A mental state examination should screen for depression, severe psychiatric illness and suicidal risk. It should be easily achieved during a 10-minute consultation.
- Assess appearance and behaviour, in particular:
- The patient's clothing- a neglected appearance may indicate depression, dementia or schizophrenia. Brightly coloured clothing may indicate mania; if dull, it often indicates depression. Patients with schizophrenia or dementia may dress strangely.
- The patient's social interaction - it is increased in mania, while psychomotor retardation, meaning reducing movements, is seen in depression. A lack of expression of emotion – blunting of affect – is seen in schizophrenia.
- The patient's movements – they may be increased in anxiety, agitated in depression or mania and decreased in depression or Parkinson's disease. They may be unexpected in response to hallucinations.
- Face and posture – depressed patients may have furrowed brows, poor eye contact and down-turned corners of the mouth.
- Weight – find out if the patient has lost or gained weight.
- Observe the patient's speech:
- Slow, monotonous speech with long pauses is characteristic or depression.
- Loud and voluble speech, possibly expressing fights of ideas, is characteristic of mania.
- Speech in response to someone who is not present in the room and strange use of words may indicate schizophrenia.
- Ask about mood - low mood, low energy, and inability to enjoy normal activities are important for the diagnosis of depression. Ask about anxiety symptoms and symptoms of mania: elevated mood, excessive self-confidence, inflated sense of one's abilities, extravagant plans and irritability.
- Ask about symptoms associated with depression, including: insomnia, poor appetite and loss of weight, poor libido, irregular periods, poor concentration and memory, feelings of guilt, pessimism and hopelessness and low self-esteem.
- Assess each patient's suicidal risk. The risk of self-harm may be increased if the patient is pessimistic or expresses hopelessness or has no social support, if there is a history of self-harm, or if he or she was discharged from a psychiatric hospital in the last year. Ask: "Are things so bad at the moment that you've thought about ending your life?" "Do you think there is a real chance that you would attempt this?" "Have you made preparations? These include writing a will or letter, giving away assets, or obtaining the means of killing him-or herself. Ask: "What has stopped you from killing yourself so far?"
- Try to obtain an idea of the patient's thought content. A delusion is a fixed idea that is unshakeable and inappropriate to the patient's society, community or religion. Grandiose delusions are seen in mania, schizophrenia and some organic disease. Ask the patient: "Do you have any exceptional talents or any special powers?" "Are you famous or related to someone famous?" Delusions of guilt can be seen in depression; ask: "Do you blame yourself for anything? Do you deserve punishment?" Hallucinations – perceptions without an object - can be present in most psychiatric disorders, and especially organic disorders. Schizophrenia and mania have no path gnomic symptoms – the total clinical picture makes the diagnosis.
- Ask about first rank symptoms, which are particularly associated with schizophrenia. They include:
- Voices – thoughts repeated, or third-person auditory hallucinations: "Now he's doing this, now he's doing that."
- Thoughts – withdrawal/block thought insertion, or thought broadcasting. The patient might say that thoughts have been "put into my head" or "taken out of my head". "Ask: "Do other people know your thoughts?
- External agency – the belief that someone else is deciding feelings, actions, impulses, or sensations. Ask: "Are you controlled by some external force?"
- Delusional perception – in which the patients reports a delusional significance for a normal perception.
- Ask bout obsess ional phenomena, which may include:
- Thoughts – there muse be some element of resistance.
Ask: "Do any thoughts keep coming into your mind even though you try hard not to have them?
- Repetitive actions – ask: "Do you have to do things over and over again which most people would only do once?" "Do you repeat activities many times in exactly the same way?"
- Try to discover if the patient has any eating disorders – ask about body image, weight and diet if you suspect that they have such a disorder.
- Perform a brief cognitive screen, such as the mini mental state score, in elderly patients or anyone whom you suspect of having an organic illness.
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