Mental Basic Examination at the first meeting (mbe)

The interview here outlined, which some European schools of psychiatry call assessment of present basal psychic functioning, is intended to provide a snap shot of the patients, a picture of them as they exist at one point in time. In fact, frequently several interactions are required, along with information about the patient's usual level of function, bias in reactions and communications, before you can come to any meaningful conclusions about their current condition. It is not conceived as a substitute of a psychiatric evaluation or the part devoted to the mind in the interview performed by neurologists, it is rather a guidance for young practitioners as well as non-specialists, and may be employed as a screening tool.

During the course of a common interview, in actual practice, most of the information relevant to assess a patient’s mental status is obtained indirectly. MBE, as a mind-bending of the aspects to test, provides a list of relevant issues to consciously think. It is a tool for self-training and a help for memory, because it prepares your mind to organize explicit memories into discrete subjects.

In the daily practice of clinical psychology or medicine and even throughout all of our interactions, we continually come across persons who have altered capacity for memory, slightly or significantly impaired cognitive abilities, disordered thought processes and otherwise abnormal mental status. The goal of the present protocol is to help to note when these abnormalities exist, avoiding that they might be missed and then to categorize them as specifically as possible. Sometimes physical conditions, as well as personality impairments or depressed level of consciousness, will preclude a complete, ordered evaluation of mental status, so flexibility is important. MBE is not tailored for the formulation of actual diagnoses (e. g. in DSM categories), which is the final step in a process starting by this protocol. Nevertheless, sometimes MBE can provide a provisional definition of a condition, as for Delirium Syndrome and Dementia.

Mental basic examination

Protocol

Appearance: How does the patient look? Neatly dressed with clear attention to detail? Well groomed?
Orientation or awareness of environment: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year?
Level of alertness and self awareness: Is the patient conscious? If not, can they be aroused? Is the patient aware of self-appearance, congruous or inadequate? Is the patient insight defective? Can they remain focused on your questions and conversation? What is their attention span?
Mood: How do they feel? You may ask this directly (e.g. "Are you happy, sad, depressed, angry?"). Is it appropriate for their current situation?
Affect: How do they appear to you? This interpretation is based on your observation of their interactions during the interview. Do they make eye contact? Are they excitable? Does the tone of their voice change? Common assessments include: flat (unchanging throughout), excitable, appropriate.
Behaviour: Pleasant? Cooperative? Agitated? Appropriate for the particular situation?
Speech: Is it normal in tone, volume and quantity?
Memory: Short-term memory is assessed by listing three objects, asking the patient to repeat them to you to insure that they were heard correctly, and then checking recall at 5 minutes. Long-term memory can be evaluated by asking about the patients’ job history, where they were born and raised, family history, etc.
Ability to perform calculations: Can they perform simple addition, multiplication? Are the responses appropriate for their level of education? Have they noticed any problems balancing their check books or calculating correct change when making purchases?
Thought Process: This is a description of the way in which they think. Are their comments logical and presented in an organized fashion? If not, how off base are they? Do they tend to stray quickly to related topics? Are their thoughts appropriately linked or simply all over the map?
Thought Content: A description of what the patient is thinking about. Are they paranoid? Delusional (i.e. hold beliefs that are untrue)? If so, about what? Phobic? Hallucinating (you need to ask if they see or hear things that others do not)? Fixated on a single idea? If so, about what. Is the thought content consistent with their affect? If there is any concern regarding possible interest in committing suicide or homicide, the patient should be asked this directly, including a search for details (e.g. specific plan, time etc.). Note: These questions have never been shown to plant the seeds for an otherwise unplanned event and may provide critical information, so they should be asked!
Judgment: Provide a common scenario and ask what they would do (e.g. "If you found a letter on the ground in front of a mailbox, what would you do with it?").
Higher cortical functioning and reasoning: Involves interpretation of complex ideas. For example, you may ask them the meaning of the phrase, "People in glass houses should not throw stones." A few common interpretations include: concrete (e.g. "Don't throw stones because it will break the glass"); abstract (e.g. "Don't judge others"); or bizarre.

Examples

Delirium Syndrome

Also referred to as Altered Mental Status, Delta MS, Acute Confusional State, or Toxic Metabolic State. This is a very common condition (particularly among hospitalized patients) notable for an acute, global change in mental status that can be the result of physiologic derangement anywhere within the body. Causes include: infection, hypoxia, toxic ingestion, impaired ability of the body to handle endogenously produced toxins (e.g. liver or kidney failure), etc.

There is a wide spectrum of presentations, ranging from unarousable to extremely agitated. Patients may appear quite ill, with markedly abnormal vital signs that in themselves can suggest the cause of the delirium (e.g. hypotension, infection). They are frequently confused, disoriented, agitated and uncooperative. Formal evaluation of mood, affect, memory, judgment or insight can be hopeless. Thought process is disordered and content notable for delusions, paranoia and hallucinations. In general, the diagnosis is suggested by the time course of the illness (i.e. the change is acute).

Treatment is dictated by the underlying insult, which can generally be determined after a detailed history (usually with the help of others who are familiar with the patient), review of medications, thorough examination, and appropriate use of lab and radiological testing. The elderly as well as those with multiple medical problems (conditions which frequently coexist) are at the highest risk for developing this condition. Delirium in this patient sub-set can be provoked by seemingly minor precipitants. Initial presentation of psychotic disorders as well as dementia can be mistaken for delirium (and vice versa). This can only be sorted out with time and appropriate testing, though these distinctions are extremely important.

Dementia

A final common pathway for multiple disorders characterized by its slow, progressive nature, taking months to years to develop. While quite uncommon under 50, the incidence increases markedly with age.

Patient's appearance and behaviour vary with the extent of involvement. This ranges from well groomed, alert and cooperative to agitated, unable to care for themselves and incapable of answering even simple questions. Mood and affect can range widely, and may or may not be appropriate for the given situation. Thought process and content have similar variability. Memory, judgment and higher cortical function deteriorate with time. As this is a progressive disease, presentation will depend on the level of advancement. Contributions from other acute, reversible medical problems must be ruled out on the basis of history, examination and laboratory testing.