The following document was written by Dr Satvir Singh FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry) Kent & Medway NHS and Social Care Partnership Trust Canterbury, Kent in Dec 2007.
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In most branches of medicine, history taking is almost always followed by physical examination and each sub-speciality has its own unique method of examination, which needs to be followed methodically to avoid missing any significant findings. Sometimes, absence of key signs is equally important to confirm or exclude the possible clinical diagnosis.
In psychiatry, mental state examination begins as soon as you see the patient and it continues while you are painstakingly going through all the sub-headings of history taking. Sometimes, it requires only a few minutes to complete the mental state examination after spending most of the available time in history taking.
Mental State Examination is nothing more than the keen observation of patient’s appearance, behaviour and mood, then some questions about their beliefs and perceptual abnormality, if any. Then follows the cognition, insight and interpretation of your findings.
The important difference in psychiatric examination and physical examination is that in psychiatry, we also record what the patient thinks, feels or believes about their dress code, personal appearance, behaviour and thought process, also, what they think and believe is the underlying cause/s responsible for their clinical (mental) state. And indeed, what may be the best treatment options for them. While in medicine, the patient may not have any opinion about their skin pallor, pale conjunctivae, fine tremor of both hands, shallow breathing or raised JVP, but in psychiatry, almost all patients would have some personal interpretation of their signs and symptoms. This often gives us clues in reaching the final diagnosis of our patients. Also in psychiatry, signs and symptoms merge easily and the boundaries are not as clear as in general medicine and surgery. A hallucinatory experience could be described as a symptom as well as a sign while presenting your case in a clinical examination.
The other key observation that we make in psychiatry is the disparity or incongruity in patient’s complaints and observed behaviour. As in cases of dementia disorders, where the patient will invariably deny any problems with his/her memory, the next minute, they are unable to give their personal history, or simply the day of the week or the current month. Similarly, eating disorder patients will often deny any problems with their weight or eating habits, despite their markedly undernourished appearance and dangerously low body weight.
In psychiatry, Mental State Examination is the easiest part of the consultation process as long as we are acutely attentive in our observations and pick up the “key clues” and ask the relevant questions. Describing a mental state in an examination must be kept as simple as possible, and where relevant, quote verbatim the patient’s point of view to describe a key sign or symptom. As elsewhere in medicine, you are also expected to mention what key symptoms and signs are missing in favour of your primary or other diagnoses. Finally, you must also formulate what other information that you may require to reach to your final diagnosis and the relevant investigation that you would wish to carry out before considering the treatment plan.
From here on, we will go through the various sub-headings of Mental State Examination and describe their significance while examining a patient with mental disorder.
The patient’s appearance and general behaviour may give you some clues about the possible diagnosis. From hypomanic to manic excitement state; withdrawn, worried, anxious and depressed states; paranoid and suspicious mood; confused and unkempt state; aggressive and abusive behaviour; mobility and gait; will give ideas about various underlying psychopathology. My Consultant once told me that it is not only the patient’s appearance and behaviour but also the appearance and behaviour of the relatives is equally important. For example, in case of hypomania and manic excitement, the patient almost always appears to be the healthiest compared to the rather worn out, exhausted and tired members of the family. Similarly, the patient with dementia disorder walks in the consultations room with no worries in the world, but the “head turning” sign towards the anxious and worried spouse in response to any questions asked soon gives away the diagnosis. A paranoid and suspicious patient would often misinterpret and “check out” their immediate surroundings. Recently, a patient wanted to know the purpose of the smoke alarm in the room. He wanted to be sure that the device had nothing to do with a hidden camera or a hearing device.
While visiting patients at their homes, especially older persons, you can gather plenty of clues from the minute you enter their homes. The state of the garden, how you are greeted at the door, state of the living room, food in fridge, state of the kitchen and how the pets have been looked after, tell us a lot about the mental health of the master. A patient with dementia would welcome you in with a smile (although not always!), while a person with paranoid state would ask at the door – “Why have you come? Who has sent you? By any chance, was it the next door neighbour?” And so on. A depressed patient would feel rather guilty in wasting your time, as he believes that he cannot be helped by anyone.
In your presentation of the case, it is always more informative to describe the patient’s behaviour and appearance in plain English rather than using terms such as hysterical, bizarre, etc.
Here our concern is only with the type and quality of speech and not the thought content. One would concentrate on the appropriateness of the speech, its volume, rate/speed, flow i.e. spontaneous or answers in short sentences when spoken to, use of proper words or approximation. Also make a note of any articulation difficulties (Dysarthria). Some patients may use new words constructed by them or attach personal meaning to existing words (Neologism). Commonly, one would see abnormality of speech in various neurological disorders, depression, mania, schizophrenia and learning disabilities.
Affect is only the brief emotional responses to a given situation. Noticing the patient’s immediate reaction to a question, a pun or a joke assesses affect. A normal affect is usually warm and reactive with appropriate facial expressions. A patient may smile or even laugh from time to time during the interview, but his/her overall mood could well be low, sad and depressed. Thus a mood state is prolonged and a reflection of the patient’s subjective emotional state. There are different states of mood from being normal (Euthymic) to extreme elation and deep depression. Other states could be one of anxiety and worry, fearful, suspicious and guarded, irritable and angry, and so on. What are significant to note are the patient’s subjective feelings and description of their mental state and your objective assessment of their mood and any fluctuations throughout the interview.
Brief fluctuations in affect and mood states could be a normal reaction to a specific situation. However, if a particular mood state is pervasive and correlates with functional impairment, at home, socially and at work, then it is invariably pathological.
Different mood states and their assessment will be described fully under various clinical disorders elsewhere.
A simple question asked or a complex situation will trigger a thought process, which involves three distinct processes:
Thought blocking and over-inclusive thinking could well be the disorder of thought formation as well as the process of Thought Content. Flights of ideas, loosening of association, derailment of thoughts, circumstantiality and circumstangentiality are clearly the disorder of the process of Thought Contents. Finally, whether the thoughts are goal directed or not, signify the state of the patient’s attention and concentration span as well as the memory functions.
All delusions are described in Thought Content and will be dealt with separately under various disorders.
Perceptual abnormalities require skilled evaluation of the phenomena in each sensory modality.
Different types of hallucinations, auditory, visual, olfactory, tactile and somatic, and their significance will be discussed elsewhere.
At this stage, some key features about any hallucinations should be enquired about methodically and recorded:
By the time you get to this point of your assessment, you have already formed your opinion about the patient’s cognitive state. If however, the patient has difficulty in giving simple details of their personal history and presenting problem, then one should shift the attention to a more detailed Cognitive Assessment early on in the process.
Simple screening test of cognition (Mini Mental State Examination – MMSE) is widely used and that may be the first step to identify any major problems with ones attention, concentration, short and long term memory functions.
If necessary, a detailed Dementia Disorder Assessment should be undertaken by a specialist team, and will be dealt with elsewhere..
Evaluation of the patient’s insight is an important aspect of psychiatric examination. It helps in arriving to the final diagnosis as well as some idea as to the patient’s probable compliance to the prescribed treatment and thus the treatment outcome and overall prognosis.
Some of the questions to elicit one’s Insight and Judgement are as follows:
All the above questions will give a fair idea about the patient’s understanding in his mental as well as physical health issues and whether he/she would comply with the prescribed treatment.
This would also help you to decide whether the patient can be treated as an outpatient or may require hospital treatment. And, finally, can the patient be treated informally or you may need to consider the treatment under the Mental Health Act.
Author:
Dr Satvir Singh
FRANZCP (Aust), FRCPsych (UK), MSc (Lon), MRCPsych (UK), DPM, MBBS
Consultant Psychiatrist & Lead Consultant for Undergraduate Medical Education (Psychiatry)
Kent & Medway NHS and Social Care Partnership Trust
Canterbury, Kent