Mental State Examination

Department of psychology
The first affiliated hospital of ZZU
Huirong guo
 Mental State Examination

 In psychiatry, as in medicine generally,

correct diagnosis depends on careful
history taking and thorough clinical
examination.
 However, psychiatry differs from the rest
of medicine in that the interview is used not
only to obtain the history but also as a way
of eliciting clinical signs.
 Mental State Examination

 This chapter begins, therefore, with an

account of the technique, it should be
remembered that interviewing is a practical
skill that the trainee can acquire only
through carrying out interviews under
supervision and watching experienced
interviewers at work
 The diagnostic interview
 Before the interview begins there are certain
preliminary requirements.
 The interview should be carried out in a room
that is reasonably soundproof and free from
interruptions.
 The patient should not be seated directly
opposite the interviewer, nor should his chair
be so much lower that he has to look upwards.
In this way he will feel at ease rather than
under constant scrutiny.
 The diagnostic interview
 For a diagnostic interview the interviewer
should sit at a writing table in order to take
notes (a psychotherapeutic interview may
require less formal arrangements with patient
and therapist both in arm chairs).
 He should not attempt to memorize the
interview and write notes afterwards, as this is
time-consuming and likely to be inaccurate.
 The diagnostic interview
 The first encounter with the patient is
important. The interviewer should welcome
him by name, and give his own name.
 If the patient is accompanied by a companion,
it is good practice for the interviewer to
welcome this person as well and to explain how
long he may expect to wait before being
interviewed himself
 The diagnostic interview
 If the patient is seen at the request of a general
practitioner, the interviewer should indicate
that the latter has written to him, but should
not reveal the contents of the letter in detail
 The interviewer should explain how he
proposes: e.g. first, I should like to hear about
your present problems. Only when I am sure
that I have understood these shall I ask you
how they began
 The diagnostic interview
 The interviewer then asks an open question such
as ‘tell me about the problems’ or ‘tell me what
you have noticed wrong’, and the patient is
encouraged to talk freely for several minutes.
 During this time the interviewer makes two
separate kinds of observations—how the patient
is talking and what he has to say. The first helps
the doctor decide how to interview the patient,
whilst the second tells him what to ask about
 The diagnostic interview
 While deciding how to interview the patient,
the interviewer observes whether he seems co-
operative, reasonably at ease, and able to
express his ideas coherently. The most
frequent difficulty is that the patient is
overanxious.
 The interviewer should consider whether such
anxiety is part of the presenting disorder or
merely fear on coming to a psychiatrist
 The diagnostic interview
 If the latter, the interviewer should take
time to discuss the patient’s apprehension
before proceeding with the interview.
Usually reassurance and a calm, unhurried
approach will put the patient more at ease.
 Sometimes the patient seems unco-
operative and resentful when he begins to
talk.
 The diagnostic interview
 This may be because the interview is talking
place against his wishes: for example, his
spouse may have persuaded him to attend, or
the psychiatrist may be interviewing him after
admission to a general hospital for treatment
of drug over dosage.
 When this happens, the interviewer should
talk over the circumstances of the referral and
try to persuade the patient that the interview is
in his own interests.
 The diagnostic interview
 Patients may appear resentful for other
reasons. Some patients’ act in a hostile way
when anxious, and some depressed or
schizophrenic patients seem unco-operative
because they do not regard themselves as ill.
 At times it becomes apparent that a patient
cannot respond adequately to the interview
because of impaired consciousness.
 The diagnostic interview
 When this seems likely, orientation.,
concentration, and memory should be
tested, and if impaired consciousness is
confirmed, an informant should be seen
before returning to the patient
 As mentioned above, the interviewer,
whilst listening to the patient’s opening
remarks, also begins to think what
questions he should ask
 The diagnostic interview
 These should begin with further inquiries
about the nature of the patient’s presenting
symptoms. It is a common mistake to start
asking about the timing of such symptoms
before their nature is clearly established.
 For example patients sometimes say they are
depressed, but further inquiry shows that they
are experiencing anxiety rather than low
spirits.
 The diagnostic interview
 If there is any doubt, the patient should
be asked to give examples of his
experiences.
 The interviewer should clearly
understand the nature of the symptoms
before asking about their timing and the
factors that make them better or worse.
 The diagnostic interview
 When all the presenting complaints have been
explored in this way, direct questions are used
to ask about other relevant symptoms.
 For example, a person the complains who
complains of feeling depressed should be asked
about ideas concerning the presenting
symptom will be apparent from reading the
chapters on the major clinical syndromes
 The diagnostic interview
 Next, the mode of onset of the complaint
is asked about and its course noted,
including any exacerbation or periods of
partial remission.
 Considerable persistence may be needed
to date the onset accurately, and if
necessary it should be related to events
the patient can remember accurately
 Controlling the interview
 As the interview continues, the doctor’s task is to
keep the patient to relevant topics by bringing
him back to the point if he strays from it.
 In doing this the interviewer should use a
minimum of leading or closed questions (a
leading question suggests the answer; a closed
question allows only the answers yes or no, thus
preventing the person from volunteering
information ). Thus instead of the closed
question ‘are you happily married?
 Controlling the interview
 When there is no alternative to a closed question,
the answer should be followed by a request for
an example. In this way the interviewer can
confirm that the answer is valid
 Although it is essential to ask direct questions
about specific items of information, it is equally
important to give the patient an opportunity to
talk spontaneously, as unexpected material may
be revealed in this way
 Controlling the interview
 Spontaneous talk can be encouraged by
prompting rather than by asking questions,
e.g. by repeating in an inquiring tone the
patient’s reply to previous questions or by
using non-verbal prompts.
 Also, before ending the interview, it is
useful to ask a general question such as ‘is
there anything else you wish to tell me?
 History taking
 Whenever possible, the history from the
patient should be supplemented by
information from a close relative or another
person who knows him well.
 This is much more important in psychiatry
than in the rest of medicine, because
psychiatric patients are not always aware of
the extent of their symptoms.
 History taking
 For example a manic patient may not realize
how much embarrassment he has caused by
his extravagant social behavior, or a
demented patient may not fully understand
the extent to which his work is impaired
 History taking
 Alternatively patients may know what their
problems are, but not wish to reveal them;
for example, alcoholics often conceal the
extent of their drinking.
 Also, when personality is being assessed,
patients and relatives often give quite
different accounts of characteristics such as
irritability, obsessional traits, and jealousy.
 History taking
 The story should always be recorded
systematically and in the same order to
ensure that the interviewer does not forget
important themes, and to make it easier to
gather information in the same with every
patient.
 Some flexibility must be allowed if the
patient is not to feel unduly restricted by
the interviewer
 History taking
 In the following, a standard scheme of
history taking is given in the form of a list
of topics to be covered. This will serve as a
check list for the beginner, and a reminder
for the more experienced interviewer, of
the topics that make up a complete history.
 However, it is neither necessary nor
possible to ask every question of every
patient.
 History taking
 Common sense must be used in judging how
far each topic needs to be explored with a
particular patient. The trainee must learn by
experience how to adjust his questioning to
problems that emerge as the interview
proceeds.
 This is done by keeping in mind the decisions
about diagnosis and treatment that will have
to be made at the end of the interview
The scheme of history taking
 General information: the patient’s name,
sex, age, date of birth, etc.; informant’s
name and the relation to patient;
interviewer’s impression of informant’s
reliability
 Main complain: a summary of the patient’s
present illness; including the main
symptoms, duration, and why the patient
sees the doctor
The scheme of history taking
 Present illness: symptoms with duration
and mode of onset of each. Description of
the time relations between symptoms and
social psychological and physical disorders.
Effects on work, social functioning, and
relationships. Associated disturbance in
sleep, appetite, and sexual drive. Any
treatment given by other doctors
The scheme of history taking
 Previous psychiatric illness: nature and
duration of illness. Date, duration, and
nature of any treatment
 Previous medical history: illness,
operations, and accidents
 The scheme of history taking
 Personal history: early development —abnormalities
during pregnancy and birth; difficulties in habit training
and delay in achieving milestones (walking, talking, etc).
health during childhood —serious illness, especially any
affecting the central nervous system. School —age of
starting and finishing each school; types of school;
academic record and sporting and other achievements.
Relationships with teachers and pupils. Occupations —
chronological list of jobs, with reasons for changes.
Present financial circumstances, satisfaction in work.
Promotion and awards. Disciplinary problems
The scheme of history taking
 Personality before present illness: relationships —
friends, few or many; superficial or close; own or
opposite sex. Relations with workmates and superiors.
use of leisure —hobbies and interests; membership of
societies and clubs. Predominant mood —anxious,
worrying, cheerful, despondent, optimistic, pessimistic,
self-depreciating, over-confident. Stable or fluctuating.
Controlled or demonstrative. Character —sensitive,
suspicious, jealous, resentful, quarrelsome, irritable,
impulsive, selfish, self-centred; timid, reserved, shy, self-
conscious, lacking in confidence; dependent, strict, fussy,
rigid. Attitudes and standards —moral and religious.
Attitude towards health and the body. Habits —food,
alcohol, tobacco, drugs, sleep
The scheme of history taking
 Menstrual history: age of menarche, regularity
and amount, dysmenorrhoea( 痛经 ),
premenstrual tension, age of menopause and
any symptoms at the time, date of last
menstrual period
 Marital history: age of patient at marriage.
How long spouse known before marriage and
length of engagement. Quality of the marital
relationship
The scheme of history taking

 Sexual history: the name, occupation,

character of patient’s family members. Social
position of family-atmosphere in the home. Is
there any psychiatric disorder, personality
disorder, epilepsy, alcoholism, and other
neurological or medical disorders in the
family members
 Mental state examination
 In the course of history taking, the interviewer
will have noted the patient’s symptoms up to
the time of the consultation.
 The mental state is concerned with the
symptoms and behavior at the time of the
interview.
 Hence there is a degree of overlap between the
history and the mental state, mainly in
observations about mood, delusions, and
hallucinations
 Mental state examination
 If the patient is already in hospital, there will
also be some overlap between mental state and
the observations made by nurses of his
behavior outside the interview room.
 The psychiatrist should pay considerable
attention to these accounts from other staff,
which are at times more revealing than the
small sample of behavior observed at mental
state examination.
 Mental state examination
 For example, a patient may deny
hallucinations at interview, but the nurses may
notice him repeatedly talking alone as if
replying to voices.
 On the other hand, mental state examination
may reveal information not disclosed at other
times, for example suicidal intentions in a
depressed patient
 Appearance and behavior
 Although the mental state examination is
largely concerned with what the patient says,
much can also be learnt from observing his
appearance and behavior
 The interviewer should first note the patient’s
body build. An appearance suggesting recent
weight loss should alert the possibility of
physical illness, or of anorexia, depressive
disorder, or chronic anxiety neurosis
 Appearance and behavior
 The patient’s general appearance and
clothing repay careful observation. Self-
neglect, as shown by a dirty unkempt look
and crumpled clothing, suggests several
possibilities including alcoholism, drug
addiction, depression, dementia, or
schizophrenia. Manic patients may wear
bright colors, adopt incongruous styles of
dress, or appear poorly groomed
 Appearance and behavior

 Facial appearance provides information

about mood. In depression the most
characteristic features are turning down of
the corners of the mouth, vertical furrows on
the brow, and a slight rising of the medial
aspect of each brow.
 Appearance and behavior

 Anxious patients generally have horizontal

creases on the forehead, raised eyebrows,
widened palpebral fissures, and dilated pupils.
The facial appearance may also suggest
physical conditions
 Appearance and behavior
 Posture and movement also reflect mood.
 A depressed patient characteristically sits leaning
forwards, with shoulders hunched, the head
inclined downwards and gaze directed to the floor.
 An anxious patient usually sits upright with head
erect, often on the edge of the chair and with hands
gripping its sides. Anxious people and patients with
agitated depression are often tremulous and
restless, touching their jewelry, adjusting clothing,
or picking at the fingernails. Manic patients are
overactive and restless
 Appearance and behavior
 Social behavior is important.
 Manic patients often break social conventions
and are unduly familiar to people they have
just met. Demented patients sometimes
respond inappropriately to the conventions of
a medical interview, or continue with their
private preoccupations as if the interview were
not taking place.
 Schizophrenic patients may behave oddly
when interviewed; patients with antisocial
personality disorders may also appear
abnormally aggressive.
 Appearance and behavior
 In recording abnormal social behavior, the
psychiatrist should give a clear description of
what the patient actually does. He should avoid
general terms such as “bizarre”, which are
uninformative. Instead he should describe what is
unusual
 Finally the interviewer should watch for certain
uncommon disorders of motor behavior
encountered mainly in schizophrenia. These
include stereotypies, posturing, negativesm,
echopraxia, ambitendence, and waxy flexibility
 Speech

 How the patient speaks is recorded under this

heading, whilst what he says is recorded later.
The rate and quantity of speech is assessed
first. It may be unusually fast as in mania, or
slow as in depressive disorders.
 Speech
 Depressed or demented patients may pause a
long time before replying to questions and
then give short answers, and may produce
little spontaneous speech.
 The same may be observed among shy people
or those of low intelligence. The amount of
speech is increased in manic patients and in
some anxious patients
 Speech
 Next the interviewer should consider the
patient’s utterances, keeping in mind some
unusual disorders found mainly in
schizophrenia. He should note whether any of
the words are neologisms, that is private words
invented by the patient, often to describe
morbid experiences.
 Before assuming that a word is a neologism it
is essential to make sure that it is not merely
mispronounced or a word from another
language
 Speech
 Disorders of the flow of speech are recorded
next. Sudden interruptions may indicate
thought blocking but are more often merely the
effects of distraction.
 It is a common mistake to diagnose thought
flight of ideas, while a general diffuseness and
lack of logical thread may indicate the kind of
thought disorder characteristic of
schizophrenia.
 It can be difficult to be certain about these
abnormalities at interview, and it is often
helpful to record a sample of conversation for
more detailed analysis
 Mood
 The assessment of mood begins with the
observations of behavior described already,
and continues with direct questions such as,
‘what is your mood like?’ or ‘how are you in
your spirits?’
 Mood
 If depression is detected, further questions
should be asked about: a feeling of being about
to cry (actual tearfulness is often denied),
pessimistic thoughts about the present,
hopelessness about the future, and guilt about
the past. Suitable questions are ‘what do you
think will happen to you in the future?’ ‘have
you been blaming yourself for anything?’
 Mood
 Anxiety is assessed further by asking about
physical symptoms and thoughts that
accompany the affect.
 The interviewer should start with a general
question such as “have you noticed any
changes in your body when you feel anxious?”,
and then go on to specific inquiries about
palpitations, dry mouth, sweating, trembling,
and the various other symptoms of autonomic
activity and muscle tension
 Mood
 Questions about elation correspond to those
about depression; for example, “how are you
in your spirits?”, followed if necessary by
direct questions such as “do you feel unusually
cheerful?”
 Elated mood is confirmed by ideas reflecting
excessive self-confidence, inflated assessment
of one’s own abilities, and extravagant plans
 Mood
 As well as assessing the prevailing mood, the
interviewer should find out how it varies and
whether it is appropriate.
 When mood varies excessively, it is said to be
labile; for example, the patient appears
dejected at one point in the interview but
quickly changes to a normal or unduly
cheerful mood.
 Any persisting lack of affect, usually called
blunting or flattening, should also be noted
 Mood
 In a normal person, mood varies in parallel
with the main themes discussed; he appears
sad while talking of unhappy events, angry
while describing things that have annoyed
him, and so on.
 When the mood is not suited to the context, it
is recorded as incongruent; for example, if a
patient giggles when describing the death of
his mother.
 This symptom is often diagnosed without
sufficient reason, so it is important to record
specific example
 Delusions
 A delusion is the one symptom that cannot bee
asked about directly, because the patient does
not recognize it as differing from other beliefs.
The interviewer may be alerted to delusions by
information from other people or by events in
the history.
 In searching for delusional ideas it is useful to
begin by asking for an explanation of other
symptoms or unpleasant experiences that the
patient has described.
 Delusions
 For example, if a patient says that life is no
longer worth living, he may also believe
that he is thoroughly evil and that his
career is ruined, though there is no
objective evidence.
 Many patients hide delusions skillfully, and
the interviewer needs to be alert to
evasions, changes of topic or other hints of
information being withheld
 Delusions
 When ideas are revealed that may or may not
be delusional, the interviewer must find out
how strongly they are held. To do this without
antagonizing the patient requires patience and
tact.
 The patient should feel he is having a fair
hearing. If the interviewer expresses contrary
opinions to test the strength of the patient’s
beliefs, his manner should be inquiring rather
than argumentative
 Delusions
 The next step is to decide whether the beliefs
are culturally determined convictions rather
than delusions. This judgement may be
difficult if the patient comes from another
culture or is a member of an unusual religious
group.
 In such case any doubt can usually be resolved
by finding a healthy informant from the same
country or religion, and by asking him
whether the patient’s ideas would be shared by
other people from that background.
 Delusions
 Some special forms of delusion, such as
delusions of thought broadcasting, thought
insertion and delusions of control etc, present
particular problems.
 Those must be interviewed in a special way
and carefully asked.
 The interviewer should also distinguish
between primary and secondary delusions
 Illusions and hallucinations
 When asked about hallucinations, some
patients take offence because they think the
interviewer regards them as mad.
 Questions can be introduced by saying: “some
people find that, when their nerves are upset,
they have unusual experiences”.
 This can be followed by inquiries about
hearing sounds or voices when no one else is
within earshot
 Illusions and hallucinations
 If the patient describes hallucinations, certain
further questions are required depending in
the type of experience.
 The interviewer should find out whether the
patient has heard a single voice, or several, if
the later, whether the voices appear to talk to
each other about the patient in the third
person
 Attention and concentration
 Attention is the ability to focus on the matter in
hand. Concentration is the ability to sustain that
focus. While taking the history, the interviewer
should look out for evidence of attention and
concentration.
 In this way he will have already formed a
judgement about these abilities before reaching
the mental state examination. Formal tests add
to this information and provide a semi-
quantitative indication of changes as illness
progresses
 Attention and concentration
 It is usual to begin with the serial sevens test.
The patient is asked to subtract 7 from 100 and
then take 7 from the remainder repeatedly until
this less than seven. The time taken is recorded,
together with the number of errors.
 If poor performance seems to be due to lack of
skill in arithmetic, the patient should be asked to
do a simpler subtraction, or to say the months of
the year in reverse order.
 If mistakes are made with these, he can be asked
to give the days of the week in reverse order
 Memory
 Whilst taking the history, questions will have
been asked about everyday difficulties in
remembering.
 During the examination of mental state are
given of immediate, recent, and remote
memory.
 None is wholly satisfactory and the results
must be assessed alongside other information
about the patient’s to remember
 Insight

 When insight is assessed, it is important to

keep in mind the complexity of the concept.
 By the end of the mental state examination,
the interviewer should have a provisional
estimate of how far the patient is aware of
the morbid nature of his experiences.
 Insight
 The interviewer should find out whether
the patient believes that he is ill; if so,
whether he thinks that the illness is
physical or mental; and whether he thinks
he needs treatment.
 The answers to these questions are
important because they determine, in part,
how far the patient is likely to collaborate
with treatment
 Physical examination
 A thorough physical examination should be
completed on all patients who are admitted to
hospital or attend as day patients, since the
psychiatrist is then responsible for the
patients’ physical health as well as his mental
condition
Thank you

See you next time

Thank you

See you next time