Module 3 - Assessment of Mental Health for People with an Intellectual Disability

The Mental State Examination

Appearance and Behaviour This section describes the appearance of the person at the time of assessment. It looks at things like grooming; hygiene; clothing including shoes; hair; nails; build; tattoos; other significant features such as body piercing It also looks at the person’s behaviour and considers whether they were appropriate, did they concentrate? Was their manner hostile, friendly, withdrawn, guarded, co-operative, uncommunicative or even seductive?

Motor Activity This looks at a person’s level of activity and movement. Is the person restless/ Do they have any repetitive behaviours? Are they overactive? Is there any tremors or hand-wringing? Any bizarre movements? Are they not moving much at all?

Speech The physical aspects of speech can be described in terms of rate, volume and quantity of information (e.g. slow, rapid, monotonous, loud, quiet, slurred, whispered). Some particular characteristics of speech that you might consider are: Mute Total absence of speech, often associated with depression or post- traumatic stress Poverty of speech Restricted amount of spontaneous speech. Replies to questions are brief or monosyllabic. Pressured speech Speech is extremely rapid, difficult to interrupt, loud & hard to understand.

Mood and affect Mood is the medical term for a person’s internal feelings and emotions which affect their behaviour and their perception of the world. The person will often describe their internal mood state (e.g. depressed). Affect is the external emotional response to the underlying mood and the environment, and is described in terms of what is observed (e.g euphoric, silly, labile, suspicious, fearful, hostile, anxious, irritable). The affect may be incongruous where the emotional response is not appropriate to the subject matter being discussed.

Form of Thought Assessed according to: Amount of thought and its rate of production (e.g. poverty of ideas, flight of ideas, slow or hesitant thinking, vague). Continuity of ideas. Refers to the logical order of the flow of ideas. Individuals may or may not be able to stick to the topic of conversation. They may digress into irrelevant conversation, completely lose their train of thought, or talk ‘around’ the topic (e.g. Refer to following box which explains some of the terms used in relation to this). Disturbances in language. Refers to the use of words that do not exist (neologisms or word approximations) or conversations that do not make sense (incoherence). Here is a link to some of the more common forms of thought disorder. THOUGHT DISORDER

Thought Content Delusions are false beliefs that are firmly held despite objective and contradictory evidence, and despite the fact that other members of the culture do not share the same beliefs. There are numerous types of delusions, some of which tend to be associated with different disorders. Here is a link to some types of delusions that clinicians may need to be familiar with: DELUSIONS Suicidal thoughts The individual needs to be asked about suicidal thoughts, especially if there are symptoms of depression (even if mild). If suicidal thoughts or intentions are reported, an urgent referral to a psychiatrist, GP, or Area Mental Health Team must be made and recorded. Other Includes obsessions, compulsions, anti-social urges, phobias, intentions, hypochondriacal symptoms and preoccupations (perhaps with illness). If any of these characteristics are prominent they are recorded in this section.

Perception Hallucinations An hallucination is a false sensory perception in which the individual sees, hears, smells, senses or tastes something that occurs in the absence of an appropriate external stimulus. Hallucinations are not necessarily associated with a psychotic disturbance and can occur when falling asleep (hypnagogic hallucinations), when waking up (hypnopompic hallucinations) or in the course of an intense religious experience. The type of hallucination and the content should be described. An auditory hallucination is probably the most common type of hallucination, and the other modailties most commonly occur in organic mental disorders but may be a part of any psychosis. Here is a link to more detailed information : TYPES OF HALLUCINATION AND OTHER PERCEPTUAL DISTURBANCES

Sensorium and Cognition Level of consciousness Consciousness is our state of awareness of ourselves and external world. Impairment of consciousness usually indicates organic brain disease. Memory There are three main areas of memory: immediate, recent and remote. A clinical psychologist or neuropsychologist is most able to assess formally for memory problems. If problems are detected at this level, a referral to a neurologist will be made, a GP referral is also advisable. Deficits in memory may indicate head injury, organic brain disease or dissociative states (e.g. a result of post-traumatic stress). Orientation Obvious disturbances in orientation are usually indicative of organic brain disease. The commonly used categories for assessment of orientation are time, place and person. Impairment usually develops in this order, and, if treatable, usually clears in the reverse order. Concentration Concentration may be assessed by asking the person to complete a task - such as making a cup of tea. This task is only necessary if you suspect that there is some degree of impairment. Performance anxiety, mood disturbance, an alteration of consciousness may interfere with the task. Abstract thoughts Abstract thinking involves the ability to: deal with concepts; extract common characteristics from groups of objects; juggle more than one idea at a time; and interpret information. Abstract thinking may be assessed by asking the individual to interpret the meanings of common proverbs (e.g. a bird in the hand is worth two in the bush). Care needs to be taken when using proverbs with different cultural groups. A lack of abstract ability is often associated with organic brain disease or thought disorder. This is less applicable to people with ID as they tend to be more concrete in their thinking.

Insight Insight is often understood as a person accepting that they have a mental illness and require treatment (if this is the case), however it is a more complex concept than this. Insight can be defined not only in terms of people's understanding of their illness, but also in terms of their understanding how the illness affects their interactions with the world. Insight is affected by numerous internal and external variables and, like any process involving thought and emotion, may be affected by the presence of mental illness.