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Toronto Notes 2019 Psychiatric Assessment Mental Status Exam
General Appearance
• posture,gait,grooming,hygiene,mannerofdress,bodyhabitus,facialexpression,chronologicalvs. apparent age, and relaxed or in distress, alertness
Attitude
• dispositionininterview(i.e.uncooperative,suspicious,orhostile)
Behaviour
• psychomotoractivity(agitation,retardation),abnormalmovementsorlackthereof(tremors,akathisia, tardive dyskinesia, paralysis), attention level and eye contact
Speech
• rate(e.g.,pressured,slowed),rhythm/fluency,volume,tone,articulation,quantity,spontaneity
Mood and Affect
• mood:subjectiveemotionalstate(inpatient’sownwords)
• affect:objectiveemotionalstateinferredfromemotionalresponsestostimuli;describedintermsof
■ quality (euthymic, depressed, elevated, anxious, irritable)
■ range (full, restricted, flat, blunted)
■ stability (fixed, labile)
■ mood congruence (inferred by comparing the patient’s subjective mood with their affect) ■ appropriateness to thought content
• manycliniciansusea0-10scale(0;worst;10:best)whenratingmoodtogetasubjectivenormforeach patient that can help to monitor changes over time and with treatment
Thought Process/Form
• coherence(coherent,incoherent) • logic(logical,illogical)
• stream
■ goal-directed: clearly answers questions in a linear, organized, logical fashion
■ circumstantial: speech that is indirect and delayed in reaching its goal; eventually comes back to the
point
■ tangential: speech is oblique or irrelevant; does not come back to the original point
■ loosening of associations/derailment: illogical shifting between topics
■ flight of ideas: quickly skipping from one idea to another where the ideas are marginally connected,
usually associated with mania
■ word salad: jumble of words lacking meaning or logical coherence
• perseveration:repetitionofthesameverbalormotorresponsetostimuli • echolalia:repetitionofphrasesorwordsspokenbysomeoneelse
• thoughtblocking:suddencessationofflowofthoughtandspeech
• clangassociations:speechbasedonsoundsuchasrhymingorpunning • neologism:useofnovelwordsorofexistingwordsinanovelfashion
Thought Content
• suicidalideation/homicidalideation
■ frequency and pervasiveness of thoughts, formulation of plan, means to plan, intent, active vs.
passive, protective factors
• preoccupations,ruminations:reflections/thoughtsatlength,notfixedorfalse
• obsession:recurrentandpersistentthought,impulse,orimagewhichisintrusiveorinappropriateand
unwanted
■ cannot be stopped by logic or reason
■ causes marked anxiety and distress
■ common themes: contamination, orderliness, sexual, pathological doubt/worry/guilt
• magicalthinking(e.g.superstition,beliefthatthinkingsomethingwillmakeithappen),normalin children and certain cultures
• ideasofreference:similartodelusionofreference,butlessfixed(therealityofthebeliefisquestioned)
• overvaluedideas:unusual/oddbeliefsthatarenotofdelusionalproportions
• first rank symptoms of schizophrenia: thought insertion/withdrawal/broadcasting
• delusion: a fixed false belief that is out of keeping with a person’s cultural or religious background and is
firmly held despite incontrovertible proof to the contrary
Perception
• hallucination:sensoryperceptionintheabsenceofexternalstimulithatissimilarinqualitytoatrue perception
■ auditory (most common), visual, gustatory, olfactory, tactile
• illusion:misperceptionofarealexternalstimulus(suchasmistakingacoatonarackasapersonlateat
night)
• depersonalization:changeinself-awarenesssuchthatthepersonfeelsunreal,distant,ordetachedfrom
his or her body, and/or unable to feel emotion
• derealization:feelingthattheworld/outerenvironmentisunreal
Psychiatry PS3
Mental Status Exam
ASEPTIC
Appearance and behaviour Speech
Emotion (mood and affect) Perception
Thought content and process Insight and judgment Cognition
The MSE is analogous to the physical exam. It focuses on current signs, affect, behaviour, and cognition
Spectrum of Affect
Full > Restricted > Blunted > Flat
There is poor correlation between clinical impression of suicide risk and frequency of attempts
Cognitive Assessment
Use MMSE to assess
• Orientation (time and place)
• Memory (immediate and delayed recall) • Attention and concentration
• Language (comprehension, reading,
writing, repetition, naming)
• Spatial ability (intersecting pentagons) Gross screen for cognitive dysfunction:
Total score is out of 30; <26 abnormal, 20-26 mild, 10-19 moderate, <10 severe
The key to differentiating obsessions and delusions is that obsessions are usually ego dystonic, meaning unwanted and not fitting in with a person’s goals and self-image, while delusions are ego syntonic
Delusions
• Persecutory: belief that others are trying to cause harm to you
• Reference: interpreting publicly known events/celebrities as having direct reference to you
• Erotomania: belief that another is in love with you
• Grandiose: belief that he or she has special powers, talents or abilities
• Religious: belief of receiving instructions/ powers from a higher being; of being a higher being
• Somatic: belief that you have a physical disorder/defect
• Nihilistic: belief that things do not exist; a sense that everything is unreal