.

1. Mental State
Examination
JMJ 1

2. Mental state Examination
• Appearance and behavior
• Speech
• Mood
• Thoughts
• Perceptions
• Cognition
• Insight
JMJ 2

3. JMJ 3

4. Appearance and
Behaviour
JMJ 4

5. Appearance and Behaviour
• General appearance
• Facial expressions
• Posture
• Movements
• Social Behaviour
JMJ 5

6. General appearance
• Physique (the shape and size of a person’s
body)
• Hair
• Make up
• Clothing
JMJ 6

7. General appearance
• Self neglected
• Dirty unkempt appearance
• Stained, crumpled clothing
• Suggests – alcoholism, drug addiction, dementia, or
schizophrenia
• Wight loss
• Physical disorders –
• cancer, hyperthyroidism
• Psychological disorders –
• anorexia nervosa, depressive disorders
• Social Problems
• Financial difficulty, homelessness
JMJ 7

8. Facial Expression
• Depression
• Turning down of corners of mouth
• Vertical furrows in the brows
• Anxiety
• Horizontal furrows on the brow
• Wide palpebral fissures
• Dilated pupils
• Parkinsonism Syndrome
• Unchanging ‘wooden’ expressions
JMJ 8

9. JMJ 9

10. Posture
• Depression
• Shoulders hunched
• With head and eyes down casted
• Anxiety
• Sits upright
• With the head erect
• Hands gripping the chair
JMJ 10

11. Movements
• Manic
• Over reactive, restless
• More rapidly from place to place and task to task
• Depressed
• Inactive and move slowly
• Stupor – when depressed patient become completely
immobile and mute
• Anxious or agitated
• Restless, sometimes tremours
• Involuntary movements
• Tics, characiform movements, dystonia, tardive dyskinesia
JMJ 11

12. Movements
Tics Choreiform Dystonia
Irregular Brief Muscle spasm
Repeated movements Involuntary
Movements
Often painful
Involving group of
muscles
Coordinated but
purposeless
May lead to
contortions
Grimacing or
movements of the arm
JMJ 12

13. Social Behaviour
• Disinhibited
• SIGNS OF IMPENDING VIOLANCE
• Restlessness
• Sweating
• Clenched fists or pointed fingures
• Intrusions into the interviewer’s ‘personal space’
• Raised voice
JMJ 13

14. Speech
JMJ 14

15. Speech
• Quantity
• ↓ in depressed
• ↑ in Manic
• Rate
• Pressure of speech – copious rapid speech which is hard to
interrupt
• Spontaneity
• Long answer latency – depressed and intoxicated
• Volume
• Quite – depressed
• Loud - Manic
JMJ 15

16. Speech
• Abnormalities of the continuity of speech
• Any sudden interruptions
• Rapid shifts of topics
• Lack of logical tread
JMJ 16

17. Mood
JMJ 17

18. Mood
• Subjective mood
• Objective Mood
• Predominant mood
• Constancy
• Congruity
JMJ 18

19. Subjective Mood
• Ask the patient
• What is your mood just now?
• Recent days
• If depressed
• A feeling of being ready to cry
• Lack of interest and enjoyment and pessimistic thoughts
• Thoughts of suicide
• If Anxious
• Palpitations
• Dry mouth
• Tremor
• Sweating
JMJ 19

20. Objective Mood
• Nature of mood/ moods
• What is the mood or moods appear to
predominate within the interview?
• Depression
• Elation
• Anger
• Anxiety
• Suspicious
• Perplexity
• Unremarkable mood
JMJ 20

21. Objective Mood
• Constancy of mood
• If normal spectrum is enhanced
• Emotional liability
• Such as in dementia, mania, after a stroke
• When it is extreme
• Emotional incontinence
• When it is decreased
• Reduced activity, blunting, flattening
JMJ 21

22. Objective Mood
• Congruity of mood
• Normally out mod, thoughts and perceptions are
closely associated and fit together logically.
• In schizophrenia – incongruity of mood
• Person appears cheerful while describing sad events
JMJ 22

23. Thoughts
JMJ 23

24. Thoughts
• Stream
• Form
• Content
• Pre-occupations
• Morbid thoughts, including suicidality
• Delusions and overvalued ideas
• Obsessional symptoms
JMJ 24

25. Abnormalities of Thoughts
JMJ 25
Abnormality
of the
Steam of
thought
Form of
thought
Content of
thought
It’s amount and
speed
The ways in
which thought
are linked
together
Pre-occupations
Morbid thoughts
Delusions
Overvalued ideas
Obsessional and compulsive
symptoms

26. Abnormalities of STREAM of
Thoughts
JMJ 26
Abnormality of
stream of
thought
Pressure of
thought
Poverty of
thought
Blocking of
thoughts
• Unusually rapid,
abundant and varied
• Characteristic of
mania
• But can occur in
schizophrenia
• Unusually slow, few
and unvaried
• Characteristic of
severe depression
• Can occurs in
schizophrenia
• Suddenly empty of thoughts
• Schizophrenia

27. Abnormalities of FORM of
Thoughts
JMJ 27
Abnormality of
form of thought
Flight of ideas
Loosening of
associations
Perseverations
• Characteristic in
mania
• Sometimes links may
be difficult to follow
• RHYME
• PUNS
• DISTRACTION
• Lacking logical
association –
Knight’s move
thinking
• Mostly occur in
schizophrenia
• Persistent & inappropriate
repetition of the same
sequence of thought.

28. Pre-occupations
• Thoughts that recur frequently but can be put
out of mind by an effort of will
• Common in
• Depressive disorders
• About suicide
• Anxiety disorders
• Sexual diorders
• Hx taking ask
• “ what sort of things do you worry about?”
• “What sort of thoughts occupy on your mind”
JMJ 28

29. Morbid thoughts
• These are particularly associate with
specific illness, through either their nature
• Suicidality
• Ask about feelings of depression and then
hopelessness before
• Moving on to ‘passive’ suicidal ideas
• Asking about ‘active’ suicidal ideas
JMJ 29

30. Delusions
• Is a belief that is held firmly
• but on inadequate grounds,
• is not affected by rational argument or
evidence to the country.
• And it is not conventional belief that the
person might be expected to hold given
• his cultural background and level of
education
JMJ 30

31. Delusions
Primary
• One that occurs
suddenly without any
other abnormal
mental even leading to
it.
• Rare
• When occur- strongly
suggest schizophrenia
Secondary
• Arise from previous
abnormal idea or
experience
• Hallucinations
• Mood
• Another delusion
JMJ 31

32. Other mental phenomena
related to delusions
• Delusional mood
• In explicable feeling of apprehension that is
followed before long by a delusion that explains
it.
• Delusional Perception
• Misinterpretation of the significance of
something perceived normally
• Delusional memory
• Retrospective delusional misinterpretation of
memories of actual events
JMJ 32

33. JMJ 33

34. Shared delusions / folie à
deux
JMJ 34

35. Delusional themes
JMJ 35
Persecutory (Paranoid) Schizophrenia , organic diorders, depression
Delusions of reference Schizophrenia
Grandiose and expansive delusions Mania, Schizophrenia
Delusions of guilt & worthlessness Severe Depressive disorders
Nihilistic delusions Severe Depressive diorders
Hypochondriacal delusions
Delusions of jealousy
Sexual or amorous delusions
Religious delusions
Delusion of control Schizophrenia
Delusions concerning the possession
of thoughts
• Delusion of thought insertion
• Delusion of thought withdrawal
• Delusion of thought broadcasting

36. Persecutory delusions
• Ideas that people or organizations are trying to
inflict harm on the patient,
• damage his reputation,
• or make him insane.
• Sometimes normal in some people
• Common in schizophrenia
• Occur in organic states and severe depressive
disorders
JMJ 36

37. Delusions of Reference
• Concerned with the idea that objects,
events or the actions of other people have a
special significance for the patient.
• Ex:
• A remark heard on television is believed to be
directed specifically to the patient, or a gesture
by a stranger is believed to convey something
about the patient
• Associate with schizophrenia
JMJ 37

38. Grandiose & Expansive
delusions
• Beliefs of exaggerated self-importance
• Occur in mania & sometimes in schizophrenia
JMJ 38

39. Delusions of guilt and
worthlessness
• Beliefs that the person has done something
shameful or sinful.
• Usually concerns innocent errors
• Most often in severe depressive disorders
JMJ 39

40. Nihilistic Delusions
• Beliefs that the patient’s career is finished,
• that he is about to die or
• has no money, or
• that the world is doomed
• Common in severe
depressive disorders
JMJ 40

41. Hypochondriacal Delusions
• False beliefs about the presence of disease.
• Common among elderly
• Related dysmorphophobic delusions –
concerned with the appearance of parts of
the body
• Severe depressive &
schizophrenia
JMJ 41

42. Delusions of jealousy
• Common among men
• ‘Morbid (pathological) jealousy’
• May lead to dangerously aggressive behavior
towards the person who is believed to be
unfaithful
JMJ 42

43. Sexual or amorous delusions
• Common among women
• They believe that she is loved by a man who
has never spoken to her & who is
inaccessible
JMJ 43

44. Religious Delusions
• May be concerned with guilt or with special
powers.
JMJ 44

45. Delusions of Control
• Beliefs that personal actions, impulses or
thoughts are controlled by an outside
agency.
• This has to be distinguished
JMJ 45

46. Delusions concerning the
possession of thoughts
• Delusions of thought insertion
• Some of the person’s thoughts have been
implanted by an outside agency
• Delusion of thought withdrawal
• Some of their thoughts have been taken away
• Delusions of thought broadcasting
• Some of their thoughts are known to other
people through telepathy, radio, or some other
unusual way
JMJ 46

47. Overvalued ideas
• Isolated,
• Preoccupying, and
• Strongly held belief,
• That dominates a person’s life and
• May affect his or her own actions,
• But which (unlike a delusion) has been
derived through normal mental processes.
JMJ 47

48. Overvalued ideas
• Example
• Someone whose parents developed cancer within
a short time of one another may be convinced
that cancer is contagious, despite having been
presented many times with evidence to the
country.
• Difficult to differentiate from delusions
• Main difference – assess the way, how the idea
developed
JMJ 48

49. Obsessional and compulsive
symptoms
JMJ 49

50. Perceptions
JMJ 50

51. Perceptions
• Perception
• Process of becoming aware of what is presented
to the body through the sense organs.
• These perceptions are experienced as real and
are real.
• Imagery
• An experience originating within the mind that
usually lacks the sense of reality that is part of
perception
• It differs from perception
• It can be initiated and terminated at will
JMJ 51

52. Perceptions
Abnormalities
of perception
Changes in
intensity
Changes in
quality
Illusion Hallucinations
JMJ 52

53. Delusional Perceptions
JMJ 53
• It is a disorder of thinking

54. Changes in intensity of
perception
JMJ 54
• In mania -
• Perception seems more intense
• Eg
• Colours – seen as very bright
• Sound of pin drop – very loud
• In depression
• Opposite of previous

55. Changes in quality of
perception
JMJ 55
• In schizophrenia
• Perceptions are distorted or unpleasant

56. Illusions
• Misperception of a real stimulus
JMJ 56
Illusions
Sensory
impairment
Inattention
Impaired
consciousness
Emotional
arousal
At dusk or dawn,
Pt is visually
impaired
Delirium Usually fear

57. Hallucinations
• Is a perception,
• experienced in the absence of an external
stimulus
• to the corresponding sense organ
• It has 2 qualities that distinguish it from
imagery
• It is experienced as a true perception
• It seems to come from outside the head
JMJ 57

58. Hypnagogic Hallucinations
• Healthy people experience hallucinations,
• especially when falling asleep
JMJ 58

59. Hypnopompic Hallucinations
• Healthy people experience hallucinations,
• especially when waking up
JMJ 59

60. Modalities of Hallucinations
Hallucinations
Auditory Visual
Smell and
taste
Tactile
Deep
sensation
JMJ 60

61. Auditory Hallucinations
JMJ 61
• Second person hallucination
• Address the patient as ‘you’
• Third person hallucinations
• Others talks about the patient “he”/”she”
• Thought echo
• Repeat what he has just been thinking

62. Visual Hallucinations
JMJ 62
• Simple, flashes of light
• Experienced as normal in size
• Associated particularly with organic mental
disorders

63. Hallucinations of deep
sensations
JMJ 63
• Viscera being pulled or distended
• As a sexual stimulation
• May be associated with delusional
interpretation

64. Diagnostic association of
hallucinations
JMJ 64
• Occurs in
• Organic disorders
• Severe affective disorders
• Schizophrenia
• Visual hallucinations
• Organic psychiatric disorders
• Severe mood disorders
• Schizophrenia
• Hallucinations of taste, smell and deep sensation
• Schizophrenia

65. Hallucinations
JMJ 65
• Command hallucinations
• Can indicate a high risk of harm to self or other

66. Cognition
JMJ 66

67. Cognition
• Assessment of
• Consciousness
• Orientation
• Attention
• Concentration
• Memory
• Language
• Visuospatial functioning
JMJ 67

68. Consciousness
• Awareness of self and the environment
JMJ 68
consciousness
Clouding of
consciousness
Stupor Confusion
State of drowsiness
with,
incomplete reaction to
stimuli, impaired
attention, concentration,
and memory , slow,
muddled thinking
Person is mute,
immobile,
& unresponsive, but
appears conscious bcoz
the eyes are open and
follow objects
Muddled thinking
Acute – delirium
Chronic – dementia

69. Orientation
• Assessed by asking about awareness of
• Time
• Place
• Person
• Disorientation
• Indicates impairment of consciousness
• Impairment of new learning
JMJ 69

70. Attention and concentration
• Attention
• Ability to focus on the matter in hand
• Concentration
• Ability to sustain that focus
• Both can be impaired in
• Anxiety disorders
• Depressive disorders
• Mania
• Schizophrenia
• Organic disorders
JMJ 70

71. Attention and concentration
• ‘Serial 7s test’
• Subtract 7 from 100 and then to take 7 from
the remainder repeatedly until it is less than 7
• Say months of the year in reverse order
• Naming the days and week in reverse order
JMJ 71

72. Memory
Memory
Immediate
memory
Recent
memory
Long-term
memory
JMJ 72

73. Memory- Immediate memory
• ‘Digit span test’
• assessed by asking patients to repeat sequences
of digits
• immediately after
• they have been spoken slowly enough for them to
register the digits
• Start with 4 digits then increase the number..
JMJ 73

74. Memory- recent memory
• Ask the patient to remember one name and
address
• Ask it later
• Score out of 6
• 0,1,2 – abnormal
• 5-6 score - normal
JMJ 74

75. Memory- long-term memory
• Asking to recall personal events or well
known public events
• Personal events
• Birth dates
JMJ 75

76. Amnesia
Amnesia
Anterograde Retrograde Jamais vu Confabulation
JMJ 76
Occurs after a
period of
unconsciousness
Impairment of
memory for events
between the ending
of complete
unconsciousness &
the restoration of
full consciousness
Loss of memory
for the events
before the onset
of unconscious
Occurs after
head injury and
ECT
Failure to recognize
events that have
been encountered
before
Déjà vu
Recognition of
events as familiar
when they never
been encountered
Reporting as
‘memory’ of events
that did not take
place at time of
questioning

77. Language
Language
Naming
Verbal
instruction
Written
instructions
Writing a
sentence
JMJ 77

78. Insight
JMJ 78

79. Insight
• The extent to which the patient’s view of
their
• symptoms, illness, prognosis, and treatment is
• identical to that of their healthcare professional
JMJ 79

80. Insight
• awareness of oneself as presenting phenomena
that other people consider abnormal (e.g. being
unusually active and elated);
• recognition that these phenomena are abnormal
(versus, for example, being a desirable mental state,
of which other people are jealous);
• acceptance that these abnormal phenomena are
caused by mental illness (versus, for example,
being excited about and energized by a new project
or idea, or having a physical illness);
JMJ 80

81. Insight
• awareness that treatment is required
(versus treatment being unnecessary and
undesirable);
• acceptance of the professional’s specific
treatment recommendations (e.g. admission
to hospital and sedative medication).
JMJ 81

82. Thank You!!!
JMJ 82