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Psychiatric History and Mental Status Examinaiton

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Psychiatric History & Mental status examination

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Psychiatric History and Mental Status Examinaiton

  1. 1. LOGO Psychiatric History & MSE Bivin JB Department of Psychiatric Nursing Mar Baselios College Of Nursing
  2. 2. History and MSE Most important diagnostic tools To obtain information to make an accurate diagnosis From the time patient enters the interview room till he/she leaves the room
  3. 3. History & MSE Rapport  A relationship of mutual understanding or trust and agreement between people
  4. 4. Basic principles of History taking • Introduce yourself • Explain the purpose and approx how long it will take • Ask Open Ended Questions • Allow the patient to Explain Things In his/her Own Words • Encourage the patient to Elaborate and Explain • Avoid Interrupting • Guide the Interview As Necessary • Avoid Asking “Why?” Questions • Listen and Observe For Cues • You might need an informant
  5. 5. History Demographic data  Name  Sex  race  Locality  marital status  Occupation  Religious belief  living circumstance
  6. 6. History Chief complaints  Patient's problem or reason for the visit  Recorded as the patient's own words  Ask leading questions such as • "What brings you here today?“ • “How can I help you?”
  7. 7. History of present illness  main part of the interview  gather basic information of specific symptoms  Include both pertinent positives and negatives  Record important life events  Different approaches may be needed depending on the circumstances • Emergency department consult • Routine Out patient evaluation
  8. 8. Onset  Abrupt  Acute  Insidious Course  Continuous  Episodic  Remittent
  9. 9. Precipitating factor A failed romance A death in the family Serious illnesses Failure in exams Problems in relationships
  10. 10. Important Obtain a clear chronological account of symptoms ( e.g. depression, psychosis) & the effects of these symptoms on behaviour
  11. 11. Past history  Psychiatric & Medical History  Life chart Family history  3 generation Genogram  Family history of Psychiatric illness  Family history of Medical illness  Living situation  Interpersonal issues
  12. 12. Personal history  Birth & early development  Disorders during childhood  Schooling and occupation  Menstrual history  Marital history
  13. 13. Premorbid personality  Social relations  Mood  Attitude towards work and responsibility  Response to criticisms and praise  Leisure activities and hobbies
  14. 14. Questions for PMP assessment • Before all this happened, how would you describe yourself? • How would other people describe you? • When you find yourself in difficult situations, how do you cope? • What sort of things do you like to do to relax? • Do you have any hobbies? • Do you like to be around other people or do you prefer your own company? • Are you religious? • Do you have any ambitions or plans?
  15. 15. Alcohol & drug history Do you smoke? How many? Since when? Do you take a drink? How much do you drink? Have you been drinking any more or less than normal recently? Have you ever taken drugs?
  16. 16. Forensic history Have you ever been in trouble with the police, or been convicted of anything? ***
  17. 17. LOGO Mental Status Examination
  18. 18. Definition • Cross-section of the patients’ psychological life and sum total of nurses’ observations & impression of that moment. • Some part of the MSE are through simple observation • Others requires asking specific questions • MSE is the evaluation of the patients’ present status
  19. 19. Descriptive Vs. Psychodyanamic Descriptive • Karl Jaspers • Method of describing subjective experience & pt behavior • Atheoretical • Not rest on any particular explanation for the cause of the abnormal status • Close-observation & empathetic exploration of the subjective experience (Phenomenology) Psychodyanamic • Sigmund Freud • Assessing the behavioral changes by explaining the psychological process which is unaware to the pt • Psychoanalysis/Hypno therapy/Dream analysis
  20. 20. Mental status examination General appearance & behavior Psychomotor activity Speech Thought Mood Perception Cognitive functions
  21. 21. General appearence  Attitude toward the interview situation  Consciousness  Orientation  Cooperativenes  Rapport and attitude toward the interviewer  Dress  Attention Span  Catatonic signs
  22. 22. Clinical implications • Dilated pupil: Drug intoxication • Pupil constriction: Narcotic misuse/dependance • Gaze shift/stooped posture: Depression • Unusual attire/colourful dress: Mania • Over familiarity: Mania • Seductive: Histrionic PD
  23. 23. Psychomotor activity Goal directed activity • Decreased • Normal • Increased  Level of activity: Lethargic, tense, restless, agitated  Type: Grimaces, Tics, Tremors  Unusual gestures
  24. 24. Disorders of motor activities  Tics:  Rapid irregular movements involving groups of facial or limb muscles  Mannerisms  Abnormal & occasional bizarre performance of a voluntary, goal-directed activity  Stereotypy  A negative & bizarre performance; Not goal-directed  Catalepsy  General term for an immobile position that is constantly maintained
  25. 25. Posturing  Assumption of various abnormal bodily positions for a long time (Psychological pillow) Negativism  Patient resists carrying out the examiners’ instructions & his attempts to move or direct the limbs Catatonia  Syndrome characterized by cataleptic posturing, stereotypy, mutism, stupor, negativism, automatic obedience, echolalia & echopraxia.  1. Excitement & 2. Retardation
  26. 26. Echopraxia  Imitation of another persons movements Ambitendency  Series of uncertain, incomplete movements carried out when a voluntary action is anticipated Abulia  Reduced impulses to act or think; associated with indifferences about the consequences of action Akinesia: Inability to move Akathisia: inability to seat/stand still
  27. 27. Clinical implications Excessive body movement (PM Agitation)  Anxiety, mania, stimulant abuse Psychomotor retardation  Depression, organicity, catatonic F20, drug- induced stupor Tics/grimaces  S/E of Psychotropic Medications Repeated movements OCD Picking up of dirt from clothes:  Delirium, Drug-toxicities
  28. 28. Speech Tone Tempo Volume Reaction time Coherent Relevant  Sample of Speech:………………………………………… ……………………………………………………
  29. 29. Disorders of speech Pressure of speech  Rapid speech that is increased in amount & difficult to interpret Poverty of speech  Restriction in the amount of speech Dysprosody: Loss of normal speech melody Dysarthria: Difficulty in articulation Cluttering: erratic & Dysrythmic speech Stuttering  Frequent repetition/ prolongation of a sound/syllable leading to markedly impaired speech fluency
  30. 30. Clinical implications Speech expressive problems  Brain involvement, developmental problems, Eg: ELD Pressure of speech  Mania Mutism/Alogia  Depressive Sx/Catatonic F20
  31. 31. Thought Form Stream Posession Content  Delusion  Overvalued idea  Depressive cognition  Suicidal idea
  32. 32. Disorders of form of thought Derailment: Thoughts slides on to a subsidiary content Substitution: Major thought is substituted by a subsidiary one Omission: Senseless omission of a thought or a part of it. Fusion: Heterogenous elements of thoughts are intervowen with each other Driveling: Distorted intermixture of constituent part of one complex thought  Evident through neologism, word salad etc
  33. 33. Disorders of stream of thought 1- Pressure of thought 2- Poverty of thought: A slowing down of the thinking process which hampers the formation of associations & may prevent the patient from reaching the original goal of his thoughts. 3-Thought blocking: The patient experiences a sudden break in the chain of thought (Schizophrenia). 4-Flight of ideas: A series of thoughts verbalized rapidly with abrupt shifts of subject matter with logical sequence. (Mania as well as in organic mental disorders)
  34. 34. 5- Loosening of associations: A disorder of thinking & speech in which ideas shift from one subject to another with remote or no apparent reasons. (F20) 6- Perseveration: Repetitive behavior or repetitive expression of a particular word, phrase, or concept during the course of speech. 7- Circumstantiality: The determining tendency is maintained but the patient can reach the goal only after having exhaustively explored all unnecessary associations arising in his mind. 8-Tangentiality: expressions or responses characterized by a tendency to digress from an original topic of conversation, in which a common word connects two unrelated thoughts.
  35. 35. Clinical implications Circumstantiality:  Defensiveness, paranoid thinking  Schizophrenia/psychotic disorders Loosening of association  Schizophrenia/psychotic disorders Perseveration  Brain damage Word salad  Severe form of thought disintegration  Chronic psychotic illness
  36. 36. Disorders of Content of thought Delusion  False unshakable belief, which is out of keeping Overvalued ideas  Ideas which are reasonable & understandable in themselves but which come to unreasonably dominate the patient's life. Depressive cognition Suicidal idea
  37. 37. Types of delusions 1. Delusions of persecution: being followed, harassed, threatened, or plotted against. 2. Delusions of grandeur: being influential and important, perhaps having occult powers, or actually being some powerful figure out of history (Napoleonic complex). 3. Delusions of reference: external events or “portents” have personal significance, such as special messages or commands.
  38. 38. Continues 4- Delusions of love characterized by the patient's conviction that another person is in love with him or her . 5- Delusions of guilt :A delusional belief that one has committed a crime or other reprehensible act. (psychotic Depression) 6- Delusions of control: The core feature is the delusional belief that one is no longer in sole control of one's own body.
  39. 39. Continues. 7- Hypochondriacal delusions founded on the conviction of having a serious disease. 8- Delusional jealousy: A delusional belief that one's partner is being unfaithful (Othello syndrome) 9- Delusional misidentification: A delusional belief that certain individuals are not who they externally appear to be. The delusion may be that familiar people have been replaced with outwardly identical strangers (Capgras syndrome) or that strangers are (really) familiar people (Fraegoli syndrome).
  40. 40. Continues. 10- Delusions of thought interference:. A group of delusions which are considered first- rank symptoms of schizophrenia. They are thought insertion, thought withdrawal, and thought broadcasting 11-Nihilistic delusion: A delusional belief that the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless. A feature of psychotic depressive illness
  41. 41. Mood Vs. Affect Mood Affect Subjective Objective (noted by the examiner) Pervasive & sustained emotion, it is not influenced by will, & is strongly related to values Subjective & immediate experience associated to ideas or mental representations of objects Sadness, aggression, joyous etc Classified as blunted, flattened, broad, labile, appropriate & congruent
  42. 42. Disorders of emotions Alexithymia:  Inability/difficulty in describing or being aware of ones emotion/mood (depression, substance abuse, PTSD) Anhedonia:  Loss of interest in, and withdrawal from all regular & pleasurable activities (Depression) Anxiety:  Feeling of apprehension caused by anticipation of danger, which may be internal or external
  43. 43. Bereavement  Feelings of grief or desolation, especially at the death or loss of a loved one. Blunted affect  Severe reduction in the intensity of externalized feeling tone (F20) Elation:  Mood consists of feelings of joy, euphoria, and intense optimism (mania) Flat affect  Absence/nearly absence of any signs of affective expression
  44. 44. Irritability:  Abnormal excessive excitability, with easily triggered anger, annoyance and impatience Melencholia:  Severe depressive state
  45. 45. Clinical implications  Euphoria, elation, exaltaion, ectacy:  Mania  Anxious/restlessness:  Depression/anxiety  Sad, irritable, angry/depressed:  Depression  Shallow, blunted, indifferent, restricted inappropriate:  Schizophrenia  Anhedonia:  F20, Depression
  46. 46. Perception Perception  Complex process Of screening of physical signals by sense organs by processing these data to represent reality. Imagery:  Awareness of a percept that has been generated within the mind. Imagery can be called up and terminated by an effort of will(voluntary).
  47. 47. Disorders of perception Illusion  Misperceptions of external stimuli (anxiety and delirium) Hallucination  A true hallucination will be perceived as in external space, distinct from imagined images, outside conscious control, and as possessing relative permanence
  48. 48. Types of hallucinations  Auditory hallucinations—false perceptions of sounds  (second person, third person)  Gustatory hallucinations—false perceptions of taste.  Olfactory hallucinations—false perceptions of smell.  Visual hallucinations—false visual perceptions with eyes open in a lighted environment.  Tactile hallucinations—false sensations of touch. (Formication)
  49. 49. Hypnagogic Vs. hypnopompic hallucinations (Pseudo AH) Autoscopic hallucination:  Experience of seeing ones own body projected in to external space, usually in front of oneself, for short periods (NDE) Reflex hallucination:  A stimulus in one sensory modality results in hallucination in another…..music-----visual hallucination
  50. 50. Clinical implications  Any form of hallucinations:  Schizophrenia (72% AH), affective disorders, and organic mental disorders.  Visual hallucinations  Suggestive of organic mental disorders but are seen in functional disorders.  Gustatory, olfactory, and tactile hallucinations  Strongly suggest organic mental disorders.  Tactile hallucinations  Common in drug and alcohol withdrawal and intoxication states.
  51. 51. Cognitive functions Consciousness and Orientation1 Attention and Concentration2 Memory3 4 Judgement5 6 Intelligence Insight
  52. 52. Insight Insight  Patients awareness of his disability & need for help Clinical grading of Insight 1. Completed denial of illness 2. Slight awareness of being sick & needing help but denying at the same time 3. Awareness of being sick, but attributed to external/physical cause 4. Awareness of being sick due to something unknown in self
  53. 53. 5. Intellectual insight: • Awareness of being ill & that the Sx/failures in social adjustments are due to own particular irrational feelings/thoughts yet does not apply this knowledge to the current/future experience 6. True emotional insight • It is different from the intellectual insight in that awareness leads to significant basic change in the future behavior personally
  54. 54. Multiaxial format in DSM -IV  Axis I- All clinical disorders  Axis II - MR, personality disorder  Axis III - General Medical Conditions  Axis IV - Psychosocial Stressors  Axis V - Global Assessment of Functioning
  55. 55. Diagnostic Clusters under ICD-10 F00-09 Organic including symptomatic, mental dis F10-19 Mental & Behavioral dis. Due to psychoactive substance use F20-29 Schizophrenia, schizotypal & delusional dis. F30-39 Mood (Affective) disorders F40-49 Neurotic-stress related & Somatoform dis. F50-59 Behavioral syndromes associated with physiological disturbances & physical factors F60-69 Dis. of adult personality & behavior F70-79 Mental retardation F80-89 Disorders of psychological development F90-98 Behavioral & emotional dis. with onset usually occurring in childhood and adolescence
  56. 56. Fuerther readings 1. Kaplan & Saddocks’ Synopsis of Psychiatry