Components of the Mental Status Examination
Table 8-4 summarizes the areas to be covered in the MSE. The following sections describe these areas in more detail:
Appearance & Behavior
From the moment the interviewer first greets the patient, he or she will be aware of the patient’s appearance. The interviewer should try to describe it in detail before drawing inferences from it. What is the patient’s physique and habitus? Is there evidence of weight loss or gain? Does the patient have any conspicuous marks or disfigurement? The interviewer should describe the patient’s face and hair. Does the patient look ill? What is the expression of the eyes and mouth? Does the patient appear to be in touch with the surroundings? Is the patient clean and neat, or does he or she exhibit deficiencies in personal hygiene revealed by poor grooming of the skin, hair, or nails? How is the patient dressed? Is the patient’s clothing neat? Is it appropriate or peculiar? After the interviewer describes these characteristics, he or she determines whether an inference may be made about the kind of “statement” the patient is attempting to make with his or her attire.
The interviewer notes general overactivity or underactivity; abnormalities of posture; gross incoordination; or impairment of large muscle function. What is the patient’s gait like and how does he or she sit? The interviewer notes any abnormalities of finer movement and posture, such as tremor, tics, or fidgeting.
Stereotypies are organized, repetitive movements or speech or perseverative postures. They are usually associated with schizophrenia, particularly the catatonic type. A striking variant of postural stereotypy is waxy flexibility, in which the patient will remain indefinitely in a position into which the interviewer places him or her (eg, standing on one leg). Other disorders of movement associated with catatonia include a stiff expressionless face; facial grimacing or contortions; stiff, awkward, or stilted body movement; and unusual mannerisms of expressive movement or speech. The latter should not be confused with the gracelessness of someone who is socially anxious. The interviewer also notes whether the patient exhibits any rituals such as a need to touch objects repetitively, as in obsessive-compulsive disorder, or any habits such as nail biting, thumb sucking, lip licking, yawning, or scratching.
The interviewer attends to the accent, pitch, tone, and tempo of the patient’s speech, paying particular attention to unusually high or low pitch and abnormal tone, as in the high-pitched “squawking” monotone sometimes encountered in children with early infantile autism.
In mutism, which may occur in advanced brain disorder, severe melancholia, catatonia, or conversion disorder or in the elective mutism of negativistic children, the patient is unable or unwilling to utter anything. In conversion disorder, mutism is less common than is aphonia, in which the patient is able to speak only in a hoarse whisper.
Relationship to the Interviewer
The interviewer should infer the quality of the patient’s relationship by how he or she behaves and by what he or she says. The relationship may be constant, it may vary with the topic being discussed, or it may be influenced by other factors. These factors may remain obscure if they are unexpressed (eg, when the patient is privately amused by an auditory hallucination). The interviewer should note whether this is the case.
Affective states are difficult to assess, aside from noting whether they are inconstant or are influenced by obscure factors. The interviewer draws on a number of behavioral clues to assess the quality of the patient’s relationship and mood. As a rule, the more inferential the judgment, the more unreliable the conclusion. Interviewers may differ in their inferences concerning a patient’s affect, especially when it is unstable, ambiguous, complex, or shielded by interpersonal caution.
The interviewer’s behavior will inevitably affect the ebb and flow of the patient’s feelings. The patient may be responding appropriately to the interviewer’s friendly approach (or rudeness, for that matter). He or she will also be responding to highly idiosyncratic internal predispositions. For example, a patient may harbor mingled anxiety and deference for somebody he or she perceives as a threatening authority figure who must be placated.
Given the fallibility of inference, the interviewer is well advised to stick closely to observations and be able to cite them. This skill requires training. The beginner may be overly impressed by brilliant intuitive leaps; the expert heeds intuition but realizes how unreliable it is. The beginner grasps for, and holds firmly to, an inference, sometimes in spite of contrary evidence. The expert makes the inference, cites the clues on which it is based, can offer alternative explanations, and discards the inference for a better one if the evidence indicates it.
The quality of the patient’s eye contact is of great importance in gauging affective states. Negativistic patients, especially those with catatonia, may avert their gaze from the interviewer. Children with early infantile autism characteristically demonstrate eccentricities of eye contact, for example, staring “through” the interviewer or averting their gaze from him or her. A delirious patient, whose sensorium is impaired, may stare into space, as may a melancholic or schizophrenic patient whose thoughts are dominated by ruminations or preoccupations. Intermittent staring is a feature of different forms of epilepsy. The interviewer notes whether the patient’s attention can be captured, albeit briefly. If not, the interviewer should suspect an organic brain disorder.
Some patients stare at the interviewer intently. He or she should distinguish the wide eyes of awe and fear from the narrowed slits of hypervigilant suspiciousness. Other patients make hesitant eye contact, particularly when they are embarrassed about what they are saying. Not all patients with shifty gaze are liars, and some prevaricators have learned to deliver their lines without batting an eyelash.
The impact of the eyes on interpersonal relations cannot be overestimated. The configuration of supraorbital, circumorbital, and facial musculature; eyelids; palpebral fissure; gaze; depth of ocular focus; pupil size; and conjunctival moisture combine to produce a range of social signals of great significance for interpersonal dominance, competition, attraction, hostility or avoidance, the initiation and punctuation of conversation, and the feedback one requires to know how another has responded to what one has said.
Eyes and face are combined with body posture and movement in a gestalt. The face provides the clues to remoteness, bewilderment, and perplexity, whereas the whole body is involved in tenseness (eg, clenched fists, sweaty palms, stiff back, leaning forward), restlessness, preoccupation, boredom, and sadness.
The patient may be uncommunicative or, in the extreme, quite mute. In contrast, he or she may be friendly and communicative, even loquacious or garrulous. Patients convey antagonism by hectoring; by being uncooperative, impertinent, or condescending; or even by making direct threats, criticizing, or verbally abusing the interviewer. In contrast, by tone of conversation and demeanor, the patient can convey respect, deference, anxiety to please, or ingratiation. The interviewer notes and describes the following attitudes in the patient: shyness, fear, suspiciousness, cautiousness, assertiveness, indifference, passivity, clowning, interest in the interviewer, clinging, coyness, seductiveness, or invasiveness.
Affect & Mood
Affect refers to a feeling or emotion, experienced typically in response to an external event or a thought. The patient’s relationship to the interviewer is a particular manifestation of affect. Affects are usually associated with feelings about the self or others who are of personal significance to the individual. Less often an affect is experienced alone, as though adrift from its reference point. Affect is the conscious component of a monitoring system that signals whether the individual is on track toward a personal goal; whether he or she is obstructed, frustrated, or prevented from achieving the goal; or whether he or she has already attained it. Compare, for example, the anticipatory pleasure at preparing to meet someone beloved; the anxiety and fear at seeing the beloved with a serious rival; the rage and despair of loss; and the exaltation of reunion. Similar, though more complex, affects may attend mountain climbing, solving mathematical puzzles, or giving birth. Whatever the goal, its remoteness, proximity, loss, repudiation, attainment, or inaccessibility are all accompanied by self-monitoring affect.
In contrast to an affect, which may be momentary, mood refers to an inner state that persists for some time, with a disposition to exhibit a particular emotion or affect. For example, a mood of depression may not prevent an individual from deriving momentary amusement from a joke; however, the expression of gloom, sadness, or desolation prevails. Affects and mood are inferred from the patient’s demeanor and spontaneous conversation. A general query such as “How are you feeling, now?” or “How have your spirits been?” can be helpful. The interviewer should try to avoid leading questions such as “Do you feel depressed?”
Demeanor and affect usually coincide, but sometimes they do not. For example, a stiff smile can mask anxiety or depression. If the interviewer suspects this to be the case, he or she can offer an indicating or clarifying interpretation to help the patient recover suppressed emotion, such as “I notice that even though you speak of sad things, you are smiling” or “It’s hard to smile when you feel bad inside.”
The interviewer describes in the mental status report the general qualities of the patient’s emotional expression. Particular morbid affects or moods are noted. For example, is the patient affectively flat, that is, emotionally dull, monotonous, and lacking in resonance? This presentation is characteristic of chronic schizophrenia and dementia. Is the patient emotionally constricted, with a narrow range of affect, as in obsessional or schizoid personality? Does the patient exhibit inappropriate or incongruous affect, in that it is not in keeping with the topic of conversation?
Does the patient show evidence of lability, suddenly changing from neutral to excited or from one emotional pole to the other? Lability is often associated with emotional intemperateness, an abrupt unreflective expression of heightened emotion (eg, excited anticipation, affection, irritation).
The interviewer notes the presence of histrionic affect, the blatant but rather shallow expression of emotion often observed in those who exaggerate their feelings in order to avoid being ignored and who need to capture, or who fear to lose, the center of the interpersonal stage. Histrionic affect is often encountered in people with histrionic, narcissistic, or borderline personality disorder.
Morbid euphoria, a sense of well-being expressed in inexorable good spirits, is encountered in hypomania or mania and less commonly in schizophrenia and organic brain disorder. Frontal lobe dysfunction, characteristic of neurosyphilis and disseminated sclerosis and after lobotomy, may be associated with fatuous joking and lack of foresight. Silliness is sometimes encountered in histrionic or immature people overwhelmed by the enormity of a difficult situation. Morbid silliness is also characteristic of some disorganized schizophrenic patients.
As it becomes exaggerated, euphoria merges into elation and excitement; although the manic patient commonly also exhibits irritation if obstructed or thwarted. An extreme and transcendent exaltation of mood may be observed in the ecstatic states that are rarely associated with acute schizophreniform or schizophrenic disorders and epilepsy.
Apathy, a pervasive lack of interest and drive (also known as anergia ), may be observed in patients with preschizophrenic, schizophrenic, depressive, and organic brain disorders. The apathetic patient has little or no enthusiasm for work, social interaction, or recreation. Anergia is usually associated with a decrease in sexual activity. Anhedonia, a subjective sense that nothing is pleasurable, is commonly associated with anergia and is observed in preschizophrenic, schizophrenic, and melancholic patients. Excessive fatigue, which may be manifested as hypersomnia, is associated with many disorders such as organic brain disorder, schizophrenia, anxiety disorders, depressive disorders, and somatization disorder.
When applied to an affect or mood, depression refers to a pervasive sense of sadness. Depression is often related to a life event involving loss, rejection, defeat, or disappointment. It may be associated with tearfulness and anger about the event. In more severe depression or melancholia, the patient feels emotionally deadened or empty, the world stale and unprofitable, and the future hopeless. The patient is preoccupied with dark forebodings and may be agitated by persistent self-recrimination about past misdeeds. Diminished concentration and a slowing of thinking and movement characteristically accompany depressed affect and gloomy ruminations. In some patients agitated depression is associated with psychomotor restlessness. Severe depression has important somatic features, including characteristic posture and facies, headache, irritability, precordial heaviness, gastrointestinal slowing, anorexia, weight loss, loss of sexual interest, and insomnia. Depression typically has a diurnal variation: dysphoria, hopelessness, and agitation are worse in the morning, and the patient brightens up by evening.
The interviewer will readily recognize open anger and irritability. These feelings may be quite understandable in the context of the patient’s circumstances. Morbid anger, however, is defined by pervasiveness, frequency, disproportionate quality, impulsiveness, and uncontrollability. Morbid anger is associated with organic brain disorder, usually in the form of catastrophic reactions to frustration, especially when the patient can no longer complete a familiar or easy task. Abnormal anger is also associated with some forms of epilepsy; personality disorders of the aggressive, antisocial, borderline, or paranoid type; attention-deficit and disruptive behavior disorders of childhood; drunkenness; paranoid disorders; hypomania or mania; and intermittent or isolated explosive disorders.
Controlled hostility may be expressed as sullenness, uncooperativeness, superiority, or mockery. It can be helpful to invite the patient to express anger or resentment directly and to define its origin. This is particularly the case with adolescents. When working with adolescents, the interviewer might consider saying,"Whenever I ask you a question, you close up. Something about being here is making you pretty uptight. Can you tell me what it is?”
Anxiety and fear refer to the subjective apprehension of impending danger, together with widespread manifestations of autonomic discharge (eg, dilated pupils; cold, sweaty palms; tachycardia; tachypnea; nausea; bowel hurry; urinary urgency). Fear has an object: the need to defend oneself against uncertain odds (eg, a charging bull, a near accident in an automobile). Anxiety is associated with the threat to an essential value, for example, being attached to someone beloved, not being a coward, being successful, or being highly regarded. Direct action (ie, fight or flight) can eliminate fear, whereas the adaptive solution to anxiety is likely to require planning and persistence. Anxiety and fear are biologically advantageous because they signal the need for constructive responses.
In morbid anxiety, affect is cast adrift from its moorings, either to float free or fasten on a substitute, phobic object or situation (eg, heights, a particular animal, elevators, enclosed spaces, being fat). Morbid anxiety appears disproportionate or eccentric and is recognized as pathologic by the patient and others. Many of the disorders of thought content (described later in this chapter) can be regarded as unconsciously determined, pathologic mechanisms that detach anxiety from its object or block and divert it at its origin.
Cognition & Memory
Table 8-5 lists the cognitive functions that can be assessed in a MSE. We describe them in more detail in the following sections:
Level of Consciousness & Awareness
The psychiatrist may be asked to consult on a comatose or stuporous patient, if a nonorganic cause is hypothesized. Coma is a state of nonawareness from which the patient cannot be aroused. Diminished awareness is called semicoma or stupor, in which case the subject is temporarily rousable (eg, by pain or noise) but reverts to stupor when the stimulus ceases. In stupor, eye movements become purposeful when the painful stimulus is applied, and wincing or pupillary constriction may occur, but the patient remains akinetic and mute. Stupor and coma occur in primary neuronal dysfunction (eg, Alzheimer’s disease), secondary neuronal dysfunction (eg, metabolic encephalopathy), supratentorial lesions (eg, infarction, hemorrhage, tumor), subtentorial lesions (eg, infarction, hemorrhage, tumor, abscess), and psychiatric disor-der (eg, dissociative disorder, depression, and catatonia).
Psychogenic coma is suggested by normal vital and neurologic signs, resistance to opening the eyes, normal pupillary reactions, and staring (rather than wandering) eyes. Swallowing, corneal, and gag reflexes are usually intact, and electroencephalography and oculovestibular reflexes are normal. Intravenous barbiturate may increase verbalization in psychogenic stupor. It depresses awareness further in organic conditions.
Torpor denotes a lowering of consciousness short of stupor. Awareness is narrowed and restricted, and apathy, perseveration, and psychomotor retardation are observed, but the more dramatic phenomena of delirium (ie, illusions, hallucinations, agitation, and so on) are lacking. Torpor is associated with severe infection and multi-infarct dementia.
In twilight or dreamy states, restricted awareness is manifested as disorientation for time and place, with reduced attention and short-term memory. In addition, the patient may have the sense of being in a dream.
Delirium is a common condition in medical and surgical wards. It is caused by a diffuse cerebral dysfunction of acute or subacute onset and fluctuant or reversible course. After prodromal restlessness and insomnia, delirium typically presents with obtundation, emotional lability, and visual illusions. The clinical features tend to worsen at night (so-called sundowning), with insomnia, agitation, hallucinations, and delusions. So-called quiet deliria are common, with little more to note than clouding of consciousness, mild disorientation for time and place, and reduced concentration. Restlessness, tremor, asterixis (irregular, asymmetrical jerking of the extremities), myoclonus, and disturbance of autonomic function are also common. Patients vary in their psychological reactions to delirium: depressive, paranoid, schizophreniform, anxious, and somatoform responses may be encountered. Patients may be fearfully or combatively hypervigilant, or torpid and apathetic.
Visual illusions, which are characteristic of delirium, involve the patient misinterpreting the moving shadows, curtains, and surrounding bedroom furniture. Physical sensations may also be misperceived. For example, the patient may mistake abdominal pain for the knives of malefactors and tinnitus for radio waves. If poorly systemized delusional beliefs arise, the patient may act on them, seeking escape or defense. Visual hallucinations are more common than auditory hallucinations in delirium. Visual hallucinations are sometimes playful (eg, animals romping), sometimes personal (eg, the face of a dead relative), or sometimes horrible or threatening (eg, dismembered bodies, accidents). They are most evident at night and can be provoked when the eyes are closed, especially when the orbits are pressed. Affect is usually labile in delirium, but persistent blunting, anxiety, suspiciousness, hostility, depression, or euphoria may be encountered and is usually congruent with the prevailing illusions or hallucinations.
Delirious patients may exhibit wandering attention and concentration; their thinking may become disconnected or incoherent and their memory impaired. These patients sometimes confabulate, linking memories out of correct sequence. Subtle restriction of consciousness often occurs during acute anxiety and results in vagueness or amnesia for traumatic experiences. Sometimes the amnesia is accentuated. The patient may wander off in a daze, turning up in an emergency room unaware of his or her name or address. This is known as dissociative fugue state and should be differentiated from epilepsy or postictal conditions.
Orientation, Attention, & Concentration
Disorders of orientation are most often involved when the sensorium is clouded, as in torpor, obtundation, dreamy states, delirium, or fugue. Orientation is usually lost in the following order: time, place, person. Disorientation for time and place usually indicates organic brain disorder. Disorientation for personal identity is rare and is associated with psychogenic or postictal fugue states, other dissociative disorders, and agnosia (loss of the ability to recognize sensory inputs). The interviewer assesses the patient’s orientation by asking him or her for the information listed in Table 8-6. The reliability of the clinical assessment of orientation is high, but its predictive validity is uncertain.
Attention is involved when a patient is alerted by a significant stimulus and sustains interest in it. Concentration refers to the capacity to maintain mental effort despite distraction. An inattentive patient ignores the interviewer’s questions, for example, or soon loses interest in them. The distractible patient is diverted from mental work by incidental sights, sounds, and ideas.
Table 8-7 describes simple clinical tests for attention and concentration. These tests have high reliability but little validity. Primarily they test the ability to concentrate. A patient’s ability to answer arithmetic questions requires not only concentration but also intelligence and education. Errors are common and are related to psychiatric disturbance, socioeconomic status, intelligence, and the patient’s ability to cope with an interview situation. The procedure helps to identify organic brain disorder but has little diagnostic specificity.
Memory has several stages. Information must first be registered and comprehended. It is then held in short-term storage. If the material is to be retained beyond immediate recall, a more durable memory trace is formed. Memory traces in long-term storage will decay, consolidate, or become simplified and schematized, partly as a result of subsequent experience. Long-term memories are retrieved or recalled from storage by tagging a pattern of sensory phenomena and matching it with long-term memory schemata.
In clinical practice, abnormal memory is manifest as amnesia (memory loss) or dysmnesia (distortion of memory). Psychogenic amnesia occurs in several forms. During and after severe anxiety, memory is likely to be defective. Some people have the ability to repress unwelcome anxiety-laden ideas; their memory is thereby rendered patchy or selective. In dissociative disorders, such as psychogenic amnesia and fugue, the patient usually loses memory for a circumscribed period of time during which profoundly disturbing events took place. Less commonly the amnesia is generalized (ie, total) or subsequent (ie, amnesia for everything after a particular time).
In addition to displaying generalized amnesia, patients in a psychogenic fugue state may travel a distance from home and assume a new identity. Often it is unclear in such cases whether unwitting self- deception or conscious imposture are involved.
Organic amnesia occurs in acute, subacute, and chronic forms. After acute head trauma, retrograde amnesia (loss of memory of past events) is likely to occur as a result of a disruption of short-term memory. The extent of anterograde amnesia (inability to form new memories) after head trauma is an index of the severity of brain injury. Amnesia also occurs in association with alcoholism (ie, blackouts) and after acute intoxication, delirium, or epileptic seizures.
Subacute amnesia (the amnestic syndrome) occurs after Wernicke’s encephalopathy, a disease caused by thiamine deficiency and encountered most commonly in alcoholic patients. Wernicke’s encephalopathy is characterized by conjugate gaze ophthalmoplegia, nystagmus, ataxia, and delirium. After the delirium clears, most patients experience a residual Korsakoff’s syndrome with disorganized memory in an otherwise clear sensorium. Patients with Korsakoff’s syndrome have difficulty recalling events from before the onset of the encephalopathy. They also experience severe impairment of the ability to lay down new memories after the encephalopathy. The retrograde amnesia affects the patient’s ability to remember the precise order in which events occurred. The anterograde amnesia, however, tends to be even more marked; the most severely affected patients, for example, are unable to store new information. As a consequence, these patients are often disoriented for place and time and may confabulate to fill the memory gaps. Thus the characteristic pattern of Korsakoff’s syndrome is of amnesia, disorientation, confabulation, a facile lack of concern, and a tendency to get stuck in the one groove of thought. Chronic amnesia, as in dementing illnesses, extends back for years. Recent memory is lost before remote memory.
Disorders of recognition include de’ja` vu, de’ja` ve’cu, and psychotic misidentification. De’ja` vu and de’ja` ve’cu are common and normal, particularly in adolescents. They involve the sudden uncanny feeling that one has experienced the present situation, or heard precisely the same current conversation, on a previous occasion. These phenomena are associated with anxiety and less commonly with temporal lobe epilepsy. Psychotic misidentification may occur in schizophrenia. These patients describe familiar people as strangers or claim to recognize people they never met. Patients with Capgras’s syndrome regard familiar individuals (such as family members) as doubles, or impersonators of themselves.
Disorders of recall include retrospective falsification and confabulation. All people indulge at times in retrospective falsification, embellishing the past to present a more appealing, tragic, or amusing impression. Histrionic people sometimes invent such an extensive and impressive past that they are drawn into imposture. Depressive individuals find sin, failure, and occasion for self-recrimination in their unexceptional lives. After recovery from psychosis, patients often repress their memories of illness and retain only bland or vague reminiscences of the acute disorder. It is inadvisable to ask them to recall their experiences in detail.
A confabulation is a false memory that the patient believes is true. Confabulations may be quite detailed, but they are often inconsistent and fanciful. Confabulations commonly fill memory gaps, especially in the amnestic syndrome. Some schizophrenic patients confabulate, spinning complicated fantasies about telekinesis, extrasensory perception, nuclear radiation, and the like. It is difficult to draw the line between confabulation and deception in the hysterical impostor or the dramatic abnormal illness behavior of the patient with Munchausen’s syndrome.
Table 8-8 lists the clinical tests for immediate, recent, and remote memory. These tests have good test-retest and interrater reliability. Their validity is affected by intelligence and age and by emotional states such as depression and to a lesser extent anxiety. The most useful tests for detecting organic lesions appear to be orientation, delayed recall, sentence repetition, and general information.
The patient’s fund of general knowledge depends on education and current interest in contemporary affairs. Table 8-9 provides a clinical test of information. Organicity is suggested if the patient makes 12 or more mistakes (60%) on this test. If administration is standardized, reliability is high. The test is quite useful as an estimate of organicity, although it does not assess a unitary cognitive function.
A patient’s comprehension is evaluated by his or her grasp of the importance of the immediate situation. For example, does the patient know why he or she is where he or she is? Does the patient appreciate that he or she is ill or in need of treatment? Does the patient understand the purpose of the examination?
There are no tests for comprehension. It is evaluated as the interview proceeds. Although comprehension is often disturbed in delirium and dementia, for example, there is no evidence that this disturbance contributes anything to the diagnosis of organicity beyond what is provided by other tests of the sensorium (ie, orientation, concentration, memory).
Conceptualization & Abstraction
Simple levels of conceptualization are assessed by testing the patient’s capacity to discern the similarities and differences between sets of individual words. The patient’s capacity to abstract is tested by asking the patient to discern the meaning of well-known metaphorical statements (Table 8-10). The tests listed in Table 8-10 have poor reliability and validity. They are affected by intelligence, educational level, culture, and age and have little discriminating power. The tests do not effectively detect organicity. Research has shown that clinicians using these tests could not distinguish between manic patients, schizophrenic patients, and creative writers. They are of most use when they tap unmistakable formal psychotic thought disorder. Consider the following examples:
A young man with disorganized and accelerated thinking responds thus to the proverb “People in glass houses should not throw stones”: “Oh yeah. My California uncle passed the shotgun out the windows and started firing!”
To the proverb “A rolling stone gathers no moss,” he answers,"Put a few pebbles in your mouth when you’re hiking. You’ll go a few more miles.”
Another young patient, who has the delusion that he is Christ, responds to the glass houses proverb as follows: “Those who know that it has been seen what they have done—and believe me it has all been seen—Let him who is without sin cast the first stone. Okay? That’s what I believe it means.”
The same patient responds to the rolling stone proverb in this way: “If you can continue to move and always move and always follow yourself and no one else, you’ll never have the evil one within yourself.”
Unfortunately the sample of thinking provoked by these tests is usually so small, and its pathology so equivocal, that these tests are of dubious virtue.
Language is a system of communication that is also used as a tool of thought. Language facilitates thinking by the way semantics hierarchically organizes ideas and concepts and by the way in which syntax indicates the relationship between those ideas and concepts.
Language competence is assessed from the patient’s speech during the psychiatric interview. Any history of spoken or written language difficulty, or any observation of clumsy articulation, disordered rhythm, and difficulty in the understanding or choice of words, should be noted and investigated further. Language comprehension is tested by asking the patient to point to single objects, and then to point to a number of objects in a particular sequence. The interviewer may also ask the patient to perform a series of actions in an arbitrary sequence (eg,"Touch your nose with your right index finger, then point that finger at me, then put it behind your back."). Language expression is evaluated by asking the patient to repeat words, phrases, and sentences and to name correctly a number of objects. Expression and comprehension are evaluated by asking the patient to read a passage aloud and to answer questions about it. Asking the patient to take dictation tests graphic language. Any errors and slowness in performance should be noted. The following sections describe some common disorders of language.
Aphasia is a dysfunction in the patient’s ability to express himself or herself. The three most common forms of aphasia are all manifest as difficulty in repeating words or phrases. In Broca’s aphasia, comprehension is relatively intact but expression dysfluent, sparse, telegraphic, and full of circumlocution. In Wernicke’s aphasia, comprehension is affected. Expression, though fluent, rambles, lacks meaning, and is full of errors to which the patient seems oblivious. In conduction aphasia, comprehension is intact, expression is fluent but full of errors and pauses, and repetition is difficult; however, reading is relatively intact.
Muteness is seldom found in neurologic disease, except in the acute phase, in seizure disorder, or in advanced cerebral degeneration. The aphasic patient is never mute. Muteness is much more commonly a sign of melancholia, stupor, catatonic stupor, somatoform disorder, dissociation or negativism in children (ie, elective mutism).
The psychiatrist’s main diagnostic problem is to differentiate schizophrenic language from the “jargon” of Wernicke’s aphasia. Schizophrenic patients tend to be heedlessly bizarre in thought content; aphasic patients are more aware of their errors and are more likely to use substitutions to overcome their language defects. The confused speech of schizophrenic patients is known as word salad. It may be so chaotic as to be barely comprehensible.
Paralogia, or talking past the point, occurs when the patient gives answers that are erroneous but that reveal knowledge of what should be the correct answer. For example, the interviewer may ask,"How many legs has a cow?” and the patient responds,"Five." Talking past the point occurs in Ganser syndrome (also called the syndrome of approximate answers). It is most likely to be observed in patients for whom hospitalization for insanity is preferable to incarceration for crime.
Neologisms are new words coined by the patient. They are often condensations of ideas that attempt to capture the ineffable. Neologisms are most common in schizophrenia; they must be distinguished from aphasic paraphasia, and circumlocution, to which the patient resorts in order to overcome expressive difficulty. Sometimes a neologism reveals that the patient has been “derailed” by the sound or sense of an associated word or idea. At other times, neologisms are a response to hallucinations or a defense (in a private code) against the intrusion by the interviewer upon the patient’s privacy.
Disorders of Thought
Pathology of thought may be found in the process, in the form, or in the content of thinking. The process and form of thinking may be disordered in terms of tempo, fluency (including continuity and control), logical organization, and intent. Normal thinking is characterized by reasonable, but not excessive speed, and a smooth and continuous flow from one idea to the next. Normal thinking has clear goal-direction, organization, and consensual logic in the links between, and the sequence of, its constituent ideas.
In psychological illness, particularly the turmoil associated with psychoses such as schizophrenia and mania, any or all of the above characteristics may be disorganized. Pathologic thinking can be sluggish, headlong, disconnected, meandering, halting, and prone to lose its track, wander off at tangents, or follow an illogical line.
Abnormal thinking can be experienced by the thinker as invading, inserted, or controlled by alien forces. It can also be sensed as leaking, stolen, lost, or broadcast from the mind into the outside world. Finally, the psychotic thinker, oblivious to the need to make sense, may lose contact with the audience or use language as a mocking camouflage.
Abnormalities of Thought Process & Form
Thinking is accelerated in flight of ideas, which may reach such a pitch that goal direction is lost and the connection between ideas is governed not by sense but by sound or idiosyncratic verbal or conceptual associations. Alliteration, assonance, rhyme (clang associations), and punning may determine the torrent of ideas that is distracted readily by internal or environmental stimuli. Flight of ideas is usually associated with pressured speech and may be experienced by the patient as racing thoughts. Flight of ideas is characteristic of mania, but it may occur also in excited schizophrenic patients, especially those in acute catatonia. In hypomania the flight of ideas is less marked, the tempo being accelerated but the associations less disorganized.
The tempo of thinking may be slowed in retardation of thought, especially in major depression. The patient often complains of fuzziness, woolliness, and poor concentration. Response time to questions is increased. There are long silences during which the patient may lose the thread of the conversation. In the extreme, retardation of thought becomes mutism or even stupor.
In circumstantiality, although the goal direction of thinking is retained, associations meander into fruitless, overly detailed, or barely relevant byways. The listener may feel impelled to hurry the speaker along. Circumstantiality is said to be characteristic of some epileptic patients whose peculiar combination of pedantry, perseveration, religiosity, and cliche’ lend their thinking a so-called viscous quality.
Perseveration refers to a tendency to persist with a point or theme, even after it has been dealt with exhaustively or the listener has tried to change the subject. It is also observed, for example, when a child fixedly repeats one aspect of a drawing, leaving multiple lines or dwelling on the shading in an exaggerated manner.
In thought blocking, the patient’s speech is interrupted abruptly by silences that last for from less than a second to much longer, even a minute or more. During the pause the patient’s eyes often flicker, particularly if he or she is listening to an auditory hallucination; sometimes the patient becomes blank mentally. Blocking is often precipitated by questions or ideas that have personal significance, particularly if their import is threatening. Blocking is an uncommon but striking sign. It tends to be identified far too often, the observer mistaking the retarded thinking of a depressed or preoccupied patient for the sudden roadblock of the true phenomenon. It is almost pathognomonic of schizophrenia but must be differentiated from the absences of petit mal epilepsy, the hesitation caused by anxiety, and the peculiar mental fixity of amphetamine intoxication.
During the period of blocking, intermediate associations may be lost, and the patient recommences on an apparently different track (tangential thinking). This can give rise to a phenomenon known as the knight’s move in thought: The listener can sometimes intuit how the patient got from A to E and realizes that the unspoken intermediate associations (B, C, and D) were quite indirect. On other occasions, the patient’s thinking appears subject to derailing (jumping the track to proceed on a quite different subject), particularly when a sore point has been touched on. Patients are often aware of disturbances in the continuity of their thinking and will describe how their thoughts become paralyzed, interrupted, or jumbled.
Akin to the subjective phenomena described in the previous section is the patient’s sense that speed, direction, form, or content of thought are out of control. Complaints such as “confused,""racing thoughts,""unable to concentrate,""scatterbrained,""jumbled," and “going crazy” often reflect the subjective perception of pathologically accelerated, dysfluent, or discontinuous thinking.
Sometimes schizophrenic patients report that their thinking is controlled by external forces or people, often by means of radio waves or other transmissions. Thinking may be perceived as directed by the external agency, or particular thoughts experienced as having been implanted by it. This is known as thought insertion or thought alienation.
In thought deprivation or thought broadcasting, the patient senses that ideas are leaking out of the mind, being stolen by others, or being broadcast via radio or television. The perception that the television picks up and repeats one’s thoughts may lead to a grandiose or persecutory delusional misinterpretation.
Psychotic thinking may reflect a deterioration in the capacity to think formally or logically. Commonly the schizophrenic patient uses a private logic, with overpersonalized concrete symbols. Within this logical framework, conceptual boundaries are blurred, and the thinking patterns are metaphorical and idiosyncratic, almost as if they emerged directly from a dream-state. Thus, to the observer, when such thoughts are expressed, they appear on the surface to be diffuse or bizarre, and lack clarity. However, it is possible to interpret their meaning in the context of the patient’s personal situation, and the issues that he or she is struggling with.
Intent of Communication
The conventional purpose of discourse is to communicate, but the clinician may be misled by the intentions of a schizophrenic patient. The schizophrenic patient may attempt to remain private or to deride the clinician, subtly, by conversing in an obscure, remote, supercilious, attacking, caricatured, or farcical manner.