The procedures

The mental state examination is systematic and is slanted towards the presenting complaint and the diagnostic possibilities especially those requiring specific treatment. It is usually performed with the patient seated and dressed-There are several components.

Appearance and demeanour. This involves assessing what the patient looks like and how the patient behaves. Abnormalities include:

• evidence of self-neglect or emaciation

• lack of cooperation and difficulty in establishing rapport

• drowsiness, evasiveness, lack of eye contact or marked suspiciousness.

Motor activity. This includes facial expression, posture and gait. The main abnormalities are:

• too much activity such as tremor or restlessness

• too little activity such as retardation

• involuntary activity such as tics or dystonia.

Speech. Again, abnormalities divide into:

• too much talk such as pressure ol speech (a feature of mania or stimulant misuse)

• too little talk such as retardation or poverty (features of depression)

• talk abnormalities such as elective mutism or stuttering

Mood. Mood is traditionally divided into subjective and objective mood slate, but there is considerable overlap w ith thought contení and sometimes behaviour or autonomic activity.

TABLE 1.12 Questions So ask lo determine the possibility of suicidal thoughts in a patient

How have you been feeling recently7

Do you feel brighter m the morning or in the evening'

Have you any difficulties with sleepm^mght waking?

Do you feel worried, irritable or depressed'

Has life seemed less worthwhile?

Have you ever seriously considered taking your own lile?

TABLE 1.13 Two short mood scales

K Anxiety

Have you felt keyed up. and on edge' Have you been worrying a lot? Have you been irritable"? Have you had difficulty relaxing' II YES to any ONE ol above, go on to: Have you been sleeping poorly? Have you had headaches or neck aches or lightness in head? Dizzy: trembly: sweating, diarrhoea; frequency: tingling etc, (autonomic anxiety)?

Been worried about health? Difficulty tailing asieep?

D. Depression Low energy? Loss ol interest? Lost confidence in yourself Felt hopeless7 If YES to any ONE of above, go on to Unable to concentrate7 Lost weight (owing to poor appetite)? Early waking? Fell slowed up? Felt worse in mornings?

1 point for each answer Add A-score; add D-score

Anxiety states usually score > 3 on A and depressive illness > 3 on D

Subjective mood is assessed by an introductory open inquiry such as 'how have you been feeling recently?' As with hi story-taking the aim is first to establish whether a nest exists and then to explore the layers through a series of inquiries, moving from the general to the specific to determine the possibility, for example, that (lie palieni is suicidal (see fable 1. 121.

Objective mootI is assessed by observation of the patient facial expression, behaviour and emotional state, resonance and responsiveness - and by picking up the general demeanour of the patient and ambience of the interview. Assessing mood objectively takes experience and awareness.

The difficulty is compounded by many patients who suffer from depression or anxiety denying or failing to recognise their abnormal mood state. Conversely, the strain of the interview itself can provoke emotional reactions such as wecpiness, irritability or emotional lability in some patients, and there exists a danger that the unwary clinician can misinterpret these responses as signs of mood illness.

Sometimes features like the loss of normal resonance in mood or the persistence of anxiousness long after the patient should have settled provide useful clues but often the diagnosis of mood illness has lo rely on other sections of the history, notably thought content.

A rapid, reliable way of assessing a suspected mood disorder is presented in Table 1.13.

Thought. Though! is traditionally divided into form and content

Form refers to how thought processes are constructed and (he relationships between ideas.

Content is often more important. 1; should be considered in terms of preoccupations and abnormal beliefs (delusions), the former being more often relevant. Preoccupations are the thoughts that recurrenlly run through the patient's mind, or particularly trouble the patient. These are usually understandable and appropriate lo the circumstances, hut they can come to dominate the patient and so become a problem in Iheir own right (Table 1.14).

Delusions are rare. A delusion is a mistaken belief which is held w ith conviction: not shared by others w ith (he same cultural or social background, or intellectual level: and cannot be shaken by persuasion or evidence to the contrary.

TABLE 1.14 Typical preoccupations associated with mood disorder

Anxiety state Anxiousness, worry, fear, apprehension, doubt, uncertainty

Depressive disorder Loss of self-worth, confidence, ability

Guilt burden, lailure, catastrophe, hopelessness Death, suicide

Unlovable, unlikeable. sell-denigration

Delusions are always erroneous hut not always absurd: (he) are e\idence of serious mental illness and require lo be distinguished from overvalued ideas which arise from eccentricity or cultural factors.

Disorders of perception. The most important abnormalities are hallucinations which arc defined as apparently normal perceptions occurring in the absence of the appropriate stimulus. Illusions differ in (hat these are misinterpretations of external stimuli. Hence a coat hanging behind a door which the patient misperceives as a person amounts lo an illusion, hut if there is no person or coat and the patient perceives somebody, then this is a visual hallucination.

Hallucinations and illusions can occur in any senson modality, but ihe commonest forms are visual and auditory, and common causes are delirium and drug intoxication. Auditory hallucinations also occur in schizophrenia, bul

TABLE 1.15 Abbreviated mental test

3 Month'

4 Year'

7 Names ol three obiecis at 2 minutes, e.g. apple, table, coin (score 1 il one item, or more, is remembered}

8. Dates of Second World War?

9. Name ol Prime Minster?

10. Count backwards from 20 to 1 (0 for any uncorrected error)

Each item scores 1 point Normal scores 8-10 Mild-moderate dementia 4-7 Moderate-severe dementia 0-3

may he a feature of other mental illnesses including organic brain disorders.

Attertt/on/concenfration. An inability io concentrate on a task, increased distractibility and occasionally an inability to attract the patient's attention, are important mental state abnormalities often cued by the history. Tor example patients may volunteer that they have difficulty in following the thread of a book or TV programme. Deficits occur in most mental disorders but particularly organic brain states and mood illnesses

Simple tests of concentration include repeating the months in reverse or performing serial sevens (starting at HKI and continuously subtracting 7). In some patients, serial threes from 40 is preferable. It takes experience to establish what amounts to an abnormal response given ihe patient's educational attainment, but in general, patients should he able to complete serial sevens in less than I minute with no more than two crTors.

Orientation. Disorientation is the cardinal feature of organic brain disorder, occurring in delirium, when it is frequently accompanied by clouding of consciousness, and in dementia. Orientation is considered in terms of lime, date, placc and person, and this forms the basis of most of the brief tests of organic brain impairment (Table 1.15).

Memory. Memory abnormalities take a variety of forms, but ihe important practical division is between recent/short term memory (STM) and remote/long-term memory (LTM). Various ways of testing registration of memory. STM and LTM exist.

• Registration can be assessed by digit span. The patient simply repeats back immediately a set of randomly chosen numbers lhat the clinician announces. It is usual to start ai ihree digits and work up to seven if possible.

Most unimpaired adults of average intelligence can manage seven. Five or fewer indicates impairment.

• STM can be tested by asking Ihe patient to recall a six-item name and address. After explanation, the patient is given a fictitious name and full address which consists of six key facts to remember, e.g. Mrs Margaret Brown, 32 Blackford Crescent, Edinburgh EH 12. This is checked immediately to ensure accurate registration, an; errors arc corrected, and ihe name and aiklres-, are repeated until the patient scores 6/6. The errors and number of trials are noted. After 5 minutes during which other matters are discussed the patieni is asked to repeat the name and address. Unimpaired adults usually score 5 ur 6, while 3 or fewer strongly suggests a significant deficit.

• LTM is tested by the clinician asking about some past well known events. Deficits in LTM are often evident in the history-taking when, characteristically, details such as names, places and sequence of events are lost. It is importan! to ask verifiable questions, and il is also necessary to bear in mind that remote memory overlaps with intellect, educational attainment and interests, so for example, an elderly lady's failure to remember the year of Scotland's last rugby Grand Slam is more likely to reflect a lack of interest in rugby!

It is a characteristic feature of dementia that patients may have remarkable preservation of LTM, compared with gross impairment of STM. and that LTM for the distant past is better than for the previous few years.

Intelligence. Assessing a patient's intelligence in the clinical interview is based on factors evident when taking the history, such as the use of vocabulary, complexity of concepts, understanding of and reactions to the illness, and the level of educational and occupational attainment.

If the patient has a learning disability this may affect the ability to understand the explanation at ihe end of ihe interview and comply with treatment.

Formal tests of intelligence can be employed, such as sim pie sums or factual knowledge. Il may also be appropriate

KEY POINTS

• Because ol the close association between physical and meniai disorders, mental state examination is an mtnnsic component ot clinical elimination

• Three categcmes of mental disorder are especially common in gene's medical practice - organic mental disorders, mood illnesses and substance abuse.

• A mental state examination should be slanted towards the diagnostic possibilities raised by the history or the physical examination

• Assessing aspects ol the mental stale involves a combmaoon ot observation, good interview technique and standard clinical tests Bnel scales can be useful in evaluating specific areas such as intellectual impairment.

to check for literacy. Plainly this requires to be handled sensitively and only when circumstances necessitate.

Insight. It may be important to explore the patient's awareness of the nature of the illness, particularly with disorders in which insight may be partially or totally lost, e.g. multiple sclerosis. The same consideration applies to somatised presentations of mental illness - can the patient recognise the basis may be mental ralher than physical? Lack of insight sometimes has diagnostic significance and frequently has crucial implications for the management.

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