We all meet people in our daily lives and as human beings we are acutely tuned to noticing difference between ourselves and others.  The step between subconscious awareness and conscious noticing and recording as an examination is one of the situations where psychiatrists demonstrate their ability, and arguably it is an area at which psychiatrists are most practiced and skilled.

A psychiatrist’s mental state examination is a systematic way asking patients about their thoughts and feelings so as to reveal and document them.  How one asks such questions, follows up on the answers, records the responses and draws conclusions from them are skills to be learnt and practiced like any other means of examination.  Technical terms to document certain phenomena which would not be known to someone who is not a student of psychopathology.

The success of a mental state examination depends in part on the cooperation and capacity of the patient to follow the psychiatrist’s questions, but cooperation is not essential.  It is more difficult to perform and children and is complicated by any barriers that may exist between psychiatrist and patient such as language and cultural differences.

By convention a mental state examination is recorded under the following headings: Appearance, behaviour, speech, mood, thought, perceptions, cognition and insight.  The mental state examination concerns the patient at a particular moment in time; historical details should not be recorded.

Appearance

In this section try to describe how the patient looks.  It can be useful to consider what would help someone else pick out a person should they need to select them from a room full of people.  Give details of patient’s apparent age, sex, ethnicity, clothing, tattoos, personal hygiene, state of self care, scars and piercings.

Behaviour

Describe what the patient was doing at the time of interview.  Were they engaged in the interview process or did they appear distracted/preoccupied/perplexed? Did they make eye contact?  Where there obvious mannerisms/tics/stereotypes?  You can document things that happen during the interview here, for example if the patient walked out of the interview before it was complete

Speech

nb: The difference between ‘speech’ and ‘thoughts’ in the mental state examination is tricky.  Psychiatrists assume that the content of what is being said by a patient is an expression of the inner process of thinking.  Therefore in ‘speech’ the form of speech is discussed, whereas in ‘thoughts’ the content of someone’s speech is recorded.

What was the rate (fast, slow, pressured), volume (quiet, shoutings) and rhythm of someone’s speech? Were they interruptible? What was the tone (monotonal, angry, agitated)?  Include errors of pronunciation, slurring, punning, rhyming, clang associations.  Was the speech circumstantial/tangential?  Was it goal directed or rambling.

Consider also whether thought disorder is present.  Terms that describe this include loosening of association, knight’s move thinking, word salad, thought block, perseveration and neologisms.

Mood

This can be described under two headings:

Objectively – how the patient appears to you – do they appear elated, flat/blunted, incongruous depressed or anxious?  Is their mood reactive, for example do they smile when talking of something that they enjoy?

Subjectively – how does the patient describe their own mood?  Are they expressing depressive attitudes?  You can ask about the symptoms of depression here if you wish, but as these are often asked about as experienced over the past two weeks, it is best dealt with in the patient’s history I feel.

Thoughts

See note on ‘speech’ above.  What do the preoccupations of the patient appear to be during the interview?  Are there any abnormal beliefs?  Are these delusional or overvalued ideas?  Do they have any paranoid ideation?  Do they think that someone is following them?  Do they have any obsessional ruminations, compulsions or rituals?

Perceptions

Ask here about any abnormal experiences.  Try to get as much information as possible about their content, personal explanations and response to the experience.  A knowledge of hallucinatory experiences is useful here.

Cognition

This is rarely done in practice unless cognition is suspected to be impaired.  It requires a cooperative patient,  and a mini mental state examination is a good place to start.

Insight

It is a feature of a lot of mental illness that someone suffering from it is unaware of their predicament.  Insight is a measure of the patient’s ability to accept that they are ill and is not an ‘all or nothing’ phenomena.  Broadly, insight runs at one extreme from those who are unwilling to accept that they have a mental illness, to those that are willing to consider that their experiences are consistent with mental disorder, to those that are accepting of a psychiatrist’s viewpoint and are compliant with medication.  There are entire books written on this.

The mental state should be tailored to the patient you meet.  With some patients their history may be such that it is sufficient to write ‘no evidence of psychotic symptoms’ under thoughts.  With others you may wish to document that you have asked after specific psychopathology consistent with psychotic illness.

The cartoon is a reminder to keep an open mind about the power relationships between doctors and patient and the risk of drawing erroneous conclusions.  See Margaret Mitchell effect

Here are some summary points on the mental health act that I wrote for a talk to medical students.  It’s not comprehensive and is intended to cover the basics.

***

The Mental Health Act 1983 was amended in 1987 and is legislation governing the formal detention and care of mentally disordered people in hospital.   The 2007 MHA also governs care of some people in the community with ‘Community Treatment Orders’

There are 50 000 compulsory admission in the UK every year.  However most mental health treatment is carried out with patient consent.

When seeking to treat someone with mental health problems the least restrictive option for treatment should always be sought.

The act defines mental disorder as ‘any disorder or disability of mind’ (further discussion)

Note that drug or alcohol dependence are not considered mental disorders but paraphilias are under the scope of the act.

When detaining someone in hospital appropriate treatment must be available for them there and actually available to the patient.

Important people to enactment of mental health leglisation are:

Section 12 doctor – someone approved to make medical recommendations under the act
AMHP (approved mental health professional)  – someone approved by the local authority to perform certain roles under the act
Nearest relative: clearly defined under the act and not the same as next of kin.  See here for details
Responsible clinician: several roles, but mostly renew and discharge detentions.   Since the 2007 Act this is no longer solely the role of a doctor

Types of commonly used sections:

Section 4:  Emergency admission for assessment

Lasts 72 hours
Requires one medical practitioner and AMHP to enact

Section 2: Admission for assessment

Max duration 28 days
Requires two medical practitioners and AMHP to enact

Section 3: Admission for treatment

Maximum duration 6 months, can be renewed
Requires two medical practitioners and AMHP
Nearest relative must consent.

Section 5(2)

Allows detention of an informal patient for up to 72 hours
Designed as an emergency order in order for a mental health act assessment to take place
Doctor does not have to be approved under section 12
One medical recommendation required.  This should be completed by doctor in charge of patient’s care.

Section 136

Allows a police officer to remove someone who appears to be suffering form a mental health disorder to a place of safety
Should not exceed 72 hours and allows patient to be assessed by medical practitioner.

The following people can discharge someone from a section of the MHA

Responsible clinician
Nearest relative (Responsible Clinician has the power to block this)
Mental health tribunal
Hospital managers

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This is a rather brief rundown.  For further details:

Mental health act 1983: Code of practice

Mental health Act manual 2009 – Richard Jones

It’s psychopathology time again, here on planet Frontier Psychiatrist.  It’s been in the family as my brother recently  attempted the Fourteen Peaks Challenge will testify.  This is his story:

‘In June 2008 my friends and me decided to attempt the 14 Peaks Challenge. This involves scaling all 14 peaks in Wales which are in excess of 3000 ft and is a very long walk, taking up to 24 hours to complete.

After driving up from London, our party started walking at about 2am.  By around 4pm the next day I was starting to experience some quite peculiar visual effects.  Every time I looked at a stone, I could immediately pick out an image of a face or the shape of an animal (typically a crocodile).  Whereas normally it would take a conscious effort to see a pattern in an inert object, the comparisons were coming to me thick and fast.  At one point I picked up a piece of quartz convinced that it had the shape of an ancient Egyptian head.

I gave up the walk at around 6pm, having not slept for around 36 hours.  My tougher companions pushed on and walked for another 10 hours.  Their visual hallucinations apparently became much more vivid than mine with objects becoming actual animals and not just resembling them.’

Depending on your bent in life, this either sounds pretty cool, or pretty scary.  Plenty of people pay good money for similar nights out.

Psychiatrists have spent a lot of time classifying abnormal experiences; psychopathology is the study of this.  This is a big subject, so I’m going to gloss over a few bits.

As human beings we have a number of senses and sense organs and the brain interprets the sensory input from these.  Thus, perception consists of two parts – sensation (visual, auditory, tactile, gustatory, olfactory, kinasthetic and proprioceptive) and interpretation (the cognitive element).

But things can go wrong:

1. The stimulus can be perceived as the corresponding object, but not accurately.  For example an object could be perceived as being the wrong size; this is called micropsia or macropsia.

2. The stimulus is perceived as an object, but not corresponding to the source.  That is to say, both the stimulus and object are present, but different from each other.  This is an illusion

3. There is no stimulus, but a perception occurs.  This is a hallucination. 

4. There is a stimulus, but no perception occurs.  This is a negative hallucination.

So, my brother wasn’t hallucinating, but was seeing an illusion.  There are three major types of illusions:

1. Affect illusions:  here the person’s emotional state leads to misperceptions – perhaps being scared leads to the incorrect interpretation of a shadow.

2. Pareidolia: here a person perceives formed objects from ambiguous stimuli, for example seeing Elvis’s head in a cloud. 

3. Completion illusion: here, due to inattention, an incomplete object is perceived as complete.  For example, CCOK might be read as COOK.

Hallucinations

Hallucinations have several important qualities.  They take place in the same space and at the same time as other real perceptions – this is different from a fantasy or imagery, which take place in subjective space, or a dream, which has no real component;  they are experienced as sensations and have all the qualities of a real object from which they are indistinguishable. They are involuntary, so unlike imagery, they are not under conscious control.

Hallucinations can occur in any modality and there are many different types:

Elementary hallucinations are the simplest kind and they are unstructured hallucinations and bear no relation to anything in the natural world.  An example of this is whirring noises in the auditory modality.  In the visual modality, a person with elementary hallucinations might see multicoloured spots.  

Auditory hallucinations often occur with psychiatric illness, and auditory hallucinations of voices are one of the first rank symptoms of schizophrenia.  Visual hallucinations on the other hand are much more common with organic illness and are very uncommon in schizophrenia.  Organic causes for hallucinations include occipital lobe tumours, post concussional states, hepatic failure and dementia.  

Elderly patients with normal consciousness and no brain pathology, but with reduced visual acuity due to ocular problems experience vivid, distinct formed hallucinations, often of men wearing hats.  This is called Charles Bonnet syndrome.  Lilliputian hallucinations involve seeing tiny people or animals.  These can occur with alcohol withdrawal.  

Other sorts of hallucinations: 

Autoscopic hallucinations are the experience of seeing oneself.  This is different from an ‘out of body’ experience, as with the latter the person sees the world and his own body from a vantage point that is other than his physical body.  In autoscopy, the person ‘remains’ in their own body.

Extracampine hallucinations occur outside the field of normal perception.  An example of this would be hearing someone discussing you down the shops which are a mile away.   

Functional Hallucinations is where an external stimulus provokes hallucination, but both hallucination and stimulus are in the same modality but individually perceived.  An example of this would be hearing a voice when the tap is running.  On the other hand, Reflex hallucinations are when hallucinations in one modality are provoked by a stimulus in another modality.  An example would be seeing a elf whenever listening to music.

Formication is a type of haptic hallucination where there is the sensation of animals crawling under the skin.  This is seen in cocaine intoxication.  A character in the beginning of the film ‘A Scanner Darkly’ has a similar problem.

NB:

A pseudohallucination is like a hallucination, but lacks the quality of a perception.  It is a form of vivid imagery.  If someone feels that they are hearing voices in their head, this is a pseudohallucination as it does not have the same qualities as a normal perception. 

Synaesthesia is the perceiving of a stimulus in one modality in a different modality, for example, ‘hearing’ the colour red.  This can happen on taking LSD

Hypnagogic and hypnopompic hallucinations are hallucinations on falling asleep and waking up, respectively.  They may be normal phenomena and are particularly seen in narcolepsy 

Further reading:

Symptoms of the Mind by Femi Oyebode (Buy from Waterstones Amazon)

Just like when a physician sees a patient and looks for signs of physical illness, when a psychiatrist meets a patient they are looking for signs of psychiatric illness.  This is important because when people are suffering a deterioration in their mental health, they often describe similar experiences and these signs of mental illness are referred to as psychopathology.  When different psychopathological signs are identified and grouped together they can lead to the formation of a psychiatric diagnosis.

One of the most interesting psychopathology signs is formal thought disorder (FTD) which refers to the sort of disorganised speech which is a manifestation of psychosis. 

When people are describing a patient’s mental state they often write ‘no FTD’ when they wish to convey that the patient is coherent and can make themselves understood.  It’s a little bit more subtle than that; if a patient is intoxicated or delirious they will be incoherent but they will not necessarily be thought disordered.  Thought disorder refers to a particular set of language errors which are seen in psychosis. 

The name is rather strange.  Although it is called ‘formal thought disorder’ it actually refers to what a patient is saying.  The name is historical as when disorders of speech due to psychiatric illness were first being described (Bleuler, amongst others, was important in this), it was felt that disorders of thought form (disorganised speech) and content (delusions) should be considered separately.  Formal thought disorder therefore is a disorder of speech rather than content*.  

Normal human thinking has three characteristics

1. Content: what is being thought about – this would include delusions and obsessional thoughts

2. Form: in what manner, or shape, is the the thought about; abnormalities of the way thoughts are linked together

3. Stream or flow: how it is being thought about – the amount and speed of thinking

Different elements of formal thought disorder have been described. With his early work, Bleuler considered FTD to be when there was a loosening of associations which lead to fragmentary ideas being connected illogically.  This is seen clearly in the picture above.  Confusingly though, there appears to be no consensus about exactly what can be included formal thought disorder; it appears that most people would now use the term ‘thought disorder’ which refers to both errors of form and stream. Content is still considered separately.  

Disorder of stream of thought 

(I’ve split up these into disorder of thought form and stream, but several could be argued both ways)

Flight of ideas is when the content of speech moves quickly from one idea to another so that one train of thought is not carried to completion before another takes its place.  The normal logical sequence of ideas is generally preserved although ideas may be linked by distracting cues in the surroundings and from distractions from the words that have been spoken.  These verbal distractions may be of three kinds: clang associations, puns and rhymes.

Retardation of thinking is often seen in depression, the train of thought is slowed down, although still goal directed.  The opposite is pressure of speech and this is often seen in mania.

Peseveration is the persistent and inappropriate repetition of the same thoughts.  In reply to a question a person may give the correct answer to the first but continue to give the same answer inappropriately to subsequent questions.  This is especially seen in ‘organic’ brain disorders like dementia.

Disorders of thought form:

Overinclusion refers to a widening of the boundaries of concepts such that things are grouped together that are not often closely connected.

Loosening of associations denotes a loss of the normal structure of thinking.  The patient’s discourse seems muddled and illogical and does not become clearer with further questioning; there is a lack of general clarity, and the interviewer has the experience that the more he/she tries to clarify the patient’s thinking the less it is understood.  Loosening of associations occurs mostly in schizophrenia

Three kinds of loosening of association have been described:

Knight’s move thinking or derailment where there are odd tangential associations between ideas. 

Talking past the point (= vorbeireden) where the patient seems to get close to the point of discussion, but skirts around it and never actually reaches it

Verbigeration (= word salad = schizophasia = paraphrasia) where speech is reduced to a senseless repetition of sounds and phrases  (this is more of a disorder of thought form)

Circumstantiality is where thinking proceeds slowly with many unnecessary details and digressions, before returning to the point.  This is seen in epilepsy, learning difficulties and obsessional personalities 

Neologisms are words and phrases invented by the patient or a new meaning to a known word

Metonyms are word approximations e.g. paperskate for pen

Derailment (aka entgleisen) is where there is a change in the track of thoughts.  There is perserved, but misdirected determining of tendency/goal of thought)

With drivelling there is a disordered intermixture of the constituent parts of one complex thought

Fusion is where various thoughts are fused together, leading to a loss of goal direction.

Omission is where a thought or part of a thought it is senselessly omitted

Substitution is where one thought fills the gap for another appropriate more ‘fitting-in’ thought.

Concrete thinking is seen as a literalness of expression and understanding, with failed abstraction.  Can be tested by the use of proverbs.

Thought block  refers to the sudden arrest in the flow of thoughts.  The previous idea may then be taken up again or replaced by another thought.

As you can tell this is a big subject and I haven’t got onto the historical attempts to characterize schizophrenic thought processes (by Kraepelin, Bleuler, Goldstein, Cameron and Schneider) or the linguistic classification of speech abnormalities in psychosis. 

Further reading

Andreasen NC. Thought, language, and communication disorders. I. A Clinical assessment, definition of terms, and evaluation of their reliability. Archives of General Psychiatry 1979;36(12):1315-21

*Quite why they choose this name though it unclear to me, and if anyone else can shed more light on it I would be grateful. 

I’m doing some more nights shifts at the moment.  As regular readers of this blog will know, for me this involves a lot of grumbling, but it also involves seeing a lot of patients who are having problems with their mental health at times when most people are asleep.

Whenever I see a patient for the first time I interview them and ask a set of particular questions.  These questions add up to a ‘psychiatric history’.  The aim of the psychiatric history is to establish in a systematic way the problems that the patient is having, their chronicity, i.e. how long these problems have been going on, and any other influencing factors. 

If you ever fancy taking a psychiatric history from one of your friends then here’s how to go about it. 

Write the date and time a the top of the page and say who you are.  In my case ‘Psychiaty doctor on call’.  In general try and write down everything that you think is important.  This not just for when others may be reading the notes later, but also from a legal standpoint if there is no record in the notes then something will be considered not to have happened. 

The first part of the history is called the history of the presenting complaint (HPC).  It involves recent events which have lead to this particular visit to hospital.  These events could be over a few weeks or months or over a few days or hours. With a cooperative patient I often start with a list of the things that are bothering them.  This can be very illuminating and provide a guide as to the help the patient would like to receive.  I also find that this is a useful way of not medicalising a patient’s problems.  It is not unusual for a patient to be referred to me for depression, but to say to me that their problems are housing related, and that their husband keeps hitting them and to not mention any psychiatric symptoms at all.

An important thing to establish here is what brought the patient to hospital.  They may have been sent by their GP, or have been brought in by a family member, or have come in of their own volition.  They may also have been brought in by the police or an ambulance.  Although your patient is your primary ‘witness’ so to speak, don’t be shy of asking other people details like this.  This called taking a ‘collateral history’. 

The next section to cover is the past psychiatric history.  Here we must establish for how long the patient has had problems with their mental health.  This usually covers doctors seen, medications taken and admissions to hospital. 

Mental illness often runs in families, and it is important to probe about this.  This is called the family psychiatric history. If we know that there is mental illness already in someone’s family then this may lend weight to any diagnosis we may make, but it will also give us information about a patient’s background.  For instance if an adolescent is living with a depressed parent then this will make a big difference to their home environment. 

Some psychiatric problems may be caused by or interact with physical problems.  So the next section concerns medical history.  I usually split this up into family medical history and patient’s medical history.  It is far from unheard of for a psychiatric problem to actually be the result of an undiagnosed physical problem so psychiatrists have to be awake to this possibility.

One of the reasons that working in mental health is so interesting is that someone’s mental health is often very tied up with their social situation and the experiences they have had up to the point of presenting.  This is why a personal history is taken.  This will include details of childhood, with important questions about developmental delay, schooling, employment and relationships.  If time is short this is part of the history that can be left to a later time.

Drug use and particularly alcoholism is rife in our society and a careful drug and alcohol history is important.  I’m always amazed by how reluctant people are to tell me how much they drink.  The usual conversation: Me: how much alcohol do you drink?  Patient: not much.  Me: how much is not much?  Patient: much less than I used to.  Me: how much is that? Patient: one or two. Me: one or two what? Patient: well I don’t drink every night of the week…..  Cannabis use is also linked to the development of psychotic illness.

If writer’s cramp is holding off, then a forensic history, detailing brushes with the law and time spent in prison can be taken, and it is also useful to ask about premorbid personality whereby the patient or their relatives tell you how they used to be can give an idea as to how out of character a patients actions are and how sick they may be.

There are quite thick books written on the subject of the psychiatric interview and so I can’t hope but provide anything but a taster here.  Sometimes the patient is able to give you all the information you might need.  Sometimes they might be so disturbed that the entire history is from a a collateral source.  Often psychiatrists need to talk to several people.  At the same time as the history is being taken information for the mental state examination is also being noted – this is a posting for another day.

PS I have a theory that if someone without the appropriate qualifications, but with a bit of guile and a crash course in the right things to say, decided to pose as a psychiatrist then it would be quite some time before they were found out.  If anyone is interested in giving this a go, then take careful note, as the ability to take a ’psychiatric history’ will be an important part of your subterfuge

I’m revising for MRCpsych papers 1 and 2 this week and have been listening to the psychiatry podcasts that are available online.

The best is the British Journal of Psychiatry podcast available from the Royal College of psychiatry website.  TV doctor Raj Persaud is the host and discusses papers in the most recent journal with their authors.  There are two podcasts available – one is for the ‘public’ and the other a longer CPD version.  The discussion is usually rather matey (about 50% of the authors work at the IoP and would be known to Dr Persaud), but Dr Persaud does often put his guests on the spot by challenging them with possible alternative interpretations for their results.  Highly recommended.

The American Journal of Psychiatry also provides a lacklustre podcast or, as they call it, ‘audio digest‘.  I have never managed to get through an entire episode as its format involves a monotonic American reading out an abbreviated AJP papers.  Unlike the BJP there is no illuminating discussion.  The Mindhacks blog describes it as being ‘like an excessively thorough lecture given by a voice synthesiser’, which is a nice summary.

Also featuring Dr Persaud, but aimed at the general public is the BBC’s ‘All in the Mind‘.  This has more of a magazine format, but is often very interesting, and does not shy away from controversial topics.  All the episodes from the series broadcast since 2005 are available to ‘listen again’. on the BBC’s All in the Mind webpage.

The Institute of Psychiatry also offers podcasts.  Their website says that they wish to put online all the public lectures and debates at the institute.  These are a mixed bag, but included in amongst them are recordings of Maudsley debates going back some time as well as lectures on a wide variety of other topics.  A sort of lucky dip by the looks of things…

Bad Science blogger Ben Goldacre has started podcasting.  It’s a fledgling initiative, judging by there only being one download available, but it’s pretty interesting, and I hope adds more soon.

The ‘My Three Shrinks’ podcast is by blogger ‘Shrink Rap‘ and friends.  I’ve not listened to this yet, but it looks informal and interesting.  There are 42 downloads available

Another podcast I’ve not yet listened to are psychiatry podcasts by the Peerview Press.  Here’s a link to their stuff on podcastdirectory.com

If you are aware of any worthy psychiatry podcasts not on this list, please let me know.