Mental state examination

As an objective assessment of the patient's present condition, made by a trained observer, this is especially important if there is any doubt as to the completeness or reliability of the history.

• Introduction. Mention quality of rapport and interview; for example, 'This was a difficult interview because the patient was unforthcoming, and we did not establish a warm rapport.'

• Appearance and general behaviour. Use factual descriptions rather than judgemental comments:

- whether cooperative

- striking physical features (such as extremes of height or weight, or deformities)

- type of dress

- standard of self-care

- degree of activity

- abnormalities of movement or gait: this would include, for example, the bizarre posturing of patients with catatonia, the jerking and writhing of tardive dyskinesia, or the stiffness and shakiness in Parkinsonism or due to antipsychotic drugs. Repetitive touching or checking movements may indicate compulsive rituals of obsessive-compulsive disorder (OCD), although these may not be apparent at interview.

• Mood. Include both patient's own description and interviewer's observations. - mood states of depression, euphoria, anxiety, perplexity, fear, or suspicion

- lability of mood: mood fluctuating during interview

- mood incongruence: inappropriate to circumstances or thought content

- somatic symptoms such as those affecting appetite and energy level

- suicidal ideation/plans.

• Speech. Obviously, it is from people's speech that we gain information about their thoughts. By convention, however, the section of the mental state covering speech is confined to the loudness of speech, and to the presence or absence of any difficulty with the production of speech, such as dysarthria or stammering.

• Thought. Again, by convention, we refer to four aspects of thought:

- Speed. This refers to the speeded-up thoughts of a patient with, for example, mania (pressure of thought), or the slowed-up thoughts of a patient with, for example, retarded depression.

- Possession. This refers to certain experiences in schizophrenia. For example, patients may relate that their thoughts are not their own: 'someone else's thoughts are in my mind'; this is so-called thought insertion. Related experiences of thought withdrawal and thought broadcasting are also seen (see Chapter 4 on schizophrenia).

- Form. This refers to disruption in the proper connection between thoughts. For example, in mania, pressure of speech may proceed to the point that the patient is jumping from topic to topic, irrationally; this is the so-called flight of ideas. In psychosis, there may be bizarre connections between thoughts, the so-called knight's move thinking. In extreme cases, speech may become a jumble of words or even syllables, the so-called word salad.

- Content. In schizophrenia or retarded depression, there may be little or no spontaneous speech, and this may be termed 'poverty of thought'. Abnormal beliefs may also occur, either 'overvalued ideas', where the patient can still be reasoned with, or frank delusions, where the patient holds to the idea in spite of all evidence and reasoned argument.

A delusion can be defined as a belief, usually but not always false, that is inappropriate, bearing in mind, the person's educational and cultural background, and that is not amenable to reasoned argument. Bizarre delusions - for example, that Martians are interfering with TV transmission - are suggestive of psychosis, particularly schizophrenia; persecutory delusions - for example, that there is a conspiracy to poison the patient's water supply - are seen in paranoid states including paranoid schizophrenia; grandiose delusions - for example, that the patient has special powers - are seen in mania; nihilistic delusions - for example, that the patient's bowels have turned to stone - are seen in psychotic depression.

Occasionally, a patient may become deluded about something that is real - for example, he may believe he is being persecuted by visits from the Gas Board. But the Gas Board may in reality be trying to get in, in order to cut off his gas if he has not paid the bill; it is the quality of the reasoning, or lack of it, behind the belief of persecution that decides whether or not the belief is a delusion or not.

Under content of thought must also be noted any subjects which preoccupy the patient, such as the negative thoughts of a patient with depression, or obsessional ruminations in OCD.

• Perception. This involves perceptual disorders, including hallucinations (false perceptions) and illusions (false interpretations of real perceptions). (Note: these terms are defined in the Glossary.) Auditory hallucinations, which are common in psychiatric inpatients, can be approached by direct enquiry about whether the patient has ever heard anyone speaking when there was no one around, or some such question. Sometimes, problems arise with such an approach when patients are repeatedly interviewed and may eventually get so fed up over being asked the question that they say yes, even though they are not experiencing auditory hallucinations. If hallucinations were truly present, they would usually be apparent to the observer without direct enquiry; for example, the patient mutters under his breath, apparently conversing with unseen voices.

• Cognitive function.

- Conscious level. This is not recorded in most cases as it is obviously normal, but if there is a possibility of organic (physical) factors affecting the mental state, it must be recorded whether the patient is clearly conscious, is slightly drowsy, or is lapsing into unconsciousness. Intoxication by alcohol or other substances would be the commonest cause of this, although acute confu-sional states and neurological conditions including head injury must also be considered.

- Orientation. Is the patient oriented in time (day, date, and time of day), place, and person (identifying the interviewer or ward staff)? Problems in this basic information indicate that the patient may have either learning disability or an organic mental state such as delirium or dementia.

- Attention and concentration. There are various tests of this, including digit span (normally at least seven forward and five backward). Subtracting 'serial sevens' from 100 (93, 86, 79, 72, etc.) is often advocated, but this is a quite difficult test - less than 50 per cent of normal subjects score perfectly, two or even three errors being not necessarily abnormal. If the patient scores poorly on digit span, it might be more realistic to proceed straight to an easy test such as 'name the months of the year backward, starting with October'.

- Memory. Even patients with early dementia can often give a good history of their early life; this is sometimes referred to as biographical memory. This is not what long-term memory means for present purposes, however. Long-term memory means things that have happened recently, such as political or sporting events that most people would remember. It can be assessed by asking about recent news events, soccer, etc., and the name of the monarch or prime minister. Tests of short-term memory include the name-and-address test: the patient is asked to repeat a name and address that the examiner writes down (to avoid trusting his own fallible memory), together with the time of starting. The patient's inability to repeat it after the examiner indicates a deficit of registration (psychologists may refer to this as 'immediate recall'). Then the patient is asked to remember it, and the interview continues, preferably on neutral subjects so that the patient does not become upset and hence forget. After 5 minutes (use an alarm, such as that on a mobile phone, so as not to forget to retest!), a patient with normal memory should remember it with only trivial errors. The three-object recall test is an easier one, more appropriate for cases of possible dementia; this can be made easier by using objects physically in front of the patient (e.g. pen, desk, phone).

(Note: do not neglect cognitive testing, which may reveal unsuspected defects pointing to organic cerebral dysfunction. Cognitive testing should always be done in examinations. It is a very valuable skill in patients with a neurological aspect, such as dementia or head injury, and in medico-legal work. Sometimes, important discrepancies can be found and documented, such as the ability to give a minutely detailed history, but very poor scores on name and address testing.)

• Insight. The final category of the mental state examination, denoted 'insight', sounds somewhat unimportant, but, in fact, it is crucial, as it is shorthand for all of the following:

- the patient's understanding of the illness

- its cause

- its effect upon his life

- his attitude to treatment

- the outcome he expects.

Patients who feel they are going to get better and take ownership of the process of treatment and rehabilitation tend to do better than pessimistic patients who rely entirely on the outside world to effect a cure. Insight is therefore closely linked to prognosis. Avoid meaningless statements such as 'partial insight present', but consider practical questions such as, does the patient believe an illness is present, or does he attribute all the symptoms to an external cause (such as poisoning by rays)? Will he accept treatment?

(Note: not all patients referred to psychiatrists are mentally ill! Apparent paranoid delusions, for example, may reflect real persecution. And not everyone involved in an accident receives an injury.)

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