1. Psychiatric Assessment
Occupation Based Practice II:
Mental Health

2. Today’s Objectives Understand terms used in a MSE
Document observations in all MSE areas
Demonstrate how to conduct a MoCA

3. History Identifying information Chief complaint Hx of present illness
Past psy hx
Family psy and med hx
Medical hx

4. Mental Status Exam Appearance Behavior Speech Emotion
Thought process & content
Perception
Attention
Orientation
Memory
Judgment
Intelligence
Insight

5. MSE
Objective report of patient’s current mental functioning as observed
Present concrete illustrations to justify every conclusion
“The client moved slowly, cried throughout the interview, and never laughed. Client stated he felt sad most of the time.”

6. Appearance
Client presented well-groomed and casually dressed in scrubs.
Child presented in unwashed, torn clothing and with dirty, unkempt hair.

7. Motor Behavior
Gait, gestures, stereotyped movements, impulse control, energy level
Catatonic, psychomotor retardation
Agitated (pacing, fidgeting, constantly getting up from chair)
Tardive dyskinesia
Biting nails, playing with hair, rocking
Heather
Extrapyramidal : Involuntary movements, Tremors and rigidity, Body restlessness, Muscle contractions, Mask like face, Involuntary movement of the eye called oculogyric crisis. Drooling, Shuffling gait, Increased heart rate

8. Speech Volume, rate, coherence but not content
Loud, rapid, pressured, slowed, soft, hesitant, slurred, dysarthria, monotonous
latent (delay in responding and initiating)
Incoherent, inaudible
Poverty of speech

9. Emotion Mood: experienced feeling, client tells you
Elevated, euphoric, expansive
Anxious, apprehensive, sad, depressed, irritable
Affect: observable expression
Broad (normal range), flat, blunt, constricted, labile, inappropriate
Mood congruency- behavior, affect, delusions, hallucinations are consistent with stated mood
Male I

10. Thought Process Word usage- neologisms, word approximations
Continuity of thought- association among ideas (clanging, echolalia, perseveration, flight of ideas, tangential, looseness of associations)
“I’ve slept in trees before. Sleeping in trees is uncomfortable. Family trees are the worst.”

11. Thought Content
Delusions, overvalued ideas, illogical thinking, magical thinking
Poverty of content* What does religion mean to you? “All that church stuff. Amazing Grace. Amazing Grace. It is personal, very personal. I understand what you mean, you who live in God’s grace.”
Incoherence- incomprehensible content
* Also seen in political speeches

12. Content or Behavior?
Obsessions- persistent, unwanted thoughts- thought content
Compulsions- ritualistic behaviors usually arising out of obsessions, or anxiety
The two are usually reported together

13. Perception
Abnormal sensations- tactile, auditory, visual, olfactory, gustatory
Hallucinations may be due to mental or physical illness or meds
SI deficits: distorted time sense, hyper/hypo sensitive, dyspraxias, abnormal gait or posture

14. Your Turn: Gerald Appearance Behavior Speech Emotion
Thought process & content
Perception

15. Orientation
Awareness of:
Time
Place
Person

16. Memory LTM (remote) or STM (recent v. immediate)
Repeat this: book, umbrella, elephant
In 5 mins I’ll ask again.
Can’t recall at least 2 ► organic deficit
Confabulation: not intentional bluffing

17. Judgment
What would you do if you found a stamped, addressed envelope lying on the street?
What would you do if you were the first to notice a fire in a theater?
What would you do if you noticed a 3 year old playing alone at the end of a pier?
Sometimes observations will answer this question for you!

18. So, what were those three items?

19. Intelligence/Information
Simple math
Abstract- How are a table, chair and desk the same?
All furniture
All made of wood
They’re not the same
You can write with them
Proverbs

20. Insight Awareness of the problem and its cause Complete denial
Dim and fleeting admission
Aware, but others are causing it
Intellectual recognition of the problem and internal cause
Acceptance of the illness

21. Not MSE: Interpersonal Demeanor
Appropriate, pleasant, cooperative, candid
Too familiar, intrusive, impulsive, clingy, vulgar
Aloof, defensive, resistant, passive-aggressive
Aggressive, controlling, manipulative, demanding, accusing, hostile, derogatory
Immature, shy, introverted, withdrawn, eccentric, odd

22. What can influence MSE? Culture Pain Distraction Don’t speak English
Dental problems
Sensory limitations
Lack of education
Medications

23. DSM IV TR Axis I Clinical Psy disorders (developmental)
Axis II Personality disorders (intellectual)
Axis III General medical conditions
Axis IV Other problems (financial, social, legal, work)
Axis V GAF

24. DSM 5 No Axis- using ICD-9 until Sept 2014, then use ICD-10 No GAF-
Using the World Health Organization Disability Assessment Schedule 2.0
WHO DAS!
International classification of Diseases

25. Understanding & Communicating
Getting Around
Self-Care
Getting along with people

26. Life activities:
Household &
School/Work
Participation in society

27. Montreal Cognitive Assessment (MoCA)
Principal author Ziad Nasreddine MD
Center for Diagnosis & Research on Alzheimer’s disease
Greenfield Park, Quebec

28. MoCA
Cognitive screening test designed to assist in detection of mild cognitive impairment
10 minutes to administer
Free for clinical, educational, & research use
Total possible = >26 = WNL

29. MoCA

30. MoCA

31. MoCA

32. MoCA

33. MoCA

34. MoCA

35. MoCA

36. MoCA

37. MoCA Confounds Sensory Deficits Poor grasp of English Poor education
Distractions
Pain
Motor Deficits
Serious Mental Illness!