested for immediate retention and recall. 9. B. Judgment. Judgment seeks to answer the question, ”Can the patient predict what to do in imaginary situations?” 10. B. Mannerisms. Observing tics, gestures, twitches, agitation, and combativeness is assessing the patient’s mannerisms. REFERENCES REQUIRED ● 💻 Perez-Rifareal, J.M.G. (2023, August, 22). Mental Status Examination [Video]. Concerns and Feedback form: http://bit.ly/YL6CFF2027 How’s My Transing? form: https://bit.ly/2027YL6HMT Mid-Semester Evaluation form: https://bit.ly/2027YL6MidSem End-of-Semester Evaluation form: https://bit.ly/2027YL6EndofSem Errata Points Trackers: https://bit.ly/YL62027EPT YL6 TransMap: https://bit.ly/2027YL6TransMap YL6:01.32 Mental Status Examination 7