Mental State Examination

Mental State Examination Department of psychology The first affiliated hospital of ZZU Huirong guo

Mental State Examination  In psychiatry, as in medicine generally, correct diagnosis depends on careful history taking and thorough clinical examination.  However, psychiatry differs from the rest of medicine in that the interview is used not only to obtain the history but also as a way of eliciting clinical signs.

Mental State Examination  This chapter begins, therefore, with an account of the technique, it should be remembered that interviewing is a practical skill that the trainee can acquire only through carrying out interviews under supervision and watching experienced interviewers at work

The diagnostic interview  Before the interview begins there are certain preliminary requirements.  The interview should be carried out in a room that is reasonably soundproof and free from interruptions.  The patient should not be seated directly opposite the interviewer, nor should his chair be so much lower that he has to look upwards. In this way he will feel at ease rather than under constant scrutiny.

The diagnostic interview  For a diagnostic interview the interviewer should sit at a writing table in order to take notes (a psychotherapeutic interview may require less formal arrangements with patient and therapist both in arm chairs).  He should not attempt to memorize the interview and write notes afterwards, as this is time-consuming and likely to be inaccurate.

The diagnostic interview  The first encounter with the patient is important. The interviewer should welcome him by name, and give his own name.  If the patient is accompanied by a companion, it is good practice for the interviewer to welcome this person as well and to explain how long he may expect to wait before being interviewed himself

The diagnostic interview  If the patient is seen at the request of a general practitioner, the interviewer should indicate that the latter has written to him, but should not reveal the contents of the letter in detail  The interviewer should explain how he proposes: e.g. first, I should like to hear about your present problems. Only when I am sure that I have understood these shall I ask you how they began

The diagnostic interview  The interviewer then asks an open question such as ‘tell me about the problems’ or ‘tell me what you have noticed wrong’, and the patient is encouraged to talk freely for several minutes.  During this time the interviewer makes two separate kinds of observations—how the patient is talking and what he has to say. The first helps the doctor decide how to interview the patient, whilst the second tells him what to ask about

The diagnostic interview  While deciding how to interview the patient, the interviewer observes whether he seems cooperative, reasonably at ease, and able to express his ideas coherently. The most frequent difficulty is that the patient is overanxious.  The interviewer should consider whether such anxiety is part of the presenting disorder or merely fear on coming to a psychiatrist

The diagnostic interview  If the latter, the interviewer should take time to discuss the patient’s apprehension before proceeding with the interview. Usually reassurance and a calm, unhurried approach will put the patient more at ease.  Sometimes the patient seems uncooperative and resentful when he begins to talk.

The diagnostic interview  This may be because the interview is talking place against his wishes: for example, his spouse may have persuaded him to attend, or the psychiatrist may be interviewing him after admission to a general hospital for treatment of drug over dosage.  When this happens, the interviewer should talk over the circumstances of the referral and try to persuade the patient that the interview is in his own interests.

The diagnostic interview  Patients may appear resentful for other reasons. Some patients’ act in a hostile way when anxious, and some depressed or schizophrenic patients seem unco-operative because they do not regard themselves as ill.  At times it becomes apparent that a patient cannot respond adequately to the interview because of impaired consciousness.

The diagnostic interview  When this seems likely, orientation., concentration, and memory should be tested, and if impaired consciousness is confirmed, an informant should be seen before returning to the patient  As mentioned above, the interviewer, whilst listening to the patient’s opening remarks, also begins to think what questions he should ask

The diagnostic interview  These should begin with further inquiries about the nature of the patient’s presenting symptoms. It is a common mistake to start asking about the timing of such symptoms before their nature is clearly established.  For example patients sometimes say they are depressed, but further inquiry shows that they are experiencing anxiety rather than low spirits.

The diagnostic interview  If there is any doubt, the patient should be asked to give examples of his experiences.  The interviewer should clearly understand the nature of the symptoms before asking about their timing and the factors that make them better or worse.

The diagnostic interview  When all the presenting complaints have been explored in this way, direct questions are used to ask about other relevant symptoms.  For example, a person the complains who complains of feeling depressed should be asked about ideas concerning the presenting symptom will be apparent from reading the chapters on the major clinical syndromes

The diagnostic interview  Next, the mode of onset of the complaint is asked about and its course noted, including any exacerbation or periods of partial remission.  Considerable persistence may be needed to date the onset accurately, and if necessary it should be related to events the patient can remember accurately

Controlling the interview  As the interview continues, the doctor’s task is to keep the patient to relevant topics by bringing him back to the point if he strays from it.  In doing this the interviewer should use a minimum of leading or closed questions (a leading question suggests the answer; a closed question allows only the answers yes or no, thus preventing the person from volunteering information ). Thus instead of the closed question ‘are you happily married?

Controlling the interview  When there is no alternative to a closed question, the answer should be followed by a request for an example. In this way the interviewer can confirm that the answer is valid  Although it is essential to ask direct questions about specific items of information, it is equally important to give the patient an opportunity to talk spontaneously, as unexpected material may be revealed in this way

Controlling the interview  Spontaneous talk can be encouraged by prompting rather than by asking questions, e.g. by repeating in an inquiring tone the patient’s reply to previous questions or by using non-verbal prompts.  Also, before ending the interview, it is useful to ask a general question such as ‘is there anything else you wish to tell me?

History taking  Whenever possible, the history from the patient should be supplemented by information from a close relative or another person who knows him well.  This is much more important in psychiatry than in the rest of medicine, because psychiatric patients are not always aware of the extent of their symptoms.

History taking  For example a manic patient may not realize how much embarrassment he has caused by his extravagant social behavior, or a demented patient may not fully understand the extent to which his work is impaired

History taking  Alternatively patients may know what their problems are, but not wish to reveal them; for example, alcoholics often conceal the extent of their drinking.  Also, when personality is being assessed, patients and relatives often give quite different accounts of characteristics such as irritability, obsessional traits, and jealousy.

History taking  The story should always be recorded systematically and in the same order to ensure that the interviewer does not forget important themes, and to make it easier to gather information in the same with every patient.  Some flexibility must be allowed if the patient is not to feel unduly restricted by the interviewer

History taking  In the following, a standard scheme of history taking is given in the form of a list of topics to be covered. This will serve as a check list for the beginner, and a reminder for the more experienced interviewer, of the topics that make up a complete history.  However, it is neither necessary nor possible to ask every question of every patient.

History taking  Common sense must be used in judging how far each topic needs to be explored with a particular patient. The trainee must learn by experience how to adjust his questioning to problems that emerge as the interview proceeds.  This is done by keeping in mind the decisions about diagnosis and treatment that will have to be made at the end of the interview

The scheme of history taking  General information: the patient’s name, sex, age, date of birth, etc.; informant’s name and the relation to patient; interviewer’s impression of informant’s reliability  Main complain: a summary of the patient’s present illness; including the main symptoms, duration, and why the patient sees the doctor

The scheme of history taking  Present illness: symptoms with duration and mode of onset of each. Description of the time relations between symptoms and social psychological and physical disorders. Effects on work, social functioning, and relationships. Associated disturbance in sleep, appetite, and sexual drive. Any treatment given by other doctors

The scheme of history taking  Previous psychiatric illness: nature and duration of illness. Date, duration, and nature of any treatment  Previous medical history: illness, operations, and accidents

The scheme of history taking 

Personal history: early development —abnormalities during pregnancy and birth; difficulties in habit training and delay in achieving milestones (walking, talking, etc). health during childhood —serious illness, especially any affecting the central nervous system. School —age of starting and finishing each school; types of school; academic record and sporting and other achievements. Relationships with teachers and pupils. Occupations — chronological list of jobs, with reasons for changes. Present financial circumstances, satisfaction in work. Promotion and awards. Disciplinary problems

The scheme of history taking 

Personality before present illness: relationships — friends, few or many; superficial or close; own or opposite sex. Relations with workmates and superiors. use of leisure —hobbies and interests; membership of societies and clubs. Predominant mood —anxious, worrying, cheerful, despondent, optimistic, pessimistic, self-depreciating, over-confident. Stable or fluctuating. Controlled or demonstrative. Character —sensitive, suspicious, jealous, resentful, quarrelsome, irritable, impulsive, selfish, self-centred; timid, reserved, shy, selfconscious, lacking in confidence; dependent, strict, fussy, rigid. Attitudes and standards —moral and religious. Attitude towards health and the body. Habits —food, alcohol, tobacco, drugs, sleep

The scheme of history taking  Menstrual history: age of menarche, regularity and amount, dysmenorrhoea( 痛经 ), premenstrual tension, age of menopause and any symptoms at the time, date of last menstrual period  Marital history: age of patient at marriage. How long spouse known before marriage and length of engagement. Quality of the marital relationship

The scheme of history taking  Sexual history: the name, occupation, character of patient’s family members. Social position of family-atmosphere in the home. Is there any psychiatric disorder, personality disorder, epilepsy, alcoholism, and other neurological or medical disorders in the family members

Mental state examination  In the course of history taking, the interviewer will have noted the patient’s symptoms up to the time of the consultation.  The mental state is concerned with the symptoms and behavior at the time of the interview.  Hence there is a degree of overlap between the history and the mental state, mainly in observations about mood, delusions, and hallucinations

Mental state examination  If the patient is already in hospital, there will also be some overlap between mental state and the observations made by nurses of his behavior outside the interview room.  The psychiatrist should pay considerable attention to these accounts from other staff, which are at times more revealing than the small sample of behavior observed at mental state examination.

Mental state examination  For example, a patient may deny hallucinations at interview, but the nurses may notice him repeatedly talking alone as if replying to voices.  On the other hand, mental state examination may reveal information not disclosed at other times, for example suicidal intentions in a depressed patient

Appearance and behavior  Although the mental state examination is largely concerned with what the patient says, much can also be learnt from observing his appearance and behavior  The interviewer should first note the patient’s body build. An appearance suggesting recent weight loss should alert the possibility of physical illness, or of anorexia, depressive disorder, or chronic anxiety neurosis

Appearance and behavior  The patient’s general appearance and clothing repay careful observation. Selfneglect, as shown by a dirty unkempt look and crumpled clothing, suggests several possibilities including alcoholism, drug addiction, depression, dementia, or schizophrenia. Manic patients may wear bright colors, adopt incongruous styles of dress, or appear poorly groomed

Appearance and behavior  Facial appearance provides information about mood. In depression the most characteristic features are turning down of the corners of the mouth, vertical furrows on the brow, and a slight rising of the medial aspect of each brow.

Appearance and behavior  Anxious patients generally have horizontal creases on the forehead, raised eyebrows, widened palpebral fissures, and dilated pupils. The facial appearance may also suggest physical conditions

Appearance and behavior  Posture and movement also reflect mood.  A depressed patient characteristically sits leaning forwards, with shoulders hunched, the head inclined downwards and gaze directed to the floor.  An anxious patient usually sits upright with head erect, often on the edge of the chair and with hands gripping its sides. Anxious people and patients with agitated depression are often tremulous and restless, touching their jewelry, adjusting clothing, or picking at the fingernails. Manic patients are overactive and restless

Appearance and behavior  Social behavior is important.  Manic patients often break social conventions and are unduly familiar to people they have just met. Demented patients sometimes respond inappropriately to the conventions of a medical interview, or continue with their private preoccupations as if the interview were not taking place.  Schizophrenic patients may behave oddly when interviewed; patients with antisocial personality disorders may also appear abnormally aggressive.

Appearance and behavior 

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In recording abnormal social behavior, the psychiatrist should give a clear description of what the patient actually does. He should avoid general terms such as “bizarre”, which are uninformative. Instead he should describe what is unusual Finally the interviewer should watch for certain uncommon disorders of motor behavior encountered mainly in schizophrenia. These include stereotypies, posturing, negativesm, echopraxia, ambitendence, and waxy flexibility

Speech  How the patient speaks is recorded under this heading, whilst what he says is recorded later. The rate and quantity of speech is assessed first. It may be unusually fast as in mania, or slow as in depressive disorders.

Speech  Depressed or demented patients may pause a long time before replying to questions and then give short answers, and may produce little spontaneous speech.  The same may be observed among shy people or those of low intelligence. The amount of speech is increased in manic patients and in some anxious patients

Speech  Next the interviewer should consider the patient’s utterances, keeping in mind some unusual disorders found mainly in schizophrenia. He should note whether any of the words are neologisms, that is private words invented by the patient, often to describe morbid experiences.  Before assuming that a word is a neologism it is essential to make sure that it is not merely mispronounced or a word from another language

Speech  Disorders of the flow of speech are recorded next. Sudden interruptions may indicate thought blocking but are more often merely the effects of distraction.  It is a common mistake to diagnose thought flight of ideas, while a general diffuseness and lack of logical thread may indicate the kind of thought disorder characteristic of schizophrenia.  It can be difficult to be certain about these abnormalities at interview, and it is often helpful to record a sample of conversation for more detailed analysis

Mood  The assessment of mood begins with the observations of behavior described already, and continues with direct questions such as, ‘what is your mood like?’ or ‘how are you in your spirits?’

Mood  If depression is detected, further questions should be asked about: a feeling of being about to cry (actual tearfulness is often denied), pessimistic thoughts about the present, hopelessness about the future, and guilt about the past. Suitable questions are ‘what do you think will happen to you in the future?’ ‘have you been blaming yourself for anything?’

Mood  Anxiety is assessed further by asking about physical symptoms and thoughts that accompany the affect.  The interviewer should start with a general question such as “have you noticed any changes in your body when you feel anxious?”, and then go on to specific inquiries about palpitations, dry mouth, sweating, trembling, and the various other symptoms of autonomic activity and muscle tension

Mood  Questions about elation correspond to those about depression; for example, “how are you in your spirits?”, followed if necessary by direct questions such as “do you feel unusually cheerful?”  Elated mood is confirmed by ideas reflecting excessive self-confidence, inflated assessment of one’s own abilities, and extravagant plans

Mood  As well as assessing the prevailing mood, the interviewer should find out how it varies and whether it is appropriate.  When mood varies excessively, it is said to be labile; for example, the patient appears dejected at one point in the interview but quickly changes to a normal or unduly cheerful mood.  Any persisting lack of affect, usually called blunting or flattening, should also be noted

Mood  In a normal person, mood varies in parallel with the main themes discussed; he appears sad while talking of unhappy events, angry while describing things that have annoyed him, and so on.  When the mood is not suited to the context, it is recorded as incongruent; for example, if a patient giggles when describing the death of his mother.  This symptom is often diagnosed without sufficient reason, so it is important to record specific example

Delusions  A delusion is the one symptom that cannot bee asked about directly, because the patient does not recognize it as differing from other beliefs. The interviewer may be alerted to delusions by information from other people or by events in the history.  In searching for delusional ideas it is useful to begin by asking for an explanation of other symptoms or unpleasant experiences that the patient has described.

Delusions  For example, if a patient says that life is no longer worth living, he may also believe that he is thoroughly evil and that his career is ruined, though there is no objective evidence.  Many patients hide delusions skillfully, and the interviewer needs to be alert to evasions, changes of topic or other hints of information being withheld

Delusions  When ideas are revealed that may or may not be delusional, the interviewer must find out how strongly they are held. To do this without antagonizing the patient requires patience and tact.  The patient should feel he is having a fair hearing. If the interviewer expresses contrary opinions to test the strength of the patient’s beliefs, his manner should be inquiring rather than argumentative

Delusions  The next step is to decide whether the beliefs are culturally determined convictions rather than delusions. This judgement may be difficult if the patient comes from another culture or is a member of an unusual religious group.  In such case any doubt can usually be resolved by finding a healthy informant from the same country or religion, and by asking him whether the patient’s ideas would be shared by other people from that background.

Delusions  Some special forms of delusion, such as delusions of thought broadcasting, thought insertion and delusions of control etc, present particular problems.  Those must be interviewed in a special way and carefully asked.  The interviewer should also distinguish between primary and secondary delusions

Illusions and hallucinations  When asked about hallucinations, some patients take offence because they think the interviewer regards them as mad.  Questions can be introduced by saying: “some people find that, when their nerves are upset, they have unusual experiences”.  This can be followed by inquiries about hearing sounds or voices when no one else is within earshot

Illusions and hallucinations  If the patient describes hallucinations, certain further questions are required depending in the type of experience.  The interviewer should find out whether the patient has heard a single voice, or several, if the later, whether the voices appear to talk to each other about the patient in the third person

Attention and concentration  Attention is the ability to focus on the matter in hand. Concentration is the ability to sustain that focus. While taking the history, the interviewer should look out for evidence of attention and concentration.  In this way he will have already formed a judgement about these abilities before reaching the mental state examination. Formal tests add to this information and provide a semiquantitative indication of changes as illness progresses

Attention and concentration  It is usual to begin with the serial sevens test. The patient is asked to subtract 7 from 100 and then take 7 from the remainder repeatedly until this less than seven. The time taken is recorded, together with the number of errors.  If poor performance seems to be due to lack of skill in arithmetic, the patient should be asked to do a simpler subtraction, or to say the months of the year in reverse order.  If mistakes are made with these, he can be asked to give the days of the week in reverse order

Memory  Whilst taking the history, questions will have been asked about everyday difficulties in remembering.  During the examination of mental state are given of immediate, recent, and remote memory.  None is wholly satisfactory and the results must be assessed alongside other information about the patient’s to remember

Insight  When insight is assessed, it is important to keep in mind the complexity of the concept.  By the end of the mental state examination, the interviewer should have a provisional estimate of how far the patient is aware of the morbid nature of his experiences.

Insight  The interviewer should find out whether the patient believes that he is ill; if so, whether he thinks that the illness is physical or mental; and whether he thinks he needs treatment.  The answers to these questions are important because they determine, in part, how far the patient is likely to collaborate with treatment

Physical examination  A thorough physical examination should be completed on all patients who are admitted to hospital or attend as day patients, since the psychiatrist is then responsible for the patients’ physical health as well as his mental condition

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