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In psychiatric practice it is imperative to clinically evaluate a person in a planned manner by observing and describing the psychological functioning of the patient at given point of time, under the domains like appearance of the patient, their attitude, behavior, mood, thought content, speech, thought process, insight or perception, cognition or reasoning,judgmentetc. Mental status examination is an area of primary expertise of a qualified mental health professional. The purpose is to obtain evidence of signs and symptoms of mental illness or disorders, along with any possible threats to oneself and others.
Thought Form Thought Content And Interpreting Disturbed Thoughts
A person’s mental state can be assessed based on the content of their thoughts or the nature of one’s thoughts. In MSE thought process denotes the tempoand logical soundness of thoughts as it cannot be quantified by the observer, rather it can only be narrated by the patient, or it may be incident from a patient's speech. Tempo refers to the rate at which the thoughts flow, regarding which some people may experience rapid thoughts that are referred to as flight of ideas and typically suggests obsession. In such people the speech may become incoherent, although on careful observation one can detect a chain of rhythmical associations in the speech of patient. Alternatively an individual may have retarded or repressed thinking, where the thoughts give the impression to progressing slowly with barely few suggestions. Scarceness of thought relates to comprehensive decline in the amount of thought.
A disruption or interrupted thought process is widely referred to as formal thought disorder or even as thought blocking, lack of association, divergent thinking or derailment of thoughts. Patient may contain unrealistic facts that may be described as circumstantial and the patient may get diverted frequently, but still may remain focused on the subject. On the other hand patients with depression represented inhibited thought process. Lack of thoughts can be seen as one of the symptoms in schizophrenic, in cases of dementia or other disorders with severe depression.
The term ‘thoughtcontent’ refers to a well- organized way of perceiving or discerning and describing patient’s psychological functioning at a particular instance. An evaluation of the thought content would define patient’s delusions, i.e., the rigidly supposed false dogmas that may not be congruent when compared to the person’s context. It may also describe other aspects of patient’s thought process such as they can have unreasonable beliefs for e.g., a person who is anorexic may strongly believe that they are fat. They also may have phobias and preoccupations, depressing thoughts or a tendency towards self- inflicted harm, thoughts of suicide, aggressive thoughts or of homicidal nature. Inconsistent thought content can be recognized by exploring a person's beliefs in an unrestricted conversational mode with respect to the intensity and the sentiments accompanying the thoughts, the extent to which the one’s own thoughts are acknowledged as under one's control and the extent of conviction concomitant with the thoughts.
In the given case scenario, Annabelle presents with a state of disruption of conscious thoughts, a lack of orientation to the real world, her judgment is impaired, she has isolated herself from the rest of the world and spends most of her time alone in her room, and also she has a disturbed understanding related to handling herself. She has an altered perception and cognition that now interferes with her daily living. She has been ignoring her health and has lost too much of weight, has been avoiding food or adequate fluid intake and has not been sleeping well too. She represents with disturbed thought process as she is delusional, disoriented and confused, she now has frequent hallucinations, and she is impulsive, gets distracted by small noises and is always suspicious.
Perception And Interpretation Of Disturbance In One Or More Senses
Perception refers to sensory experience, is associated with consolidating, identifying and inferring the interpretation of sensory information to exemplify and comprehend the existing facts, or surroundings. All the perceptions are sensory, involving nervous system that stimulated the sensory system via physical and chemical stimuli. Perception is not just the submissive reception of such signals but it rather is molded of the memory, anticipation and attention of the patient. It can be divided into two processes, first is the processing the sensory input, that converts the a low level information into a higher one and second the processing which is associated with the notions and expectations of a person and discerning mechanisms that affect the perception of the person. The processing takes place away from the conscious awareness. Disturbances in these sensory stimulations are considered as disturbed perceptions. These disturbances have been divided into three broad types, hallucinations, pseudo hallucinations and illusions. Hallucinations are sensory perceptions that occur in absence of an external stimuli and can be experienced in an objective or external space, and thus perceived as real by the patient on the other hand, illusion is the term used for deceitful sensory perception when an external stimulus is present, and results from distorted sensory experience and is perceived by the patient in similar way. The pseudo hallucination can be a sensory experience in internal or subjective space where the patients reports of ‘voices in my head’ and is observed as analogous to fiction. Apart from these the abnormalities of perception may include distortion of sense of time, having frequentdéjà vudue temporal lobe epilepsy that results in distortion of a sense of self and the sense of real world, these are known as depersonalization and de-realization respectively. Hallucinations can occur in any of the senses but visual and auditory are encountered more frequently as seen in the case of Annabelle, as she the things she saw and heard did not exist in the real world and were reported by her as if they were real. Besides these she is also having tactile hallucinations as she keeps pinching the sores in her hand and that something was under her skin and in her veins. The auditory hallucinations she has are typical of psychosis as she hears voices talking to her which are suggestive schizophrenia.
She presented with characteristic features of disturbed sensory perceptions like lack of concentration, restlessness, altered response to normal stimuli like physical contact, irritability, disorientation to time place and people and change in behavior pattern that was wayward from normal she was restless initially and then started screaming and crying at the end. Her body movements were abnormal as she kept wringing her hands as if she was in constant danger, her facial expressions were not normal or relaxed rather she was distressed. She was unable to understand the purpose of her visit and also she had no sense of place, she was confused, frightened and had auditory, visual as well as tactile distortions suggestive of disturbed sensory perception.
Affect And Mood And The Range And Intensity Of Affect
Affect is an instantaneously conveyed and perceived feeling. A feeling becomes an affect when it is noticeable like in cases of modulation or change of voice. It should be differentiated from the mood that is associated with persistent and ubiquitous emotions like sadness and euphoria. A person’s affect is defined as the expression of feelings or emotions that are expressed to others via facial expressions, hand gestures, laughing, crying, tone of one’s voice, etc. a normal range of affect is known as the broad affect that may differ in people from different ethnicity and even with the ethnic group. Some people may present with dramatic facial expressions in response to a social condition or any stimulus while others may show a bit of outward behavior to the social interactions.
Mood is an inescapable and constant emotion that in the extreme, distinctly ensigns a person’s perception of the surrounding environment or the world. Mood corresponds to affect in the similar way as climate corresponds to weather. Mood and affect are related but at times they differ from one another in terms of the stability of pattern over time. Affect usually is less stable and more often fluctuates whereas mood is a constant emotional state. Contrary to affect mood is not always noticeable and needs to be reported.
Patients with psychological disorders at times show variations in their affect, which can be a restricted one or a blunted one. The range of affect is subjected to the variation in expressions of emotions observed in a clinical session. The restricted or constricted affect refers to the display of feelings that are mildly restricted in range and intensity. As this reduction becomes more intense or severe the blunted type of restriction may be observed. In case exhibition of any emotions is absent it may be called as a flat affect in which the voice is monotonous, the patient has expressionless face and the body is stiff and immobile. Apart from this there is a labile affect that displays emotional instability or altering moods that may be dramatic. In case of Annabelle her display of emotions were disturbed as it was way out of the context at times, as she giggled while describing sadness. Such affect are termed as inappropriate.
On the other hand, mood disorders contain a variety of disorders that display as serious change in mood, these include, major depressions, bipolar disorders that includes mania, over inflated ego, unrealistic behavior. The mood disorders in Annabelle can be categorized as depression and bipolar disorder, as at a time she was happy and laughing and at other instance she cried and sobbed and was extremely sad not caused by any of physical stimuli. Her mood states suggested a state of Dysphonic presentation as she had sustained emotional state showing anxiety, sadness and irritability. The intensity of affect in Annabelle was overly dramatic displaying extreme sadness, while the range was of restricted range of affect as she presented only limited emotional expression.
Behavior And Appearance As Set Out In Mse.
The key element of examining a patient at initial psychiatric assessment in out-patient setting is observing the appearance and behavior of the patient. The appearance and behavior of a person reveals the psychiatric disorder underneath. The clinician can assess the appearance of the patient based on the physical appearance these include age, weight, height, health, dressing and grooming style, Use of colors in clothing, status of self-health care, accessories, etc. Such as for Annabelle, as she appeared in the ED she was dressed in a dirty jeans, t-shirt and was barefooted. Her hair was shabby, matted and dyed in blue and pink and she had multiple piercings suggesting schizophrenia or depression. Physical appearances may also help assess presence of any drug abuse or alcoholism apart from malnutrition. Severe loss of weight may suggest depressive disorders, anorexia, chronic illness or chronic anxiety. For example, the history has suggested that the patient has been ignoring her health and has been suffering from malnutrition because of poor intake of food and fluids. She also shows abnormal behavior as she is instantly and highly responsive to any sounds or movements in the ED that draws her attention.
Recording the behavior of the patient also include recoding the abnormal movements if present like athetoid movements often indicate neurological symptoms. In the presented scenario Annabelle shows abnormal movements as she keeps wringing her hands and behaving as if she was in constant danger. Also movements like tremors may indicate adverse effects from antipsychotic drugs whereas presence of involuntary movements may present symptoms of syndromes. On the other hand inability to sit still may also suggest behavioral disturbances. A generalized increase in arousal i.e., hyperactivity, may reflect mania or a decrease in arousal can indicate a condition of dementia or Parkinson’s disease. For example in this case, Annabelle is unable to sit still and keeps pacing up and down in the corridor that may suggest of akathisia, which is a side effect of antipsychotic medicines.
An examination of the eye movements suggests the emotional state and suggests of any hallucination being experienced by the patient. She also avoids eye contact and keeps staring at the ceiling suggesting depression, she keeps glancing repeatedly at the ceiling indicating that she is having hallucinations. She is not cooperative, as she hesitates before entering the cubicle and she is not in relaxed state and is hostile. When explained why she is here she is incapable of thinking abstractly or lacks concrete thinking and does not pay any attention to the interviewer or subject of interview. She lacks thought cohesiveness, feels that all around her environment is unreal, does not follow or respond to what her mother or the interviewer says.
The information attained by MSE assists in generating a diagnosis, psychiatric formulation and treatment planning based on the factual and social facts obtained from the patient. In the given case scenario Annabelle presents with signs and symptoms indicating schizophrenia, for which proper health care assistance needs to be provided. The expected outcome will be that Annabelle is mentally stable, relaxed, feels connected to the real world and has good social life.
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