Brain Calipers 2nd Ed. Descriptive Psychopathology and the Psychiatric Mental Status Examination David J. Robinson, M.D., F.R.C.P.C Diplomate of the American Board of Psychiatry and NeurologyBrain Calipers — Second Edition Rapid Psychler Press CO Suite 374 Suite 203 3560 Pine Grove Ave. 1673 Richmond St. Port Huron, Michigan London, Ontario USA 48060 Canada N6G 2N3 Toll Free Phone 888-PSY-CHLE (888-779-2453) Toll Free Fax 888-PSY-CHLR (888-779-2457) Outside the U.S. & Canada - Fax 519-675-0610 website www.psychler.com email - rapid@psychler.com ISBN 1-894328-02-7 Printed in the United States of America © 2001, Rapid Psychler Press Second Edition, First Printing All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form or by any means without express written permission. Unauthorized copying is prohibited by law and will be dealt with by a punitive superego as well as all available legal means (in- cluding a lawyer with a Cluster B Personality Disorder). Please support creativity by not photocopying this book. Allcaricatures are purely fictitious. Any resemblance to real people, either living or deceased, is entirely coincidental (and unfortunate). The author assumes no responsibility for the consequences of diagnoses made, or treatment instituted, as a result of the contents of this book - such determina- tions should be made by qualified mental health profes- sionals. Every effort was made to ensure the information in this book was accurate at the time of publication. However, due to the changing nature of the field of psychiatry, the reader is encouraged to consult additional, and more re- cent, sources of information.Dedication Dedication ——$ To my godparents, Brian and Fanny Chapman, for giving me my first transitional object (a teddy bear), and for all of the support and kindness you've shown me ever since,Brain Calipers — Second Edition Rapid Psychler Press produces books and presentation media that are: * Comprehensively researched * Well organized * Formatted for ease of use * Reasonably priced * Clinically oriented, and * Include humog that enhances education, and that neither demeans patients nor the efforts of those who treat themTable of Contents Table of Contents 1. Principles of the Mental Status Exam Psychiatry as a Branch of Medicine 3 A Method for Understanding Mental Illness 4 The Evaluation Process in Psychiatry 7 Anatomy of the Psychiatric Interview 8 What is the MSE? 9 Components of the MSE 9 Remembering the Components of the MSE 11 Necessity of the MSE ll Starting the MSE 12 The MSE vs. the Psychiatric History 14 Integration of the MSE and History 15 The Unpopular MSE 16 Conceptualizing the MSE 17 Diagnostic Decision Making and the MSE 18 Practical Examples 19 Medicolegal Need for the MSE 21 Interviewing Skills 22 Practice Points 23 Summary 24 2. Appearance 30 Diagnostic Significance 32 The Psychiatric Physical Exam 33 Gender & Cultural Background 35 Actual & Apparent Age 35 Attire 36 Hygiene & Grooming 37 Body Habitus 38 Physical Abnormalities 38 Jewelry & Cosmetic Use 39 Tattoos 40Brain Calipers — Second Edition Body Piercing Practice Points Summary 3. Behavior Diagnostic Significance Activity Akathisia Automatisms Catatonia Choreoathetoid Movements Compulsions Dystonias Other Extrapyramidal Symptoms Practice Points Tardive Dyskinesia Practice Points Tics Tremors Negative Symptoms Practice Points Comparison of Repetitive Behaviors Summary 4. Cooperation & Reliability Diagnostic Significance Eye Contact Attitude & Demeanor Attentiveness to the Interview Level of Consciousness Affect Secondary Gain Malingering Detection of Malingering Factitious Disorder False Information Summary 42 44 44Table of Contents 5. Speech 116 Diagnostic Significance 119 Primary Language Disorders 120 Medical vs. Psychiatric Speech Disturbances 125 Non-Fluent Aphasias 127 Fluent Aphasias 129 Practice Points 132 Accent & Dialect 133 Amount of Speech 133 Prosody 136 Practice Points 140 Testing of Aphasias 141 Summary 143 6. Thought Process 148 Diagnostic Significance 150 Disorders of Thought Process 151 List of Thought Process Disturbances 153 Circumstantiality 155 Tangentiality 156 Flight of Ideas 157 Rambling Speech 159 Loose Associations 159 Comparison of Thought Process Disorders 160 Thought Blocking & Thought Derailment 161 Fragmentation 162 Jargon 163 Word Salad 163 Incoherence 164 Clang Associations 165 Echolalia 165 Neologisms 165 Non-sequiturs 166 Private Use of Words 167 Pressure of Speech/Pressure of Thought 168 Puns 168 Rate of Speech/Rate of Thought 169 Practice Points 169Brain Calipers — Second Edition Psychiatric vs. Neurologic Terminology Summary 7. Thought Content Diagnostic Significance Delusions Persecutory Delusions Grandiose Delusions Delusions of Jealousy Erotomanic Delusions Somatic Delusions Delusions of Passivity or Control Culture-Bound Syndromes Mood Congruence & Ego Syntonicity Practice Points Overvalued Ideas Obsessions OCD vs. OCPD Practice Points Phobias Agoraphobia Fear vs. Anxiety Summary 8. Suicidal & Homicidal Ideation Diagnostic Significance Suicide Assessment Risk Factors for Suicide Psychological Factors in Suicide Inquiring About Suicidal Thoughts Measures of Suicide Risk Difficulties in Dealing With Suicidal Patients Countertransference Reactions Practice Points Conditions Associated With Violence Why Patients Become Violent Asking About Violent Intentions Psychiatric Patients and the Legal System 170 171 176 178 182 188 189 190 192 193 194 196 197 198 198 199 202 203 204 205 208 209 214 216 218 219 233 234 235 236 238 239 240 241 244 244Table of Contents Methods for Predicting Dangerousness 245 Legal Issues 246 Practice Points 247 Protecting Yourself in Interviews 248 Summary 250 9. Affect & Mood 256 Diagnostic Significance 258 Type/Quality of Affect 261 Range/Variability of Affect 262 Stability /Reactivity of Affect 263 Appropriateness of Affect 264 Congruence of Affect 265 Practice Points 267 Type/Quality of Mood 268 Reactivity of Mood 272 Intensity of Mood 273 Stability of Mood 274 Patterns of Mood Disturbance 275 Congruence of Psychotic Symptoms 276 Asking About Mood Symptoms 277 Rating Scales for Mood Symptoms 278 Practice Points 279 Summary 279 . 10. Perception 282 Diagnostic Significance 284 Hallucinations 287 Auditory Hallucinations 288 Visual Hallucinations 291 Practice Points 292 Olfactory Hallucinations 293 Gustatory Hallucinations 295 Somatic Hallucinations 295 Illusions 297 Disturbances of Self & Environment 298 Disturbances of Quality or Size 299 Disturbances in the Intensity of Perception 299Brain Calipers — Second Edition Disturbances of Experience 300 Pseudohallucinations 301 Asking About Perceptual Hallucinations 302 Perceptual Disorders in Substance Use 304 Practice Points 307 Summary 307 . 11. Insight & Judgment 310 Diagnostic Significance 313 Components of Insight 314 Measuring Insight 314 Insight Scales © 317 Describing Insight 318 Asking About Insight 318 Determining the Degree of Judgment 319 Asking About Judgment 320 Traditional Tests of Judgment 321 Proverbs 322 Ego Defenses 324 Practice Points 327 Summary 327 12. Sensorium & Cognitive Functioning 332 Diagnostic Significance 334 Why Cognitive Functions Are Assessed 336 Level of Consciousness 338 Orientation 339 Attention & Concentration 341 Memory 345 Estimation of Intelligence 353 Knowledge Base/Fund of Information 354 Capacity to Read & Write 354 Abstraction / Concrete Thinking 355 Visuospatial Ability 357 Practice Points 358 Summary 359Table of Contents 13. Reporting the MSE 362 Example 1 364 Example 2 365 Example 3 366 Example 4 368 Example 5 369 14. The Mini-Mental State Exam (MMSE) 373 The Folstein Mini-Mental State Exam 374 Instructions for Administering the MMSE 376 Critique of the MMSE 377 Other Versions of the MMSE 379 Practice Points 380 15. Bedside Screening Instruments 382 Reliability of a Scale 384 Validity of a Scale 384 Comparison of Domains Tested 385 Clock Drawing 389 Practice Points 389 16. The MSE and the Elderly 395 General Interviewing Techniques 396 Appearance 397 Behavior 397 Thought Form 397 Thought Content 397 Affect & Mood 398 Perception 398 Insight & Judgment 398 ADLs & IADLs 399 Cognitive Assessment 399