Topics on exams

PSYCHOANALYTIC THEORY AND

DEFENCE MECHANISMS

• PSYCHOANALYTIC THEORY IS BASED

ON FREUD’S CONCEPT THAT THE

BEHAVIOR IS DETERMINED BY FORCES

DERIVED FROM UNCONSCIOUS

MENTAL PROCESSES.

• PSYCHOANALYSIS AND RELATED

THERAPIES ARE BASED ON THIS

CONCEPT.

FREUD’S THEORY OF MIND

• TO EXPLAIN HIS IDEAS FREUD ,FREUD

DEVELOPED , THE TOPOGRAPHIC AND

STRUCTURAL THEORY OF MIND.

TOPOGRAPHIC THEORY OF THE MIND

• IN THE TOPOGRAPHIC THEORY, THE MIND

CONSISTS OF THREE LEVELS: THE UNCONSCIOUS,

PRECONSCIOUS AND CONSCIOUS.

• THE UNCONSCIOUS MIND:

– CONTAINS REPRESSED THOUGHTS AND

FEELINGS WHICH ARE NOT AVALIBLE TO

CONCIOUS MIND AND USES PRIMARY PROCESS

OF THINKING

– THE PRIMARY PROCESS IS TYPE OF THINKING

ASSOCIATED WITH PRIMITIVE DRIVE, WISH

FULFILLMENT AND PLEASURE SEEKING AND HAS

NO LOGIC AND CONCEPT OF TIME.

– PRIMARY PROCESS THINKING IS SEEN IN

CHILDRENS AND PSYCHOTIC ADULTS.

– DREAMS REPRESENT GRATIFICATION OF

UNCONCIOUS INSTINCTIVE IMPULSES AND WISH

FULFILLMENT.

• THE PRECONSCIOUS MIND:

– CONTAINS MEMORIES THAT ARE NOT IMMEDIATELY

AVALIBLE BUT CAN BE EASILY ACCESSED.

• THE CONSCIOUS MIND:

– CONTAINS THOUGHTS THAT PERSON IS CURRENTLY

AWARE OF

– IT WORKS IN CLOSE COMMUNICATION WITH THE

PRECONCIOUS MIND BUT DOES NOT HAVE ACCESS

TO UNCONCIOUS MIND.

– THE CONCIOUS MIND USES SECONDARY THINKING

PROCESS WHICH IS LOGICAL, MATURE AND TIME

ORIENTED AND CAN DELAY GRATIFICATION.

FREUD’S STRUCTURAL THEORY OF MIND

IN STRUCTURAL THEORY, MIND CONSISTS

OF THREE PARTS: THE ID, THE EGO AND

SUPEREGO.

• ID:

– WORKS AT UNCONSCIOUS LEVEL

– PRESENT AT BIRTH

– CONTAINS INSTINCTIVE SEXUAL AND AGGRESSIVE

DRIVES

– CONTROLLED BY PRIMARY PROCESS OF THINKING

– NOT INFLUENCED BY EXTERNAL REALITIES.

• EGO:

– WORKS AT UNCONSCIOUS, PRECONSCIOUS AND CONSCIOUS

LEVEL

– BEGINS TO DEVELOP IMMEDIATELY AFTER BIRTH

– CONTROLS THE EXPRESSION OF ID TO ADAPT TO THE

REQUIREMENTS OF THE EXTERNAL WORLD PRIMARILY BY USE

OF THE DEFENSE MECHANISMS

– ENABLES ONE TO SUSTAIN SATISFYING INTERPERSONAL

RELATIONSHIP

– THOUGHT REALITY TESTING, THAT IS , CONSTANTLY

EVALUATING WHAT IS VALID AND THEN ADAPTING THAT TO

REALITY,ENABLES ONE TO MAINTAIN A SENSE OF REALITY

ABOUT THE BODY AND THE EXTERNAL WORLD.

• SUPEREGO:

– WORKS AT UNCONSCIOUS, PRECONSCIOUS AND CONSCIOUS

LEVEL

– DEVELOPED BY THE AGE 6

– ASSOCIATED WITH MORAL VALUES AND CONSCIENCE

– CONTROLS THE EXPRESSION OF ID.

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Differentiate between amnesia: i.e. mini status examination

A psychiatric “physical exam”

and cognitive assessment

Mental Status Examination

Introduction to Mental Status

• Almost all psychiatric diagnoses are

made clinicaclinically

– i.e. from taking a history, making

observations during the interview, etc.

– Not solely from laboratory values, virology

reports, or imaging studies

Mental Status Examination

• Can be divided into 2 sections:

– 1. Observational Data

• Most areas assessed while taking a

history

– 2. Formal Cognitive Testing: MMSE

(Mini-Mental State Exam), etc.

• Requires more formal assessment thru

use of cognitive screening tools

KEY POINT: MSE ≠ MMSE

• The Mental Status Exam (MSE) is the

whole shebang, and includes ALL of the

observations made during an interview,

such as the formal cognitive testing, or

Mini-Mental-State-Exam

• Thus, the MMSE is part of, but not

synonymous with the MSE

What Should You Observe?

The Mental Status ExaminatioThe Mental Status Examination

Anything and Everything…

• All aspects of the interviewee are

subject to scrutiny

– Body odors

– Unusual movements

– Grooming/dress abnormalities

– The kind of stuff that might be tactfully

avoided in social situations

What You’ll Want to Observe:

• Appearance

• Behavior

• Cooperation/ Attitude

• Speech

• Thought Process/Form

• Thought Content

What You’ll Want to Observe:

• Perceptions

• Mood and Affect

• Insight and Judgment

• Cognitive Functioning and Sensorium

Appearance: the “lingo”

• Apparent Age-

• Attire

• Hygiene and Grooming

– “Disheveled”- ruffled appearance

– “Unkempt”- poor attention to grooming

Appearance

• Body habitus, nourishment status

– General description of body type/build and

nutritional status

Behavior- Movements

• Range and Frequency of Spontaneous

Movements

– Psychomotor activity

– Abnormal movements

“Psycho-what”?

• Psychomotor refers to

movements that appear driven

from within, by one’s internal

emotions at the time

– Psychomotor Agitation, vs.

– Psychomotor Retardation

Psychomotor Agitation defined

• Physical restlessness, usually with a

heightened sense of tension and

increased arousal

• Results from inner feelings of anxiety,

restlessness, anger, confusion, etc.

• Common Signs include: hand-wringing,

fidgeting, frequent shifts in posture,

foot-tapping, complaints of

“restlessness”

Psychomotor Retardation

• An overall slowness of voluntary and

involuntary movements

– Results from emotions such as apathy,

depression, etc.

Abnormal Movements

• Mannerisms: goal-directed,

complex behaviors carried out in

an odd or exaggerated fashion

Abnormal Movements

• Tardive Dyskinesia (TD)-

involuntary choreoathetoid movements

of delayed onset, resulting from

chronic antipsychotic administration

– Choreiform movements are jerky,

spasmodic, usually in face and arms

– Athetoid movements are slow, writhing

(like a snake), in distal extremities

Abnormal Movements

• Compulsions- repetitive

behaviors (or mental acts) the

person feels compelled to perform

in response to an obsession or

according to rigid rules

– Stereotyped (repeated over and over)

– Ritualistic (always done the same way)

– Ex. Checking, counting, touching,

arranging things, confessing, washing

Abnormal Movements

• Tics- involuntary, sudden,

recurrent, stereotyped (repeated

over and over) movements or

vocalizations

– Very brief (one second)

– Simple Tics: Blinking, twitches,

coughing, humming, throat clearing

– Complex Tics: Smelling objects,

coprolalia

Abnormal Movements

• Catatonia- diverse group of postural

and movement disturbances in which

individual is unresponsive to the

environment

Catatonic Behaviors

• Catatonic stupor: immobility and

mutism

VS.

• Catatonic excitement: excessive and

aimless motor activity

Catatonic Behaviors

• Catatonic rigidity: patient assumes

fixed posture, resisting efforts to move

• Echolalia: repeating others’ speech

More Catatonic Behaviors

• Catalepsy (waxy flexibility): patient

assumes and maintains often awkward

postures positioned by the examiner

Cooperation/ Attitude

• Attitude/Relatedness

• Eye contact

• Level of Alertness/ Attentiveness

– Easily distracted, hypervigilant (constantly

scanning the environment)

Speech

• The mechanical (motor) qualities of

verbal expression

• Speech refers to ALL forms of

verbal expression, including

utterances, words, phrases,

sentences

Qualities of Speech

• Quantity/Amount

– Normal = “Spontaneous, fluent”

– Slurred

– Too much

– Too little = “Paucity of speech,

impoverished”

– None = mutism (absence of speech)

Qualities of Speech

• Articulation- clarity with which words

are spoken

– dysarthric (poorly articulated speech)

• Rate

– Ex: “Pressured”: increased rate (and

amount); driven to keep talking;

uninterruptible

Prosody

• The emotional or affective components

of speech; adds emphasis, maintains

listener’s interest

Speech Abnormalities

• Neologisms- made up words that

have unique meaning to the patient,

i.e. idiosyncratic

• Circumlocution- “beating around the

bush”; a description is given instead of

the item itself

Speech

• Speech is an observable representation

of one’s internal thought processes...

Thought Process/ Form

• How ideas are put together, organized,

and ultimately produced (as speech)

• Assessed via speech, writing, and

behavior

• Thus, there is considerable overlap

between speech and thought process

Thought Process Parameters

• Goal-directedness- is there an “end

to the means?”, “any point to the

story?”

• Continuity: tightness of associations

between topics

• Productivity: rate/flow of ideas

• Use of language (are there

idiosyncracies)

• Capacity for abstraction

What’s a “Normal” Thought Process?

• Linear

• Logical

• Goal-directed

Some Key Terms

• Neologisms: Made up words that have

unique (idiosyncratic) meaning to the

patient

• Idiosyncracies: Private use of words;

understanding is unique to the patient

• Clang Associations: Primitive

connections made based on sounds- ex.

Rhyming, punning, etc.

Normal Variants or Pathological

• Circumstantiality- overly detailed;

over-inclusive; (can be normal variant)

• Tangentiality- starts out in general

vicinity of goal /target, but never

reaches; (can be normal variant but

more often a sign of pathology)

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Abnormal Thought Processes:

Flight of Ideas

• Non-goal directed

• Abrupt topic changes

• Ideas weakly linked by primitive

associations such as rhyming, and

punning

• Has a rapid quality

Abnormal Thought Processes

• Loose Associations- Loss of

meaningful connections between ideas.

Word Salad

• Word salad- extreme form of loosened

associations; words have no connection

Abnormal Thought Processes

• Thought Blocking- Sudden,

involuntary interruption in thought (and

speech); often described as having idea

removed or losing the train of thought

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Abnormal Thought Processes:

Perseveration

• Persistent repetition of the same

response to new and unrelated stimuli

• Can be repetition of behavior/s too;

• Inability to shift sets

Thought Content

What’s on your mind?

Thought Content (TC)

• Refers to predominant themes,

preoccupations

• Some elements of thought content are

readily volunteered... while others are

not

Normal vs. Abnormal TC

• Normal = absence of abnormalities

• Abnormal:

– Overvalued ideas

– Delusions

– Obsessions/ Compulsions (mental)

– Suicidal /Homicidal Ideations

– Phobias

12

17

Mood and Affect

How they describe emotional

state vs. what you see

Mood

• Mood: internal emotional tone; a

pervasive and sustained tone that colors

the person’s perception of the world

– Ex. “happy”, “angry”, “nervous”, “fine”

Affect

• Observable, external expression of

emotional tone

– Parameters include:

• Range

• Reactivity

• Intensity

• Variability/Modulation

• Congruence/Appropriateness

Insight and Judgment

• Insight- understanding and

appreciation of current situation, illness

• Judgment- ability to make sound

decisions; best assessed via recent

history

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Mental Status Examination

(MSE)

Basic Components

• Physical appearance

• Arousal and attention

• Psychomotor activity

• Speech

• Mood

• Affect

• Memory

• Thought processes

• Thought content

Physical Appearance

• Signs of physical illness

• patient dressed appropriately

• Patient’s grooming

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Arousal and Attention

• Is the patient hyper alert, alert,

lethargic, stuporous or comatose?

• If patient can focus & sustain attention

on questions or tasks.

• Test:

– SERIAL SEVEN: Ask the patient to perform

sequential subtractions.

Memory and Cognition

• Immediate memory:

– Tested by Digit Span: pt is given randomly

seven digit and ask to repeat, ie, telephone

no.

• Recent memory:

– Orientation test: degree of orientation to

correct time, date and place

– Three object in five minutes: assign three

objects and ask about them in five minutes.

• Long term memory:

– Demographic information

– Pts name, D.O.B, names of family members, address,

etc.

• Language: ask pt to name objects in the room

or by pts comprehension of spoken or written

instructions.

• Recognition: if pt can recognize familiar objects

• Complex motor behavior: ask the pt to

demonstrate tying shoe laces or preparing

food.

• Ability to plan and execute: ask pt to describe

steps in planning shopping or mailing a letter.

MINI MENTAL STATUS

EXAMINATION (MMSE)

FOLSTEIN MMSE

21

Mini-Mental State Examination ( MMSE

)

• A brief instrument designed to grossly

assess cognitive functioning.

• It assesses orientation, memory,

calculations, reading and writing capacity,

Visio spatial ability, and language.

• The patient is measured quantitatively on

these functions; a perfect score is 30 points.

• A score less than 24 indicate probable

cognitive and less than 17 of definite

cognitive deficit.

• The MMSE is widely used as a simple, quick

assessment of possible cognitive deficits.

components

• Orientation

• Registration

• Attention and calculation

• Recall

• Language

ORIENTATION

• What is the…..Time, date, day, month,

year. 5pts

• Where are we…. Country, state, city,

hospital, floor or department

5pts

Registration

• Name three objects in the room and

ask the pt to repeat them

3pts

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Attention and calculation

• Tested by serial seven

• Stop after 5 answers

• Or can give a five letter word and ask

them to spell backward

5pts

Recall

• Ask about three objects used for

registration 3pts

Language

• Name to common objects 2 pts

( pen or watch)

• Accurate repetition of a phrase 1 pt

‘no ifs, ands or buts”

• Follow three stage command 3pts

• Read and obey 1 pt

• Write a sentence 1 pt

• Copy a design 1 pt

Total = 30

23

Scoring'>Folstein Mini Mental Status Examination

Task Instructions Scoring

Date

Orientation "Tell me the date?" One point each for year, season, date, day

of week, and month 5

Place

Orientation "Where are you?" One point each for state, county, town,

building, and floor or room 5

Register 3

Objects Name three objects slowly and clearly. Ask the patient to repeat them. One point for each item correctly repeated 3

Serial Sevens Ask the patient to count backwards from 100 by 7. Stop after five answers.

(Or ask them to spell "world" backwards.)

One point for each correct answer (or

letter) 5

Recall 3

Objects Ask the patient to recall the objects mentioned above. One point for each item correctly

remembered 3

Naming Point to your watch and ask the patient "what is this?" Repeat with a pencil. One point for each correct answer 2

Repeating a

Phrase Ask the patient to say "no ifs, ands, or buts." One point if successful on first try 1

Verbal

Commands

Give the patient a plain piece of paper and say "Take this paper in your right

hand, fold it in half, and put it on the floor." One point for each correct action 3

Written

Commands

Show the patient a piece of paper with "CLOSE YOUR EYES" printed on

it. One point if the patient's eyes close 1

Writing Ask the patient to write a sentence. One point if sentence has a subject, a verb,

and makes sense 1

Drawing

Ask the patient to copy a pair of intersecting pentagons

onto a piece of paper. One point if the figure has ten corners and

two intersecting lines 1

Scoring A score of 24 or above is considered normal. 30

Mental Status Examination

(MSE)

Basic Components

Physical appearance

Arousal and attention

Psychomotor activity

Speech

Mood

Affect

Memory

Thought processes

Thought content

Physical Appearance

Signs of physical illness

patient dressed appropriately

Patient’s grooming

Arousal and Attention

Is the patient hyper alert, alert, lethargic,

stuporous or comatose?

If patient can focus & sustain attention on

questions or tasks.

Test:

– SERIAL SEVEN: Ask the patient to perform

sequential subtractions.

Psychomotor Activity

Quantity: increased, normal or deceased

Quality:

– appropriate or inappropriate

– Any focal deficit, incoordination or abnormal

movements.

Test:

– HANDSHAKE TEST: gives you coordination,

motor strength & abnormal movements.

Speech

coordination: clear or slurred

Quantity: is the speech pressured ( fast),

normal, dysarthric?

Thought processing: is the speech

coherent or incoherent

Intelligence: is the vocabulary in native

language superior, normal or

impoverished.

Mood

Mood is inferred by level of psychomotor

activity, self report and facial expressions?

Describe id the mood is euphoric,

depressed, irritable, anxious or neutral?

Affect

Affect is the moment to moment modulation of

psychomotor activity, as revealed by

psychomotor activity, facial expression, voice

intonation and fine motor activity.

Quality: appropriate or inappropriate

Range: is the patient affect is flat, blunted,

normal or labile?

Intensity: is the affect is bland (unconcerned),

normal or constricted ( intense)

Memory and Cognition

Immediate memory:

– Tested by Digit Span: pt is given randomly

seven digit and ask to repeat, ie, telephone

no.

Recent memory:

– Orientation test: degree of orientation to

correct time, date and place

– Three object in five minutes: assign three

objects and ask about them in five minutes.

Long term memory:

– Demographic information

– Pts name, D.O.B, names of family members, address,

etc.

Language: ask pt to name objects in the room or

by pts comprehension of spoken or written

instructions.

Recognition: if pt can recognize familiar objects

Complex motor behavior: ask the pt to

demonstrate tying shoe laces or preparing food.

Ability to plan and execute: ask pt to describe

steps in planning shopping or mailing a letter.

Thought processes

Thought can be divided into process ( or form ),

and content.

Process refers to the way in which a person

puts together ideas and associations, the form in

which a person thinks. Process or form of

thought may be logical and coherent or

completely illogical and even incomprehensible.

Content refers to what a person is actually

thinking about: ideas, beliefs, preoccupations,

obsessions

Process (or Form) of Thought

Loosening of associations or derailment

Flight of ideas

Racing thoughts

Tangentiality

Circumstantiality

Word salad or incoherence

Neologisms

Clang associations

Punning

Thought blocking

Vague thought

Thought Process ( Form of

Thinking ).

flight of ideas: rapid thinking carried to the extreme

loose associations: the ideas expressed appear to be

unrelated and idiosyncratically connected

Blocking: an interruption of the train of thought before an

idea has been completed

Circumstantiality: in the process of explaining an idea,

the patient brings in many irrelevant details and

parenthetical comments but eventually does get back to

the original point.

Tangentiality: a disturbance in which the patient

loses the thread of the conversation and pursues

tangential thoughts stimulated by various external or

internal irrelevant stimuli and never returns to the

original point

clang associations (association by rhyming )

punning ( association by double meaning )

neologisms ( new words created by the patient

through the combination or condensation of other

words )

Content of Thought

Delusions

Paranoia

Preoccupations

Obsessions and compulsions

Phobias

Suicidal or homicidal ideas

Ideas of reference and influence

Poverty of content

Thought Content.

Delusions—fixed, false beliefs out of keeping

with the patient's cultural background—may be

mood congruent ( in keeping with a depressed

or elated mood ), or mood incongruent.

Delusions may have themes that are

persecutory or paranoid, grandiose, jealous,

somatic, guilty, nihilistic, or erotic. Ideas of

reference and of influence should also be

described.

Examples of ideas of reference

include a person's belief that the television

or radio is speaking to or about him or her.

Examples of ideas of influence are

beliefs about another person or force

controlling some aspect of a person's

behavior.

MINI MENTAL STATUS

EXAMINATION (MMSE)

FOLSTEIN MMSE

Mini-Mental State Examination

( MMSE )

A brief instrument designed to grossly assess

cognitive functioning.

It assesses orientation, memory, calculations,

reading and writing capacity, Visio spatial ability,

and language.

The patient is measured quantitatively on these

functions; a perfect score is 30 points.

A score less than 24 indicate probable cognitive

and less than 17 of definite cognitive deficit.

The MMSE is widely used as a simple, quick

assessment of possible cognitive deficits.

components

Orientation

Registration

Attention and calculation

Recall

Language

ORIENTATION

What is the…..Time, date, day, month,

year. 5pts

Where are we…. Country, state, city,

hospital, floor or department 5pts

Registration

Name three objects in the room and ask

the pt to repeat them 3pts

Attention and calculation

Tested by serial seven

Stop after 5 answers

Or can give a five letter word and ask

them to spell backward

5pts

Recall

Ask about three objects used for

registration 3pts

Language

Name to common objects 2 pts

( pen or watch)

Accurate repetition of a phrase 1 pt

‘no ifs, ands or buts”

Follow three stage command 3pts

Read and obey 1 pt

Write a sentence 1 pt

Copy a design 1 pt

Total = 30 points