Mental Status Assessment of an Un-cooperative Patient. Case The psychiatric mental status examination includes cognitive screening to understand .. Many a times, the clinicians are faced with non-cooperative patients. the mental status of an un-cooperative patient is given by Kirby () and assessment. It includes conceptual models, matching patients with typical typologies, . Although separate schedules for the examination of non-cooperative patients exist, . Kirby GH. Guides for history taking and clinical examination of psychiatric. Often, agitated patients are uncooperative or unable to give a relevant on the patient’s mental status examination, to guide the appropriate course of care.
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Mental status examination is an important skill to be learnt by a resident and is akin to physical examination in medicine. MSE includes cognitive functions, intelligence, uncooperatiev, mood, perception, insight and judgement. Though examination of uncooperatjve is an objective phenomena, symptoms are mind are mostly subjective experiences, hence it is difficult to differentiate between signs and symptoms MSE.
Secondly, the identification and categorization of mental symptoms depends on the discipline of descriptive psychopathology, or phenomenology. Phenomenology is referred to the method of evaluating patients experience embracing a broader individualized and subjective experience, with less categorical approach to mental assessment.
Psychiatric assessment and the art and science of clinical medicine
When we present a case we divide the information into history and MSE. However both history and MSE are not mutually exclusive and occur simultaneously during the interview process.
Present Status Examination takes one month duration from the day of interview while a routine MSE for case presentation is of past one week duration. As with the history, categorizing and recording mental state has a fairly standard structure, covering the domains of appearance and behavior, speech, mood and affect, thought content and perception, concluding with cognition and insight.
The exact ordering of these is, however, determined largely by convention. The MSE process starts right from the time the patient walks into the room latient even before the interview has actually begun. General appearance and behavior should include the observation of the patient during the process of interview and ward behaviors if the patient is hospitalized.
It refers not only to matters of dress and grooming, but would cover physical characteristics worthy of note, such as posture, build, age appropriateness of appearance. Whether the patient is well kempt or poorly kempt. This depends on whether that patient has dressed and groomed appropriate to his or her age and maintains cleanliness. If a patient kurby the fashion of some identifiable subculture, example tribal background, it is appropriate to record this, even though it is not in itself indicative of clinical abnormality.
Rapport is an important element in the engagement of patient. Establishing rapport is ezamination important step towards successful evaluation of phenomenology of the patients.
The major abnormalities of movement and behavior are those associated with schizophrenia and affective disorder. Acutely psychotic patients may act in response to delusions searching for knives in cupboards, etc.
They may be readily distractible by incidental noises, or suspicious or bewildered and unforthcoming. Any automatic motor behaviors should be noted, such as restlessness, fidgetiness and nervousness, kigby well as involuntary movements such as dyskinesia should be described and documented. Any loss of expected motor activity in relation to, for example, facial expression, expressive posture and gesture, can be recorded here or above, as noted.
Catatonia is characterized primarily by disturbance in volition and psychomotor disturbances. Catatonia can be seen in organic, psychotic, neurotic conditions.
Various manifestations of catatonia include. Any goal directed activity in uncooperxtive recent past and during the course of interview examinatino in psychomotor activity of the patient. Speech consists of words, which articulate vocal sounds that symbolize and communicate ideas. Tempo is the speed of speech which is determined kitby the individuals thinking process. It can be either increased or decreased depending on the thinking process, usually seen in uncooperatkve disorders. Volume is evaluated looking at the Speech output.
If it is less than 10 — 15 words per minute is examinatoon to be low or reduced and is reduced in retarded depression. Spontaneous speech output of more ucnooperative words per minutes is said to be pressure of speech, which is usually seen in patients in mania with flight of ideas.
Prosody of the speech is the intonations used while speaking. It can be reduced in patients with schizophrenia. Tone of speech reflects the intensity of sound, which is reduced in depressive patients. Thought is a subjective process and the primary means open to us to make inferences regarding its form is via speech. Form of thought is the structure and organization of thinking. Various definitions of normal thinking and disorders of thinking have been described, details of which will be discussed subsequent topics.
Important clinical considerations before judging the form of thought includes. Speech Sample from the patient verbatim is essential for evaluation of form and stream of thought. If there is impairment in the structure of thinking in the form of loss of goal directedness due to any of the following causes like derailment or tangentiality, presence of neologisms, incoherence, exzmination of content, absence of abstract meaning can be judge as presence formal thought disorder.
Stream of thinking is related to the flow of thought process which is the determining tendency of thinking. This is significantly influenced by the emotional state of the individual.
Oc patients with mania or hypomania, there is increase in the flow of thinking which results in excessive thinking. Flight of ideas — When the flow is significantly increased like in mania, there is loss of direction in thinking resulting in irrelevant and incoherent speech.
It is usually associated with pressure of speech and distractibility. There can be chance association between the thoughts and is usually related to internal and external cues. When there is increase speech, kirbh the individual reaches goal, then it is called as prolixitywhich is usually seen in hypomania.
In prolixity the person has increase speech output associated with lively embellishment and is able to reach the goal. Thought block is the sudden arrest of train of thought, leaving a blank and the some patients may become acutely aware of the same. It is usually seen in patients with schizophrenia. Perseveration i s the persistence of the examinstion operations beyond the point of relevance and thus prevent progressive thinking.
It can be of three types — compulsive, inability to switch and ideational perseveration. It can be either verbal or ideational. It is usually seen in organic disorders of brain like dementia — frontotemporal dementia and in chronic schizophrenia. Normally the subject experiences his thinking as being his own although this sense of personal possession is never in the foreground of his consciousness.
Full text of “Guides for history taking and clinical examination of psychiatric cases”
There is also a feeling of control over his thinking. It can be affected when there is loss of sense of control over this thinking. Thought alienation phenomenon is present when the individual feels that he has lost control over his thinking and an outside agency is trying to control or participating in his thinking. Commonest symptom experienced by the patient kiry thought broadcast. In thought broadcast, the patient knows that as he is thinking everyone else is thinking in unison with him.
Patient reports that others are getting to know what he is thinking simultaneously as he is thinking and some time he feels this kirbby are getting diffused from his mind. Thought insertion is said to occur when the patient thinks that thoughts are being inserted in to his mind against his will and he recognizes it to be foreign and coming from without.
In thought deprivation the patient finds that as he is thinking his thought suddenly disappear and he kirbt acutely aware of the same. Evaluation of content of thought is necessary to understand the patients concerns and ideas. It is also appropriate to record here any abnormal ideas and beliefs the prototypical abnormality being delusions, others include overvalued ideas, obsession and compulsions, depressive ideas about future, self and environment, ideas of reference.
All patients attending a psychiatrist should be evaluated for suicidality. While describing any delusions, initially patients report of his belief should be recorded verbatim, followed by making a judgement on the below aspects of the delusion.
Where a delusion seems obviously secondary to another psychotic symptom — e. Delusions of reference must be distinguished from simple ideas of reference, which are an exaggerated form of self-consciousness, usually driven by social anxiety, comprising an uncomfortable feeling taking notice of them. Almost everyone has experienced this symptom at some time e. Simple ideas of reference can, however, become pervasive and socially incapacitating in some conditions, such as anxiety and depressive states.
Obsessional thoughts and compulsions: Obsessions have three characteristics:. Overvalued ideas are beliefs which, because of the excess of emotional tone invested in them, come to dominate to an abnormal degree. They do not have obsessional characteristics i.
Examples include querulous paranoid states, morbid jealousy and hypochondriasis. Mental status assessment is incomplete without evaluating the suicidality in all patients with mental illness.
While assessing suicidal ideas and behavior, it is necessary to be sensitive and ask appropriate questions to elicit risk of suicidality.
Presence of thoughts of helplessness, worthlessness and hopelessness may be the beginning of suicidal behavior. The flow chart below describes how hopelessness and wish to die progresses to suicidal attempt. Assessment of mood is the one of important part of mental status examination and the difficult one too. Subjective mood state should be explored and described in the history but it is important to summarize the key findings at this point in the MSE.
The objective expression of mood should also be noted and can be considered along two axes breadth and depth. Range of mood is described as the entire range from being sad to happy to anger to fear. While hallucinatory experiences may occur in any sensory modality, in clinical practice hallucinations of hearing auditory hallucinations are the most frequent and important. While describing a hallucination some of the following aspects should be considered.
They may be elementary or rudimentarycomprising tapping, banging, music or preverbal whispers, mutterings and mumblings where individual words cannot be made out but onto which the patient may still graft content. They may comprise a single voice heard only sporadically, through conversations involving several parties to thousands of voices babbling constantly mass hallucinations.
They may arise from locations outside the normal perceptual sphere, e. Visual hallucinations can be formless shapeless images, lights, shadows or formed objects fiery crosses, faces, people. Visual hallucinations are perhaps most commonly described in delirium, where they may take all these forms.
George Hughes Kirby
Visual hallucinations are less common in schizophrenia than auditory hallucinations, but the view that they are so uncommon that their presence should point to an organic disorder.
Somatic hallucinations can be classified on the basis of the specific sensation they replicate — e. Like somatic hallucinations, olfactory and gustatory hallucinations may be simple or elaborated in delusional ways. While olfactory hallucinations are not an uncommon symptom of psychosis, their occurrence in organic brain disorders especially temporal lobe epilepsy must be borne in mind.
These are sensory deceptions where the patient has sensory phenomenon similar to hallucinations, but occurring in the subjective space and lacks the veridicality as that of true percept or hallucination.
It can be seen in patients with schizophrenia and mood disorders.