The Neuropsychiatric Mental Status Examination

The Neuropsychiatric Mental Status Examination

By Michael Alan Taylor, M.D. Professor and Chairman Department of Psychiatry and

Behavioral Sciences University of Health Sciences The Chicago Medical School Chicago, Illinois

Springer-Science+ Business Media, B.V.

ISBN 978-0-89335-130-4 ISBN 978-94-011-7391-9 (eBook) DOI 10.1007/978-94-011-7391-9

Copyright© 1981 Springer Science+ Business Media Dordrecht Originally published by Spectrum Publications, Inc. in 1981 Softcover reprint of the hardcover 1st edition 1981

All rights reserved. No part of this book may be reproduced in any form, by photostat, microform, retrieval system, or any other means without prior written permission of the copyright holder or his license.

Library of Congress Cataloging in Publication Data

Taylor, Michael Alan. The neuropsychiatric mental status examination.

Includes bibliographical references and index. 1. Neuropsychiatry-- Programmed instruction.

I. Title. [DNLM: 1. Mental disorders--Diagnosis-­Programmed texts. WM 18 T 2 44n] RC341. T 39 616. 89'075'076 80-36794

For Christopher and Andrew

Acknowledgments

I wish to thank the following people for their contributions to this work:

Ms. Sierra-Franco's detailed review of the program structure was of singular help to me. Whatever weaknesses remain in the design are solely my responsibility and undoubtedly exist from my resistance to respond to one of her many perceptive suggestions. Ms. Ingrid Hendricks edited an earlier revision of the manuscript and coordinated its field trials.

Ms. Sandra Mott typed and retyped multiple manuscript drafts and revisions and generally facilitated the process of writing and preparing the book. Ms. Peggy Pfeiffer and Brad Greenspan, M.D. posed for the photographs which were taken by Professor Jack DeBruin, Medical Photo­grapher in the Department of Medical Communication at the University. Ralph Reitan, Ph.D. kindly gave his permission to use test items from his Reitan-Indiana Aphasia Screening Test. The medical students who partic­ipated in the field trials provided many insightful suggestions and were always encouraging. Ellen Taylor put up with the debris of work and hours of non-communication. She was always supportive and made life a lot easier.

Preface

There are almost as many explanations for psychiatric disorders as there are patients with them. Each explanation is intriguing, some of them are systematic, all of them have intellectually powerful champions. Yet their very multitude is a scandal. It provokes the professionally debilitating challenge: Why does every psychiatric explanation satisfy some people and not others? Recently this question has received a simple answer. We cannot satisfactorily explain that which we lack the skill to describe.

To develop the fundamental skill a student must see many patients under the direction of an experienced and involved instructor to whom he can show his results, accept correction and advance in his abilities. But we need a means to amplify the clinical experience, a text to supplement the instructor in bringing forth and strengthening the vocabulary needed to describe the phenomenology, presentations and distinctions amongst psychiatric patients.

A "programmed text" such as this one is a satisfactory means because it can cover rapidly many themes and variations of a vast clinical experi­ence. It can permit the reader to progress at his own speed but bring a sense of mastery to him as he progresses. He can check his knowledge as he sees patients on the clinical services. This kind of text combined with patient practice is thorough, fast and fun, but should succeed in the important task of rapidly building for the student an authentic set of terms and concepts suitable for both clinical work and research.

Thus, this text approximates an individual instruction method. It supplements it but does not replace it. All phenomenological events need to be seen to be believed, but this step by step conversation with an author that is the strength of the programmed approach finds here a situation that is apt for it.

This book leads to progress not because everything in it is bound to command assent but because it uses the method of breaking complex problems down to smaller elements, fights for clarity, strengthens its reader through the question and answer approach and calls directly for engagement with the teacher and the patient.

I enjoyed this book for still other reasons that emerge from the intentions of the author. This is no "back to basics" book although there are plenty of basics to learn. Rather this book is a piece with the "let's get down to work" approach that has vitalized the academic psychiatric world in the

last decade. Its scholarly roots extend back to Kraepelin but reach broadly to encompass empirical work wherever it is found. It presents its information in a way that permits the reader to wrestle with it, check its reasoning and its references and to argue with the author. Here is a two-fisted "new world" style for the dissemination of information on the characteristics of psychiatric patients that is direct and unabashedly confident, but as well friendly, open to challenge, alive with vigor. It is a product of a teacher who admires his students and enjoys his subject and is prepared for the benefit of both to show how he thinks. Such an approach wins readers, respect and results. I expect this book to find a place in teaching programs that want to bring on a phenomenological interest in psychiatry. Since this is a major theme in contemporary work, it should have a large audience.

Introduction

Although much effort has been expended to develop a reliable and valid nosology of mental disorder, the process of clinical psychiatric diag­nosis remains very much an art. Unfortunately, inspiration and talent, applied without effective technique and divorced from a valid data base are frequently unsuccessful. The inexperienced clinician, almost instinct­ively recognizing the need for technique and data, gropes for a process which will enhance recognition of signs and symptoms and which will or­ganize these phenomena into a usable structure. The phenomenologic ap­proach towards clinical psychiatric diagnosis is one such process. Its rel­iance on a structured examination, objective observation and precise de­finitions of clinical phenomena makes phenomenology an extremely useful tool for the evaluation and subsequent diagnosis of individuals with men­tal disorder.

This book is an introduction to the language, technique and concepts of the phenomenologic school. It is not intended to substitute for a well­taught course in basic psychopathology, nor can it replace hours of pa­tient contact required to become a skilled clinician. It is a beginning.

The book is in two parts. Part I presents basic phenomenologic prin­ciples, the behaviors that comprise the major areas of concern in the men­tal status examination, some suggestion on how to conduct the examination and a brief exposure to behavioral relationships which lead to a clinicial diagnosis. Part II builds upon Part I. It develops and reinforces the items dealing with techniques, elaborates the phenomenologic principles of diag­nosis, presents diagnostic criteria which have been found to be reliable and valid in the classification of major mental disorder and presents data which aid in the delineation of those disorders.

This is a programmed book and not a comprehensive text. Reading it is not a passive experience. To gain from it, you must participate in the program. Filling in the blanks, drawing lines or circles are all part of the process of helping you learn not just from eye to brain but from hand to brain. Some items will seem absurdly simple and you will be able to rap­idly go through those parts of the program. More difficult parts will take proportionately longer. Some items present new information, some review old information or present old information in new forms. The sequence is important and has been developed so the correct response to any item is either within that item or within previous items. Each page of questions or test items will be followed on the next page by the correct answers to those items. If you make an error, read back into the text until you find the items that explain the correct response. Do not skip items, for

like the good mystery novel, if you read the last page first , the rest are partially ruined.

Unlike standard textbooks, this book cannot be of value if picked up for only a few moments at a time and then discarded for days or longer. Throughout the program, there are natural breaks, and pausing there wi best achieve your learning goals. When starting again, a brief review of past items will help put you in the proper "set" for reading new material. insure the correct response, always read the directions before attemptint to answer.

Although many of the statements in the text are referenced, addition I readings will be required to flesh out the concepts in the program and to document others further.

In my opinion, the best general English language text of adult psych· iatry is the book by Slater and Roth ( 1969). For the reader who does no; plan to specialize in psychiatry, this survey plus Woodruff, Goodwin and Guze's small, but well documented primer of Psychiatric Diagnosis (1974) should suffice.

For a more in-depth understanding of the phenomenological approach to psychopathology, Taylor and Heiser ( 1971) and Taylor (1972) should initially be read, followed by Hamilton's revisions of Fish's classic books. For those made of heroic stuff, Kurt Schneider's seminal work and Karl Jaspers' great General Psychopathology remain unsurpassed.

Further clinical descriptions, rich in detail and priceless in insight into the early development of clinical psychiatry, can be found in Bleuler' famous monograph ( 1950) on schizophrenia and in the more recent fascim­ilies of Kraepelin's lectures (1968) and treatises on dementia praecox ( 197 and manic- depressive illness ( 197 6) and Kahlbaum' s monograph on cat a­tonia (1973).

For a more in-depth presentation of neuropsychology, the Luria (197: and Golden ( 1978) texts should suffice as an introduction to the study of higher cortical functions. A discussion of the relationships between high• cortical dysfunction and psychopathology can be found in Pincus and Tuc ker's (1978) Behavioral Neurology. Slater and Beard ( 1963), Herrington ( 1969) and Benson and Blumer ( 1975) provide detailed discussions of the behavioral manifestations of coarse brain disease.

Bibliography

Benson, D.F., Blumer, D. (Eds.): Psychiatric Aspects of Neurologic Disease. New York, Grune & Stratton, 1975.

Bleuler, E.: Dementia Praecox or the Group of Schizophrenias, (Trans. Zinkin), Int. University Press, 1950.

Golden, C. J. : Diagnosis & Rehabilitation in Clinical Neuropsychology, Springfield, C.C. Thomas, 1978.

Hamilton, M. (Ed.): Fish's Clinical Psychopathology, Signs and Symptoms in Psychiatry, Revised Reprints, Bristol, John Wright & Sons, Ltd. , 1974.

Hamilton, M. (Ed.): Fish's Schizophrenia, Revised Reprints, Bristol, John Wright & Sons, Ltd. , 1976.

Herrington, R.M. (Ed.): Current Problems in Neuropsychiatry: Schizo­phrenia, Epilepsy, the Temporal Lobe. Brit. J. Psychiat. , Special Publication #4, Ashford, Kent. Headley Bros., Ltd., 1969.

Jaspers, K.: General Psychopathology, (Trans. J. Heonig and M.W. Ham­ilton), University Chicago Press, 1968.

Kahlbaum, K. L. : Catatonia, (Trans. Levy, Y. and Priden, T.), Baltimore, Johns Hopkins University Press, 1973.

Kraepelin, E. : Dementia Praecox & Paravhrenia, (Trans Barcley, R .M. ; Ed., Robertson, G.M.), Foes. 1919Edltion, Huntington, New York, R.E. Kruger Publishing Company, 1971.

Kraepelin, E.: Lectures on Clinical Psychiatry, (Johnstone, T. Ed.) New York, Hafner, 1968.

Kraepelin, E. : Manic-Depressive Insanity and Paranoia, New York, Arno Press, 1976.

Luria, A.R.: The Working Brain: An Introduction to Neuropsychology, New York, Basic Books, Inc., 1973.

Pincus, J.H., Tucker, G.J.: Behavioral Neurology, 2nd Edition, New York, Oxford University Press, 1978.

Schneider, K.: Clinical Psychopathology, (Trans. M. W. Hamilton), New York, Grune & Stratton, 1959.

Slater, E. , Roth, M. : Mayer Gross' Clinical Psychiatry, 3rd Edition, Baltimore, Williams & Wilkins, 1969.

Slater, E., Beard, A.W.: The Schizophrenia-like Psychoses of Epilepsy: 2. Psychiatric Aspects. Brit. J. Psychiat. 109:95-150, 1963.

Taylor, M.A., Heiser, J.: Phenomenology: An Alternative Approach To Diagnosis of Mental Disease. Compr. Psychiatry 12:480-486, 1971.

Taylor, M.A.: Schneiderian First Rank Symptoms and Clinical Prognostic Features in Schizophrenia. Arch. Gen. Psychiatry 26: 64-67, 1972.

Woodruff, R.A., Goodwin, D.W., Guze, S.B.: Psychiatric Diagnosis, New York, Oxford University Press, 1974.

Preface

Introduction

Part I

Basic Concepts Interview Considerations General Appearance, Motor Behavior

and Catatonia Affect Language Function (Thought Process) Delusions ( Apophany) Perception and First Rank Symptoms Cognitive Function Frontal Lobe Cognitive Dysfunction Verbal Memory Parietal Lobe Function Language Disorder Review Section Clinical Evaluations Phenomenologic Mental Status Outline Cognitive Function Evaluation Outline References

Part II

Introduction Diagnosis

Major Affective Disorder Schizophrenia

Diagnostic Criteria-summary Coarse Brain Disease Frontal Lobe Syndromes Temporal Lobe Syndrome Parietal Lobe Syndromes Anxiety States (DSM-Ill Term:

Anxiety Disorders) Minor Depression (DSM-III Term:

Dysthymic Disorder) Obsessional Conditions Hysteria (DSM-Ill Term:

Somatoform Disorders) Sociopathy (DSM-Ill Term: Antisocial

Personality Disorder) Alcoholism Clinical Evaluations References

Contents

2 8

12 36 48 94

108 136 146 162 174 194 224 240 264 265 266

273 274 276 302 328 340 356 370 384

402

434 440

444

460 468 478 500

The Neuropsychiatric Mental Status Examination

THE HUMORLESS SMILE CALLED "GRIMACE" SEEN IN CATATONIC PATIENT

T!-IE SAD EXPRESSION OF DEPRESSION