Transcript The Mental Status Exam

The Mental Status Exam
John Wurzel MD
Outline and Objectives
1. To review the major points of the mental status
examination and learn a little vocabulary.
2. To understand the role of the mental status
exam in in diagnostic, prognostic, and
therapeutic thinking.
3. To understand how to use mental status exam
findings in context to assess a patient.
4. To practice performing various elements of the
mental status exam.
What is the Mental Status Exam?
•
Let’s start with a caveat: I’m teaching you my (and most of my colleagues’) interpretation of
what a mental status exam is and what purpose it serves. However, other interpretations
exist, and are also valid.
• That said…what is a mental status exam?
– It is a medical examination; an extension of the physical
exam.
– Like a physical exam it includes both objective and
subjective evidence gathered about the patient.
• And, what purpose does a medical examination serve?
– To aid in diagnostic, prognostic, and therapeutic thinking.
• Therefore, the elements of the mental status exam
should all provide pertinent positive or negative
information.
What are the elements of the MSE?
• Well?
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Appearance
Behavior
Speech
Mood
Affect
Thought process
Thought content
Cognition
Insight/Judgment
Appearance
• What sorts of things should you note when
describing appearance that help us determine
diagnosis or choose treatment?
– Clothing (casual, work-appropriate, formal, dirty
or clean, torn, stained, etc.)
• A well dressed psychotic person likely has a strong
social network; this is useful information for treatment
planning.
• A professional in grossly inappropriate dress might
make you concerned for psychosis or mania.
– Grooming (cleanliness, pertinent comments on
make-up or hair, dentition)
• Depression often produces poor grooming, mania or
psychosis bizarre grooming, and these also speak to
level of social support.
More Appearance
– Body habitus
• Very thin patients should raise diagnostic concern for
anorexia, end stage dementia, severe decompensations
in psychosis, etc.
• Obese patients are often obese because of medications
that we are prescribing for them.
• Our medications can cause gynecomastia
– Scars
• Raise possibility of previous self harm (suicidal or nonsuicidal)
More Appearance
– Acute or chronic injuries
• Perhaps due to recent self-harm attempt, but also useful in
terms of psychosocial thinking and treatment planning
• May be complications of mediations that we are prescribing
(i.e. amputation from diabetes secondary to an
antipsychotic).
– Patient’s posture and or location in the hospital room
• More relevant in consult work, this again speaks to
functionality
– Odors (alcohol, feces, urine, etc.)
– Track marks
Appearance continued…It’s all about
context
• What about tattoos or piercings? Well, what does a tattoo
tell you diagnostically?
– I usually don’t mention them unless they are truly remarkable.
– But…If I worked with Jehovah's Witnesses, or the president of
the anti-tattoo league, I certainly would.
• Religious symbols or attire?
– If your patient comes in wearing a Habib or a yarmulke, or a
cross, what does it really tell you about them?
– However, if my conservative Islamic patient in a Hijab tells me
that she’s taken up drinking and has slept with eight different
men in as many days, I’m going to comment on the Hijab (and
the rest of it, obviously).
• Anything that seems out of place, or anything that
represents a change deserves comment.
– I’m usually not very excited if my patient, who is a successful
lawyer, comes in in a pant suit. But after six weeks of seeing her
in sweat pants, the change makes the pant suit pertinent.
Appearance Continued
Here’s a couple examples:
1. Dress casual clothing, fair and appropriate
grooming, well-healing scar on right forearm and multiple
healed and faded similar scars over both forearms.
2. Obese man in a wheelchair missing left leg
below the knee as well as right foot, in clean sweat pants
and sweat shirt.
3. Lying in hospital bed in hospital gown, in five
point restraints, poor but appropriate grooming.
Bandages over left side of skull, intubated.
Examples: Let’s practice describing
appearance…
Behavior
• Again, what sorts of things should you note when
describing behavior that help us determine diagnosis
or choose treatment?
– What is their level of agitation?
•
Are they calm and cooperative, irritable, impatient, angry, falling
asleep?
– This may help inform me of how to structure my interview, how
to suggest interventions, whether to believe their answers to
questions, and may speak to various diagnoses. For example,
pseudodementia is classically characterized by poor effort and
cooperation, while true dementia is not.
– Psychomotor agitation or retardation; what might it tell
you?
•
ADHD, manic or anxious patients (or those high on stimulants) are
classically activated, depressed patients are classically retarded.
Behavior
– Motor tics; why would your patient have motor
tics?
•
Perhaps Tourette’s syndrome, perhaps a medication
side effect from an antipsychotic (tardive dyskinesia).
– Tremor; what is the psychiatric differential?
•
Parkinson’s disease, antipsychotic-induced
parkinsonism, lithium tremor (possibly lithium
toxicity), alcohol or benzodiazepine withdrawal,
stimulant intoxication, etc.
Behavior
– Eye contact; what kinds of patients have what
kinds of eye contact?
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Depressed patients typically have poor eye contact
Anxious patients also have poor eye contact, though
for different reasons
Psychotic patients often have unusually intense eye
contact because they don’t pick up on social cues (and
an increased blink rate).
– What might gait findings tell you?
•
Acute intoxication can cause ataxia, Parkinson’s or
parkinsonism cause shuffling gait, etc.
So how would you describe the
following behaviors?
This is tardive dyskinesia, in a case of antipsychotic withdrawal dyskinesia.
This, however, is psychomotor agitation during (probably)
methamphetamine intoxication…
Speech
What are the four descriptors for speech?
• Rate; purely a comment on speed. Who speaks
fast?
– Anxious, manic, stimulant intoxicated, etc. Who speaks
slow?
– Depressed, patients with parkinsonism, etc.
• Rhythm; the articulation, prosody, any slurring,
latency, and I consider pressured speech to be a
rhythm.
– Pressured speech refers not to the rate, but to whether
the speech is interruptible.
• Classically, pressured speech is also rapid and is coming from a
manic patient or someone on stimulants
• However, you will rarely meet someone with slow, pressured
speech. If you’re anything like me, it will be intensely
frustrating.
Speech
• Volume; self-explanatory.
• Content; this refers mostly to neurologic
findings like aphasias, perseveration, etc.
However, it can also refer to findings like
monosyllabic responses, very poor vocabulary,
etc.
Let’s try describing this woman’s
speech…
I would describe this woman’s speech as rapid and bordering on pressured.
Mood
• The prevalent emotional state the patient tells
you they feel.
• Often placed in quotes since it is what the
patient tells you.
• Examples “Fantastic, elated, depressed,
anxious, sad, angry, irritable, good.”
Affect: The radio dials…
• I think of affect like a radio; it has a dial for
volume, and one for station.
– The station dial: what emotional state are you
observing? It can pretty much be anything…
• Dysphoric (sad), euthymic (neutral), euphoric (happy),
anxious, irritable, excited, annoyed, frustrated,
plethoric...don’t be limited by “psychiatric terms”, just
describe it accurately.
Affect
– The volume dial: how much range does the patient’s
affect display? Or, how much does their affect vary
from the state you described?
• Patients whose affect varies little might be called blunted,
restricted, constricted.
• Patients with normal variation (i.e. they can smile at jokes or
at happy thoughts, but they can look sad or cry at sad
thoughts) I typically describe as having “normal range.”
• Patient’s whose affect seems to vary out of proportion to
the conversation have “labile” affect. Sometimes a labile
affect is so labile that you can’t identify a core mood state.
• Flat affect is the physical inability to convey emotion. You
might see it in severe parkinsonism, supranuclear palsy,
amyotrophic lateral sclerosis, comatose patients, etc. It is
essentially a neurological condition. A patient cannot have
“dysphoric, flat” affect. It can only be “flat” if it is truly flat.
Affect: Other Considerations
• Congruity: Does the observed affect match the
mood that the patient describes?
• Appropriateness: Is the affect appropriate to the
subject of conversation?
Every time I describe affect, I use at least two
words: the “station” or emotional state, and the
“volume” or the emotional range. If congruity or
appropriateness seem important, then I comment
on them, too.
If a picture is worth a thousand words,
how many is a video worth? And what
affect do you see here?
I would describe Data as having a highly restricted, euthymic affect. It
is also incongruous relative to his stated mood and somewhat
inappropriate to the subject matter (a joke). You might call it flat if you
ignore the fake laughing.
And what about in this video?
This woman has a labile affect. It’s actually so labile that I can’t tell if she is
fundamentally happy or sad. To really stretch my analogy, you might say that
the radio volume is turned up so high that you can’t make out the words
anymore.
Thought Process: How organized are their thoughts?
First, I’ll need a volunteer…
How does one describe a normal thought process?
• Linear, logical, goal oriented.
Tangential: Li/Lo
Circumstantial: Li/Lo/~GO
Q
Normal Thought Process: Li/Lo/GO
A
Word salad
Loosening of
associations (a
string of loosely
related tangents):
~Li/~Lo
Flight of Ideas (a
string of
unconnected
tangents): ~Li
(Clanging)
Video! What is this man’s thought
process like?
I would say his thought process is characterized by loose associations, frequent
flights of ideas, and even occasional clanging.
• For bonus credit, what about his speech?
• Rapid and truly pressured
Thought Content
• What thought content abnormalities do we ask
about?
– Hallucinations: seeing or hearing things that aren’t
really there (typically auditory of visual)
– Illusions: misinterpreting sights or sounds that
actually are there (for example, seeing a coat rack
as a person, or hearing radio static as a voice)
Thought Content
– Delusions: fixed, false beliefs firmly held in
spite of contradictory evidence
• Control: outside forces are controlling actions
• Erotomanic: a person, usually of higher status, is in love
with the patient
• Grandiose: inflated sense of self-worth, power or
wealth
• Somatic: patient has a physical defect
• Reference: unrelated events apply to them
• Persecutory: others are trying to cause harm
More Thought Content Abnormalities
– Ideas of reference: the idea that something refers
to you when it does not (for example, the idea
that a TV show or radio program has special
messages just for you, or that two strangers across
the street are having a conversation about you
when they have no reason to)
– Thought insertion (mind reading) or thought
broadcasting (other people reading your mind)
Even More Thought Content
Abnormalities
– Paranoia: believing that people or organizations
are out to get you
– Thought blocking: the sense that you can’t finish
your thoughts
– Suicidal or homicidal ideation, intent, and plan are
usually mentioned here.
Let’s discuss this man’s thought
process and content…
He is displaying loose associations, with paranoid delusions and possible ideas of reference.
And this woman’s thought content…
She is describing tactile hallucinations, has clear ideas of reference, and also
displays paranoia. She may have thought broadcasting as well.
Cognition
• Think about cognition diagnostically:
– What are core cognitive domains that fail in dementia?
• Executive function
– Includes planning, visuospatial, etc.
• Language (covered in speech)
• Memory
• Recognition (or naming)
• Coordination
– And what are the primary diagnostic clues for delirium?
• Level of attention (alert, appropriate vs. waxing,
inconsistent, drowsing off)
• Disorientation
Cognition Continued
• If you tested these domains, then provide the test
and the results (i.e. “Short term recall 3/3”, or
“Able to perform serial 7’s”, “MOCA 28/30” etc.)
• Don’t say that you assessed cognitive domains
unless you actually did.
• Every MSE should include some comment on
memory, orientation, and level of attention.
Other domains should be discussed if pertinent.
The Mini-Cog: A Useful Screening Tool
• Clock draw:
– Shape of contour must be correct
– Numbers must be in the correct places
– Hands must be accurate (you should always ask for a time that
places the hands in two different quadrants)
• Three item recall after five minutes.
• Scoring:
– If they pass the three item recall, they pass
– If they get 0/3, they fail
– If they get 1-2/3, they pass if the clock is right and fail if the
clock is wrong.
– If they pass, the patient is quite unlikely to have dementia (up to
99% sensitivity in some studies).
– If they fail, they merit further evaluation (MOCA, Mini-Mental,
SLUMS, etc.)
Insight and Judgment
• Insight and judgment are not the same things.
• What is insight?
– An awareness of one’s own situation or condition.
• On a superficial level, it refers to a patient
understanding the medical elements of their condition
• On a deeper level, it refers to a patient understanding
the social and even psychological contributions to their
situation.
Insight and Judgment
• What is judgment?
– The ability to anticipate the consequences of one’s
behavior and make decisions that protect oneself
and others in the context of one’s own moral
compass
• Functionally, it usually boils down to whether the
patient is doing what their providers are
recommending, regardless of why they are doing it.
• Who can give me some examples of insight
and judgment?
Now a couple full practice
assessments…
Write your own MSE for a couple minutes, then we’ll all compare notes.
Practice #1
• Appearance: Appropriately though casually
dressed, fair grooming. Appears to be
bleeding at the mouth.
• Behavior: Calm, though confused. Repeatedly
tries to put hands in mouth. No gross
psychomotor agitation or retardation.
• Speech: Somewhat slurred, with labile
volume.
• Mood: “I feel funny”
Practice 1 Continued
• Affect: Mildly dysphoric and clearly confused.
Somewhat labile.
• Thought process: Linear and logical in general
but at times displays disorganization in that he
loses the thread of conversation.
• Thought content: Some evidence of
responding to internal stimuli. SI, HI not
assessed.
• Cognition: Not formally assessed, but
cognition appears impaired. Memory grossly
impaired to recent events. Attention waxing
and waning during interview.
• Insight/Judgment: Poor/Poor.
More practice..
Write your own MSE for a couple minutes, then we’ll all compare notes.
Practice #2
• Appearance: Dressed and groomed casually
but appropriately. Notable bilateral facial
scars.
• Behavior: Generally calm, though with a
violent outburst toward the end. Tearful
throughout. No psychomotor agitation or
retardation noted.
• Speech: Limited by tears, but characterized by
stutter, brief statements, and quiet volume.
• Mood: “I always thought I was funshine
bear…”
Practice #2 Continued
• Affect: Restricted to dysphoria. Tearful.
• Thought process: Linear and logical on a
superficial level.
• Thought content: No evidence of responding to
internal stimuli. Clear HI, with intent, plan, and
access to means.
• Cognition: Not formally assessed, but cognition
appears superficially intact. Memory grossly
intact. Attention appropriate throughout.
Orientation not formally assessed.
• Insight/Judgment: Fair/Fair?