Mental status examination

Appearance

The first thing to do is describe from a general point of view how do you see at first the patient in the room, describe the personal identification, as: 1. Personal identification: general attitude toward the circumstance and the medical doctor. a. General behavior: how the patient behaves in the room. Examples: If the patient stands still and doesn't sit down, the patient is restless, agitated, if he/she walks around and doesn't sit down and speak to me. The general behavior of the patient is not suitable for the situation. b. Attitude toward the examiner: is the patient cooperative or reticent, hostile or defensive or evasive? In which way does she/he speak to you? c. Eye contact. 2. General description: of his/her look, clothes; address if the patient is dressing in a way that doesn't fit with the circumstances (Ex: with a coat in summer or doesn't wear shoes). 3. Behavior and psychomotor activity: a. Mimic and gesture: b. Mannerism: an awkward/unnatural/strange.

Behavior - Tics: rapid and involuntary movement

Retardation or agitation:

Hyperactivity:

Speech

1. Spontaneity: does the patient speak spontaneously or only if questioned?
2. Reaction time: the latency between the question and the patient's response. The speech is not slow itself; the reaction time is slow.
3. Productivity: does the patient have logorrhea? Excess of productivity, difficult to stop speaking. Or on the other hand, the patient uses just a few words (the patient answers with just: yes, no, I don't know).
4. Speed: the way of speech is too fast or too slow.
5. Volume: loud or whispered.
6. Vocabulary: is the language appropriate to the level of education of the patient? Example: the patient has a high education but she/he is still using a low level of vocabulary. It could mean that at that moment there are some cognitive disturbances. On the other hand, if we are visiting a patient with a low level of education but the vocabulary is rich and cultured, it is probably a

signs that the patient has a high intelligence, despite the scarce educational opportunity. Sensorium and cognition are indicative of some problems in specific parts of the brain. Through specific tests, it is possible to evaluate the functional areas of the brain. You should evaluate: 1. Alertness: This can be evaluated through simple talking, evaluation of the speech, and the patient's ability to change the subject. 2. Concentration: Reduced ability to maintain focus is common in many different psychiatric disorders. Concentration can be evaluated through calculation (obviously, you shouldn't do a math exam). In a depressive episode, there is a severe alteration of concentration and alertness. 3. Orientation: Evaluate the patient's orientation in time (what time it is, do they know the day, do they know the year?), person (who the patient is?), and space (where they are). If one of these three dimensions is lacking, it indicates subconfusion. If the patient loses more than one dimension, it indicates confusion. Delirium: This is a medical condition (not psychiatric) in which the patient loses

1. Dimensions of orientation:
   • Adapt your language based on the patient
2. Memory:
   • The ability to recollect information or experiences
   • Memory is involved in two processes:
     • Fixation (encoding, storing, retaining) - by repeating some experiences or somenotions you fixate better the concept
     • Recalling
   • 2 types of memory - remote, recent
3. Abstract thinking:
   • Alteration during schizophrenia or brain tumor
4. Perception:
   1. Illusion - I have an object but I do not perceive the object in a correct way (I have apen but I think that it is a snake). Also illusions can happen with sounds and othersenses
   2. Hallucination - perceive something in the absence of stimulation (imaginaryconversation). Are psychotic symptoms of specific neurological diseases(schizophrenia, bipolar disorders,). The most common hallucinations are voices,typical of schizophrenia
5. Thinking:
   • Form of thinking - how the ideas are connected, evaluation of two aspects:
     • Speed

Productivity: rapid thinking, slow thinking. Speed can increase in cases of anxiety. In bipolar disorders, you can have a depressive episode (bad mood and slow thinking, moving slow, thinking slow) and a second phase in which your mood is very good.

Association: how one idea connects to the other, following the rules of logical connection. Incoherent speech: connection not based on logic but on sounds (presents: Are you present?). Normal form of thinking.

Content of thinking: if the content is not correct, it means that delusions (problem in the content of thinking) are present. A delusion is characterized by:

1. Impossibility: falsity of content
2. Certainty: held with absolute certainty
3. Incorrigibility: not changeable by compelling counter arguments or proofs

b and c are the most important. A patient with delusions is NOT going to change his/her idea.

Delusions: persecution, influence (someone is influencing your thoughts), religious delirium, and thought insertion (you think that someone)

is trying to change your thinking): schizophrenia Reference (you think that all that happens around you is referred to you), Grandeur (you think that you are the absolute perfection): bipolar disorder in hypomanic phase Guilt → depression Somatic (you are sure that there is something wrong in your body, ie you might think that your leg is broken even though it is not) Mood - pervasive and sustained emotion that colors a person's perception of the world. ● Euthymic → good mood ● Depressed ● Expansive, euphoric, manic (expansive= can be euphoric but also irritable, Euphoric=the patient feels very fine. Manic≈ expansive) ● Irritable, dysphoric (synonyms, the patient is angry and aggressive, both during manic and depressive phases) Patients with bipolar depression usually tend to experience the worst symptoms in the morning. Alarm system As a response to stress → fight or flight response, it is a very important system that protects us. it is physiological 1. Fear → in

Response to an external threat (situation or object) that is commonly recognized as dangerous:

1. Phobia - Abnormal reaction in response to a situation or object which according to common sense is not recognized as a threat (i.e. getting in an elevator). It becomes pathological when there is an impact on the patient's function (if I have a phobia of snakes but I live in Turin, I will probably not have a phobic disorder. If I have a phobia of an object which is common in my life, then I might develop a phobic disorder. For example, if I have a phobia of driving and I have to drive).

Types of phobias:

1. Acrophobia - Phobia of height
2. Aerophobia - Phobia of flying
3. Arachnophobia - Phobia of spiders
4. Astraphobia - Phobia of thunders and lightning
5. Autophobia - Phobia of being alone
6. Claustrophobia - Phobia of small spaces
7. Hemophobia - Phobia of blood