Psychiatric History and Mental State Examination (MSE)

BRAIN AND BEHAVIOUR
PRESENTER:-SAPANA SHAHI
ROLL NO:-41
BATCH:-2017
2/8/2021 6th Semester Psychiatry Seminar 1

BRAIN AND MIND
Brain is part of the visible , tangible world of the body. It is the physical
thing that has a definite shape and a definite place in human body and can
be seen and touched.
Mind is the part of invisible, transcendent world of thought , perception ,
belief , feeling , attitude and imagination. It is the mental thing that is
considered to be present in brain and refers to person’s understanding and
conscience. It also refers to a person’s thought process.
They are not same but are related to each other.

Development of brain
• Brain is the part of central nervous system that develop from the
enlarged cranial part of the neural tube.

Brain
Brain consists of:
1. Brainstem
2. Limbic system and
3. Cerebral cortex

Brainstem
It consists of;
1. Medulla
2. Pons and
3. Mid brain
Function :
• Contain important reflex centres associated with the control of
respiration and cardiovascular system.
• Controls consciousness , regulates muscle tone ,inhibit pain etc.
• Maintains sleep-wake cycle.

The Limbic System
The limbic system consist of cortical and subcortical structures. The cortical
region include :
• Limbic lobe
• Hippocampal formation
• Septal area
• Olfactory areas
Subcortical structures include
• Amygdaloid nuclear complex
• Hypothalamus
• Anterior nucleus of thalamus
• Habenular nucleus and
• Reticular formation

Functions of the limbic system
• Integration of the olfactory, visceral, and somatic impulses
• Control of activities necessary for survival of the animal including
procuring of food and eating behaviors
• Controls of activities necessary for survival of the species including
sexual behaviour
• Emotional behaviour
• Retention of recent memory

cerebral cortex
Subdivided into
• Frontal lobe-personality, emotional response ,
social behaviour
• Parietal lobe-calculation , language ,
planned movement , appreciation of shape ,
size , weight and texture
• Temporal lobe – auditory perception , speech,
language, verbal memory
• Occipital lobe –analysis of vision

Brain also subdivided into right and left hemispheres
• The Right hemisphere – responsible for creativity , imagination , holistic
thinking , intuition , art , rhythm , feeling , visualization etc.
• The left hemisphere –responsible for logic analysis, sequencing ,
mathematics , language, think in word etc.

Behaviour
• Behaviour is the way in which one acts or conducts oneself especially
toward other.
Types of behaviour
• Overt behaviour-visible type of behaviour like eating food , riding on a
bicycle etc.
• Covert behaviour- is not visible example: thinking

DEVELOPMENT OF BEHAVIOUR
The brain of the new born child is physically immature.
A Child can independently perform some basic skills.
Development in child occurs gradually like as in thinking and learning
process.
From infancy to about 3 years, child leaves a protected life with intimate
contact with his mother.
After 3 years of age, child learn to do more for himself.

BEHAVIOUR DEPENDS UPON
• Physical factors- age , health , genetic , brain dysfunction etc.
• Psychological factors – knowledge ,attitudes and personality etc.
• Environment factors – family , society ,and cultural factors etc.

References:
• Class notes
• Macleod's Clinical Examination 13th edition
• Inderbir Singh's Textbook of Neuroanatomy

Psychiatric Assessment and
History Taking
Presented by Adarsha Neupane (4th Batch)
15
2/8/2021 6th Semester Psychiatry Seminar

Approach to the Clinical Interview
• When taking a history from a patient, forming a therapeutic alliance is
going to lay the foundation with that patient. So making an alliance is
extremely important factor.
16

• First, greet the patient and then proceed to introduce yourself.
• Allow the patient to feel comfortable by creating
a room in an atmosphere that’s inviting and
welcoming for them.
17

• Always encourage the patient to share a narrative or a story.
• Avoid asking YES and NO questions but rather open the floor to them and be
nonjudgmental as they tell you what’s on their mind.
• Always follow your patient’s lead. They may go off on tangents but it’s important
to follow their ‘train of thought’.
• Remember to respect the patient’s wishes to avoid certain subjects in the first
encounter because they can be interviewed on the subject after some time.
18

This helps them feel comfortable and it lets them feel as if they can trust you.
19

Starting the interview
- Interviewers should welcome the patient and then proceed to
introduce themselves by name and explain their role.
Example: “Good Afternoon Mr. XYZ, Please take a sit and make yourself
comfortable. I’m your Psychiatrist Dr. ABC and I’m going to discuss the
issues you are currently facing to see if I could help. Would that be right
with you?...”
20

The interviewer begins with a general question to encourage the
patient to express their problems in their own words.
Example:
“tell me about your problem”,
“tell me what you have noticed wrong”,
“tell me why you’re here”.
21

- Interviewers should notice whether their patients are calm or distressed
If the patient is distressed, Interviewers should try to identify the nature of the difficulty and
attempt to overcome it.
22

Taking a history
• Patient Particulars:
• Name (including aliases and pet names), Age, Sex, Marital status, Education,
Occupation, Income, Religion, Residential and Ofﬁce Address(es).
• Informant
• The reliability of the information provided by the informants should be
assessed on the following parameters:
1. Relationship with patient
2. Intellectual and observational ability
3. Familiarity with the patient and length of stay with the patient, and
4. Degree of concern regarding the patient.
23

• Presenting chief complains
In patient’s own words & in informant’s own words.
Eg: - Sleeplessness X 3 weeks
- Loss of appetite & hearing voices X 2 weeks
- talking to self X 2 weeks
24

• History of present illness
Onset - Acute (within a few hours)
-Subacute (within a few days)
- Gradual (within a few weeks)
Duration – days, weeks or months
Intensity – same / increasing or decreasing
Precipitating factors – yes / no (if yes explain)
History of current episode (explain in detail regarding the presenting complaints)
Associated disturbances – include present medical problems
(eg: Disturbance in sleep, appetite & social functioning, occupation etc).
• When the patient was last well or asymptomatic should be clearly noted.
• The symptoms of the illness, from the earliest time at which a change was noticed (the onset) until the present
time, should be narrated chronologically, in a coherent manner.
• The presenting (chief) complaints should be expanded.
• It is also essential to consider and record any important negative history (such as history of alcohol/ drug use in new
onset psychosis).
25

• Past psychiatric and medical history
• A past history of any serious medical or neurological illness, surgical procedure, accident or
hospitalization should be obtained.
-Number of episode with onset & course
-Complete or incomplete remission
-Duration of each episode
-Treatment details & its side effects if any
-Treatment outcomes
-Detail if any precipitating factors if present
• Treatment history
• History of Treatment received to date is an essential component in psychiatric history
taking.
26

• Family history
• Family structure: Drawing of a ‘family tree’ (pedigree chart) can help in recording all the
relevant information in very little space which is easily readable
• Family history of similar or other psychiatric illnesses, major medical illnesses, alcohol or
drug dependence and suicide (and suicidal attempts) should be recorded.
• Current social situation: Home circumstances, per capita income, socioeconomic status,
leader of the family (nominal as well as functional) and current attitudes of family members
towards the patient’s illness should be noted.
27

• Personal History
Pre-natal history
- Maternal infection
- Exposure to radiation etc.
- Check ups
- Any complications
Natal history:
- Types of delivery
- Any complications
- Breath & cried at birth
Mile Stones: - Normal or delayed

Behavior during childhood:
- Excessive temper tantrums
- Feeding habit
- Neurotic symptoms
- Pica
- Habit disorders
- Excretory disorders etc.
Illness during childhood
- Look specifically for CNS infections
- Epilepsy
-Neurotic disorder
Malnutrition

Schooling
- Age of going to school
- Performance in the school
-Relationship with teachers
(Specifically look for learning disability & attention deficit)
- Look for conduct disorders Eg. Truancy, stealing
Occupational history
- Age of joining job
- Relationship with superiors, subordinates & colleagues
- Any changes in the job – if any give detail
- Reasons for changing jobs

Sexual history
- Age of attaining puberty (female-menstrual
cycles are regular)
-Source & extent of knowledge about sex, any
exposures
- Marital status

References:
• Class Notes
• Psychiatry, Fourth Edition - Oxford Medical Publications
• Gelder, M., Harrison, P. & Cowen, P. (2006). Shorter Oxford
Textbook of Psychiatry, 5th edn
• https://www.lecturio.com/magazine/psychiatric-history-
taking/#introduction-to-psychiatric-history-taking

Thankyou!

MENTAL STATE EXAMINATION
-The aim of mental state examination is to elicit the patient’s current
psychopathology.
-It collects both objective and subjective information.

Objective-what you observe about patient during interview
Subjective-the patient’s current psychological symptoms
• Mental State Examination gives a detail description of:
1. Appearance and Behavior
2. Speech
3. Affect(Mood)
4. Thought process
5. Perception
6. Attention and concentration
7. Orientation
8. Memory
9. Intelligence
10. Grasp of general knowledge and IQ
11. Judgment, and
12. Insight

APPEARANCE AND BEHAVIOUR
• The mental state examination should start with a brief description of what
the patient look like.
• It includes the description of patient’s.
1. Patient’s general description (Age, sex, body built, hygiene)
2. Dress (Particulars, colour, combination, cleanliness)
3. Description of his hair, face, eyes, gait, posture, body movement)
4. Description of patient’s behavior:

FACE AND EYES
• We have to observe:
1. Forehead: Furrows, wound or scar, tikas and chandan
2. Eyes: a. Colour
b. Textures/brightness
c. Palpebral fissures
d. Any significant content: Tears, Dirt?
e. Graze: direction and fixation
f. Movement of eyes, rate of blinking of eyelids
3. Mouth: a. Closed or Open?
b. Teeth
c. Hygiene
d. Deviation
4. Skin and unusual marks/scars/tattoos and makeup

GAIT AND POSTURES
A. GAIT
1. QUANTITATIVE: Normal, slow, fast
2. QUALITATIVE: Any abnormal gait if present e.g. ataxic gait,
shuffling gait, scissor like gait, etc
B. POSTURES:
1. Straight, lean forward, lean backward or to one slide
2. Where he/she sits: at the edge of the chair? Or places himself comfortably
3. Where he places his hands, arms?
4. Position of body, head, and shoulder
5. Stupor or stupor like postures

Movements
• Observe the movements of hand, legs, and whole body
• Whether the movement is fast or slow?
• Normal or abnormal?
• If abnormal then,
-Tremors
-Rigidity
-Gestures
-Rocking to and fro or side by side, changes position
-Ticks
-Choreiform movement

Behaviour
• Level of consciousness and cooperative
• Manners, attitude
• Rapport and eye contact

Speech
• Content of speech comes under “thought”
• Assessment of speech:
1.Quantitative assessment:
-Rate
-Rhythm
-Volume
-Tone
-Pitch
2.Qualitative assessment:
-Spontaneous,
-Coherent, Relevant, Goal directed, Understandable,
-and if presence any abnormal difficulties or observations such as aphasia, neologism, etc

MSE: MOOD AND THOUGHT
Presented by: Avishek Limbu (4th batch)
8-Feb-21 6th semester Psychiatry Seminar 46

• Contents:
*ASSESSMENT OF MOOD
*ASSESSMENT OF THOUGHT

ASSESSMENT OF MOOD AND AFFECT
• Feeling-positive or negative reaction to any experiences or event.It is
subjective experience .eg.depression,fear
• Emotion-It is stirred up body condition due to physiological changes
caused by some events or experience.
• Mood-pervasive and sustained emotion which can be described
under following heading
• Type:predominant mood(high,low,euthymic)
• Intensity
• Duration
• Fluctuation
• Affect-It is a short lived emotion or predominant emotion at the
moment

ASSESSMENT OF MOOD
• SUBJECTIVE MOOD EVALUATION
Detailed explanation of the predominant mood given by the subject or
the patient.IT is described in the exact way how the patient tells about
their prevailing mood in their own local language.
• OBJECTIVE MOOD EVALUATION
Evaluation of predominant mood by observation of different
characteristics like facial expression,posture,body
movement,autonomic activity and content of patients thought

•Objective assessment of mood consist of
1. Predominant or sustained mood during the course of interview
2. Range of the emotional expression
3. Adequacy and congruency of the emotion reaction
4. Reactivity or Fluctuation:to what extent?How rapid?

Evaluation
The mood or affect of the patient can be evaluated as
1. Normal or abnormal
Normal emotional reaction like grief,happy,anxious,low mood
Abnormal emotional reaction like anxiety,panic attack,depression,phobia
Some depressed,schizophrenic patient may exhibit abnormal emotion or may not
even exhibit any.
Patient who cannot completely express emotion or emotional reaction to any event
have dissociation of affect and who cannot even show any emotion in stressful
situation or event have feeling of numbness.

2.INADEQUATE EMOTIONAL REACTIONS OR EXPRESSONS
It is characterized as inadequate response or reduction in the usual range of normal
emotional reactions to an event or experience.
If the usual range of emotional response is limited,than it is called flattening of
affect.
If there is complete loss of emotion or emotional response to an event,than it is
called blunting of affect.

3.INAPPROPRIATE EMOTIONAL REACTION
Rapid and abrupt changes in emotion without any external stimuli without
any warning.
In lability of affect patient,the patient has difficulty controlling emotion.
In affective incontinence ,there is no control of emotion which can be seen in
forced laughing or crying.
4.INCONGURENT EXPRESSION OF EMOTION
It is a emotional state in which the mood and the thought of the patient are
not in synchronization or congruent.eg.the patient may laugh or smile while
describing death of close people or may cry describing their happiest
moment.

ASSESSMENT OF THOUGHT
• Cognition-Psychological result of perception,learning and reasoning
• Thought-Content of cognition
• Thought can be either normal or abnormal.
• Characteristics of thought
1.Personal experience
2.Subjective space
3.Ownership
4.Sense of control
5.Privacy

• A healthy thought is characterized by constancy,organization and
continuity.
• Thought of the patient can be evaluated by the patients
1.Speech
2.Mood
3.Body language,posture,facal expression,movement

CLASSIFICATION OF ABNORMAL THINKING PROCESS
• Abnormality of stream of thought
Both the amount and the speed of thought is changed in this disorder.
1.Pressure of thought:thoughts are usually rapid abundant and varied.Specially
seen in mania
2.Poverty of thought:Thought are usually slow few and unvaried.Seen in depressive
sisorder
3.Blocking of thought:It is an experience in which the mind gets suddenly empty of
thoughts.Seen in schizophrenic patient

• DISORDER OF POSESSION OF THOUGHT
In this disorder,patient experiences that their thought are under control of outside
agency or someone has access to their thought
1.Thought insertion
2.Thought withdrawl
3.Thought broadcasting

ABNORMALITY OF THE FORM OF THOUGHT
• Flight of thought:In this state,there is train of thought but they are not complete
and are unassociated with each other.But some understandable links like rhymes
and puns between the thoughts can be appreciated.
• Loosening of association:There is lack of logical connection between the
thoughts.Also nown as Knights move thinking.
• Perseveration:It is the persistant and inappropriate repetition of same sequence
of thought.Mostly seen in patient with dementia.

ABNORMALITY OF CONTENT OF THOUGHT
• Preoccupied ideas:These are the ideas that predominates the patients mind and
are appropriate to the patients circumstances and may affect patients mood and
behavior.These may be normal but in pathological case,the content of thought
can be important for diagnosis.
• Overvalued ideas:These are the beliefs which are strongly held about by the
patient.This can be seen in people living in same environment or place.
• Obsessive thoughts:These are recurrent and repetitive thought,which occur
against patients will but the patient has insight of the condition and thought as
false and tries to resist it.Obsessive compulsive disorder(OCD) is the defect of
thought and belief with action in combination.eg.Germophobia

• Delusions:A belief that is held firmly but on inadequate grounds, is not affected by
rational argument or evidence to the contrary,and is not a conventionall belief that the
person might be expected to hold given his cultural background and level of education.
• Classified as:
1.According to origin;primary or secondary
2.According to congruency;Mood congruent or mood incongruent
3.According to content;Persecutory delusion,Delusion of love,Delusion of gransiosity,Delusion of guilt

• Circumstantiality: It occurs when thinking proceeds slowly with many unnecessary details
but the goal of thinking is never completely lost and finally the target is reached.Seen in
epilepsy
• Tangentiality:The patient gives appropriate response or answer but keeps on talking
about irrelevant minor issues.The patient is unable to control flow of thoughts.

FORMAT FOR THOUGHT ASSESSMENT
• FOMATION:Pressure of speech,poverty of speech,thought block
• PROGRESSION:Flight of ideas,perseveration,circumstantiality,tangentiality
• CONTENT:Preoccupied ideas,Overvalued ideas,obseesive ideas

References:
• Class Notes
• Psychiatry, Fourth Edition - Oxford Medical Publications
• Gelder, M., Harrison, P. & Cowen, P. (2006). Shorter Oxford
Textbook of Psychiatry, 5th edn

THANKYOU!

PERCEPTION, ATTENTION AND
CONCENTRATION
MENTAL STATUS EXAMINATION
By: Aarapi Bhusal

OBJECTIVES
• PERCEPTION: Definition and characteristics
• Disorders of perception – Types and subtypes .
• Attention and concentration: Definition
• How to assess one’s attention & concentration
capability?

PERCEPTION
It is the process of being aware of the environment
both external and internal through proper organ of sense.
CHARACTERISTICS OF TRUE PERCEPTION

SENSORY DISTORTION
Constant real objective is perceived in a
distorted way.

-Change in intensity (Hyperesthesia or Hypoesthesia)

- Change in quality (Xanthopsia,chloropsia & erythropsia)

-Change in spatial form (Dysmegalopsia)

SENSORY DECEPTION
A new perception, that may or maynot be in response to
external stimulus,occurs. Divides into:
- Imagery
- Illusion
- Hallucination

IMAGERY
• It describes vivid visual experiences, which can be produced and
manipulated voluntarily in absence of real stimulus.
• Exist in subjective space & lacks sense of reality.
• Generally terminated when a real perception starts.

Illusion is defined as a false perception of a real
object.

Pareidolia:
Result of excessive fantasy thinking and vivid
visual imagery, depends on will and emotion.

HALLUCINATIONS
False perception which is neither sensory distortion nor
misinterpretation, but which occurs at the same time as a real
perception.
Causes:
- Intense emotion
- Suggestion
- Disorder of sense organs
- Disorder of cns
- Psychiatric disorder

HALLUCINATION OF INDIVIDUAL SENSE
1)AUDITORY e.g whistling,bells,voices
-THOUGHT ECHO:
Hears thoughts spoken aloud at the same time.
-GEDANKENLAUTWERDWWEN:
Hears his own thought before he has thought of it.
-ECHO DE LA PENSEE: hears after the thoughts have
occurred.
Hearing one’s own thoughts being spoken aloud.

3)GUSTATORY
-Loss of taste or that all food tastes the same.
4) OLFACTORY
e.g: Patient smell gas & enemies poisoning them by
pumping gas.
5) TACTILE
e.g: small animals crawling over the hand.
2)VISUAL
In the form of flashes of light.
e.g visions of object, people or animals.

PSEUDOHALLUCINATIONS
It is an involuntary sensory experience vivid enough to be regarded as
hallucination, but considered by the person as subjective & unreal like
true hallucination.
- Seen in full consciousness.

Special kinds of hallucination
• Functional hallucination(Auditory stimulus causes hallucination)
• Reflex hallucination( stimulus in one sensory field produces
hallucination in another)
• Extracampine hallucination(outside the limits of sensory field)
• Autoscopy( Experiencing of seeing own body in external space)
• Hypnagonic and hypnopompic hallucination (experiencing when
person is falling asleep and on waking with eyes only open
respectively.

Lilliputian hallucination (Experiencing image
as tiny people or dwarf objects.)
Phantom limb (Experiencing sensation
from the amputate limbs.)

ATTENTION& concentration
• Attention is generally taken to be the process by which people are
able to concentrate on certain information or processes, while
ignoring other events .
• Concentration is the ability to sustain attention on selected stimuli for
a period of time.

Record with right and wrong responses, mistakes
committed ; time taken
• Serial 7 test : ask the patient to substract 7 from 100 and again 7 from
the remaining number upto responses.
• Serial 3 test : Ask to substract 3 from 20 and again 3 from the
remaining upto 6-7 responses.
• Days and months forward and backward.

REFERENCE:
• Class notes
• OXFORD TEXTBOOK OF PSYCHIATRY
• FISH’S CLINICAL PSYCHOPATHOLOGY

Psychiatric History and Mental State Examination (MSE)

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