Day # 7: Mental Status Exam in Schizophrenia and Related Disorders

Last week we spent one day discussing an overview of the mental status exam. As promised, today we will cover elements of the first half of the mental status exam that are particularly important in psychotic spectrum disorders. These are important clues that will help you with diagnosis as well as treatment response. Let's get started.


Today's Content Level: Beginner; Intermediate


Reminder of the Mental Status Exam Components

•Appearance

•Behavior

•Speech/Language

•Mood

•Affect

•Thought process

•Thought content

•Perceptual Disturbances

•Cognition

•Insight

•Judgement


Appearance


•There is no one-size-fits-all when it comes to appearance and behavior of patients with schizophrenia.


•Patients may be poorly groomed, fail to bathe, and dress "inappropriately" (example: dress much too warmly for the prevailing temperatures)


•These patients can have a wide range of appearances. You may have a patient that is completely disheveled, screaming and agitated. You might also see someone that is obsessively groomed, completely silent, and immobile. Many patients will present somewhere in the middle of these spectrums.


Behavior


•Pay particular attention to either extremes of behavior as this can be highly clinically relevant. For example, a patient that becomes agitated or violent, and is unprovoked, may be responding to intense hallucinations. In contrast, a patient that is silent, automatically obedient, or sits very still may be suffering from catatonia or may be severely depressed.


•Less extreme subtypes of catatonia include social withdrawal, lack of spontaneous speech or movement, absence of goal-directed behavior, or even odd clumsiness or stiffness in body movements.


•Pay attention to behaviors that may indicate adverse side effects from antipsychotics such as akathisia (fidgeting, can't sit still), parkinsonism (tremor, slowed speech or movements, rigid muscles), or dystonia (repetitive facial movements, unnaturally twisting or flexing body parts). These cluster of symptoms will be discussed in detail in upcoming lessons.


Speech / Language


•This is not all-inclusive but below are described some of the ways that speech / language can be commonly affected in psychotic disorders.


Incoherence: speech or thought is difficult or impossible to understand because words or phrases are not connected in a logical way. See thought process for examples.


Neologism: creation of new words that are meaningless except to the person coining the term


Paucity of speech: there is a lack of unprompted speech. Another term for this is alogia. This is considered a negative symptom of schizophrenia. From my clinical experience working with other residents/students this seems to be something that is commonly missed and not commented on in their notes.


Poverty of content: speaking without substance. This type of speech requires excessive speech to convey their message.


Mood/Affect


•Two common affective symptoms in schizophrenia are 1) Reduced emotional responsiveness and 2) "Inappropriate" emotions such as extremes of rage, happiness, and anxiety.


•Reduced emotional responsiveness can be described along a continuum and this applies to any patient not just those with psychotic features. This responsiveness can be described in terms of its intensity, range, and stability.

  • Constricted/Restricted is a mild reduction in the range and intensity of expression.

  • Blunted is a significant reduction (greater than constricted).

  • Flat is an absence or near absence of affective expression.


•Reduced emotional responsiveness in these patients can actually occur from a number of mechanisms. Differentiating these can be a challenge.

  • Symptom of the underlying disease process in the brain

  • Adverse effects of antipsychotic medications (parkinsonism)

  • Depression


"Innappropriate" emotions are those emotions displayed by the patient that don't "match" the content of speech or what would normally be felt in the circumstances. Example: They may describe how sad they were when their mother died but they are grinning and laughing uncontrollably. These discordant emotions can also be far ranging and may include religious ecstasy, inappropriate terror or anxiety over common things, overwhelming ambivalence, etc...


•Fun fact: Some experienced clinicians report feeling something described as a "precox" feeling, which is an "intuitive experience of their inability to establish an emotional rapport with a patient". Although the experience is common, no data indicate that it is a valid or reliable criterion in the diagnosis of schizophrenia. (Source: page 312)


Conclusion


The original plan was to completely cover the mental status exam for psychotic disorders in one day, but after writing the content we realized that it was realistically too long to cover in five minutes or less. We want to make these daily readings high yield and manageable! Tune back in tomorrow to round out this discussion of the mental status exam and we will cover thought process, thought content, perceptual disturbances, cognition, insight, and judgement as it pertains to schizophrenia.


Content for this post comes from Kaplan and Sadock's Synposis of Psychiatry and Pocket Psychiatry.



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