Domains Mental status examination

1 domains

1.1 appearance
1.2 attitude
1.3 behavior
1.4 mood , affect
1.5 speech
1.6 thought process
1.7 thought content
1.8 perceptions
1.9 cognition
1.10 insight
1.11 judgment

domains
appearance

clinicians assess physical aspects such appearance of patient, including apparent age, height, weight, , manner of dress , grooming. colorful or bizarre clothing might suggest mania, while unkempt, dirty clothes might suggest schizophrenia or depression. if patient appears older or chronological age can suggest chronic poor self-care or ill-health. clothing , accessories of particular subculture, body modifications, or clothing not typical of patient s gender, might give clues personality. observations of physical appearance might include physical features of alcoholism or drug abuse, such signs of malnutrition, nicotine stains, dental erosion, rash around mouth inhalant abuse, or needle track marks intravenous drug abuse. observations can include odor might suggest poor personal hygiene due extreme self-neglect, or alcohol intoxication. weight loss signify depressive disorder, physical illness, anorexia nervosa or chronic anxiety.

attitude

attitude, known rapport, refers patient s approach interview process , quality of information obtained during assessment.

behavior

abnormalities of behavior, called abnormalities of activity, include observations of specific abnormal movements, more general observations of patient s level of activity , arousal, , observations of patient s eye contact , gait. abnormal movements, example choreiform, athetoid or choreoathetoid movements may indicate neurological disorder. tremor or dystonia may indicate neurological condition or side effects of antipsychotic medication. patient may have tics (involuntary quasi-purposeful movements or vocalizations) may symptom of tourette s syndrome. there range of abnormalities of movement typical of catatonia, such echopraxia, catalepsy, waxy flexibility , paratonia (or gegenhalten). stereotypies (repetitive purposeless movements such rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such gesture or abnormal gait) may feature of chronic schizophrenia or autism.

more global behavioural abnormalities may noted, such increase in arousal , movement (described psychomotor agitation or hyperactivity) might reflect mania or delirium. inability sit still might represent akathisia, side effect of antipsychotic medication. similarly, global decrease in arousal , movement (described psychomotor retardation, akinesia or stupor) might indicate depression or medical condition such parkinson s disease, dementia or delirium. examiner comment on eye movements (repeatedly glancing 1 side can suggest patient experiencing hallucinations), , quality of eye contact (which can provide clues patient s emotional state). lack of eye contact may suggest depression or autism.

mood , affect

the distinction between mood , affect in mse subject disagreement. example, trzepacz , baker (1993) describe affect external , dynamic manifestations of person s internal emotional state , mood person s predominant internal state @ 1 time , whereas sims (1995) refers affect differentiated specific feelings , mood more prolonged state or disposition . article use trzepacz , baker (1993) definitions, mood regarded current subjective state described patient, , affect examiner s inferences of quality of patient s emotional state based on objective observation.

mood described using patient s own words, , can described in summary terms such neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. alexithymic individuals may unable describe subjective mood state. individual unable experience pleasure may suffering anhedonia.

vincent van gogh s 1889 self portrait suggests artist s mood , affect in time leading suicide.

affect described labelling apparent emotion conveyed person s nonverbal behavior (anxious, sad etc.), , using parameters of appropriateness, intensity, range, reactivity , mobility. affect may described appropriate or inappropriate current situation, , congruent or incongruent thought content. example, shows bland affect when describing distressing experience described showing incongruent affect, might suggest schizophrenia. intensity of affect may described normal, blunted affect, exaggerated, flat, heightened or overly dramatic. flat or blunted affect associated schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, , overly dramatic or exaggerated affect might suggest personality disorders. mobility refers extent affect changes during interview: affect may described fixed, mobile, immobile, constricted/restricted or labile. person may show full range of affect, in other words wide range of emotional expression during assessment, or may described having restricted affect. affect may described reactive, in other words changing flexibly , appropriately flow of conversation, or unreactive. bland lack of concern 1 s disability may described showing la belle indifférence, feature of conversion disorder, historically termed hysteria in older texts.

speech

the patient s speech assessed observing patient s spontaneous speech, , using structured tests of specific language functions. heading concerned production of speech rather content of speech, addressed under thought form , thought content (see below). when observing patient s spontaneous speech, interviewer note , comment on paralinguistic features such loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity , latency of speech. structured assessment of speech includes assessment of expressive language asking patient name objects, repeat short sentences, or produce many words possible category in set time. simple language tests form part of mini-mental state examination. in practice, structured assessment of receptive , expressive language reported under cognition (see below).

language assessment allow recognition of medical conditions presenting aphonia or dysarthria, neurological conditions such stroke or dementia presenting aphasia, , specific language disorders such stuttering, cluttering or mutism. people autism or asperger syndrome may have abnormalities in paralinguistic , pragmatic aspects of speech. echolalia (repetition of person s words) , palilalia (repetition of subject s own words) can heard patients autism, schizophrenia or alzheimer s disease. person schizophrenia might use neologisms, made-up words have specific meaning person using them. speech assessment contributes assessment of mood, example people mania or anxiety may have rapid, loud , pressured speech; on other hand depressed patients typically have prolonged speech latency , speak in slow, quiet , hesitant manner.

thought process

the paintings of outsider artist adolf wölfli seen visual representation of formal thought disorder.

thought process in mse refers quantity, tempo (rate of flow) , form (or logical coherence) of thought. thought process cannot directly observed can described patient, or inferred patient s speech. regarding tempo of thought, people may experience flight of ideas, when thoughts rapid speech seems incoherent, although careful observer can discern chain of poetic associations in patient s speech. alternatively individual may described having retarded or inhibited thinking, in thoughts seem progress few associations. poverty of thought global reduction in quantity of thought , thought perseveration refers pattern person keeps returning same limited set of ideas. pattern of interruption or disorganization of thought processes broadly referred formal thought disorder, , might described more thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight s move thinking. thought may described circumstantial when patient includes great deal of irrelevant detail , makes frequent diversions, remains focused on broad topic. flight of ideas typical of mania. conversely, patients depression may have retarded or inhibited thinking. poverty of thought 1 of negative symptoms of schizophrenia, , might feature of severe depression or dementia. patient dementia might experience thought perseveration. formal thought disorder common feature of schizophrenia. circumstantial thinking might observed in anxiety disorders or kinds of personality disorders.

thought content

a description of thought content describe patient s delusions, overvalued ideas, obsessions, phobias , preoccupations. abnormalities of thought content established exploring individuals thoughts in open-ended conversational manner regard intensity, salience, emotions associated thoughts, extent thoughts experienced 1 s own , under 1 s control, , degree of belief or conviction associated thoughts.

a delusion can defined false, unshakeable idea or belief out of keeping patient s educational, cultural , social background ... held extraordinary conviction , subjective certainty , , core feature of psychotic disorders. patient s delusions may described persecutory or paranoid delusions, delusions of reference, grandiose delusions, erotomanic delusions, delusional jealousy or delusional misidentification. delusions may described mood-congruent (the delusional content in keeping mood), typical of manic or depressive psychoses, or mood-incongruent (delusional content not in keeping mood) more typical of schizophrenia. delusions of control, or passivity experiences (in individual has experience of mind or body being under influence or control of kind of external force or agency), typical of schizophrenia. examples of include experiences of thought withdrawal, thought insertion, thought broadcasting, , somatic passivity. schneiderian first rank symptoms set of delusions , hallucinations have been said highly suggestive of diagnosis of schizophrenia. delusions of guilt, delusions of poverty, , nihilistic delusions (belief 1 has no mind or dead) typical of depressive psychoses.

an overvalued idea false belief held conviction not delusional intensity. hypochondriasis overvalued idea 1 suffering illness, dysmorphophobia overvalued idea part of 1 s body abnormal, , people anorexia nervosa may have overvalued idea of being thin.

an obsession undesired, unpleasant, intrusive thought cannot suppressed through patient s volition , unlike passivity experiences described above, not experienced imposed outside patient s mind. obsessions typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. person can describe obsessional doubt, intrusive worries whether have made wrong decision, or forgotten something, example turn off gas or lock house. in obsessive-compulsive disorder, individual experiences obsessions or without compulsions (a sense of having carry out ritualized , senseless actions against wishes).

a phobia dread of object or situation not in reality pose threat , , distinct delusion in patient aware fear irrational. phobia highly specific situations , reported patient rather being observed clinician in assessment interview.

preoccupations thoughts not fixed, false or intrusive, have undue prominence in person s mind. clinically significant preoccupations include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated personality disorders, depressive beliefs (for example 1 unloved or failure), or cognitive distortions of anxiety , depression. mse contributes clinical risk assessment including thorough exploration of suicidal or hostile thought content. assessment of suicide risk includes detailed questioning nature of person s suicidal thoughts, belief death, reasons living, , whether person has made specific plans end or life.

perceptions

a perception in context sensory experience, , 3 broad types of perceptual disturbance hallucinations, pseudohallucinations , illusions. hallucination defined sensory perception in absence of external stimulus, , experienced in external or objective space (i.e. experienced subject real). illusion defined false sensory perception in presence of external stimulus, in other words distortion of sensory experience, , may recognized such subject. pseudohallucination experienced in internal or subjective space (for example voices in head ) , regarded akin fantasy. other sensory abnormalities include distortion of patient s sense of time, example déjà vu, or distortion of sense of self (depersonalization) or sense of reality (derealization).

hallucinations can occur in of 5 senses, although auditory , visual hallucinations encountered more tactile (touch), olfactory (smell) or gustatory (taste) hallucinations. auditory hallucinations typical of psychoses: third-person hallucinations (i.e. voices talking patient) , hearing 1 s thoughts spoken aloud (gedankenlautwerden or écho de la pensée) among schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations (voices talking patient) threatening or insulting or telling them commit suicide, may feature of psychotic depression or schizophrenia. visual hallucinations suggestive of organic conditions such epilepsy, drug intoxication or drug withdrawal. many of visual effects of hallucinogenic drugs more correctly described visual illusions or visual pseudohallucinations, distortions of sensory experiences, , not experienced existing in objective reality. auditory pseudohallucinations suggestive of dissociative disorders. déjà vu, derealization , depersonalization associated temporal lobe epilepsy , dissociative disorders.

cognition

this section of mse covers patient s level of alertness, orientation, attention, memory, visuospatial functioning, language functions , executive functions. unlike other sections of mse, use made of structured tests in addition unstructured observation. alertness global observation of level of consciousness i.e. awareness of, , responsiveness environment, , might described alert, clouded, drowsy, or stuporous. orientation assessed asking patient or (for example building, town , state) , time (time, day, date).

attention , concentration assessed serial sevens test (or alternatively spelling five-letter word backwards), , testing digit span. memory assessed in terms of immediate registration (repeating set of words), short-term memory (recalling set of words after interval, or recalling short paragraph), , long-term memory (recollection of known historical or geographical facts). visuospatial functioning can assessed ability copy diagram, draw clock face, or draw map of consulting room. language assessed through ability name objects, repeat phrases, , observing individual s spontaneous speech , response instructions. executive functioning can screened asking similarities questions ( x , y have in common? ) , means of verbal fluency task (e.g. list many words can starting letter f, in 1 minute ). mini-mental state examination simple structured cognitive assessment in widespread use component of mse.

mild impairment of attention , concentration may occur in mental illness people anxious , distractible (including psychotic states), more extensive cognitive abnormalities indicate gross disturbance of brain functioning such delirium, dementia or intoxication. specific language abnormalities may associated pathology in wernicke s area or broca s area of brain. in korsakoff s syndrome there dramatic memory impairment relative preservation of other cognitive functions. visuospatial or constructional abnormalities here may associated parietal lobe pathology, , abnormalities in executive functioning tests may indicate frontal lobe pathology. kind of brief cognitive testing regarded screening process only, , abnormalities more assessed using formal neuropsychological testing.

the mse may include brief neuropsychiatric examination in situations. frontal lobe pathology suggested if person cannot repetitively execute motor sequence (e.g. paper-scissors-stone ). posterior columns assessed person s ability feel vibrations of tuning fork on wrists , ankles. parietal lobe can assessed person s ability identify objects touch alone , eyes closed. cerebellar disorder may present if person cannot stand arms extended, feet touching , eyes closed without swaying (romberg s sign); if there tremor when person reaches object; or if or unable touch fixed point, close eyes , touch same point again. pathology in basal ganglia may indicated rigidity , resistance movement of limbs, , presence of characteristic involuntary movements. lesion in posterior fossa can detected asking patient roll or eyes upwards (parinaud s syndrome). focal neurological signs such these might reflect effects of prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders.

insight

the person s understanding of or mental illness evaluated exploring or explanatory account of problem, , understanding of treatment options. in context, insight can said have 3 components: recognition 1 has mental illness, compliance treatment, , ability re-label unusual mental events (such delusions , hallucinations) pathological. insight on continuum, clinician should not describe present or absent, should report patient s explanatory account descriptively.

impaired insight characteristic of psychosis , dementia, , important consideration in treatment planning , in assessing capacity consent treatment.

judgment

judgment refers patient s capacity make sound, reasoned , responsible decisions. traditionally, mse included use of standard hypothetical questions such if found stamped, addressed envelope lying in street? ; contemporary practice inquire how patient has responded or respond real-life challenges , contingencies. assessment take account individual s executive system capacity in terms of impulsiveness, social cognition, self-awareness , planning ability.

impaired judgment not specific diagnosis may prominent feature of disorders affecting frontal lobe of brain. if person s judgment impaired due mental illness, there might implications person s safety or safety of others.