Assessment of Patient.  The psychiatric history taking and Mental Status Examination

Demographic data

The presenting complaints

Personal history

Past medical and psychiatric history

Family medical and psychiatric history

Personality

Main Components of Mental Status Examination (MSE) are to evaluate and being able to correctly describe the ptx:

1.      Presentation

2.      Cognition

3.      Emotional state

4.      Thought and perception

5.      Intelligence, Judgment and insight

1. Presentation

A. Appearance

1.      Mimic

2.      Posture

a.       Conventionality, Bizarreness, Adequate, inadequate, Hypomimia, Mannerism

3.      Grooming

4.      Appearance for age

5.      Clothing etc. Describe as many relevant details as you can

B. Behavior

1.      Mannerism

2.      Psychomotor speed/behavior

3.      Tics

4.      Attitude toward the situation

a.       Cooperative

b.      Seductive

c.       Hostile

d.      Defensive

C. Talk

1.      Articulation, Volume, Speed, Pitch, Deficient

1.      Pressure of speech

2.      Coherence/incoherence

3.      Neologism, verbigeration, bizarreness

4.      Organic language disorders, Aphasia, Broca,s aphasia, Wernicke’s aphasia, Nominal Aphasia, Amnestic aphasia, Apraxia, Anosia, Prosopagnosia, Visual agnosia, Auditory Agnosia, Anosognosia, Dysarthria

                       

2. Cognition

            Level of consciousness

Conscious

Lethargic / drowsy / dizzy/stupefied

Sleepy

Orientation

Autopsychic

Allopsychic

Place

Time

Memory

Immediate

Recent

Short term

Remote

(Dementia, Amnestic disorder, Korsakoff’s syndrome, Psychogen amnesia, Psychogen fugue, multiple personality, Paramnesia, Confabulation, Depersonalization, Derealization, Déjà vu, Jamais Vu, Reduplicative phenomena

Attention & concentration

Tenacity

Vigility

Cognitive ability

Verbal

Spatial

Abstraction

3. Emotional state

Mood

Euthymic etc

Low, hopeless, suicidal, depressed, hypothymic

Anxiety, Ambivalent

High, euphoric, irritable, hyperthymic, elated

Subjective experience, objective finding (discrepancy?

Affect

Appropriateness, Inappropriate, Incongruent, Labile, Blunt, Flat, Restricted, Flat, Decolored, Congruence,

4. Perception & Thought

Perception

Illusions, Hallucinations, ‘as if’ hallucinations, non-verbal auditory hallucinations (e.g. acoasma), verbal auditory hallucinations, Dissociative hallucinations,commenting hallucinations, imperative hallucinations, mood congruent and incongruent verbal hallucinations, Tactile and somatic hallucinations, visual hallucinations, metamorphopsia,

Depersonalization, Derealization, Delusional mood, Hightened perception, Changed perception

Thought

            Form

Flight of ideas, Clanging, Incoherence, Neologism,

Perseveration, Echolalia

Bizarreness, Derailment, Poverty of (thought)speech, Thought block, Tangentiality

           

Content

Compulsions, Obsessions, Phobias (Agoraphobia, Social Phobia, Simple Phobia) Hypochondria. Nihilistic

Suicidal thoughts, Homicidal thoughts, (Overt / Covert) Dissimulation

Delusions (Bizarre, Grandiose, Persecutory, Expansive, Delusion of Reference, Delusion of Control) Overvalued ideas,

Poverty of content, Illogicality, Thought withdrawal, Thought Insertion, Thought broadcasting, Nihilistic Delusion, Somatic delusion, Delusion of Guilt, Delusional Jealousy, Erotomanic Delusion, Mood congruent delusion, Mood incongruent delusion, Systematized delusion,

5. Judgment & Insight

Intelligence, judgment & insight

Impulse control, aggressiveness

Rapport

Other Investigations

Psychological Tests

§Intelligence

§Achievement

§Personality & Psychopathology tests

Definitions:

§Achievement: culture specific measure of knowledge and skills acquired from education and experience

§Intelligence: measure of an individual innate potential for learning. Quantified by the ability to reason, to think logically and come to conclusion; to understand abstract concepts; to assimilate, recall, analyze and organize information; to meet the special needs of new situation

Intelligence Tests

§Wechsler Adult Intelligence Scale-Revised (WAIS-R)

§Wechsler Intelligence Scale for Children-Revised (WISC-R)

§Wechsler Preschool and Primary Scale of Intelligence (WPPSI)

§Stanford-Binet Intelligence Scale

Achievement Tests

§Medical College Admissions Test (MCAT)

§USMLE, board licensing exams

Personality and Psychopathology Tests

§Minnesota Multiphasic Personality Inventory (MMPI)

§Rorschach Inkblot Test

§Sentence Completion Test (SCT)

§Thematic Apperception Test (TAT)

§Mental Status Examination (MSE)

§Beck Depression Inventory-II (BDI-II)

§Zung Self-rating Depression Scale

§Hamilton Rating Scale for Depression (HAM-D)

§Raskin Depression Scale

Intelligence tests

§Mental age

§Chronological age

§IQ = MA/CAx100

§Because above 15 y the MA does not change, usually 15 used in the denominator

§SD for IQ scores 15

§Person with an IQ that is more than 2xSD below the mean (IQ=70) fits into mental retardation category

Mental retardation DSM-IV-TR

§Mild (IQ 50-70)                    sixth grade level

§Moderate (IQ 35–55)                        second grade level

§Severe (IQ 20-40)                 below grade                                                                             school level

§Profound (IQ less 20)                       significantly below                                                                  grade school level

            Wechsler Adult Intelligence Scale-Revised (WAIS-R)

            What is measured?

§Verbal (IQ)

§General knowledge

§Comprehension and social judgment

§Arithmetic

§Similarities

§Digit span

§Vocabulary

§Performance (IQ)

§Picture completion

§Block design

§Picture arrangement

§Object assembly

§Digit-symbol

Used between 16-75 years

Large difference between VQ and PQ indicate organic disorder, for example

            Righ hemisphere lesion: better VQ than PQ

            Left hemisphere lesion: better PQ than VQ

Personality tests

§Objective personality tests

§Projective personality tests

Ø  Objective personality tests: general aim: to differentiate between personality traits and personality disorders

Minnesota Multiphasic Personality Test (MMPI)

§556 T/F statements

§Scales:

pDepression

pParanoia

pSchizophrenia

pHypochondriasis

§Validity scales:

pFaking bad

pFaking good

The Million Clinical Multiaxial Inventory II (MCMI-II)

p175 T/F statement selection

pScales on:

§Basic personality patterns

pSchizoid

pAvoidant

pDependent

pHistrionic

pNarcissistic

pAntisocial

pCompulsive

pPassive aggressive

§Personality disorders

pBorderline

pSchizotypal

pparanoid

§Less sever clinical syndromes

pAnxiety

pSomatoform

pHypoman

pDysthymia

pAlcohol abuse

§Severe clinical syndromes

pPsychotic thinking

pPsychotic depression

pPsychotic delusion

Ø  Projective Personality Tests

§Rorschach Test

§Taught disorders

§Defense mechanisms

§Thematic Apperception Test (TAT)

§Unconscious emotions and conflicts

§Sentence Completion Test (SCT)

§Motivations and conflicts

Further medical Investigations in differential dg

Investigations

nHistory

nPE

nLaboratory

nSome organic diseases may manifest as/together with psychiatric symptoms:

nDepression   

pHypothyroidism (Myxodema)

pAddison’s disease

pCushing’s syndrome

pPancreas tumor

nAnxiety:

nHyperthyroidism (thyrotoxicosis)

nPheochromocytoma

nHypoglycemia

nHyperglycemia

nPsychosis or personality changes:

nAIDS dementia complex

nAcute intermittent porphyria

nSLE, rheumathoid arthritis (connectiv tissue disorders)

nHypoparathryreoidism

nHyperparathyroidism

nWilson’s disease

nHuntington’s disease

nAcute psychosis (delirium)

nPneumonia

nErysipelas

nDrug withdraval

nFat embolism

pDrug blood level & parameters to monitor:

nCarbamazepine

nValproic acid (liver function)

nClozapine (Clozaril)   agranulocytosis

nLithium: T3, T4, TSH + BUN, creatnine + SeLi

nFor research purpose:

nHVA

nVMA

nMHPG

n5-HIAA

pDST (dexamethasone suppression test)

pDexamethason 1 mg supress endogenious cortisol secretion in normal persons

pSupression is absent in patients with depression

pPatents with ‘positive DST test’ likely to respond well to antidepressant or ECT treatment

pBut

nFalse positive

nSchizophrenia

nDementia

nPregnancy

nAnorexia nervosa

nWeight loss

nCushing disease

nAlcohol abuse

nBenzodiazepine withdrawal

nFalse negative:

nAddison’s disease

nBenzodiazepine th

nSteroid therapy

nAmytal interview:

nAnxiety states

nDissociative disorders

nConversion disorders

nMute psychotic conditions

nMalingering

nSodium lactate infusion / CO2 inhalation:

nIn panic disorders induce panic attack

nGalvanic skin response:

nElectric resistance of the skin. “Lie” detector

nAnxious patient may have positive result, while “antisocial personality” false negative test

nNeuroimaging:

pCT

pMRI

pfMRI

pPET

pSPECT

Neuroimaging techniques give us excellent quality radiologic pictures of the structure of the brain

MRI also gives information about the functioning of the brain. The image above shows diminished function (e.g. blood oxygen or glucose extraction) of the frontal lobes in a patient with schizophrenia

Imaging studies can give valuable information about drug (pharmacon) effects on different brain areas

nElectrophysiology

pEEG: The above registratum is typical for epilepsy. Observe the ‘spike-and-wave’ form bursts

pEP or Evoked Potentials: For any sensory stimulus (visual, acoustic, sensory) there is an electric response in CNS mirroring the signal conduction, which can be detected. Each relay point with known anatomic location gives typical spikes in expected time. If the curve above is disturbed, the shape will refer to the location of the disease.

nNeuropsychological tests:

nAssess:

nIntelligence

nMemory

nReasoning

nOrientation

nPerceptuomotor performance

nLanguage

nAttention

nconcentration

nHalstead-Reitan Battery: localized brain damage

nLuria-Nebraska Neuropsychological Battery

nBender Visual Motor Gestalt test

nFolstein Mini Mental State Examination: Strongly recommended in routine clinical practice because of its simplicity and reliability

Points:

nOriantation (Where you, date time, persons etc ?)     10

nLanguage (Name the object e.g.pencil)                                  8

nAttention & Calculation (serial 7)                              5

nRegistration (repeat the names of 3 objects)              3

nRecall            (after 5 min….)                                                            3

nConstruction (copy this design)                                 1

Max score on MMSE: 30

less than 25: cognitive problem,

less than 20 significant impairment

nGlasgow Coma Scale (GCS) (See below) Strongly recommended in routine clinical practice, because it is simple, easy to follow up the improvement or worsening of patient’s condition, and it eliminates the biases between different observers

Case Studies

v  When an examiner asks a patient to count backward by 7, starting at 100 (referred to as serial sevens), what is principally being tested?

(A) recent memory

(B) remote memory

(C) concentration

(D) fund of knowledge

(E) mathematics skills

Answer

(C) Concentration refers to the ability to sustain focus on a cognitive task. Performing serial sevens and spelling world backward are tests of concentration. Although a certain facility with the remaining choices is necessary to perform each task (no cognitive function is tested in absolute isolation), the serial sevens test provides a window on a patient’s concentration.

Remote memory involves the recall of events long past, for example, information from a patient’s childhood. Recent memory is recall of events occurring in the last several minutes.

Fund of knowledge is a test of information the patient readily has available to him or her; knowledge of current events is often used to assess this. The MSE often contains tests of mathematics skills, but testing mathematics skills is not the purpose of the serial sevens test. Any test of cognitive function must take into account the patient’s cultural, educational, and social background.

v  A 35-year-old woman presents with episodic anxiety and complains of the occasional feeling that she has heard or perceived things prior actually hearing them. She expresses her concern that she is “going crazy.” You assure her that this can occur in anxiety disorders. What this phenomenon called?

(A) déjà vu

(B) jamais vu

(C) déjà entendu

(D) folie à deux

(E) la belle indifference

Answer

 (C) Déjà entendu is the feeling that one is hearing something one has heard before. It is usually associated with anxiety states or fatigue.

Déjà vu is a similar experience, but refers to the sensation that something has been seen before.

Jamais vu is the opposite of déjà vu in that it refers to something that should be familiar but seems quite unfamiliar. Folie à deux is a shared delusion aroused in one person by the influence of another. La belle indifférence is the indifference shown toward a deficit or loss of function classically seen in a conversion disorder.