Psychiatric history, MSE and cognitive assessment

Question 1

components of the cognitive assessment?

Answer 1

GOAL-CRAM:
general
orientation-time,place,person
attention and concentration
language
calculation
R hemisphere function-visual-spatial orientation
abstraction-concepts
memory

Question 2

what is the premorbid personality and why is this important to ask about?

Answer 2

this is the personality of the pt before the onset of mental illness
important to look for change in the personality of the pt

Question 3

what do you want to know about the history of presenting complaint?

Answer 3

nature
severity-amount of distress and functional impairment?
onset-when did it start, was this sudden? was it spontaneous or related to stressful events?-?precipitators, a delusional perception in schizophrenia-misinterpreting the significance of something perceived normally.
duration?
course-static, worsening, improving,fluctuating?
factors making problem worse or better

Question 4

what is important to note with regards to past psychiatric history?

Answer 4

have you ever felt like this before? what was done about it? what support was sought? hosp admission? willingness for this? medication? compliance?
nature of illness, problems such as this in the past?
number and severity of episodes
requiring inpt hosp admission?
treatments given an their success?
did the pt think that they were unwell?
any assoc. with risks to self e.g. self-harm, or to others?

Question 5

components of the MSE?

Answer 5

appearance and behaviour-eye contact, psychomotor agitation/retardation, hygiene, dress, smell, rapport?, abnormal behaviours e.g. fidgety suggesting anxiety?, facial expression, posture, movement
speech-rate, rhythm, content-logic?, tone, formal thought disorder?
mood-objective and subjective
thoughts-stream, form, content-preoccupatons, morbid thoughts including suicidality, delusions and overvalued ideas, obsessional symptoms. thought insertion, broadcast and withdrawal?-*schizophrenia. paranoia- anyone trying to harm you? people referring to you on TV or the radio?
perception-hallucinations, illusions, pseudohallucinations, thought echo-form of auditory hallucination.
cognition-general obs, MMSE, specific lobe exam., orientation, attention and conc, memory, language, visuospatial functioning. simple qns- time, place and person orientation.
insight-do you think that you may be unwell? mental illness?

Question 6

what must we assess in the MSE when considering a patient’s insight?

Answer 6

do they realise that they are unwell?
do they understand that they have a mental illness?
do they think they need treatment?
are they willing to accept treatment?
do they understand the usefulness of that treatment?

Question 7

what may suggest self-neglect when observing the pt?

Answer 7

dirty, unkempt appearance
crumpled stained clothing

appearance suggests alcoholism, drug addiction, dementia or schizophrenia. ?depression.

Question 8

movement disorders that may be noted on general appearance of pt?

Answer 8

tics-irregular repeated movements involving a group of muscles
choreiform movements-brief involuntary movements, coordinated but purposeless
dystonia-muscle spasm, often painful and may lead to contortions.

Question 9

name given to copious rapid speech difficult to interrupt seen in manic patients?

Answer 9

pressure of speech

Question 10

abnormalities in the form of thought?

Answer 10

flight of ideas-seen in mania
loosening of associations (knight’s move thinking)-seen in schizophrenia
perseveration-persistent and inappropriate repetition of same sequence of thought, e.g. giving the same answer as given for the 1st question as the answer to a series of questions although these require different answers. Occurs most often in dementia.

Question 11

how can preoccupations be asked about?

Answer 11

what sort of things do you worry about?

what sort of thoughts occupy your mind?

Question 12

how to ask about suicidal ideation when considering thoughts in the MSE?

Answer 12

consider feelings of hopelessness-how do you see your future?
do you think that life is worth living?
have you had any thoughts about not wanting to live anymore? ever wished you might not wake up one morning?
any thoughts about ending your life?-what were these, how might you do it?
any plans to end your life?
any attempts to end you life? what stopped you? who was present?

Question 13

how may the stream of thought be abnormal?

Answer 13

pressure of thought-thoughts rapid, varied, abundant
poverty of thought-slow, few, unvaried
blocking of thought- may be linked to delusion of thought withdrawal seen in schizophrenia

Question 14

what is a secondary delusion?

Answer 14

most common form
arises from a previous idea or experience e.g. a hallucination-person may hear a voice and believe he is being followed, mood- depressed, may have feelings of worthlessness and believes other people feel the same about him, or another delusion.

Question 15

what phenomena are not delusional in nature but are closely related to delusions?

Answer 15

delusional mood-inexplicable feeling of apprehensions shortly followed by a delusion that explains it
delusional perception-misinterpretation of the significance of something perceived normally
delusional memory-delusional misinterpretation of memories of actual events

Question 16

how might persecutory delusions in schizophrenia and severe depressive disorder differ from one another?

Answer 16

depression-pt accepts that supposed actions of persecutor are justified by his behaviour
schizo-pt resents the actions

Question 17

how can overvalued ideas be distinguished from delusions?

Answer 17

based on how the pt came to believe what they did
an overvalued idea is a preoccupying strongly held belief that affects the pt’s actions but has been derived through normal mental processes.

Question 18

how are obsessions different from delusions?

Answer 18

patient recognises an obsession to be their own thought, and often tries to resist it
with obsessional thoughts, they know they are irrational and do not wish to carry them out.

Question 19

what is a compulsion?

Answer 19

a recurrent, persistent stereotyped action that the person feels compelled to carry out but resists, recognises as senseless, and as a product of their own mind.

Question 20

asking about obsessions?

Answer 20

do any thoughts keep coming repeatedly into your mind, even when you try hard to get rid of them?

Question 21

when are illusions more likely?

Answer 21

impaired consciousness e.g. in delirium
inattention
emotional arousal, usually fear
sensory impairment

Question 22

what is consciousness?

Answer 22

awareness of self and the environment

Question 23

how do levels of consciousness vary between alertness and coma?

Answer 23

clouding of consciousness-state of drowsiness
stupor-person mute, immobile and unresponsive but appears conscious as eyes open and follow objects
confusion
drowsiness

Question 24

difference between attention and concentration?

Answer 24

attention-ability to focus on matter in hand

concentration-ability to sustain that focus

Question 25

what might the ‘clock drawing test’ be used for?

Answer 25

this is a test of visuospatial functioning for testing cognition
often impaired in dementia patients

Question 26

What are the important components of a history in a patient with suspected dementia?

Answer 26

memory loss- how long? have you noticed yourself getting forgetful? do your family say you repeat questions to them? do you forget where you have left things in the house?
orinetation-do you ever leave your house and can’t find your way back?
language-problems saying what you want to or understanding others?
personality- have your family felt you have changed recently?
abnormal thoughts?-are your thoughts clear to you?
abnormal perceptions?
have you been wandering?restless?irritable?disinhibited?behaviour out of the ordinary?
risk factors- HTN, smoking, high cholesterol, DM, obesity, alcohol, AF, CVD, previous TIAs or strokes? if young patient, do they have a family history of memory loss/AD?

Question 27

what is ACE?

Answer 27

a form of assessing cognition- the Addenbrooke’s cognitive examination-III
score out of 100

Question 28

how is attention and concentration assessed in a patient when considering assessment of a patient’s cognition?

Answer 28

attention-ability to focus-recognition and recollection- ask them to repeat a 5 component address and to remember this to rpt again later on.
concentration-ability to sustain focus- ask them to count back from 100 in 7s.

Question 29

what risks are there to consider in a patient with dementia?

Answer 29

being unable to complete daily tasks e.g. making a cup of tea and burning themselves-? due to forgetting what they are doing and agnosia.
getting lost when they leave the house, and causing
falls risk due to reduced visual-spatial awareness and mobility? gait apraxia?
danger to themselves e.g. walking near a river
trying to drive-danger to themselves and others
sexual disinhibition
aggressiveness towards family and others
inability to self-care, risks of incontinence and skin irritation
risks to patient from their family?-homocide may be considered the best option for the pt by their family if they feel unable to cope anymore with looking after the pt and feel the pt has no QOL.

Question 30

qns to ask to determine objective mood in MSE?

Answer 30

how is your mood at the moment?
how would you score it out of 10, if 0 is the lowest you’ve ever felt, and 10 is the best?
how does this compare to how you have been feeling recently?

Question 31

open qn to start asking about thoughts in MSE?

Answer 31

are your thoughts clear to you?

can then go on to ask: do you feel that your thoughts are being put into your head by someone else?-thought insertion
do you feel that others come to know what you are thinking without you telling them?-thought broadcast
do you feel that your thoughts are being taken away from you?-thought withdrawal

Question 32

what qns to ask when considering perception in the MSE?

Answer 32

aud hallucinations: can you hear any voices now other than my own?
visual: can you see anything now which others may find unusual?
persecutory/paranoid delusions: is anyone else listening to our conversation now?