DEFINITION

A structural way of observing and describing a patient’s state of mind

Part of the clinical examination

Standard format in which psychiatric signs and symptoms are recorded at the time of the interview.

Cross sectional description of patient’s state of mind

Evaluation of patient’s thinking at a point in time.

Provides information of patients thinking, reasoning, feeling, behavior etc.

Examiner interprets the meaning of of the patient’s communication- verbal and non-verbal

Based on this the diagnostic formulation and treatment planning is done

Helps examiner comprehend patient’s experiences through his own description

OUTLINE Appearance, Attitude, Behavior, and Social Interaction

Motor activity

Mood

Affect

Speech

Thought

Intelligence

Judgment and impulse control

Insight

APPEARENCE

Appearance provides many clues to patient’s mental state.

The following can be noted on careful observation

Physical health and hygiene

Self care and grooming

Comfortable or restless

Gait and posture

Intoxication

DISHEVELLED

WELL GROOMED

ATTITUDE

How the person relates to the examiner and the interview situation

Maybe summarized in one or several words such as-guarded, suspicious, hostile, friendly, manipulative, seductive, cooperative, threatening etc.

Interested/ Disinterested/ Apathetic

Eye Contact- initiated/ not initiated/ maintained/ not maintained

Attention – aroused/not aroused/ sustained/not sustained

Reflects upon the patient’s ability to function and relate

HOSTILE

SEDUCTIVETHREATENING

BEHAVIOUR

Social and n0n verbal

Hallucinating behavior- inappropriate smiling, muttering, gesticulations

Compulsions

Conversion episodes

Motor behavior- stereotypies( repeated non goal directed) mannerism( goal directed) posturing, other catatonic signs

RAPPORT Foundation of assessment

Important to note if rapport has been established or not

Establish rapport by:

Welcoming the patient, state purpose of the meeting, maintaining privacy

Provide comfort, calming and respectful demeanor, encourage open communication

Acknowledge and validate the patient’s distress/concerns

MOOD

Pervasive feeling tone which is sustained and colors the total experience of the person

Subjective

In answer to the question- how do you feel

Described in the patients words

Euthymic, relaxed, happy , worried, angry, fearful, depressed,

AFFECT

Outward objective expression of the emotional expression of the emotional experience at a given time

No question asked

Interpreted by the examiner

Judged based on – 1)quality 2) congruency 3)appropriateness 4)stability (stable or labile) 5)intensity 6)range (normal, restricted, blunted or flat)

ANGRY WORRRIED

SAD

HAPPY

SPEECH

Elements in evaluation include-

Quantity - Mute, talkative, articulate

Rate- normally responsive, rapid or slow.

Tone and volume- loud, whispered, mumbled

Flow and rhythm- spontaneous, stilted

Quality- slurred or stuttering

ABNORMAL SPEECH

Pressure of speech- difficult to stop the patient from talking

Flight of ideas- chance connections between ideas

Proxility- similar to flight of ideas but less in severity. Seen in hypomania

Thought block- sudden cessation of chain of thought and previous thought cant be remembered

THOUGHT

Thought is judged based on

Process

Content

THOUGHT PROCESS

Thought process describes how the thoughts are formulated, organized and expressed.

A patient may have normal thought content but abnormal process and vice versa

Normal thought process is describes as linear, organized and goal directed.

DISORDERS OF THOUGHT PROCESS

Circumstantiality

Tangentiality

Loose associations

Verbigeration

Word salad

Neologism

Clang association

Echolalia

Normal thought

I was home

I felt some chest pain

So I called my son And he called an ambulance

And I now am here

circumstanstiality

I was homeI felt some chest pain

So I told my son

And now I am here

The circumstantial patient over-includes details and

material that is not directly relevant to the subject or

answer to the question but does eventually return to

address the subject or answer the question. Typically the

examiner can follow a circumstantial train of thought,

seeing connections between the sequential statements.

tangentiality

I was homeNow I am here

I felt some chest pain

So I told my son

Tangential thought process may at

first appear similar to

circumstanstiality, but the patient

never returns to the original point or

question. The tangential thoughts

are seen as irrelevant and related in a minor, insignificant manner.

Loose thoughts or associations differ from circumstantial and tangential thoughts in that with loose thoughts it is difficult or impossible to see the connections between the sequential content.

Perseveration is the tendency to focus on a specific idea or content without the ability to move on to other topics. The perseverative patient will repeatedly come back to the same topic despite the interviewer's attempts to change the subject.

Neologisms refer to a new word or condensed combination of several words that is not a true word and is not readily understandable although sometimes the intended meaning or partial meaning may be apparent.

Word salad is speech characterized by confused, and often repetitious, language with no apparent meaning or relationship attached to it.

THOUGHT CONTENT

Thought content is essentially what thoughts are occurring to the patient. This is inferred by what the patient spontaneously expresses, as well as responses to specific questions aimed at eliciting particular pathology.

ABNORMAL THOUGHT CONTENT

OBSESSIONS

Obsessional thoughts are unwelcome and repetitive thoughts that intrude into the patient's consciousness. They are generally ego-alien and resisted by the patient.

Compulsions are repetitive, ritualized behaviors that patients feel compelled to perform to avoid an increase in anxiety or some dreaded outcome.

DELUSIONS

Delusions are false, fixed ideas that are not culturally sanctioned and persist in spite of evidence to the contrary.

can be divided into bizarre and nonbizarre(nonbizarre delusions refer to thought content that is not true but is not out of the realm of possibility).

Common delusions that have recognition in the DSM-IV-TR as types of delusional disorder include grandiose, erotomanic, jealous, somatic, and persecutory.

PERSECUTION

R

E

F

E

R

E

N

C

E

GRANDIOSE

SUICIDE AND HOMICIDE

Simply asking if someone is suicidal or homicidal is not adequate.

One must get a sense of ideation, intent, plan, and preparation.

Other variables that can be useful in the assessment of both suicidal and homicidal thoughts and impulses include whether there is a contingency involved (if this happens then I will commit suicide), whether the thoughts are new or chronic, and what prevents the patient from acting on them.