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Mental state examination

Appearance & behaviour

The big three to look out for are self neglect, eye contact and rapport. For more details:

Physical

  • Posture
  • Motor abnormalities

Appearance

  • Clothes
  • Accessories
  • Self Care

Behaviour

  • Rapport
  • Eye contact
  • Emotion
  • Expressions

Speech

Rate

  • Slow in depression
  • Fast in mania
  • Sponteneity – do they talk with being asked

Quality

  • Makes sense
  • Volume (loudness) - quiet in depression, loud in mania
  • Articulation - dysarthria
  • Unusual speech rhythm, melody, pitch - dysprosody

Mood & Affect

Mood

Subjective mood - what the patient says, ie. "I feel like death!" Objective mood - how the patient comes across, ie. fidgeting and hesitant speech.

Affect

How fast mood changes:

  • Labile affect: changes too much - Someone can't have a yoghurt and they scream with rage, and then start crying - think hormonal teenage girl.
  • Blunt affect: changes too little - Their dog dies, and they say "Oh. That's a shame". They win the lottery, and they say "Oh. That's great".
  • Incongruous: doesn't fit - Their mum dies, and they're incredible happy.

Thoughts

Form

  • disorganised thought
    • tangential thinking - never reaches point, keeps going off on tangents: "pub, tub [because of rhyming], I like ice cream!" [comes in tubs]
    • loosening of association - less severe than tangential thinking: "pub, alcohol, smoking, smoking ban"
    • circumstantiality - eventually get to the point but take ages
  • flight of ideas
  • thought blocking - common schizophrenic symptom

Content

  • thought alienation - thought broadcast, insertion and withdrawal "People hear/insert/remove thoughts from my head"
  • delusions of control - "I'm not in control of my body"
  • persecutory delusions - "The FBI are stealing my biscuits"
  • grandiose delusions - "I'm the King of the world"
  • religious delusions - "I'm a ninja Jesus"

Perception

  • Hallucinations - I see a monkey over there (there's nothing over there)
  • Illusions - I see a monkey over there (there's a dog over there)

Cognition

Check they know Time, Place, Person.

  • What time is it? What is the date?
  • Where are you?
  • What is your name?

If they fail that, do a 'mini mental' cognitive exam, and further testing if needed

Insight

Do they know they are ill? Be tactful, to avoid scaring them - don't ask "How long have you been mental?"; try "Why are you in hospital?"