Mental Status Examination • -waxy flexibility: Condition in which a person

Signs and Symptoms of Mental Disorders maintains the body position into which they
are placed with slight resistance to movement
Exa m i n ati o n a n d D i ag n os i s of th e Psych i atri giving it a waxy feel. See also cerea flexibilitis.
c Pati ent
History+Physical Examination=Diagnosis • Speech
History +Mental Status Examination=Diagnosis • Fluency.(stuttering, word finding
difficulties or paraphasic errors)
Mental Status Examination • Amount. Normal, Inc, dec
• Appearance and Behavior • Rate and speed. Rapid, slow
• Motor Activity • Tone. pressured, hesitant, emotional,
• Speech irritable, anxious, dysphoric
• Mood • Volume. loud, quiet, timid, angry, or
• Affect childlike
• Thought Content
• Thought Process • , monotonous, loud, wh ispered, slu rred,
• Perception mumbled, stuttering, echolalia, i ntensity,
• Cognition pitch, ease, spontaneity, productivity,
• Abstract Reasoning manner, reaction time, vocabu lary, prosody
• Insight
• Judgment • Mood
• Subjective
Mental Status Examination with Signs and Symptoms • Depth
of Mental Disorders • Intensity
• Appearance and Behavior • Duration
• Age • Fluctuations
• Clothing • depressed, despairing, irritable,
• Grooming, hygiene. disfigurations, anxious, terrified, angry, expansive,
scars, and tattoos euphoric, empty, guilty, awed, futile,
• Attitude to examiner. cooperative, self-contemptuous, anhedonic,
attentive, interested, frank, seductive, alexithymic
defensive, hostile, playful,
ingratiating, evasive, guarded • pervasive and sustained emotion that colors
the person's perception of the world
• Motor Activity • How does patient say he or she feels; depth,
• normal, slowed, agitated intensity, duration, and fluctuations of mood-
• gait, freedom of movement depressed, despairing, irritable, anxious,
• unusual or sustained postures, pacing terrified, angry, expansive, euphoric, empty,
• Tics, jitteriness, tremor, restlessness, guilty, awed, futile, self-contemptuous, an
lip-smacking, tongue protrusions hedonic, alexithymic ]]
• Mannerisms, gestures, twitches, • alexithymia: Inability or difficulty in describing
stereotypes, picking, touching or being aware of one's emotions or moods;
examiner elaboration of fantasies associated with
• echopraxia, clumsy, agile, limp, rigid, depression, substance abuse, and
retarded, hyperactive, agitated, posttraumatic stress disorder (PTSD).
combative, waxy

• Gait, mannerisms, tics, gestures, twitches, • AFFECT

stereotypes, picking, touching examiner, • objective
echopraxia, clumsy, agile, limp, rigid, • Quality.broad, restricted, blunted or
retarded, hyperactive, agitated, combative, flat, shallow
waxy • Quantity. Mild to severe
• Range. Restricted, normal, labile
 • Appropriateness
• Congruency
• outward expression of the patient's inner
experiences): How examiner evaluates
patient's affects-broad, restricted, blunted or
flat, shallow, amount and range of expression;
difficulty in initiating, sustaining, or
terminating an emotional response; is the
emotional expression appropriate to the
thought content, culture, and setting of the
examination; give examples if emotional
expression is not appropriate
• Disturbance of affect manifested by a severe
reduction in the intensity of externalized
feeling tone
• Thought Content
• What
• Obsessions and Compulsions
• Suicidal and Homicidal Ideations.
intent, plan, preparation
• Preoccupations. illness,
environmental problems
• Phobias
• Delusions. Bizarre and non-bizarre,
ideas of reference, grandiose,
erotomanic, jealous, somatic,
persecutory ,mood congruent,
incongruent
• Preoccupations: About the illness,
environmental problems; obsessions,
compulsions, phobias; obsessions or plans
about suicide, homicide; hypochondriacal
symptoms, specific antisocial urges or
impulses
• Thought Process
• How
• Productivity. Overabundance,
paucity, flight of ideas, rapid, slow or
hesitant thinking
• Continuity of thought: goal directed,
relevant, or irrelevant, loose
associations; lack of causal relations,
illogical, tangential, circumstantial,
rambling, evasive, perseverative,
blocking,verbigeration
• Language impairments: word salad,
clang associations, neologisms
• Productivity:
• Overabundance of ideas, paucity of ideas,
flight of ideas, rapid thinking, slow thinking,
hesitant thin king;
• does patient speak spontaneously or only
when questions are asked, stream of thought,
quotations from patient
• b. Continuity of thought:
• Whether patient's replies really answer
questions and are goal directed, relevant, or
irrelevant; loose associations;
• lack of causal relations in patient's
explanations; illogical, tangential,
circumstantial, rambling, evasive,
perseverative statements, blocking or
distractibil ity
• c. Language impairments: Impairments that
reflect disordered mentation, such as
incoherent or incomprehensible speech (word
salad), clang associations, neologisms linear,
organized, goal-directed
• Circumstantiality. Overinclusion of trivial or
irrelevant details that impede the sense of
getting to the point.
• Clang associations. Thoughts are associated
by the sound of words rather than by their
meaning (e.g., through rhyming or
assonance).
• Derailment. (Synonymous with loose
associations.) A breakdown in both the logical
connection between ideas and the overal l
sense of goal di rectedness. The words make
sentences, but the sentences do not make
sense.
• Flight of ideas. A succession of multiple
associations so that thoughts seem to move
abruptly from idea to idea; often (but not
invariably) expressed through rapid,
pressured speech.
• Neologism. The invention of new words or
phrases or the use of conventional words i n
idiosyncratic ways.
• Perseveration. Repetition of out of context
words, phrases, or ideas.
• Tangentiality. In response to a question, the
patient gives a reply that is appropriate to the
general topic without actually answering the
question. Example: Doctor: "Have you had any
trouble sleeping lately?" Patient: "I usually
sleep in my bed, but now I'm sleeping on the
sofa."
• Thought blocking. A sudden sruption of
thought or a break i n the flow of ideas.
• Perceptual Disturbance
• Hallucinations.auditory-What, when,
how; visual, tactile, olfactory, taste,
hypnagogic
• Illusions
• Depersonalization and derealization
• Delusions: Content of any delusional system,
its organization, the patient's convictions as to
its validity, how it affects his or her life:
persecutory delusions-isolated or associated
with pervasive suspiciousness; mood
congruent or mood incongruen
• Hallucinations and illusions: Whether patient
hears voices or sees visions; content, sensory
system involvement, circumstances of the
occurrence; hypnagogic or hypnopompic
hallucinations; thought broadcasting
• b. Depersonalization and derealization:
Extreme feelings of detachment from self or
from the environment
• COGNITION
• Alertness
• Orientation. Place, person, time
• Concentration
• Memory. Immediate, remote
• Calculation
• Fund of Knowledge
• Abstract Reasoning
• General concepts and specific
examples
• Similarities and differences
• Proverb interpretation
-Culture and educational
factors
• Insight
• 1.Complete denial of illness
• 2. Slight awareness of being sick and
needing help but denying it at the
same time
• 3 . Awareness of being sick but
blaming it on others, on external
factors, on medical or unknown
organic factors
• 4. Intellectual Insight
• 5. True emotional insight
• Degree of personal awareness and under
Complete denial of illness
• 2 . Slight awareness of being sick and needing
help but denying it at the same time
• 3 . Awareness of being sick but blaming it on
others, on external factors, on medical or
unknown organic factors
• 4. Intellectual insight: Admission of ill ness
and recognition that symptoms or failures in
social adjustment are due to irrational
feelings or disturbances, without applying
that knowledge to future experiences
• 5. True emotional insight: Emotional
awareness of the motives and feelings within,
of the underlying meaning of symptoms; does
the awareness lead to changes in personality
and future behavior; openness to new ideas
and concepts about self and the important
persons in his or her life standing of ill ness
• Judgment
• person's capacity to make good
decisions and act on them
• 1.Social judgment
• 2. Test judgment
• Social judgment: Subtle manifestations of
behavior that are harmful to the patient and
contrary to acceptable behavior in the
culture; does the patient understand the likely
outcome of personal behavior and is patient
influenced by that understanding; examples
of impairment
• 2. Test judgment: Patient's prediction of what
he or she would do in imaginary situations
(e.g., what patient would do with a stamped
addressed letter found i n the street)
• Appearance and general behavior
• Body habitus, grooming habits, interpersonal
style, degree of eye contact, how the patient
looks compared with his or her age
• Disheveled appearance may suggest
schizophrenia
• —
• Provocative dress may suggest bipolar
disorder
• Appearance: well-groomed, immaculate,
attention to detail, unkempt, distinguishing
features (e.g., scars, tattoos), ill- or well-
appearing
• Unkempt appearance may suggest
depression, psychosis
• Eye contact: good, fleeting, sporadic, avoided,
none
• Poor eye contact may occur with psychotic
disorders
• General behavior: congenial, cooperative,
open, candid, engaging, relaxed, withdrawn,
guarded, hostile, irritable, resistant, shy,
defensive
• Paranoid, psychotic patients may be guarded
• Irritability may occur in patients with anxiety
• Motor activity
• Body posture and movement, facial
expressions
• Parkinsonism, schizophrenia, severe major
depressive disorder, posttraumatic stress
disorder, anxiety, medication effect (e.g.,
depression), drug overdose or withdrawal,
anxiety
• —
• Akathisia (restlessness), psychomotor
agitation: excessive motor activity may
include pacing, wringing of hands, inability to
sit still
• Bradykinesia, psychomotor retardation:
generalized slowing of physical and emotional
reactions
• Symptoms may develop within weeks of
starting or increasing dosages of antipsychotic
agents
• Catatonia: neurologic condition leading to
psychomotor retardation; immobility with
muscular rigidity or inflexibility; may present
in excited forms, including excessive motor
activity
• Tendency toward exaggerated movements
occurs in the manic phase of bipolar disorder
and with anxiety
• Speech
• Quantity: talkative, expansive, paucity,
poverty (alogia)
• Schizophrenia; substance abuse; depression;
bipolar disorder; anxiety; medical conditions
affecting speech, such as cerebrovascular
accident, Bell palsy, poorly fitting dentures,
laryngeal disorders, multiple sclerosis,
amyotrophic lateral sclerosis
• —
• Rate: fast, pressured, slow, normal
• Volume and tone: loud, soft, monotone, weak,
strong, mumbled
• Fluency and rhythm: slurred, clear, hesitant,
aphasic
• Coherent/incoherent
• Mood and affect
• Affect: physician's objective observation of
patient's expressed emotional state Mood:
patient's subjective report of emotional state
• Depression, bipolar disorder, anxiety,
schizophrenia
• How are your spirits?
• How would you describe your mood?
• Have you felt discouraged/low/blue lately?
• Have you felt angry/irritable/on edge lately?
• Have you felt energized/high/out of control
lately?
• Thought process
• Form of thinking, flow of thought
• Anxiety, depression, schizophrenia, dementia,
delirium, substance abuse
• —
• Thought content
• What the patient is thinking about
• Obsessions, phobias, delusions (e.g.,
schizophrenia, alcohol or drug intoxication),
suicidal or homicidal thoughts
• Obsessions: Do you have intrusive thoughts or
images that you can't get out of your head?
• Phobias: Do you have an irrational or
excessive fear of something?
• Delusions: Do you think people are stealing
from you? Are people talking behind your
back? Do you think you have special powers?
Do you feel guilty, as if you committed a
crime? Do you feel like you are a bad person?
(Positive responses to last two questions may
also suggest a psychotic depression)
• Suicidality: Do you ever feel that life is not
worth living? Have you ever thought about
cutting yourself? Have you ever thought about
killing yourself? If so, how would you do it?
• Homicidality: Have you ever thought about
killing others or getting even with those who
have wronged you?
• Perceptual disturbances
• Hallucinations
• Schizophrenia, severe unipolar depression,
bipolar disorder, dementia, delirium, acute
intoxication and withdrawal
• Do you see things that upset you? Do you ever
see/feel/hear/smell/taste things that are not
really there? If so, when does it occur? Have
you had any strange sensations in your body
that others do not seem to have?
• Sensorium and cognition
• Sensorium: level and stability of consciousness
• Underlying medical conditions, dementia,
delirium
• See Tables 2 and 3
• Cognition: attention, concentration, memory
• Insight
• Patient's awareness and understanding of
illness and need for treatment
• Bipolar disorder, schizophrenia, dementia,
depression
• What brings you here today? What is your
understanding of your problems? Do you think
your thoughts and moods are abnormal?
• Judgment
• Patient's recognition of consequences of
actions
• Bipolar disorder, schizophrenia, dementia
• What would you do if you found a stamped
envelope on the sidewalk?
• Physician should adapt questions to clinical
circumstances and patient's education level
• Information from references 1 through 4.
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