Chapter Twenty-one Mental status assessment
When considering the background issues related to mental status examination you may need to review the anatomy and physiology related to neurological assessment which is detailed in Chapter 22. In this chapter (Ch 21) the relevant terms related to mental status assessment are defined.
Mental status is a person’s emotional and cognitive functioning. Optimal functioning aims towards simultaneous life satisfaction in work, in caring relationships and within the self. Mental health is relative and ongoing. Everyone has ‘good’ and ‘bad’ days. Usually, mental status strikes a balance, allowing the person to function socially and occupationally.
The stress surrounding a traumatic life event (death of a loved one, serious illness) tips the balance, causing transient dysfunction. This is an expected response to a trauma. Mental status assessment during a traumatic life event can identify remaining strengths and can help the individual mobilise resources and use coping skills.
A mental disorder is apparent when a person’s response is much greater than the expected reaction to a traumatic life event. A mental disorder is defined as a significant behavioural or psychological pattern that is associated with distress (a painful symptom) or disability (impaired functioning) and has a significant risk of pain, disability or death or a loss of freedom (American Psychiatric Association, 2000). Mental disorders include organic disorders (due to brain disease of known specific organic cause, e.g. delirium, dementia, intoxication and withdrawal) and psychiatric mental illness (in which organic aetiology has not yet been established, e.g. anxiety disorder or schizophrenia). Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.
Mental status cannot be scrutinised directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual’s behaviours:
Consciousness: being aware of one’s own existence, feelings and thoughts and aware of the environment. This is the most elementary of mental status functions which can be objectively assessed using the Glasgow Coma Scale (see Ch 22).
Language: using the voice to communicate one’s thoughts and feelings. This is a basic tool of humans and its loss has a heavy social impact on the individual.
Mood and affect: both of these elements deal with the prevailing feelings; affect is a temporary expression of feelings and state of mind, and mood is more durable, a prolonged display of feelings that colour the whole emotional life.
Orientation: the awareness of the objective world in relation to the self.
Attention: the power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli.
Memory: the ability to lay down and store experiences and perceptions for later recall. Recent memory evokes day-to-day events; remote memory brings up years’ worth of experiences.
Abstract reasoning: pondering a deeper meaning beyond the concrete and literal.
Thought process: the way a person thinks: the logical train of thought.
Thought content: what the person thinks—specific ideas, beliefs, the use of words.
Perceptions: an awareness of objects through the five senses.
The maturation of emotional and cognitive functioning is described in detail in Chapter 2. It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed; the infant cannot distinguish the self from the mother’s body. Consciousness gradually develops along with language, so that by 18 to 24 months the child learns that it is separate from objects in the environment and has words to express this. We also can trace language development: from the differentiated crying at 4 weeks, the cooing at 6 weeks, through one-word sentences at 1 year to multi-word sentences at 2 years. Yet the concept of language as a social tool of communication occurs around 4 to 5 years of age, coincident with the child’s readiness to cooperatively play with other children.
Attention gradually increases in span through preschool years so that, by school age, most children are able to sit and concentrate on their work for a period of time. Some children are late in developing concentration. School readiness coincides with the development of the thought process; around age 7, thinking becomes more logical and systematic, and the child is able to reason and understand. Abstract thinking, the ability to consider a hypothetical situation, usually develops between ages 12 and 15, although a few adolescents never achieve it.
The ageing process leaves the parameters of mental status mostly intact. There is no decrease in general knowledge and little or no loss in vocabulary. Response time is slower than in youth; it takes a bit longer for the brain to process information and react to it. Thus performance on timed intelligence tests may be lower for the ageing person—not because intelligence has declined, but because it takes longer to respond to the questions. The slower response time affects new learning; if a new presentation is rapidly paced, the older person does not have time to respond to it (Alwin, 2009; Birren and Schaie, 2005).
Recent memory, which requires some processing (e.g. medication instructions, 24-hour diet recall, names of new acquaintances), is somewhat decreased with ageing. Remote memory is not affected.
Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Ch 14) may result in apathy, social isolation and depression. Hearing changes are common in older adults (see the discussion of presbycusis in Ch 24). Age-related hearing loss involves high sound frequencies. Consonants are high-frequency sounds, so older people who have difficulty hearing them have problems with normal conversation. This problem produces frustration, suspicion and social isolation and also makes the person look confused.
The era of older adulthood contains more potential for loss than do earlier eras, such as loss of loved ones, loss of job status and prestige, loss of income and the loss of an energetic and resilient body. The grief and despair surrounding these losses can affect mental status. These losses can result in disorientation, disability or depression.
There is a significant correlation with the development of mental health issues with specific cultural groups and social circumstances within the Australian and New Zealand communities. Refer to Chapter 4 for a discussion of these issues.
Alterations in mental status can significantly affect the person’s ability to manage their health, roles and relationships, sexuality, self-concept, coping ability and activities of daily living. You also need to keep in mind that the consequence of illness and its treatment can also impact on mental health. Therefore you are likely to frequently need to assess the mental status of your patients. Nurses routinely conduct mental status examinations across a variety of clinical settings including: accident and emergency departments, surgical and medical wards, general practitioner clinics, community health settings, aged person’s services, midwifery settings with a particular focus on disorders of postpartum difficulties, or posthospitalisation in the client’s own home where ongoing treatment is offered by community-based district nursing services.
The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described here, though, rarely need to be taken in their entirety. Usually, you can assess mental status through the context of the health history interview. During that time, keep in mind the four main headings of mental status assessment:
Integrating the mental status examination into the health history interview is sufficient for most people. You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction.
It is necessary to perform a full mental status examination when you discover any abnormality in affect or behaviour, and in the following situations:
• Family members concerned about a person’s behavioural changes, such as memory loss, inappropriate social interaction.
• Brain lesions (trauma, tumour, cerebrovascular accident/stroke). A mental status assessment documents any emotional or cognitive change associated with the lesion. Not recognising these changes hinders care planning and creates problems with social readjustment.
• Aphasia (the impairment of language ability secondary to brain damage). A mental status examination assesses language dysfunction as well as any emotional problems associated with it, such as depression or agitation.
• Symptoms of psychiatric mental illness, especially with acute onset.
In every mental status examination, note these factors from the health history that could affect your interpretation of the findings:
• Any known illnesses or health problems, such as alcoholism or chronic renal disease.
• Current prescribed medication side effects may cause confusion or depression.
• The usual educational and behavioural level—note that factor as the normal baseline, and do not expect performance on the mental status examination to exceed it.
• Responses to personal history questions, indicating current stress, social interaction patterns, sleep habits, drug and alcohol use.
In the following examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity for the steps to follow. That is, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. Or, if language is impaired, subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions.
Equipment needed (Occasionally) Pencil, paper, reading material
| Procedures and normal findings | Abnormal findings and clinical alerts | |
|---|---|---|
| APPEARANCE | ||
| Posture. Posture is erect and position is relaxed. | Sitting on edge of chair or curled in bed, tense muscles, frowning, darting watchful eyes, restless pacing occurs with anxiety and hyperthyroidism. Sitting slumped in chair, slow walk and dragging feet occurs with depression and some organic brain diseases. | |
| Body Movements. Body movements are voluntary, deliberate, coordinated and smooth and even. | ||
| Dress. Dress is appropriate for setting, season, age, gender and social group. Clothing fits and is put on appropriately. | ||
| Grooming and hygiene. The person is clean and well groomed; hair is neat and clean; women have moderate or no make-up; men are shaved or beard or moustache are well groomed. Nails are clean (though some jobs leave nails chronically dirty). Note: A dishevelled appearance in a previously well-groomed person is significant. Use care in interpreting clothing that is dishevelled, bizarre or in poor repair, piercings and tattoos, because these sometimes reflect the person’s economic status or a deliberate fashion trend (especially among adolescents). | Unilateral neglect (total inattention to one side of body) occurs following some strokes. Inappropriate dress, poor hygiene and lack of concern with appearance occur with depression and severe Alzheimer’s disease. Meticulously dressed and groomed appearance and fastidious manner may occur with obsessive-compulsive disorders. |
|
| BEHAVIOUR | ||
| Level of consciousness. The person is awake, alert, aware of stimuli from the environment and within the self and responds appropriately to stimuli. | Lethargic, obtunded (see also use of the Glasgow Coma Scale in Ch 22; see Table 22.2). | |
| Facial expression. The look is appropriate to the situation and changes appropriately with the topic. There is comfortable eye contact unless precluded by cultural norm. | Flat, mask-like expression can occur with parkinsonism, depression, hyperthyroidism and myasthenia gravis. | |
| Speech. Judge the quality of speech by noting that the person makes laryngeal sounds effortlessly and shares conversation appropriately. | Dysphonia is abnormal volume, pitch, see Table 22.3. Monopolises interview. Silent, secretive or uncommunicative. |
|
| The pace of the conversation is moderate, and stream of talking is fluent. | Slow, monotonous speech with parkin-sonism, depression. Rapid-fire, pressured and loud talking occur with manic syndrome. | |
| Articulation (ability to form words) is clear and understandable. | Dysarthria is distorted speech, see Table 22.3 Misuse of words; omits letters, syllables or words; transposes words; occurs with aphasia. Circumlocution, or repetitious abnormal patterns: neologism, echolalia, see Table 21.4 | |
| Word choice is effortless and appropriate to educational level. The person completes sentences, occasionally pausing to think. | Unduly long word-finding or failure in word search occurs with aphasia. | |
| Mood and affect. Judge this by body language and facial expression and by asking directly, ‘How do you feel today?’, or ‘How do you usually feel?’ The mood should be appropriate to the person’s place and condition and change appropriately with topics. The person is willing to cooperate with you. | See Table 21.3 Wide mood swings occur with bipolar affective disorder. Bizarre mood is apparent in schizophrenia. | |
| COGNITIVE FUNCTIONS | ||
| Disorientation occurs with organic brain disorders, such as delirium and dementia. Orientation is usually lost in this order–first to time, then to place and rarely to person. | ||
| Attention span. Check the person’s ability to concentrate by noting whether they complete a thought without wandering. Note any distractibility or difficulty attending to you. Or, give a series of directions to follow and note the correct sequence of behaviours, such as ‘Please take this glass of water with your left hand, drink from it, shift it to your right hand, and place it on the table’. Note that attention span commonly is impaired in people who are anxious, fatigued or drug intoxicated. | ||
| Recent memory. Assess recent memory in the context of the interview by the 24-hour diet recall or by asking the time the person arrived at the agency. Ask questions you can corroborate. This screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. | Recent memory deficit occurs with organic disorders, e.g. delirium, dementia, amnestic syndrome or Korsakoff’s syndrome in chronic alcoholism. | |
| Remote memory. In the context of the interview, ask the person verifiable past events; for example, ask to describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person. | Remote memory is lost when cortical storage area for that memory is damaged, such as in Alzheimer’s dementia or any disease that damages the cerebral cortex. | |
New learning–the four unrelated words test. This tests the person’s ability to lay down new memories. It is a highly sensitive and valid memory test (Benedict and MacNeil-Horton, 1990). It requires more effort than does the recall of personal or historic events. It also avoids the danger of unverifiable material. To the person, say, ‘I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them’. To be sure the person has understood, have the words repeated. Pick four words with semantic and phonetic diversity: |
People with Alzheimer’s dementia score a zero- or one-word recall. Impaired new learning ability also occurs with anxiety (due to inattention and distractibility) and depression (due to lack of effort mobilised to remember). See also MiniMental Examination below. | |
| 1 brown | 1 fun | |
| 2 honesty | 2 carrot | |
| 3 tulip | 3 ankle | |
| 4 eyedropper | 4 loyalty | |
| After 5 minutes, ask for the recall of the four words. To test the duration of memory, ask for a recall at 10 minutes and at 30 minutes. The normal response for persons under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay (Strub and Black, 2000). | ||
| Additional testing for persons with aphasia | ||
Word comprehension. Point to articles in the room, parts of the body, articles from pockets, and ask the person to name them. Reading. Ask the person to read available print. Be aware that reading is related to educational level. Use caution that you are not just testing literacy. Writing. Ask the person to make up and write a sentence. Note coherence, spelling and parts of speech (the sentence should have a subject and verb). |
Aphasia is the loss of the ability to speak or write coherently, or to stand speech or writing, due to a stroke. See Table 22.3 under- Reading and writing are important in planning health teaching and rehabilitation. |
|
| Higher intellectual function | ||
| These tests measure problem-solving and reasoning abilities. Results are closely related to the person’s general intelligence and must be assessed considering educational and cultural background. Tests of higher intellectual functioning have been used to discriminate between organic brain disease and psychiatric disorders; errors on the tests indicate organic dysfunction. | ||
| Although they have been widely used, there is little evidence that most of these tests are valid in detecting organic brain disease. Furthermore, most of these tests have little relevance for daily clinical care. Thus, many time-honoured standard tests of higher intellectual function are not discussed here, such as fund of general knowledge, digit span repetition, calculation, proverb interpretation and similarities to test abstract reasoning or hypothetical situations to test judgment. | ||
| Judgment | ||
| A person exercises judgment when they can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person’s response to a hypothetical situation (e.g. ‘What would you do if you found a stamped, addressed envelope lying on the footpath?’), you should be more interested in the person’s judgment about daily or long-term life goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behaviour. | Impaired judgment (unrealistic or impulsive decisions, wish fulfillment) occurs with mental retardation, emotional dysfunction, schizophrenia and organic brain disease. | |
| To assess judgment in the context of the interview, note what the person says about job plans, social or family obligations and plans for the future. Job and future plans should be realistic, considering the person’s health situation. Also, ask the person to describe the rationale for personal healthcare, and how they decided about whether or not to comply with prescribed health regimens. The person’s actions and decisions should be realistic. | ||
| THOUGHT PROCESSES AND PERCEPTIONS | ||
| Thought processes. Ask yourself, ‘Does this person make sense? Can I follow what the person is saying?’ The way a person thinks should be logical, goal directed, coherent and relevant. The person should complete a thought. | Illogical, unrealistic thought processes. Digression from initial thought. Ideas run together. Evidence of blocking (person stops in middle of thought). See Table 21.4 | |
| Thought content. What the person says should be consistent and logical. | Obsessions, compulsions. See Table 21.5 | |
| Illusions, hallucinations. See Table 21.6 Auditory and visual hallucinations occur with psychiatric and organic brain disease and with psychedelic drugs. Tactile hallucinations occur with alcohol withdrawal. | ||
Screen for suicidal thoughts. When the person expresses feelings of sadness, hopelessness, despair or grief, it is important to assess any possible risk of physical harm to themself. Begin with more general questions. If you hear affirmative answers, continue with more specific questions: • Have you ever felt so down you thought of hurting yourself? • Do you feel like hurting yourself now? • Do you have a plan to hurt yourself? |
||
| It is very difficult to question people about possible suicidal ideas, especially for beginning nurses. Examiners fear invading privacy and may have their own normal denial of death and suicide. However, the risk is far greater if you skip these questions when you have the slightest idea that they are appropriate. You may be the only health professional to pick up clues of suicide risk. You are responsible for encouraging the person to talk about suicidal thoughts. Sometimes you cannot prevent a suicide when someone really wishes to kill themself. However, for the people who are ambivalent, and they are the majority, you can buy time so the person can be helped to find an alternative route through the situation. Share any concerns you have about a person’s suicide ideation with a mental health professional. | Verbal suicide messages (defeat, failure, worthlessness, loss, giving up, desire to kill self) Death themes in art, jokes, writing, behaviours Saying goodbye (giving away prized possessions) Additional content on mental disorders is listed in Tables 21.7 to 21.11. |
|
| SUPPLEMENTAL MENTAL STATUS EXAMINATION | ||
The MiniMental State Examination tool is a simplified scored form of the cognitive functions of the mental status examination (Folstein et al, 1975; replicated by Depaulo and Folstein, 1978; McKenzie, Copp, Shaw et al, 1996; Schwam and Xu, 2010) (see Table 21.1). It is quick and easy, includes a standard set of only 11 questions, and requires only 5 to 10 minutes to administer. It is useful for both initial and serial measurement, so you can demonstrate worsening or improvement of cognition over time and with treatment. It concentrates only on cognitive functioning, not on mood or thought processes. It is a valid detector of organic disease; thus it is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness. The maximum score on the test is 30; people with normal mental status average 27. Scores between 24 and 30 indicate no cognitive impairment. |
Scores that occur with dementia and delirium are classified as follows: 18–23 = mild cognitive impairment; 0–7 = severe cognitive impairment. | |
| DEVELOPMENTAL CONSIDERATIONS | ||
The mental status assessment of infants and children covers behavioural, cognitive and psychosocial development, and examines how the child is coping with their environment. Essentially, you will follow the same A-B-C-T guidelines as for the adult, with special consideration for developmental milestones. Your best examination ‘technique’ arises from thorough knowledge of develop mental milestones as described in Chapter 2. Abnormalities are often problems of omission; the child does not achieve a milestone you would expect. The parent’s health history, especially the sections on the developmental history and personal history, yields most of the mental status data. |
||
| In addition, the Denver II screening test (see Ch 3) gives you a chance to interact directly with the young child to assess mental status. For the child from birth to 6 years of age, the Denver II helps identify those who may be slow in development in behavioural, language, cognitive and psychosocial areas. An additional language test is the Denver Articulation Screening Exam. | ||
| For school-age children, ages 7 to 11, who have grown beyond the age when developmental milestones are very useful, the ‘Behavioural checklist’ (Table 21.2) is an additional tool that can be given to the parent along with the history. It covers five major areas: mood, play, school, friends and family relations. It is easy to administer and lasts about 5 minutes. | ||
| For the adolescent, follow the same A-B-C-T guidelines as described for the adult. | ||
It is important to conduct even a brief examination of all older people admitted to the hospital. Confusion is common in ageing people and is easily misdiag-nosed. Between one third and one half of older adults admitted to acute-care medical and surgical services show varying degrees of confusion already present. In the community, about 5% of adults over 65 and almost 20% of those over 75 have some degree of clinically detectable impaired cognitive function (Kane et al, 2003). |
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Check sensory status before assessing any aspect of mental status. Vision and hearing changes due to ageing may alter alertness and leave the person looking confused. When older people cannot hear your questions, the results of the test may be inaccurate. One group of older people with psychiatric mental illness tested significantly better when they wore hearing aids (Kreeger et al, 1995). Follow the same A-B-C-T guidelines as described for the younger adult with these additional considerations: |
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Level of consciousness. In a hospital or extended care setting, the Glasgow Coma Scale (see Ch 22) is a quantitative tool that is useful in testing consciousness in ageing persons in whom confusion is common. It gives a numerical value to the person’s eye-opening responses: best verbal and best motor. This system avoids ambiguity when numerous examiners care for the same person. |
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Orientation. Many ageing persons experience social isolation, loss of structure without a job, a change in residence or some short-term memory loss. These factors affect orientation, and this person may not provide the precise date or complete name of agency. You may consider ageing persons oriented if they know generally where they are and the present period. That is, consider them oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g. the hospital) and the name of the town. |
People with Alzheimer’s dementia do not improve their performance on subsequent trials. | |
New learning. In people of normal cognitive function, an age-related decline occurs in performance in the Four Unrelated Words Test described above. Persons in the eighth decade average two of four words recalled over 5 minutes. They will improve their performance at 10 and 30 minutes after being reminded by verbal cues (e.g. ‘one word was a colour; a common flower in Holland is ——————’). |
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| Supplemental mental status examination There are two predominant supplemental mental status examination scales used in the Australian context. Firstly the Geriatric Depression Scale indicates the level of depression a person may be experiencing but is not used to determine cognitive impairment whereas the Psychogeriatric Assessment Scale (PAS) is administered to assess for clinical changes in dementia, depression and cognitive impairment (Garlick and Koch, 2010). | ||
TABLE 21.1 Mini-Mental State Examination (MMSE)
| MMSE Sample Items |
|---|
| Orientation to Time |
| “What is the date?” |
Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549, from the Mini Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. by calling +1 (813) 968-3003.
TABLE 21.2 Behavioural checklist
| 1 | Prefers to play alone |
| 2 | Gets hurt in major accidents |
| 3 | Does he/she ever play with fire? |
| 4 | Has difficulties with teachers |
| 5 | Gets poor grades in school |
| 6 | Is absent from school |
| 7 | Becomes angry easily |
| 8 | Daydreams |
| 9 | Feels unhappy |
| 10 | Acts younger than other children his/her age |
| 11 | Does not listen to parents |
| 12 | Does not tell the truth |
| 13 | Unsure of himself/herself |
| 14 | Has trouble sleeping |
| 15 | Seems afraid of someone or something |
| 16 | Is nervous and jumpy |
| 17 | Has a nervous habit |
| 18 | Does not show feelings |
| 19 | Fights with other children |
| 20 | Is understanding of other people’s feelings |
| 21 | Refuses to share |
| 22 | Shows jealousy |
| 23 | Takes things that are not his/hers |
| 24 | Blames others for his/her troubles |
| 25 | Prefers to play with children not his/her age |
| 26 | Gets along well with grownups |
| 27 | Teases others |
| Scoring is a point system: 0—never; 1—sometimes; 2—often. Scoring is reversed for items 20 and 26. Scores between 15 and 22 indicate closer following; scores above 22 warrant psychiatric evaluation. | |
From Jellinek M, Evans N, Knight R: Use of a behavior checklist on a pediatric inpatient unit, J Pediatr 94:156–158, 1979.
TABLE 21.3 Abnormalities of mood and affect
| Type of mood or affect | Definition | Clinical example |
|---|---|---|
| Flat affect (blunted affect) | Lack of emotional response; no expression of feelings; voice monotonous and face immobile | Topic varies, expression does not |
| Depression | Sad, gloomy, dejected; symptoms may occur with rainy weather, after a holiday, with an illness; if the situation is temporary, symptoms fade quickly | ‘I’ve got the blues.’ |
| Depersonalisation (lack of ego boundaries) | Loss of identity, feels estranged, perplexed about own identity and meaning of existence | ‘I don’t feel real.’ ‘I feel like I’m not really here.’ |
| Elation | Joy and optimism, overconfidence, increased motor activity, not necessarily pathological | ‘I’m feeling very happy.’ |
| Euphoria | Excessive wellbeing, unusually cheerful or elated, which is inappropriate considering physical and mental condition, implies a pathological mood | ‘I am high.’ ‘I feel like I’m flying.’ ‘I feel on top of the world.’ |
| Anxiety | Worried, uneasy, apprehensive from the anticipation of a danger whose source is unknown | ‘I feel nervous and high strung.’ ‘I worry all the time.’ ‘I can’t seem to make up my mind.’ |
| Fear | Worried, uneasy, apprehensive; external danger is known and identified | Fear of flying in aeroplanes |
| Irritability | Annoyed, easily provoked, impatient | Person internalises a feeling of tension, and a seemingly mild stimulus ‘sets them off’ |
| Rage | Furious, loss of control | Person has expressed violent behaviour towards self or others |
| Ambivalence | The existence of opposing emotions towards an idea, object, person | A person feels love and hate towards another at the same time |
| Lability | Rapid shift of emotions | Person expresses euphoric, tearful, angry feelings in rapid succession |
| Inappropriate affect | Affect clearly discordant with the content of the person’s speech | Laughs while discussing admission for liver biopsy |
TABLE 21.4 Abnormalities of thought process
| Type of process | Definition | Clinical example |
|---|---|---|
| Blocking | Sudden interruption in train of thought, unable to complete sentence, seems related to strong emotion | ‘Forgot what I was going to say.’ |
| Confabulation | Fabricates events to fill in memory gaps | Gives detailed description of his long walk around the hospital although you know Mr J remained in his room all afternoon. |
| Neologism | Coining a new word; invented word has no real meaning except for the person; may condense several words | ‘I’ll have to turn on my thinkilator.’ |
| Circumlocution | Round-about expression, substituting a phrase when cannot think of name of object | Says ‘the thing you open the door with’ instead of ‘key’. |
| Circumstantiality | Talks with excessive and unnecessary detail, delays reaching point; sentences have a meaningful connection but are irrelevant (this occurs normally in some people) | ‘When was my surgery? Well I was 27, I was living with my aunt, she’s the one with psoriasis, she had it bad that year because of the heat, the heat was worse then than it was in the summer of 2009 …’ |
| Loosening associations | Shifting from one topic to an unrelated topic; person seems unaware that topics are unconnected | ‘My boss is angry with me and it wasn’t even my fault. (pause) I saw that movie too, Lord of the Rings. I felt really bad about it. But she kept trying to land the aeroplane and she never knew what was going on.’ |
| Flight of ideas | Abrupt change, rapid skipping from topic to topic, practically continuous flow of accelerated speech; topics usually have recognisable associations or are plays on words | ‘Take this pill? The pill is blue. I feel blue. (sings) She wore blue velvet.’ |
| Word salad | Incoherent mixture of words, phrases and sentences; illogical, disconnected, includes neologisms | ‘Beauty, red based five, pigeon, the street corner, sort-of.’ |
| Perseveration | Persistent repeating of verbal or motor response, even with varied stimuli | ‘I’m going to lock the door, lock the door. I walk every day and I lock the door. I usually take the dog and I lock the door.’ |
| Echolalia | Imitation, repeats others’ words or phrases, often with a mumbling, mocking or mechanical tone | Nurse: ‘I would like you to take your pill.’ Patient (mocking): ‘Take your pill. Take your pill.’ |
| Clanging | Word choice based on sound, not meaning, includes nonsense rhymes and puns | ‘My feet are cold. Cold, bold, told. The bell tolled for me.’ |
TABLE 21.5 Abnormalities of thought content
| Type of content | Definition | Clinical example |
|---|---|---|
| Phobia | Strong, persistent, irrational fear of an object or situation; feels driven to avoid it | Cats, dogs, heights, enclosed spaces |
| Hypochondriasis | Morbid worrying about their own health, feels sick with no actual basis for that assumption | Preoccupied with the fear of having cancer; any symptom or physical sign means cancer |
| Obsession | Unwanted, persistent thoughts or impulses; logic will not purge them from consciousness; experienced as intrusive and senseless | Violence (parent having repeated impulse to kill a loved child); contamination (becoming infected by shaking hands) |
| Compulsion | Unwanted repetitive, purposeful act; driven to do it; behaviour thought to neutralise or prevent discomfort or some dreaded event | Handwashing, counting, checking and rechecking, touching |
| Delusions | Firm, fixed, false beliefs; irrational; person clings to delusion despite objective evidence to contrary | Grandiose—person believes they are God; famous, historical or sports figure; or other well-known person |
| Persecution | A belief that the person is being conspired against, cheated, spied on, followed, poisoned, maligned or harassed | ‘They are out to get me.’ |
TABLE 21.6 Abnormalities of perception
| Type of perception | Definition | Clinical example |
|---|---|---|
| Hallucination | Sensory perceptions for which there are no external stimuli; may strike any sense: visual, auditory, tactile, olfactory, gustatory | Visual: seeing an image (ghost) of a person who is not there; auditory: hearing voices or music |
| Illusion | Misperception of an actual existing stimulus, by any sense | Folds of bedsheets appear to be animated |
TABLE 21.7 Delirium, dementia and amnestic disorders*
* The terms organic mental disorder and organic brain syndrome are no longer used for these disorders. These diagnostic categories are meant to be illustrative, not inclusive. Please refer to the original source for additional details and for further categories.
Adapted from the American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edn. Washington DC, 2000, American Psychiatric Association. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. © 2000 American Psychiatric Association.
TABLE 21.8 Substance use disorders
TABLE 21.9 Schizophrenia*
| A | Characteristic symptoms |
| Two (or more) of the following, each present for a significant part of a 1-month period: | |
| 1 | Delusions, i.e. involving a phenomenon that the person’s culture would regard as totally implausible, such as thought broadcasting, being controlled by a dead person |
| 2 | Hallucinations (auditory are more common), e.g. voices speaking directly to the person or commenting on their ongoing behaviour |
| 3 | Disorganised speech, e.g. frequent derailment or incoherence |
| 4 | Grossly disorganised or catatonic behaviour |
| 5 | Negative symptoms, i.e. affective flattening, alogia (inability to speak) or avolition |
| B | Social/occupational dysfunction |
| One or more major areas of functioning such as work, interpersonal relations or self-care are markedly below the level achieved prior to onset of the disturbance | |
| C | Duration |
| Continuous signs persist for at least 6 months, including at least 1 month of symptoms from criterion A (i.e. active phase) and may include periods of prodromal or residual symptoms | |
* These diagnostic categories are meant to be illustrative, not inclusive. The reader is referred to the original source or a psychiatry textbook for further categories and schizophrenia subtypes, such as Paranoid Type, Catatonic Type, Disorganised Type.
Adapted from the American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edn. Washington DC, 2000, American Psychiatric Association. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. © 2000 American Psychiatric Association.
TABLE 21.10 Mood disorders*
* These diagnostic categories are meant to be illustrative, not inclusive. The reader is referred to the original source or a psychiatry textbook for further categories, such as personality disorders or somatiform disorders.
Adapted from the American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edn. Washington DC, 2000, American Psychiatric Association. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. © 2000 American Psychiatric Association.
TABLE 21.11 Anxiety disorders*
* These diagnostic categories are meant to be illustrative, not inclusive. The reader is referred to the original source or a psychiatry textbook for further details and categories of anxiety disorders.
Adapted from the American Psychiatric Association: Diagnostic and statistical manual of mental disorders, 4th edn. Washington DC, 2000, American Psychiatric Association. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th edn. © 2000 American Psychiatric Association.
Lola P is a 79-year-old married woman, with a recent hospitalisation for evaluation of increasing memory loss, confusion and socially inappropriate behaviour. Her family reports that Mrs P’s hygiene and grooming have decreased; she eats very little and has lost weight, does not sleep through the night, has angry emotional outbursts that are unlike her former demeanour and does not recognise her younger grandchildren. Her husband reports that she has drifted away from the stove while cooking, allowing food to burn on the stovetop. He has found her wandering through the house in the middle of the night, unsure of where she was. She used to ‘talk on the phone for hours’ but now he has to push her into conversations. During this hospitalisation, Mrs P has undergone a series of medical tests, including a negative lumbar puncture test, normal electroencephalogram (EEG) and a benign head computed tomography (CT) scan. Her physician now suggests a diagnosis of senile dementia of the Alzheimer’s type (SDAT).
Appearance: Sitting quietly, somewhat slumped, picking on loose threads on her dress. Hooded, zippered windcheater top worn over dress. Hair is gathered in loose ponytail with stray wisps. No make-up.
Behaviour: Awake and gazing at hands and lap. Expression is flat and vacant. Will make eye contact when called by name, although gaze quickly shifts back to lap. Speech is a bit slow but articulate; some trouble with word choice.
Cognitive functions: Oriented to person and place. Can state the season, but not the day of the week or the year. Is not able to repeat the correct sequence of complex directions involving lifting and shifting glass of water to the other hand. Scores a one-word recall on the Four Unrelated Words Test. Cannot tell examiner how she would plan a grocery shopping trip.
Thought processes: Experiences blocking in train of thought. Thought content is logical. Acts with hostility and suspicion towards family members. No suicidal ideation.
MiniMental State Examination score is 17, and shows poor recall ability and marked difficulty with serial 7s.
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http://www.sane.org.au/ http://www.sane.org.au/ SANE is a national organisation promoting a better life for people with mental illness. In particular it coordinates Stigmawatch, a national campaign to respond to stigma and discrimination towards people with a mental illness in the media. This site will also provide useful links to other websites.
http://www.beyondblue.org.au/site http://www.beyondblue.org.au/site Beyondblue is a national initiative focusing on depression that provides information for consumers and carers, the general public and health professionals. It also supports research into depression.
http://www.depressionet.com.au http://www.depressionet.com.au/ Provides an independent, comprehensive resource for information help and 24-hour support for people living with depression.
http://www.eppic.org.au http://www.eppic.org.au/ An integrated and comprehensive psychiatric service aimed at addressing needs of older adolescents and young adults with emerging psychotic disorders.