Nervous System

Higher mental functions:

Cranial nerves:

Sensory system:

Motor system:

Reflexes:

Cerebellar system:

Meningeal signs:

A.

B.

C.

D.

•

DIAGNOSIS FORMAT

Axis I:

Clinical syndromes and physical diagnosis.

Axis II:

Disabilities ( disabilities range from normal to complete loss of function;

where normal is given grade of 1 and loss of function grade 4):

Personal:

Occupational:

Family:

Social:

Total duration:

Current duration:

Axis III:

Environmental/circumstantial and personal lifestyle/life management

factors.

Examples

Example 1:

Axis I:

Bipolar affective disorder, current episode mania without psychotic

symptoms, and hypertension.

Axis II:

Total duration of illness 5 years current episode 1 week

A3B2C2D2.

AXIS III:

Family history of other mental and behavioral disorders.

Example 2:

Axis I:

Paranoid schizophrenia episodic with stable deficit and diabetes mellitus.

•

Axis II:

Total duration of illness 8 years current duration 1 month.

A3B2C2D4.

Axis III:

Problems in relationship with spouse or partner.

–

–

–

–

–

–

–

i.

ii.

iii.

iv.

v.

vi.

vii.

viii.

ix.

DISCUSSION ON EXAMINATION

MENTAL STATUS EXAMINATION

I. General details of examination:

Language of interview:

Use of interpreter: Y/N

Time taken for interview:

Date and time:

Describe explicitly the observations (e.g. behavior, mental phenomena

on tests, etc.) that are interpreted as clinical signs and symptoms.

II. Consciousness, rapport, and general behaviors:

Consciousness Level and stability. If the subject is not fully alert,

mention amount of stimulation needed for arousal and duration of

time patient can maintain attention.

Rapport:

General appearance and behavior (described as follows):

Appearance and appropriateness of the situation, personal

cleanliness

Body build [record body mass index (BMI)]

Handedness

Grooming: Note whether patient is well-groomed or has poor

hygiene

Facial expression and posture

Otto Veraguth sign: Increased forehead marking seen in

depression

Signs of anxiety: Excess perspiration and tensed voice

Attitude towards examiner

(cooperative/guarded/playful/hostile/agitated, etc.)

Motor behavior (describe under following qualities—rate or

speed, purposiveness, goal-directedness, response to

command, environmental stimuli, and repetitiveness)

x.

i.

ii.

iii.

iv.

a.

b.

Arousal—determine the level of consciousness (especially in

case of delirium).

III. Cognitive status:

Attention and concentration:

(Assessed by clinical behavior of patient and by asking the patient

to count backwards, e.g. counting 100 minus 7 consecutively (or)

calling out months of year or days of the week in backwards

fashion.)

Language functions:

(Neurological aspects—comment on phonation, articulation,

comprehension (give a three stage command, e.g. “place index

finger of right hand on your nose and then on your left ear”),

naming (name a pencil and watch), repetition (repeat “No ifs,

ands, or buts”), reading (ask patient to read and obey a written

command on a piece of paper stating “Close your eyes”), writing

(ask the patient to write a sentence. Assess if it is sensible and

has a subject and a verb.)

Orientation:

(Assess by clinical behavior. Time—day, date, week, month, year;

place—room, hospital, city, etc.; person—self and others)

Memory:

(Examiner names three objects (e.g. apple, table, and penny).

Patient asked to repeat them, later asked for names of three

objects learned earlier.

IV. Thought:

Speech:

Assess fluency and speed (e.g. slow/retarded speech in depression

and word-finding difficulty).

Thought abnormalities:

Thought formation:

Is the speech coherent? Or is there loosening of association?

(Suggests schizophrenia).

Thought possession:

Ask the patient if the thoughts are his own or if it is controlled by

external source. It can be:

c.

•

•

•

•

•

•

•

•

•

•

•

Thought insertion Someone else’s thoughts are being put in one’s mind

Thought withdrawal One’s thoughts are being removed from one’s mind

Thought broadcast Many people are getting to know one’s thoughts

Thought content:

Determined by asking “What are your main concerns?” Look for

presence of delusions and obsessions.

Delusions

Definition:

It is a false, unshakeable belief that is out of keeping with the patient’s social and

cultural background and is due to internal morbid process.

Types of delusion:

Persecutory (e.g. belief that others are out to harm me)

Grandiose [e.g. belief that one has special powers or status (suggests mania)]

Nihilistic (e.g. conviction that “My head is missing”, “I have no body”, and “I am

dead”)

Erotomanic delusions (e.g. believing a movie star loves them)

Somatic delusions (e.g. believing head is filled with air/worms—parasitosis)

Delusions of reference (e.g. belief that the story in a book is referring to them)

Delusions of control/passivity (e.g. believing one’s thoughts and movements are

controlled by aliens)

Other delusions are delusion of misinterpretation, hypochondriacal delusion,

delusion of jealousy, and delusion of infidelity.

Obsessions

Definition:

An obsession is a thought that persists and dominates an individual thinking despite

individual awareness beyond the point of relevance.

Types:

Theme of obsessions can be of following types:

Cleanliness: Fears of contamination

Forbidden or taboo thoughts: Aggressive, sexual, and religious obsessions

Harm (e.g. thoughts about harm on oneself or others).

V. Mood and affect:

Mood: Ask the patient how he felt in the last 1 week. Example:

Sad/happy/anxious/tensed/worried.

•

•

•

•

Affect: Assessed by observing facial expression, posture, and

movements. Example: Depressed/elated-elevated mood with excess

energy and reduced need for sleep (suggests mania), feeling guilty or

hopeless, thoughts of self-harm (suggests depression).

VI. Perception:

Observe for presence of hallucination or illusion.

Hallucination:

It is perception without external stimuli, i.e. wakeful sensory experiences

of stimuli that are not actually present. It is a disorder of thought

perception.

It can occur in any sensory modality, most common being auditory

(thought echo, command hallucination, running commentary) or visual

(e.g. seeing “visions”).

Other types include tactile (cocaine bug and phantom limb), olfactory,

and gustatory.

Pseudohallucinations are a type of mental image that, although clear

and vivid, lack the substantiality of perception and are located in

subjective space (e.g. inside the head). They are involuntary and are

seen in full consciousness.

Illusions:

In contrast to hallucinations, illusions are misperceptions of real external

stimuli (e.g. mistaking a shrub for a person in poor light).

VII. Other psychotic phenomena:

(Somatic passivity, made action/affect/impulse.)

VIII. Other phenomena:

(Depersonalization/derealization, body image disturbances, specify

negative symptoms, and other phenomena not listed above.)

IX. Insight:

(Verbatim report on the presence, nature, remedy of the problem, and

possible outcomes, i.e. awareness/attribution/acceptance of intervention

and comment on Grade I–VI of levels.)

Grading of insight

Grade I Denies illness

Grade II Ambivalent about the illness

Grade III Aware of illness but attribution is to external causes like black magic and

medical illness

Grade IV Admission of illness and recognition that symptoms or failures in social

judgment are due to irrational feelings or disturbances; without applying that

knowledge to future experience

Grade V Intellectual insight, but able to apply knowledge appropriately

Grade VI Emotional insight—fully aware of illness, consequences, and need for

appropriate treatment and can make decision to choose treatment options

DISCUSSION ON DISEASES AND DIAGNOSTIC CRITERIA

Relationship of various psychiatric illnesses has been shown in Figure

9.1.

Fig. 9.1: Relationship of various psychiatric illnesses.

Table 9.1 presents differences between psychosis and neurosis.

Table 9.1: Differences between psychosis and neurosis.

Feature Psychosis Neurosis

Contact with

reality

Lost Preserved

Interpersonal

behavior

Marked disturbance in reality

and behavior

Preserved

Empathy Absent Present

Insight Absence of understanding

current symptoms

Present symptoms are recognized

as undesirable

Symptoms Delusions, illusions and

hallucinations

Usually physical or psychic

symptoms

Dealing with

reality

Capacity is grossly reduced Preserved

Examples Schizophrenia Anxiety, phobia, depression

Mood Disorders (Fig. 9.2 and Table 9.2)

Fig. 9.2: Spectrum of mood disorders.

Table 9.2: Classification of mood disorder.

Unipolar Bipolar Mood disorders with known etiology

Major depressive

disorder

Bipolar I

disorder

Substance-induced mood disorder

Dysthymic

disorder

Bipolar II

disorder

Mood disorder due to general medical condition

Cyclothymic

disorder

Depression, mania, bipolar disorders, depressionaffect, mood, syndrome

Diagnostic criteria for manic episode

Three to four of the following criteria are required during the elevated, expansive or

irritable mood, lasting at least for 1 week.

Self-esteem Highly inflated and grandiosity

Sleep Decreased need for sleep and rested after only a few hours

Speech Pressured

•

•

•

•

•

•

Thoughts Racing thoughts and flight of ideas

Attention Easy distractibility

Activity Increased goal-directed activity

Hedonism High excess involvement in pleasurable activities (sex, spending, and travel)

Diagnostic criteria for major depressive episode

General criteria for a major depressive episode require five or more of the below

symptoms to be present for at least 2 weeks; one symptom must be depressed mood

or loss of interest or pleasure. The symptoms must also cause distress or

impairment.

Mood Depressed mood most of the day, nearly everyday (dysphoria)

Sleep Insomnia or hypersomnia

Interest Marked decrease in interest and pleasure in most activities (anhedonia)

Guilt Feelings of worthlessness or inappropriate guilt

Energy Fatigue or low energy nearly everyday

Concentration Decreased concentration or increased Indecisiveness

Appetite Increased or decreased appetite or weight gain or loss

Psychomotor Psychomotor agitation or retardation

Suicidality Recurrent thoughts of death, suicidal ideation, suicidal plan, and suicide

attempt

Psychotic Disorders

Schneider’s 11 first rank symptoms of schizophrenia

3 Thought phenomenon

Thought insertion

Thought withdrawal

Thought broadcasting

3 Made phenomenon

Made volition acts

Made feelings

Made impulse

•

•

•

•

•

•

•

•

1.

2.

3.

4.

3 Disorders of thought perception

Auditory hallucinations:

Audible thoughts

Voices arguing

Voices commenting on ones’ action

2 Special phenomenon

Somatic passivity phenomenon

Delusional perception

Negative and positive symptoms of schizophrenia

Negative symptoms Positive

symptoms

Alogia: “Lack of words”, including poverty of speech and of speech

content in response to a question

Affective flattening: Decreased expression of emotion, such as lack of

expressive gestures

Avolition-apathy:

Loss of function

Impaired concentration

Diminished social engagement

Anhedonia-asociality: Few friends, activities, interests, impaired

intimacy, little sexual interest

Attention impairment

Hallucinations

Delusions

Bizarre behavior

Conceptual

disorganization

Aggressive/agitated

Delirium

(For a definitive diagnosis, symptoms, mild or severe, should be present in each one

of the following areas)

Impairment of consciousness and attention.

Global disturbance of cognition (illusions and hallucinations—most often visual;

impairment of immediate recall and of recent memory but with relatively intact remote

memory; disorientation for time as well as, in more severe cases, for place and person).

Psychomotor disturbances (hypo- or hyperactivity and unpredictable shifts from one to

the other.

Disturbance of the sleep-wake cycle (insomnia or, in severe cases, total sleep loss or

reversal of the sleep-wake cycle; daytime drowsiness; nocturnal worsening of

symptoms).

5. Emotional disturbances, e.g. depression, anxiety or fear, irritability, euphoria or

wondering perplexity.

Table 9.3 presents differences between delirium, dementia, and

psychosis.

Table 9.3: Differences between delirium, dementia and psychosis.

Condition Onset Pattern Orientation Attention Memory Duration

Delirium Acute Fluctuating Usually

impaired

Impaired/fluctuating Impaired Hours or

days

Dementia Insidious Progressive Normal or

impaired

~Normal Impaired Months

or years

Psychosis Variable Variable ~Normal Normal or impaired Normal

or

impaired

Variable

Table 9.4 presents differences between delirium and dementia.

Table 9.4: Differences between delirium and dementia.

Features Delirium Dementia

Onset Rapid (hours to days) Gradual (years)

Course Wide fluctuations; may continue for

weeks if cause is not found

Slow but continuous decline

loss of

consciousness

(LOC)

Hyperalert to difficult to arouse Normal

Orientation Disoriented, confused Disoriented, confused

Attention Always impaired May be intact; may focus on

one thing for long periods

Sleep Always disturbed Usually normal

Behavior Agitated, restless May be agitated or apathetic;

may wonder

Memory Especially recent memory

impairment

Especially recent memory

impairment

Cognition Disordered reasoning Disordered reasoning and

calculation

1.

2.

3.

4.

5.

6.

1.

2.

3.

4.

• •