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CHAPTER 5

PROFESSOR GARCIA MENTAL STATUS


Health care providers
Recognition and
often miss subtle clues
treatment rates are low.
of mental illness.

Patients often have


It is important to learn
more than one mental
how to assess both
OVERVIEW mental and physical
disorder, with
symptoms that mirror
changes.
medical illnesses.

Patient health, function,


and quality of life at risk
without adequate
assessment and
treatment.
 Understanding Patient Symptoms:
SYMPTOMS AND  What do they mean?
BEHAVIOR  Psychological? Relating to mood or
anxiety
 Physical? Relating to body sensation
(somatic)
 30% symptoms are medically unexplained
 Functional syndromes
 Unexplained symptoms
 Patients with depression
 2/3 present with somatic complaints
 1/2 present with multiple unexplained somatic complaints
 Functional syndrome: frequently co-occur and share key symptoms and selective objective
abnormalities

SYMPTOMS AND BEHAVIORS


(CONT.)
 Patient Indicators for Selective Mental Health Screening
 Medically unexplained physical symptoms
SYMPTOMS AND  Multiple physical or somatic symptoms or “high symptom
BEHAVIORS count”
 High severity of presenting somatic symptom
(CONT.)  Chronic pain
 Symptoms for more than 6 weeks
 Patient Indicators for Mental Health Screening (cont.)
 Rating as a “difficult encounter”
SYMPTOMS AND  Recent stress

BEHAVIORS  Low self-rating of health


High use of health care services
(CONT.) 
 Substance abuse
 High-Yield Screening Questions for Patients
 Depression
 Over the past 2 weeks, have you felt down, depressed, or hopeless?
 Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?

SYMPTOMS AND BEHAVIORS


(CONT.)
 High-Yield Screening Questions for Patients
SYMPTOMS AND (cont.)

BEHAVIORS  Anxiety
 Anxiety disorders include: generalized

(CONT.) anxiety disorder, social phobia, panic


disorder, posttraumatic stress disorder,
and acute stress disorder.
 Over past 2 weeks: feel nervous, anxious,
on edge, unable to stop worrying
 Over past 4 weeks, have you had an
anxiety attack, suddenly feeling fear or
panic?
SYMPTOMS AND  High-yield screening questions for patients
BEHAVIORS  Alcohol and substance abuse

(CONT.)  CAGE questions (see Chapter 4, pp. 74–75)


QUESTION

 A symptom that lacks an adequate medical or physical explanation is referred to as:


A. Somatoform symptom
B. Functional symptom
C. Physical symptom
D. Iatrogenic symptom
A physical symptom can be
explained physically or
ANSWER A symptom that lacks an
adequate medical or physical
explanation is referred to as:
A. Somatoform symptom
medically or can be
unexplained. A somatoform
symptom lacks an adequate
medical or physical explanation.
 Common or concerning symptoms
 Changes in attention, mood, or speech
 Changes in insight, orientation, or memory
 Delirium or dementia

THE HEALTH HISTORY


TERMINOLOGY: THE MENTAL STATUS EXAMINATION

Level of Alertness or State of Awareness of the Environment


Consciousness
Attention The ability to focus or concentrate over time on one task or
activity—an inattentive or distractible person with impaired
consciousness has difficulty giving a history or responding to
questions
Memory The process of registering or recording information, tested by
asking for immediate repetition of material, followed by storage
or retention of information
Orientation Awareness of personal identity, place, and time, requires both
memory and attention
TERMINOLOGY: THE MENTAL STATUS EXAMINATION
(CONT.)

Level of Alertness or State of Awareness of the Environment


Consciousness
Perceptions Sensory awareness of objects in the environment and their
interrelationships (external stimuli), also refers to internal
stimuli such as dreams or hallucinations

Thought processes The logic, coherence, and relevance of the patient’s thought as
it leads to selected goals, or how people think

Thought content What the patient thinks about, including level of insight and
judgment
Insight Awareness that symptoms or disturbed behaviors are normal
or abnormal
TERMINOLOGY: THE MENTAL STATUS EXAMINATION
(CONT.)

Level of Alertness or State of Awareness of the Environment


Consciousness
Judgment Process of comparing and evaluating alternatives when deciding
on a course of action; reflects values that may or may not be
based on reality and social conventions or norms

Affect An observable, usually episodic, feeling or tone expressed


through voice, facial expression, and demeanor

Mood A more sustained emotion that may color a person’s view of


the world
TERMINOLOGY: THE MENTAL STATUS EXAMINATION
(CONT.)

Level of Alertness or State of Awareness of the Environment


Consciousness
Language A complex symbolic system for expressing, receiving, and
comprehending words, as with consciousness, attention ad
memory, language is essential for assessing other mental
functions
Higher cognitive Assessed by vocabulary, amount of information, abstract
functions thinking, calculations, and construction of objects that have two
or three dimensions
 Overview
 Level of alertness and orientation
THE HEALTH  Mood

HISTORY  Attention

(CONT.) 

Memory
Insight and judgment
 Recurring or unusual thoughts or perceptions
 Attention, Mood, Speech, Insight, Orientation, Memory

 Level of consciousness

 General appearance
THE HEALTH  Mood (depression or mania)
HISTORY  Ability to pay attention
(CONT.)  Remember

 Understand

 Speak
 Neurocognitive Disorders
 Delirium
 Presents in varying states
 Related to metabolic or structural brain alteration
 Considered separate classification of neurocognitive disorders

THE HEALTH HISTORY


(CONT.)
 Neurocognitive Disorders (cont.)
 Major Neurocognitive Disorder
 Dementia (document in parenthesis due to widespread clinical usage)
 Mild Neurocognitive Disorder
 Traumatic brain injury or HIV infection–related impairment in younger individuals

THE HEALTH HISTORY


(CONT.)
 The awareness of personal identity, place, and time are
referred to as:
A. Level of consciousness
QUESTION B. Perceptions
C. Orientation
D. Memory
01 02 03
The awareness of C. Orientation Orientation refers to the
ANSWER personal identity, place,
and time are referred to
patient’s awareness of
their personal identity,
as: where they are, and the
time. It requires both
memory and attention.
 Important Areas of the Mental Status Examination
 Appearance and behavior
 Speech and language

PHYSICAL  Mood
Thoughts and perceptions
EXAMINATION 
 Cognition, including memory, orientation, attention, and higher
cognitive functions such as information and vocabulary,
calculations, abstract thinking, and constructional ability
 Appearance and Behavior
PHYSICAL  Level of consciousness
EXAMINATION  Awake and alert?

(CONT.)  Responding appropriately and


reasonably quickly?
 Lose track of topic?
 Fall silent or even asleep?
 Appearance and Behavior (cont.)
 Posture and motor behavior
 Patient lie in bed or prefer to walk around?
 Body posture?
 Able to relax?
 Pace, range, and character of movements?

PHYSICAL EXAMINATION
(CONT.)
PHYSICAL EXAMINATION  Dress, Grooming, and Personal Hygiene

(CONT.)  Clothing clean and appropriate for age and


weather?
 Hair, nails, teeth, skin, and beard?
 Groomed?
 Grooming and hygiene comparable to other
people?
 Compare one side of body to other?
 Facial expression

PHYSICAL  At rest?
 During interaction with others?
EXAMINATION  Variations with topics?
(CONT.)  Appropriate?
 Relatively immobile?
 Manner, Affect, and Relationship to People
PHYSICAL and Things

EXAMINATION  External expression of inner emotional


state?

(CONT.)  Vary appropriately?


 Labile, blunted, or flat?
 Inappropriate or extreme at times?
 Openness, approachability, and reactions
to others and surroundings?
 Hear or see things that you don’t?
 Speech and Language
 Quantity
 Talkative or silent?
 Spontaneous or only responsive to direct questions?
 Rate
 Fast or slow?
 Loudness?
 Loud or soft?

PHYSICAL EXAMINATION
(CONT.)
 Speech and Language (cont.)
PHYSICAL  Articulation of words
EXAMINATION  Clearly and distinctly?

(CONT.)  Nasal quality to speech?


 Speech and Language
 Fluency
 Rate, flow, and melody of speech?
PHYSICAL  Content and use of words?

EXAMINATION  Hesitancies and gaps?


Disturbed inflections?
(CONT.)

 Circumlocutions?
 Paraphasias?
PHYSICAL EXAMINATION
(CONT.)

 Speech and Language


 Testing for aphasia

Word Comprehension Ask patient to follow one-stage command; try two-


stage command
Repetition Ask patient to repeat a phrase or one-syllable
words (the most difficult repetition task)
Naming Ask patient to name the parts of a watch
Reading Comprehension Ask the patient to read a paragraph aloud
Writing Ask the patient to write a sentence
PHYSICAL EXAMINATION
(CONT.)

 Mood
 Sadness and deep melancholy
 Contentment, joy, euphoria, elation
 Anger and rage
 Anxiety and worry
 Detachment and indifference
 Mood (cont.)
 Do you get pretty discouraged?
PHYSICAL  How low do you feel?

EXAMINATION  What do you see for yourself in the future?

(CONT.) 

Have you ever thought of doing away with yourself?
Do you have the means to carry out a suicide?
 What do you think would happen after you are dead?
PHYSICAL EXAMINATION
(CONT.)

 Thoughts and Perceptions


 Thought processes

Variations and Abnormalities in Thought Processes


Circumstantiality Speech with unnecessary detail, indirection, and delay in
reaching the point. Some topics may have a meaningful
connection
Blocking Sudden interruption of speech in midsentence or before
the idea is completed, attributed to “losing the thought”;
can occur in normal people
PHYSICAL EXAMINATION
(CONT.)

Variations and Abnormalities in Thought Processes (cont.)


Flight of ideas An almost continuous flow of accelerated speech with
abrupt changes from one topic to the next.

Confabulation Fabrication of facts or events in response to questions, to


fill in the gaps from impaired memory

Incoherence Speech that is incomprehensible and illogic, with lack of


meaningful connections, abrupt changes in topic, or
disordered grammar or word use.
PHYSICAL EXAMINATION
(CONT.)

Variations and Abnormalities in Thought Processes (cont.)


Derailment “Tangential” speech with shifting topics that are loosely
connected or unrelated. Patient is unaware of lack of
association
Neologisms Invented or distorted words, or words with new and highly
idiosyncratic meanings
Perseveration Persistent repetition of words or ideas
Echolalia Repetition of the words and phrases of others
Clanging Speech with choice of words based on sound rather than
meaning, as in rhyming and punning
 Thoughts and Perceptions
 Thought content
 Follow appropriate leads as they occur
 May need to make more specific inquiries
 Be tactful and accepting

PHYSICAL EXAMINATION
(CONT.)
 Perceptions
PHYSICAL  Inquire about false perceptions in manner similar to that used
for thought content
EXAMINATION  “When you heard the voice speaking to you, what did it say?”
(CONT.)  “Sometimes after major surgery like this, people hear peculiar or
frightening things. Have you experienced anything like that?”
PHYSICAL EXAMINATION
(CONT.)

Abnormalities of Perception
Illusions Misinterpretations of real external stimuli, such as
 Perceptions (cont.) mistaking rustling leaves for the sound of voices
Hallucinations Perception-like experiences that seem real, but unlike
illusions, lack actual external stimulation. Person may or
may not recognize the experiences as false. May be
auditory, visual, olfactory, gustatory, tactile, or somatic
 Insight and Judgment

 Usually best assessed during interview

 Insight

 Note whether patient is aware that a particular mood, thought, or perception is abnormal or part of an illness

 Judgment

 Note patient’s responses to family situations

 Note whether decisions and actions are based on reality or on impulse, wish fulfillment, or disordered thought content

PHYSICAL EXAMINATION
(CONT.)
 Cognitive functions

 Orientation

PHYSICAL  Can be determined by interview

EXAMINATION  Ask naturally for specific dates, address, phone number, etc.

– Person
(CONT.) – Place

– Time

– Situation
 Cognitive function (cont.)
PHYSICAL  Attention
EXAMINATION  Digit span

(CONT.)  Serial 7s
 Spelling Backward
 Need to consider possibility of limited
education
 Cognitive function (cont.)

PHYSICAL  Remote memory


 Birthdays, anniversaries, SSN, names of schools attended, jobs held,
EXAMINATION past historical events

(CONT.)  Recent memory


 Events of the day, weather, today’s appointment time, laboratory tests
taken during the day
 Cognitive Function
 New learning ability
 Give patient three or four words
 Ask them to repeat
 Wait 3 to 5 minutes, then ask them to repeat back again
 Note accuracy of response

PHYSICAL EXAMINATION
(CONT.)
 Higher Cognitive Function
 Information and Vocabulary
PHYSICAL  Provide rough estimate of person’s intelligence

EXAMINATION  Assess during interview


 Ask about hobbies, work, reading, favorite television programs, etc.
(CONT.)  Ask about specific facts
– Name of president, names of last four or five presidents, names of five large
cities
 Higher cognitive functions (cont.)
PHYSICAL  Calculating ability
EXAMINATION  Simple addition and multiplication

(CONT.)  Abstract thinking


 Proverbs
– Ask what people mean
 Similarities
– Note accuracy and relevance
PHYSICAL EXAMINATION
(CONT.)

 Higher cognitive functions (cont.)


 Constructional ability
 Copy figures or draw clock face with numbers and hands
 Patients who are drowsy but open their eyes and look at
you, respond to questions, and then fall asleep are referred
to as:

QUESTION A. Comatose
B. Obtunded
C. Stuporous
D. Lethargic
Lethargic patients are drowsy, open their
eyes, respond to questions and then fall

ANSWER
asleep. Obtunded patients open their eyes
Patients who are drowsy but open their and look at you but respond slowly and are
eyes and look at you, respond to questions, D. Lethargic confused. Stuporous patients are unaware
and then fall asleep are referred to as: of the surroundings and may be
unresponsive to painful stimuli. Comatose
patients are unconscious and do not
respond to painful stimuli.
 Mini-mental state examination (MMSE)
SPECIAL  Brief test useful in screening for cognitive

TECHNIQUES dysfunction or dementia


 Can use to follow patient’s course over
time
 Sample items
 Orientation to time
 Registration
 Naming
 Reading
 Recording behavior and mental status
 Mental status
 Grooming
 Speech
 Thought process
 Orientation
 Memory

RECORDING YOUR FINDINGS


 Important topics
 Screening for depression
 Screening for suicide risk
 Screening for substance use disorder

HEALTH PROMOTION AND COUNSELING


HEALTH
PROMOTION
AND
COUNSELING
(CONT.)
 Depression
HEALTH  Major depression
PROMOTION  Common mental illness

AND 


Frequently coexists with other mental disorders
Frequently accompanies other serious illnesses
COUNSELING  Primary care providers often miss early signs

(CONT.)  Screening in clinical settings to provide accurate diagnosis, treatment,


and follow-up
 Suicide
 Preventing suicide is national public health initiative
 Tenth leading cause of death in the United States
 Clues to pending suicide are variable and subtle
 Watch for risk factors
 Depression, other mental disorders, substance abusers, prior attempts, delusional or
psychotic thinking, family history of suicide, family violence, incarceration

HEALTH PROMOTION AND COUNSELING


(CONT.)
 Substance Use Disorder, Including Alcohol and Prescription
Drugs
HEALTH  Interactions and comorbidity of alcohol and substance abuse
PROMOTION with mental disorders and suicide are both extensive and
profound
AND  Alcohol, tobacco, and illicit drugs account for more illness,

COUNSELING deaths, and disabilities than any other preventable condition


 See Chapter 4 – The Health History: Alcohol and Illicit Drugs
(CONT.)  See Chapter 16 – GI and Renal Systems: Screening for Alcohol
Abuse
 High-risk patients may have obvious early signs of depression.
A. True
B. False

QUESTION
High-risk patients may have
subtle early signs of depression
ANSWER High-risk patients may have
obvious early signs of
depression.
A. False
including low self-esteem, loss
of pleasure in daily activities,
sleep disorders, and difficulty
concentrating on making
decisions.