102 Station 38 Speech assessment
Conditions most likely to come up in a speech assessment station
• Expressive dysphasia results from damage to Broca’s area in the left inferior frontal gyrus:
– ‘telegraphic’ speech with omission of unimportant words such as ‘to’ and ‘the’
– inaccurate grammar and syntax
• Receptive dysphasia results from damage to Wernicke’s area in the left superior posterior
– inability to understand language and follow commands
– speech sounds fluent with normal rhythm but content is meaningless
• Global dysphasia results from widespread damage to the language areas, for example, owing
to a middle cerebral artery infarct in the dominant (usually left) hemisphere:
– both expression and comprehension of language are impaired, making communication
• Nominal dysphasia results from damage to the parietal lobe:
– still able to describe what the object does
• Conductive dysphasia results from damage to the arcuate fasciculus:
– isolated difficulty in repeating words and phrases
– language and speech are otherwise intact
• Pseudobulbar palsy or spastic dysarthria results from bilateral lesions of the upper motor
neurons in the corticobulbar tracts:
– increased tone of oropharyngeal muscles
– harsh-sounding ‘Donald Duck’ speech
• Ataxic dysarthria results from lesions of the cerebellum:
– slurred speech (the patient may sound drunk)
• Hypo- or hyper-kinetic dysarthria results from lesions of the basal ganglia:
– slow, monotonous speech in Parkinson’s disease
– loud and erratically stressed speech in Huntington’s disease
• Bulbar palsy or flaccid dysarthria results from lesions of the lower motor neurons in the
– hypernasal speech owing to decreased tone of the oropharyngeal muscles
– hoarse ‘breathy’ voice owing to paralysis of the vocal cords
• Dysphonia is a hoarse voice resulting from vocal cord pathology:
– neurological causes include vagus nerve lesions leading to vocal paresis, and
neuromuscular disease, such as myasthenia gravis, leading to vocal fatigue
– non-neurological causes include laryngitis, vocal cord nodules, corticosteroid inhalation,
laryngeal cancer, and vocal straining
Dyslexia, dyscalculia, dysgraphia:
• These symptoms result from lesions in the dominant parietal lobe.
Family, social, and personal history are particularly relevant to psychiatry.
In taking a psychiatric history, it is especially important to put the patient at ease and to
be seen to be sensitive, tactful, and empathetic.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Ensure that he is comfortable.
• Name, age, and mode of referral.
Presenting symptoms and history of presenting symptoms
• Start with open questions and listen attentively without interrupting:
– “Can you tell me why you came to the hospital today?”
– “How have you been feeling lately?”
• For each symptom identified, cover:
– exacerbating and relieving factors, including any treatments
• Ask screening questions about mood, abnormal beliefs, and abnormal perceptions (see
Station 40: Mental state examination).
• Try to form a diagnostic hypothesis and to validate or falsify it through further questioning.
• Previous episodes of mental illness.
• Previous psychiatric admissions, formal (under a section) and informal.
• Previous physical and psychological treatments and their outcomes.
• History of self-harm and attempted suicide.
• Past and childhood illnesses, including head injury.
• Past hospital admissions and surgery.
104 Station 39 General psychiatric history
• Current psychological treatments.
• Recent changes in prescribed medication.
• Over-the-counter drugs and herbal remedies.
• Determine if anyone in the family has suffered from psychiatric illness or attempted suicide, e.g.
“Has anyone in the family ever had a nervous breakdown?”
• Enquire about family structure and relationships:
– “Do you have a partner or spouse?” If ‘yes’, ask about their age, occupation, and health
– “Do you have any children?” If ‘yes’, ask about their age, health, where they live, and who is
– “Have there been any recent events or changes in the family?”
• Ask about social support and care:
– “Who lives with you at home?”
– “Who else are you close to?”
– “Do you feel like you have enough support?”
• Determine adequacy of housing and finances:
– “Do you live in your own house?”
– “Are you getting any help with your housing?”
– “Do you have any money worries?”
• Map out activities and interests:
– “How do you spend a typical day?”
– “What sorts of things do you enjoy doing?”
– “Are you aware of any problems when you were a baby?”
– “How would you describe your childhood?”
– “Were both your parents around when you were growing up?”
– “How did you get on at school?”
– “What qualifications did you leave with?”
– “What jobs have you had in the past?”
– “Why did you leave each job?”
Station 39 General psychiatric history 105
– “Have you ever had any trouble with the police or the law?”
– “Have you ever been convicted of any offence?”
– “Have you spent time in prison?”
– “I’m going to ask you some sensitive questions which we ask everyone. Do you have any problems
– “Have you ever experienced violence or abuse from your partner or anyone else?”
• Religious or spiritual orientation:
– “Is religion or spirituality important to you?”
• Ask the patient if there is anything he might add that you have forgotten to ask about.
• Indicate that you could check the patient’s psychiatric records (if any) and take an informant/
• Summarise your findings and offer a differential diagnosis.
Common conditions most likely to come up in a general psychiatric history station
• Anxiety disorder, e.g. agoraphobia, social phobia, panic disorder, generalised anxiety disorder.
• Obsessive–compulsive disorder.
• Mania and bipolar affective disorder.
• Schizophrenia and other delusional disorders.
NB. For descriptions of these conditions, see Table 18 at the end of Station 40.
Specifications: The MSE is roughly analogous to the physical examination, and provides a snapshot
the patient–actor might by replaced by a real patient on a video recording.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you would like to explore his thoughts and feelings, and ask him if this is OK.
The mental state can be assessed under 7 main headings:
Begin by asking the patient some open questions, and focusing your attention on his appearance and
• Appearance: body build, posture, general physical condition, grooming and hygiene, dress,
physical stigmata such as scars, piercings, and tattoos.
• Behaviour and attitude to the examiner. In particular note: facial expression, degree of eye
contact, and quality of rapport.
• Motor activity/disorders of movement, e.g. agitation, retardation, tremor, dystonias, mannerisms.
• Amount, rate, volume, and tone of speech, e.g. logorrhoea (large amount of speech), pressure
by excessive or irrelevant detail and parenthetical remarks. In tangentiality, speech is organised
but not goal-oriented in that it is only very indirectly related to the questions being asked.
Station 40 Mental state examination 107
• Current mood state and severity. If there is the suggestion of depression, ask the patient to rate
his mood on a scale of 1 to 10, with 1 being the worst that he has ever felt and 10 being normal.
• Biological symptoms: sleep, appetite, libido, energy.
• Ideas of harm to self, e.g. “People with problems similar to those that you have been describing
then this should be explored further: “Have you ever thought of killing yourself?” “Have you made
any plans?” “Would you carry out those plans?” “What stops/would stop you?”.
• Anxiety and anxiety symptoms, e.g. butterflies, giddiness, clamminess, palpitations, difficulty
catching breath. If there is the suggestion of an anxiety disorder, this should be explored
You are likely to fail this station if you do not ask about ideas of harm in an at-risk patient.
• Stream of thought, e.g. pressure of thought, poverty of thought, thought blocking.
• Form of thought, e.g. flight of ideas, loosening of associations, over-inclusive thinking.
compulsive acts, “Do you ever find yourself spending a lot of time doing the same thing over and
over again even though you’ve already done it well enough?”
– phobias, e.g. “Do you have any special fears, like some people are afraid of spiders or snakes?”
– delusions and overvalued ideas. For obvious reasons, you cannot easily ask directly about
delusions. Begin by an introductory statement and general questions, such as “I would like to
ask you some questions that might seem a little bit strange. These are questions that we ask to
everyone who comes to see us. Is that all right with you? Do you have any ideas that your friends
and family do not share?” Explore any delusions and in particular ask about their onset, their
effect on the patient’s life, and the patient’s explanation for them (degree of insight). If
necessary, ask specifically about common delusional themes, e.g. delusions of persecution,
reference, control, guilt, grandeur
• Illusions and hallucinations. Again, begin by an introductory statement and general questions,
such as “I gather that you have been under quite some pressure recently. When people are under
people cannot hear?” Ask about all five modalities and explore any positive findings for content,
onset, frequency, duration, and effect on the patient’s life. Exclude pseudohallucinations and
hypnogogic and hypnopompic hallucinations. For auditory hallucinations of voices, determine
if there is more than one voice, and if the voices talk to the patient (second person) or about him
on his every thought and action (running commentary)? Other forms of auditory hallucinations
are écho de la pensée and gedankenlautwerden, both first rank symptoms of schizophrenia.
108 Station 40 Mental state examination
Differentiating between true hallucinations and pseudo-hallucinations
A pseudo-hallucination may differ from a true hallucination in that:
• it is perceived to arise from the mind (inner space) rather than the sense organs (outer space).
• the patient may have some degree of control over it.
True hallucinations tend to be a feature of functional disorders, whereas pseudo-hallucinations tend
to be a feature of personality disorder. This is, however, not a hard and fast rule.
• Depersonalisation and derealisation, e.g. for depersonalisation “Have you ever felt unreal?” And
for derealisation, “Have you ever felt that things around you are unreal?”
Generally speaking, a quick and informal cognitive assessment can be carried out by recording the
• Orientation in time, place, and person.
• Attention and concentration, e.g. serial sevens test, spelling ‘world’ backwards. Record the time
taken and the number of errors.
– short-term memory: ask the patient to name and remember three objects, then carry out the
serial sevens test, then ask him to recall the three objects
– recent memory: ask him how he came to the clinic this morning/afternoon
– remote memory: ask him where he was born, where he grew up, etc.
• Grasp: ask the patient to name the prime minister and reigning monarch.
available, the Montreal Cognitive Assessment (MoCA). Both the MMSE and MoCA are scored out of 30.
To determine degree of insight, ask the patient:
• “Do you think there is anything wrong with you?”
• “Why did you come to hospital?”
• “What do you think is wrong with you?”
• “What do you think the cause of it is?”
• “Do you think you need treatment?”
• “What are you hoping treatment will do for you?”
After the mental state examination
• Ensure that he is comfortable.
• Offer a differential diagnosis.
Station 40 Mental state examination 109
Table 18. Principal features of key psychiatric disorders
See ICD-10 or DSM-IV for detailed diagnostic criteria.
Depressive disorder See Station 43
Mania • Garish clothing, accessories, and makeup
• Hyperactive, flirtatious, hypervigilant, assertive, and/or aggressive
• Pressured speech; abnormalities of the form of speech
• Euphoric or irritable or labile mood
• Grandiose thoughts with flight of ideas and loosening of
associations; mood congruent delusions
• Disorganised or catatonic behaviour
Agoraphobia Persistent irrational fear of places difficult or embarrassing to escape
from, such as places that are confined, crowded, or far from home.
Increased reliance on trusted companions for accompaniment or, in
severe cases, restriction to the home.
Social phobia Persistent irrational fear of being scrutinised by others and of being
embarrassed or humiliated, either in most social situations or in specific
social situations such as public speaking.
Specific phobia Persistent irrational fear of one or more objects or situations. Common
specific phobias include heights, darkness, enclosed spaces, storms,
animals, flying, driving, blood, injections, and dental and medical
Panic disorder Panic attacks are characterised by rapid onset of severe anxiety lasting
for about 20–30 minutes. They may occur in the phobic anxiety
disorder listed above or in other disorders such as OCD, PTSD, and
In panic disorder, panic attacks occur recurrently and unexpectedly.
There is fear of the implications and consequences of an attack, e.g.
having a heart attack, losing control, ‘going crazy’. Anticipatory fear
of panic attacks develops and may itself lead to further panic attacks
and to significant behavioural changes such as the development of
110 Station 40 Mental state examination
Table 18. Principal features of key psychiatric disorders – continued
Long-standing free-floating anxiety that may fluctuate but that is
neither situational (phobic anxiety disorders) nor episodic (panic
disorder). There is apprehension about a number of events far out
of proportion to the actual likelihood or impact of the feared events.
Other common symptoms include symptoms of autonomic arousal,
irritability, poor concentration, muscle tension, tiredness, and sleep
An obsessional thought is a recurrent idea, image, or impulse that is
perceived as being senseless, that is unsuccessfully resisted, and that
results in marked anxiety and distress.
A compulsive act is a recurrent stereotyped behaviour that is not
useful or enjoyable but that reduces anxiety and distress. It is
usually perceived as being senseless and is unsuccessfully resisted.
A compulsive act may be a response to an obsessive thought or
according to rules that must be applied rigidly.
A protracted and sometimes delayed response to a highly threatening
or catastrophic experience characterised by numbing, detachment,
flashbacks, nightmares, partial or complete amnesia for the event,
avoidance of (and distress at) reminders of the event, and prominent
anxiety symptoms. Associated psychiatric disorders are very common,
especially depressive disorders, anxiety disorders, and alcohol and
Adjustment disorder A protracted response to a significant life change or life event
characterised by depressive symptoms and/or anxiety symptoms that
are not severe enough to meet a diagnosis of depressive disorder or
anxiety disorder, but that nevertheless lead to an impairment of social
A long history of multiple and severe physical symptoms that cannot
be accounted for by a physical disorder or other psychiatric disorder.
Compare to factitious disorders such as Münchausen syndrome and to
A fear or belief of having a serious physical disorder despite medical
Eating disorders See Station 46.
Alcohol dependence See Station 45.
Testing of higher cerebral function begins by the bedside, opening the door to more formal
neuropsychological assessments.
• Introduce yourself to the patient.
• Make sure that the conditions are optimised, e.g. you are in a quiet room, the patient is neither
sedated nor suffering from side-effects, he is wearing his glasses or hearing aid.
• Check orientation in time and place. “What day of the week is it today?” “What’s the date?” “What
town are we in?” “What building are we in?” If the patient is disoriented, give him the correct
• If the patient is disoriented in time and place, check orientation in person.
• Test insight. “People seem quite concerned about you. Why is that?” “Why are you here?”
[Note] The dominant cerebral hemisphere is usually, although not always, the one on the left.
• Note the patient’s use of language. In the presence of an impaired ability to communicate
(dysphasia), fluency suggests receptive or Wernicke’s dysphasia, whereas hesitancy suggests
expressive or Broca’s dysphasia (see Station 38: Speech assessment).
• If receptive dysphasia is a possibility, test ability to understand commands, e.g. “Raise both
arms.” “Touch your left ear with your right thumb.”
• You can also test for nominal aphasia, a common form of expressive dysphasia, by asking the
patient to name some common objects such as a watch, pen, or penny coin; then to name the
components of some of these objects, e.g. hour hand, winder, strap.
• Having ascertained that the patient is literate, test for dyslexia by asking him to read a couple
of sentences, and for dysgraphia by asking him to write a sentence.
• Test for dyscalculia with ‘serial sevens’, e.g. “What’s 100 minus 7? What’s 93 minus 7? Can you
• Test ability to recognise objects (agnosia) by, for example, placing a pen, paper, and name
badge on a table and asking the patient to pick up the pen.
In summary, assess the dominant hemisphere by testing for receptive dysphasia, expressive and
nominal dysphasia, dyslexia, dysgraphia, dyscalculia, and agnosia.
• Geographical agnosia, e.g. “Show me how you would go to the bathroom and return to your bed.”
• Dressing apraxia, e.g. “Can you please button up your cardigan?”
• Constructional apraxia, e.g. “Can you draw a clock for me?”
112 Station 41 Cognitive testing
The following memory tests may be of use in an alert patient who is neither confused nor dysphasic.
• Immediate memory (digit span): “Can you repeat after me, 5438879?”
• Recent memory: “Can you tell me how long you’ve been in hospital?”
• Remote memory: “Where did you live 10 years ago?” “Who was the last Prime Minister?”
• Verbal memory: “I would like you to repeat the following sentence, ‘The quick brown fox jumps
over the lazy dog.’ Now, I would like you to remember that sentence, because I’m going to ask you
to repeat it again in 15 minutes’ time.”
According to ICD-10, dementia is: “a syndrome due to disease of the brain, usually of a chronic or
progressive nature, in which there is disturbance of multiple higher cortical functions, including
memory, thinking, orientation, comprehension, calculation, learning capacity, language, and
judgement. Consciousness is not clouded… Dementia produces an appreciable decline in intellectual
functioning, and usually some interference with personal activities of daily living…”.
The more important risk factors for dementia are listed in Table 19.
Table 19: Risk factors for dementia
• Mild cognitive impairment (MCI)
The primary requirement for diagnosis, again according to ICD-10, is “evidence of a decline in both
is also impairment of thinking and reasoning capacity, and a reduction in the flow of ideas”.
The diagnosis of the type of dementia (e.g. Alzheimer’s disease versus vascular dementia or mixed
post-mortem. In some cases, owing to the progressive nature of disease, an observation time of 6–12
months may be required to make a diagnosis. The order in which symptoms develop can be suggestive
as to the type of dementia involved.
cognitive impairment and conducts a basic dementia screen. This includes a bedside standardised test
such as the Mini-Mental State Examination (MMSE), the General Practitioner Assessment of Cognition
(GPCOG), or the Montreal Cognitive Assessment (MoCA), the latter being particularly useful if the
malnutrition, burns, or falls.
Routine blood tests and investigations include:
• FBC and serum vit-B12 and folate to rule out anaemia.
• Metabolic panel to exclude dyshomeostasis of electrolytes and glucose.
• Serum TSH to exclude hyper- or hypothyroidism.
• Urine dipstick to exclude UTI (if delirium is a possibility).
[Note] Further investigations should be ordered on a case-by-case basis and might include HIV
testing; syphilis serology; vasculitic, autoimmune, neoplastic, and toxicological screens;
copper studies; cerebrospinal fluid examination; and genetic testing. Brain biopsy itself
114 Station 42 Dementia diagnosis
The diagnosis of dementia subtypes is made on the basis of disparate sets of diagnostic criteria,
including DSM-IV for Alzheimer’s disease, the NINDS-AIREN criteria for vascular dementia, the
International Consensus Consortium Criteria for dementia with Lewy bodies, and the Lund–Manchester
helpful in identifying cognitive impairments and in confirming a diagnosis.
Clinical features vary not only according to the severity of the dementia, but also according to the
of progression for Alzheimer’s disease) memory loss, impaired thinking, language impairments,
Alzheimer’s disease Insidiously progressive memory loss and personality changes. Other
spheres of cognitive and non-cognitive impairment are added over the
A recently recognised entity that overlaps with Alzheimer’s
disease and parkinsonian dementias. It is the second commonest
cause of dementia, and is characterised by marked fluctuations in
cognitive impairment and alertness, vivid visual hallucinations, early
parkinsonism, and frequent falls.
Vascular dementia Classically marked by an abrupt onset and step-wise progression.
Clinical features are variable and depend on the location of infarcts,
but mood and behavioural changes are common. Significantly,
comorbidity leads to a shorter survival than in Alzheimer’s disease.
Pick’s disease A frontotemporal dementia characterised by early and prominent
personality changes and behavioural disturbances, eating
disturbances, mood changes, cognitive impairment, language
impairment, and motor signs. Onset is in middle-age and loss of
memory may not be a prominent feature.
and carers. This involves treating symptoms and complications of dementia, addressing functional
problems, and providing education and support to carers. Anticholinesterase inhibitors such as
donepezil, rivastigmine, galantamine, and tacrine act by increasing cholinergic neurotransmission
and can modestly and temporarily ameliorate cognitive performance and behavioural problems in
some patients with Alzheimer’s disease and dementia with Lewy bodies. Owing to their serious and
mostly on a time-limited basis.
Station 42 Dementia diagnosis 115
Principal differential diagnosis of dementia
• Mild cognitive impairment (MCI).
• Delirium (including delirium superimposed upon dementia).
• Depressive disorder (‘pseudodementia’) – although note that depressive and anxiety disorders
affect about 50% of dementia sufferers.
• Late-onset schizophrenia (paraphrenia).
• Amnestic syndrome e.g. Wernicke–Korsakoff syndrome.
• Iatrogenic causes, particularly drugs.
For this station, it is especially important to put the patient at ease and to be sensitive,
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some questions about his feelings, and obtain consent.
• Ensure that he is comfortable.
• Ask about the onset of illness, and about its triggers and causes.
• The core features of depression:
• Other common features of depression:
– poor self-esteem and self-confidence
• The somatic (i.e. biological) features of depression:
– loss of appetite and/or weight loss
– agitation and/or retardation
• Screen for possible anxiety, hallucinations, delusions, and mania, so as to exclude other possible
• Take brief past medical, drug, family, and social histories. Remember that drugs and alcohol are
commonly associated with depression.
• Assess the severity of the illness and its effect on the patient’s life.
Ask about suicidal ideation and potential risk to any dependants, or you may fail this
Station 43 Depression history 117
Asking about suicidal ideation
Asking about suicide can feel uncomfortable for some. Use a formulation such as, “People with
thought of killing yourself?” “Have you made any plans?” “Do you have the means to carry out those
plans?” “Would you carry out those plans?” “What stops/would stop you?”
• Ask the patient whether he has any questions, and whether there is anything that you have
Health Team, intensive support from the Crisis Team, admission to a psychiatric unit.
And so it was I entered the broken world
To trace the visionary company of love, its voice
An instant in the wind (I know not whither hurled)
But not for long to hold each desperate choice.
From Broken Tower, by Hart Crane (b. 1899; d. 1932, by suicide)
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some difficult questions about his thoughts, and ask if
Do not hesitate to ask about suicide for fear of planting the idea into the patient’s head.
There is nothing to suggest that asking about suicide increases its risk.
• The history of the current episode of self-harm (if any) to determine degree of suicidal intent
(higher intent/lower intent – guidelines only):
– what was the precipitant for the attempt? (serious precipitant/trivial precipitant)
– was it planned? (planned/unplanned)
– what was the method of self-harm, and did he expect this to be lethal? (violent method/
– did he make a will or leave a suicide note? (suicide note/no suicide note)
– was he alone? (alone/not alone)
– did he take any precautions against discovery? (precautions/no precautions)
– did he seek help after the attempt? (sought help/did not seek help)
– how did he feel when help arrived? (angry or disappointed/relieved)
• Assess risk factors for suicide:
– male sex, especially if between the ages of 25 and 44
– divorced, widowed, or single
– unemployed or in certain occupations, e.g. medicine, farming
– poor level of social support
– family history of depression, substance misuse, or suicide
• Mental state: assess current mood and exclude psychosis.
• Ask about current suicidal ideation. Has he made any plans?
Station 44 Suicide risk assessment 119
• Summarise your findings and state your opinion of the patient’s suicide risk.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain to the patient that you would like to ask him some questions to evaluate his drinking
Screening for an alcohol problem
Use the CAGE questionnaire to screen for an alcohol problem. A positive response to one or more of
the four questions ought to trigger further questioning.
• “Have you ever felt that you should Cut down on your drinking?”
• “Have people Annoyed you by criticising your drinking?”
• “Have you ever felt Guilty about your drinking?”
– how much (try to quantify in units of alcohol; see Figure 29)
• Onset and duration of alcohol problem, e.g. “How old were you when you first started drinking?“
“When do you think it got out of hand?” “Have you ever tried going dry?” “How did that go?”
• Features of alcohol dependence:
1. compulsion to drink/craving
2. primacy of drinking over other activities
3. stereotyped pattern of drinking, e.g. narrowing of drinking repertoire
4. increased tolerance to alcohol, i.e. needing more and more to produce same effect
5. withdrawal symptoms, e.g. anxiety, sweating, tremor (‘the shakes’), nausea, fits, delirium
6. relief drinking to avoid withdrawal symptoms, e.g. ‘eye opener’ first thing in the morning
7. reinstatement after abstinence
occurring at any time during a 12-month period.
Station 45 Alcohol history 121
Ask about the psychological and physical complications of alcohol abuse:
• Psychological: depression, anxiety
• Neurological: peripheral neuropathy, Wernicke–Korsakoff syndrome
• Gastrointestinal: peptic ulceration, oesophageal varices, pancreatitis, cirrhosis
• Cardiovascular: ischaemic heart disease, MI, stroke
Ask about prescription and illicit drug use. Co-morbid abuse of illicit substances is common in
alcoholics, as is abuse of certain prescription drugs such as benzodiazepines. Moreover, alcohol
• Alcohol abuse in other members of the family.
• The effect of alcohol abuse on relationships, particularly with the partner and children (if need
be, carry out a risk assessment).
• The effect of alcohol abuse on employment, finances, and housing.
• Whether the patient has come into any trouble with the police or law.
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