Psychiatric History & Mental status examination

1. LOGO
Psychiatric History & MSE
Bivin JB
Department of Psychiatric Nursing
Mar Baselios College Of Nursing

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. History & MSE
Rapport
 A relationship of mutual understanding or trust
and agreement between people

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. History
Demographic data
 Name
 Sex
 race
 Locality
 marital status
 Occupation
 Religious belief
 living circumstance

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. 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. Onset
 Abrupt
 Acute
 Insidious
Course
 Continuous
 Episodic
 Remittent

9. Precipitating factor
A failed romance
A death in
the family
Serious
illnesses
Failure in
exams
Problems in
relationships

10. Important
Obtain a clear chronological account of
symptoms ( e.g. depression, psychosis) &
the effects of these symptoms on
behaviour

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. Personal history
 Birth & early development
 Disorders during childhood
 Schooling and occupation
 Menstrual history
 Marital history

13. Premorbid personality
 Social relations
 Mood
 Attitude towards work and responsibility
 Response to criticisms and praise
 Leisure activities and hobbies

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. 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. Forensic history
Have you ever been in trouble with the
police, or been convicted of anything?
***

17. LOGO
Mental Status Examination

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. 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. Mental status examination
General appearance & behavior
Psychomotor activity
Speech
Thought
Mood
Perception
Cognitive functions

21. General appearence
 Attitude toward the interview situation
 Consciousness
 Orientation
 Cooperativenes
 Rapport and attitude toward the interviewer
 Dress
 Attention Span
 Catatonic signs

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. Psychomotor activity
Goal directed activity
• Decreased
• Normal
• Increased
 Level of activity: Lethargic, tense, restless,
agitated
 Type: Grimaces, Tics, Tremors
 Unusual gestures

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. 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. 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. 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. Speech
Tone
Tempo
Volume
Reaction time
Coherent
Relevant
 Sample of
Speech:…………………………………………
……………………………………………………

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. Clinical implications
Speech expressive problems
 Brain involvement, developmental problems,
Eg: ELD
Pressure of speech
 Mania
Mutism/Alogia
 Depressive Sx/Catatonic F20

31. Thought
Form
Stream
Posession
Content
 Delusion
 Overvalued idea
 Depressive cognition
 Suicidal idea

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Irritability:
 Abnormal excessive excitability, with easily
triggered anger, annoyance and impatience
Melencholia:
 Severe depressive state

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. 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. 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. 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. 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. 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. Cognitive functions
Consciousness and Orientation1
Attention and Concentration2
Memory3
4
Judgement5
6
Intelligence
Insight

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. 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. 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. 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. Fuerther readings
1. Kaplan & Saddocks’ Synopsis of
Psychiatry