Mental status examination and mental health interview process

Mental health examination includes

• appearance and behavior

• speech and language

• mood and affect

• thoughts and perceptions

• cognition

  • memory

  • attention

  • information and vocabulary

  • calculations

  • abstract thinking

  • constructional ability

Appearance and behavior - LOC

LOC: how aware of environment

• alert - the patient is awake and aware. Orientation to time, place, person and situation

• lethargic - you must speak to the patient in a loud forceful manner to get a response

• obtunded - you must shake a patient to get a response

• stuporous - the patient is unarousable except by painful stimuli

• coma - the patient is completely unarousable

Appearance and behavior things to assess

• LOC

• Posture

• motor behavior

• personal hygiene, dress, grooming

• affect

Appearance and behavior - posture

Does the patient sit in a chair or exam table or prefer to walk around?

is the patient agitated with repetitive movements

appearance and behavior - hygiene

generally, grooming and hygiene deteriorate in depression and schizophrenia

appearance and behavior - affect

• facial expression

• is it appropriate to the stated mood or situation

• examples of disturbed affect

  • flat

  • labile

  • inappropriate

  • stony (parkinsonism)

Flat affect

lack of facial movement - can be seen due to a physical reason such as parkinson’s or a psychological reason such as profound depression

Speech and language - assessing for what?

quantity

rate

volume

articulation

fluency

comprehension

language use

Hesitancies in speech

often seen in patients with aphasia such as from strokes

monotone inflections associated with

severe depression or schizophrenia

circumlocutions

words or phrases that are substituted for the word a person cannot remember

ex: the thing you block out your writing with for an eraser

paraphasias

words are malformed (“I write with a den”), wrong (“I write with a branch”) or invented (“I write with a dar”)

Discrepancy between fluency and comprehension

when a patient can speak well but cannot understand

when a patient can understand but cannot articulate

Fetal Alcohol Syndrome effect on speech

Speech is clear but not understand concepts

Wernicke disorder

speech is fluent, rapid, effortless but words and sentences lack meaning. May have paraphasia as well

Affect definition

the observable mood of a person expressed through facial expressions, body language, body movements and voice

Mood definition

the sustained emotion of the patient

Euthymic

normal mood

dysthymic

depressed mood

manic

elated mood

Thought processes

the logic, coherence, organization and relevance of a patient’s thoughts as they lead to thoughts and goals": HOW people think

examples of disorders of thought processes

flight of ideas or derailment

thoughts and ideas jump rapidly - difficult to follow what patient is saying

insight

ability or awareness that thoughts, symptoms, or behaviors are normal or abnormal

ex: distinguishing that a daydream or hallucination is not real

assess by asking the patient about the reasons they are at the clinic visit

patients with psychological disorders often lack insight into their disease

Judgement

process of comparing and evaluating different possible courses of action

may be able to assess judgment by noting the patient’s responses to stressors - ex: relationships, jobs, finances

Perceptions

external stimuli — sensory awareness of the objects in the environment to the five senses and their interrelationships ex. burning hand on stove

internal stimuli — dreams or hallucinations

abnormalites of perceptions

illusions and hallucinations

illusions

false idea or belief, deceptive impression or wrongly perceived

misinterpretations of real stimuli - the postman leaves mail therefore there is a plot to poison the patient h

hallucinations

a stimuli the patient hears, sees or feels that others do not and that the patient may not recognize as false; these can be auditory, visual, olfactory, gustatory or tactile

ex: Abe lincoln speaks to the patient from the back of a penny

Do not include false perceptions associated with dreaming/falling asleep

attention

the ability to focus or concentrate over time on one task or activity

memory

the process of recording and retrieving information

short term - minutes to days before

long term - days to months before

higher cognitive functions assess by

level of intelligence assessed by vocabular, knowledge base, calculations and abstract thinking skills

assessing calculating ability

ask the patient to perform more difficult calculations such as making change

abstract thinking

interpreting proverbs: a stitch in time saves nine, squeaky wheel gets the grease

similarity exercise: what do a ball and orange have in common

how to assess attention

three digit recal - give the patient 3 nimbers to recite back to you in a few minutes

serial 7s: ask the patient to subtract serial 7s from 100

spelling backwards: ask the patient to spell WORLD backwards

constructional ability assessment

ask a patient to copy a geometric figure onto a sheet of paper such as a triangle, circle, pentagon, diamond or a cube

ask a patient to draw a clock face indicating 5

Mini-mental state examination (MMSE)

used to assess cognitive dysfunction or dementia

standardized score - highest possible 28

psychological assessment resources

standardized mental examinations for anxiety

Mobility inventory for agoraphobia (MIA)

agoraphobia cognitions questionnaire (ACA)

Body sensations questionnaire (BSQ)

standardized mental examinations for Depression

primary care evaluation of mental disorders (PRIME-MD)

beck depression inventory

hamilton depression rating scale

Edinburgh postnatal depression scale

Chief complaints that mental health patients may present with FNP

• not sleeping well

• feel tired all the time

• can’t concentrate

• kids failing school

• loss of family member

• e.g my head hurts, my stomach hurts ect.

Chief complaints mental health patient may present with PMHNP

• my wife/husband told me to come in. I don’t know why I’m here

• my kids wont listen to me

• my wife is driving me nutes

• I feel scared all the time

• referred by PCP. They can’t figure out whats wrong with me so they send me here - its not my head they are wrong

Mental health interview OARS

Open ended questions

affirmations - patient is doing the best they an do. affirm their strengths

reflective listening - let patient know you heard them, ask clarifying questions

summarize

principles of interviewing (mental health)

Find out whats important to the patient - goals and motivation

remember we do not have the answer for the patient’s situation

mostly listen while the person tells their story and understand their life situation and their internal motivation

allow the patient to come up with their own answers — much more likely to change

Screening for depression (screening category level) and population

USPSTF cat B

Screen for depression in adolescents, the general adult population including pregnant and postpartum women

screen should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow up

PHQ 2 scoring

Score of 3 — 90T% specificity for major depressive disorder (MDD), 95% specificity for any depressive disorder

score of 6 — 99.8% specificity for MDD

if 3 or higher then have patient fill out PHQ9

PHQ9 scoring

score —- depression severity

0-4 - none

5-9 - mild

10-14 - moderate

15-19 moderately severe

20-27 severe

Suicide and screening

people who committed cuicide are more likely to have seen their primary care provider than mental health provider in the 4 weeks prior to death

always ask about suicidality

Columbia suicide severity rating scale questions

• wished to be dead?

  • have you wished you were dead or wished you could go to sleep and not wake up?

• Suicidal thoughts?

  • have you actually had any thoughts of killing yourself?

• Suicidal thoughts with method? (no specific plan)

  • Have you been thinking about how you might kill yourself?

• Suicidal intent (without specific plan)

  • have you had these thoughts and had some intention on acting on them?

• Suicide intent with specific plan?

  • have you started to work out or have worked out the details of how to kill yourself and do you intend to carry out this plan?

• suicide behavior

  • have you done anything or started to do anything, or prepared to do anything to end your life?