Typical signs and symptoms of
psychiatric illness
and
Mental Status Examination
Lucie Bankovská Motlová
Introduction to psychopathology:
Overview
Typical signs and symptoms of psychiatric
disorders:
• overview and definitions
• recognition in clinical setting (patient or
videotraining)
• report Mental Status Examination
Clinical Examination of the Psychiatric Patient
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Identifying data
First impression
Family history
Alcohol and other substances history
Personal history
Previous psychiatri illnesses
History of present illness
Mental status examination
Diagnosis and differential diagnosis
Further diagnostic studies
Treatment plan
Summary
Sign, symptom, syndrome
• Sign: objective finding observed by the
physician (psychomotor retardation)
• Symptom: subjective experiences
described by the patient (decreased
energy)
• Syndrome: group of signs and symptoms
that occur together as a recognizable
condition (depressive syndrome)
Mental status examination: Outline
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Alertness and level of consciousness (clouding, somnolence, stupor)
Orientation (to time, place, person)
Appearance (healthy, sickly, bizarre, moist hands, perspiring forehead, tense posture, wide eyes)
Attitude toward examiner (cooperative, friendly, attentive, seductive, apathetic, hostile)
Behavior and psychomotor activity (mannerism, tics, echopraxia, hyperactivity, restlessness, purposeless
activity)
Concentration and attention (subtracting serial 7s).
Speech (quantity, rate of production, quality: talkative, unspontaneous, monotonous, loud, slow, pressured)
Mood (depressed, despairing, irritable, anxious, angry, euphoric, empty, guilty, frightened)
Affect (within normal range, constricted, blunted, flat, difficulties in initiating, sustaining or terminating an emotional
response)
Perceptual disturbances (hallucinations, illusions; auditory, visual, olfactory, tactile, depersonalization,
derealization)
Thought (form: flight of ideas, loose associations, blocking, circumstantiality, tangentiality, clang associations,
neologisms; content of thought: delusions, ideas of reference, obsessions, phobias, poverty of content)
Abstract thinking (proverbs)
Fund of information and intelligence
Memory (registration, retention and recollection of material)
Cognition (Mini Mental State Examination, MMSE)
Judgment (capability for social judgment: “What would you do, if you smelled smoke in a crowded movie
theater?”)
Reliability (capacity to report situation accurately)
Insight (degree of awareness and understanding that they are ill)
Suicide ideation, plan
Impulse control (is the patient capable of controlling sexual, aggressive, and other impulses?)
Sum total of the examiner's observations and
impressions derived from the initial interview
Alertness and level of consciousness
Disturbances
Clouding
Stupor
Delirium
Coma
Coma vigile (akinetic mutism)
Twilight state
Dreamlike state
Somnolence
Orientation
• Time: patient identifies the day correctly; or
approximate date, time of day; if in a hospital,
knows how long he or she has been there;
behaves as though oriented to the present
• Place: patient knows where he or she is
• Situation: patient understands the context of the
situation
• Person: patient knows who he or she is
Level of consciousness, orientation
Delirium
• Alcohol Withdrawal Delirium (Delirium
Tremens)
• Delirium due to a General Medical
Condition
Video
Delirium Tremens
Appearance
• posture, bearing, clothes, grooming, hair, nails;
healthy, sickly, angry, frightened, apathetic,
perplexed, contemptuous, ill at ease, poised, old
looking, young looking, effeminate, masculine;
signs of anxiety—moist hands, perspiring
forehead, restlessness, tense posture, strained
voice, wide eyes; shifts in level of anxiety during
interview or with particular topic
Attitude toward examiner
• cooperative, attentive, interested, frank,
seductive, defensive, hostile, playful,
ingratiating, evasive, guarded
Behaviour and psychomotor activity
• The aspect of psyche that includes
impulses, wishes, drives, instincts,
craving, as expressed by a person´s
behaviour or motor activity
Disturbances of motor behaviour
• Overactivity: psychomotor agitation,
hyperactivity, tic, akathisia, compulsion,
ritual
• Hypoactivity: psychomotor retardation
Psychomotor agitation:
Nun
Disturbances of motor behaviour
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Echopraxia
Catatonia
Negativism
Cataplexy: temporary loss of muscle tone and weakness
precipitated by emotional state
Stereotypy
Mannerism
Automatism
Command automatism
Mutism
Overactivity
Catatonia
• Catalepsy: general term for an immobile
position that is constantly maintained
• catatonic excitement
• catatonic stupor
• catatonic rigidity
• catatonic posturing
Video
1942
• cerea flexibilitas
Concentration and attention
Disturbances
• Distractibility
• Selective inattention
• Hypervigilance
• Trance
Test
subtracting 7 from 100 and keep subtracting 7s
(Video Jakub)
Disturbances in speech
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Pressure of speech
Logorrhea
Poverty of speech
Dysarthria
Stuttering
Homework!
The King´s Speech
Emotion, mood and affect
• Emotion: a complex feeling state with psychic,
somatic, and behavioral components that is
related to affect and mood
• Affect: observed expression of emotion; may be
inconsistent with patients´description of emotion
• Mood: a pervasive and sustained emotion,
subjectively experienced and reported by the
patient and observed by others
• Other emotions
Mood
• a pervasive and sustained emotion that
colors the person's perception of the world
• how does patient say he or she feels;
depth, intensity, duration, and fluctuations
of mood—depressed, despairing, irritable,
anxious, terrified, angry, expansive,
euphoric, empty, guilty, awed, futile, selfcontemptuous, anhedonic, alexithymic
Disturbances of mood
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Dysphoric
Expansive
Irritable
Mood swings
Elevated
Euphoria
Ecstasy
Depression
Ahnedonia
Grief or mourning
alexithymia
Physiological disturbances
associated with mood
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Anorexia
Hyperphagia
Insomnia: initial, middle, terminal
Hypersomnia
Diurnal variation
Diminished libido
Other emotions
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Anxiety
Free-floating anxiety
Fear
Agitation
Tension
Panic
Apathy
Ambivalence
Abreaction
Shame
Guilt
Affect
• the outward expression of the patient´s inner
experiences
• how examiner evaluates patient's affects—
broad, restricted, blunted or flat, shallow, amount
and range of expression; difficulty in initiating,
sustaining, or terminating an emotional
response; is the emotional expression
appropriate to the thought content, culture, and
setting of the examination;
Disturbances of affect
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Inappropriate
Blunted
restricted
Flat
labile
Perception
• Mental process by whoch sensory stimuli
are brought to awareness
Disturbances of perception
• Hallucination: false sensory perception not
associated with real external stimuli; there
may or may not be delusional
interpretation of the hallucinatory
experience
• Illusion: mispercetion or misinterpretation
of real external sensory stimuli
Visual hallucination
„cotton“
Hallucination
• Hypnagogic: false sensory perception occuring while
falling asleep
• Hypnopompic: false sensory perception occuring while
awakening from sleep
• Auditory
• Visual
• Olfactory
• Gustatory
• Tactile
• Somatic
• Synesthesia: e.g. words are experienced as being seen
Thinking
Goal-directed goal of ideas, symbols and
associations initiated by a problem or a
task and leading toward a reality-oriented
conclusion
Disturbances
• In form of thought: the way in which ideas
are linked, not the ideas themselves
• In content of thought
Form of thinking
• Productivity: overabundance of ideas, paucity of ideas, flight of
ideas, rapid thinking, slow thinking, hesitant thinking; does patient
speak spontaneously or only when questions are asked, stream of
thought, quotations from patient
• Continuity of thought: whether patient's replies really answer
questions and are goal directed, relevant, or irrelevant; loose
associations; lack of cause-and-effect relationships in patient's
explanations; illogical, tangential, circumstantial, rambling, evasive,
perseverative statements, blocking or distractibility
• Language impairments: impairments that reflect disordered
mentation, such as incoherent or incomprehensible speech (word
salad), clang associations, neologisms
Content of thinking and Thought
disturbances
• Preoccupations: about the illness, environmental
problems; obsessions, compulsions, phobias;
obsessions or plans about suicide, homicide;
hypochondriacal symptoms, specific antisocial urges or
impulses
• Delusions: content of any delusional system, its
organization, the patient's convictions as to its validity,
how it affects his or her life
• Ideas of reference and ideas of influence: how ideas
began, their content, and the meaning the patient
attributes to them
Mr. Z
Disturbances in form of thought
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Neologism
Word salad
Circumstantiality
Tangentiality
Incoherence
Perseveration
Verbigeration: meaningless repetition of specific words
Echolalia
Loosening of association
Flight of ideas
Clang association
Blocking
Circumstantiality
Overinclusion of trivial or irrelevant details that impede the
sense of getting to the point.
• Example: A 79-year-old woman is describing her
headaches to her doctor. "They usually start in the
morning. I'll wake up at 6 or 6:30, and then by the time I
have my coffee . . . well sometimes I'll have tea. I like it
with lemon and just a bit of sugar . . . or honey
sometimes. I always take milk with coffee. And like I was
saying, after coffee I may turn on the TV for a half hour
or so. Well, unless there's something really good. If I'm
watching the news, I may not even notice the
headaches, but by lunch they're so bad I have to lie
down."
Clang association
Thoughts are associated by the sound of words
rather than their meaning, for example, though
rhyming or assonance.
• Example: A 31-year-old man in the manic phase
of bipolar disorder was asked if he had any
trouble sleeping. He replied, "I never have
trouble sleeping. I never have trouble peeping. I
never have trouble pooping."
Derailment (loose associations)
There is a breakdown in both the logical
connection between ideas and the overall sense
of goal-directedness. The words make
sentences, but the sentences don't make sense.
• Example: A 19-year-old man with a first
psychotic episode describes the week at home
before coming into the hospital. "I . . . I watched
TV, but the newspaper didn't come. I . . . David
is at school, too. Sometimes it's better to be
alone, you know, to save for a rainy day."
Flight of ideas
A succession of multiple associations, so that
thought seems to move abruptly from idea to
idea. Often (but not invariably) expressed
through rapid, pressured speech.
• Example: A 37-year-old man who is in the
middle of a manic episode is speaking with great
rapidity: "I just got back from New York. Call it
the Big Apple, but it's rotten to the core. Nobody
can take me. I could beat up my father. He was
tough, a salesman. He sold his soul for a pig in a
poke."
Neologism
Invention of new words or phrases or the use of
conventional words in idiosyncratic ways.
• Example: A 25-year-old man with a diagnosis of
chronic undifferentiated schizophrenia described
his activities during a pass from a psychiatric
hospital: "We went to the park. It was hot, but
not too hot. It was burging."
President
DSA
Perseveration
Repetition out of context of words, phrases, or
ideas.
• Example: A psychiatrist is evaluating an 86-yearold woman in a nursing home.
• Psychiatrist: Do you know what day it is?
• Woman: Yes, Tuesday.
• Psychiatrist: And where are we now?
• Woman: Tuesday.
Tangentiality
In response to a question, the patient gives a reply
that is appropriate to the general topic without
actually answering the question.
• Example: A 40-year-old man with depression is
being evaluated by a psychiatrist.
• Psychiatrist: Have you had trouble sleeping
through the night lately?
• Patient: I usually sleep in my bed but now I'm
sleeping on the sofa.
Thought blocking
A sudden disruption of thought or break in the flow of ideas.
• Example: A psychiatrist is interviewing a 55-year-old man.
• Psychiatrist: Have you been drinking more than usual in the last
couple of months?
• Patient: Not really. I've always been a pretty big drinker. . . could
hold my liquor pretty well.
• Psychiatrist: How much would you drink in a normal day?
• Patient: Maybe a pint. Two pints sometimes. . . no [pause]
• Psychiatrist: What?
• Patient: I forgot. What were we talking about? What did you ask me?
Disturbances in content of thought
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Poverty of content
Delusion
Obsession
Phobia
Delusion
Homework!
Beautiful Mind
• fixed false belief,
• based on incorrect inference about external reality,
• not consistent with patient´s intelligence and cultural
background,
• not shared by others as part of a religious or subcultural
group,
• that cannot be corrected by reasoning,
• rigidly held regardless of evidence to the contrary,
• not displaced by evidence,
• results in behaviour based on them
Delusions
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Bizarre
Systematized
Mood-congruent
Mood-incongruent
Nihilistic
Delusion of poverty
Somatic delusion
Of infidelity (delusional jealousy)
Erotomania
Delusions
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Paranoid
Of persecution
Of grandeur
Of reference
Paranoid - persecutory
Delusion
Out of the shadow
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Delusions
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Delusions of self-accusation
Of control
Thought withdrawal
Thought insertion
Thought broadcasting
Thought control
Methods for eliciting delusional beliefs
• Have you had trouble getting along with people?
• Have you felt that people are against you?
• Has anyone been trying to harm you or plot against
you?
• Have you walked into a room and thought people
were talking about you or laughing at you?
Abstract thinking
• disturbances in concept formation; manner in
which the patient conceptualizes or handles his
or her ideas;
• similarities (e.g., between apples and pears),
differences, absurdities;
• meanings of simple proverbs,answers may be
concrete (giving specific examples to illustrate
the meaning) or overly abstract (giving
generalized explanation); appropriateness of
answers
Proverbs
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Between the devil and the deep sea
First come, first served
Barking dogs seldom bite
A rolling stone gather no moss
All that glitters is not gold
Fund of knowledge
• level of formal education and selfeducation; estimate of the patient's
intellectual capability and whether capable
of functioning at the level of his or her
basic endowment; counting, calculation,
general knowledge; questions should have
relevance to the patient's educational and
cultural background
Memory
• Function by which information stored in
the brain is later recalled to consciouness
Memory
• impairment, efforts made to cope with impairment—denial,
confabulation, catastrophic reaction, circumstantiality used to
conceal deficit; whether the process of registration, retention, or
recollection of material is involved
• Remote memory: childhood data, important events known to have
occurred when the patient was younger or free of illness, personal
matters, neutral material
• Recent past memory: past few months
• Recent memory: past few days, what did patient do yesterday, the
day before, have for breakfast, lunch, dinner
• Immediate retention and recall: ability to repeat six figures after
examiner dictates them—first forward, then backward, then after a
few minutes' interruption; other test questions; did same questions, if
repeated, call forth different answers at different times
• Effect of defect on patient: mechanisms patient has developed to
cope with defect
Disturbances of memory
Amnesia: partial or total inability to recall
past experiences; may be organic or
emotional in origin
• Anterograde: for events occuring after a
point in time
• Retrograde: amnesia prior to a point in
time
Disturbances of memory
• Paramnesia: falsification of memory by
distortion of recall (e.g. Confabulation)
Cognition
• Mini Mental State Examination
Judgment
• Social judgment: subtle manifestations of
behavior that are harmful to the patient and
contrary to acceptable behavior in the culture;
does the patient understand the likely outcome
of personal behavior and is patient influenced by
that understanding
• Test judgment: patient's prediction of what he or
she would do in imaginary situations; for
instance, what patient would do with a stamped,
addressed letter found in the street
Insight
• degree of personal awareness and understanding of illness
• Complete denial of illness
• Slight awareness of being sick and needing help but denying it at
the same time
• Awareness of being sick but blaming it on others, on external
factors, on medical or unknown organic factors
• Intellectual insight: admission of illness and recognition that
symptoms or failures in social adjustment are due to irrational
feelings or disturbances, without applying that knowledge to future
experiences
• True emotional insight: emotional awareness of the motives and
feelings within, of the underlying meaning of symptoms; does the
awareness lead to changes in personality and future behavior;
openness to new ideas and concepts about self and the important
people in his or her life
Suicide ideation, plan
• depressive symptoms?
• suicidal thoughts, intents, plans, attempts?
Impulse control
• Is the patient capable of controlling sexual,
aggressive and other impulses?