in the eighth and final section of the mental status examination training we will learn about psychosis my name is Tom field and I produced and narrated this training series let's return to the overview in this training series we have learned via a scaffolding process in this section of the training we will learn about psychosis and during guided practice activities we will review affect and mood thought process memory motor speech into personal and intrapersonal issues at the conclusion of this eighth section is the end of training test I encourage you to follow the handout as we progress you can use scrap paper for guided practice there's also a sheet available for this and there will be occasions when viewing guided practice video case studies when a section of the mental status examination is not fully evident and on those occasions it is okay to indicate unable to assess the definition of psychosis is beliefs and perceptual experiences that are idiosyncratic not experienced by others and outside the realm of realistic possibility psychosis includes both delusions and hallucinations the definition of a delusion is a fixed belief that is experienced as odd strange or eccentric by others and outside the realm of realistic possibility this belief is associated most commonly with schizophrenia the definition of Hallucination is a sensory perception that is not experienced by others this sensory perception is associated with schizophrenia but also bipolar disorder depression delirium and substance abuse there are forms of hallucinations that are sleep related hypnogogic hallucinations occur when an individual is falling asleep hypnopompic hallucinations occur when an individual is Awakening from sleep and if an individual only has hallucinations when falling or Awakening from sleep these hallucinations might be considered normal or typical the delusions explored in this section of the training include bizar control Grandeur infidelity persecution reference and aotto manic delusions the types of hallucinations explored in this section of the training include responding to internal stimuli not cover covered in depth but important for you to know about are types of hallucinations these corresp respond to the five aspects of the human sensory system auditory which uh have to do with hearing for example hearing voices visual hallucinations which have to do with vision for example seeing um an image of something that isn't really there Al Factory hallucinations which have to do with smell for example the smell of burnt toast say gustatory hallucinations which have to do with taste for example the taste of milk and tactile hallucinations which have to do with touch a common tactile Hallucination is the feeling of spiders running up and down the skin usually you won't be able to tell which kind of hallucinations a client is experiencing without their verbal disclosure the obvious exce exception to this is tactile hallucinations when a client May itch or scratch frantically note that even in this example the individual may also experience tactile hallucinations without scratching so a verbal disclosure is usually required thus counselors should ask directly about hallucinations similarly as they would for suicidal adiation and that's the reason we are not covering these five aspects of hallucinations in depth through video case studies because typically these are not indicated on the mental status examination unless unless the client gives a verbal disclosure that they are experiencing one of these things genuine hallucinations are typically frightening to the individual whereas pseudo hallucinations are not the latter is associated with malingering personality disorders and substance abuse as an aside be attentive to any reports of olfactory or gustatory hallucinations these can be symptoms of stroke or brain tumors a famous example is when a person smells smoke that is not really there not covered in this section of the training in depth but important for you to know about is appearance appearance has two major facets grooming and dress both exist on a Continuum from low level to high level for grooming at low level grooming is unkempt or disheveled a high level of grooming is immaculate and a balanced level of grooming is well groomed for dress a low level of grooming is underdressed and a high level of grooming is overdressed and a balanced level is appropriate dress appearance is often its own section in mental status examination assessments however the the reason that we are not covering this in depth through video case study is that in my clinical experience appearance has only been of clinical interest when a client is unkempt or disheveled which is usually associated with psychosis or developmental disability while Immaculate and overdressed clients may be hypothesized to be conceited or compulsive I have found that this is rarely the case as an aside when a client is underdressed it becomes clinically important especially when paired with flirtatious or regressed behavior here is an example of what to write if no psychotic symptoms are apparent the client's appearance was well groomed with appropriate dress the client denied symptoms of psychosis hallucinations delusions note here that the client deny meaning that the interviewer or the clinician asked so let's explore psychosis in a bit more detail through some through some video case studies a bizarre delusion is described as a fixed belief outside the realm of realistic possibility this belief is strange odd and eccentric to others so I'm still trying to understand what exactly you meant when you said that you're half donut and half human it's the same thing my dad made me in the donut shop so yeah I'm a person but where I started was in the middle of all these donuts and how does that make you half donut and half human because my dad had made half of me this client's defensive rationalization of a bizarre and odd belief of being half woman and half donut seems flimsy yet they themselves are convinced of such an eccentric belief and it is this degree of being convinced of the belief that makes it a delusion a controlled illusion is described as an individual's fixed belief that their will or thoughts or feelings are being controlled by someone or something else um so this is what's going on aliens are trying to get into my brain they haven't gotten completely but they put a microchip in there and they're I think they're trying to control my thoughts but it's not um I'm not really sure what's going on yet I've been trying to communicate with them um and I actually get better reception through the chip if I'm higher up like if I'm in a really high building or something like that that's why can spend a lot of time on the roof this client believes their thoughts are controlled by aliens and the strength of their belief has resulted in changes to their behavior for example they believe that elevation is a means to access communication with aliens and so they've been spending a lot of time on the roof and you can see here how the client's degree of um being convinced in their belief causes real life changes to their behavior and actions Grandeur delusion is described as an individual's fixed belief in their elevated sense of importance or power or specialness let's watch an example in fact you know I've been working on this this writing for some time and and and I'm really I really believe that I I could win this Nobel Prize I've gotten lots of great feedback from other people and you know I've tried to talk with my girlfriend about it she just doesn't get it she doesn't see how great of a writer I am and and how much uh I have to offer and and how close I am to winning this Nobel Prize and this example the client believes or is convinced that they are going to receive an outlandish award for their work and their degree of elevated specialness in regards to their work is well defended for example the client mentions that several others have commented on how good his work is but the PE person who uh is fairly critical and by the way this is probably the person who knows the client best their girlfriend has doubts and these doubts are rejected because they are not consistent with their delusional belief remember delusions are firmly held beliefs infidelity delusion is described as an individual's fixed belief that their partner or lover is being unfaithful to their relationship I'm convinced Steve is cheating on me this week he didn't return my calls it was three and he had I he didn't return my calls for three hours and I know he was at work so I know he was available is it possible perhaps that when he didn't return youi he was just busy at work no I I I really think he's cheating on me you know I know if he wasn't cheating on me he would have return my calls he always returns my calls this client infers that because they have not received return phone calls at work from their husband that he is cheating on her the attempts of the interviewer to interrogate this are met with resistance because of the strength of the client's belief of course if a husband really was cheating then this would not be a delusion a persecution delusion is described as an individual's fixed belief that they are being harassed or persecuted by others let's watch an example I I know that the that the FBI is monitoring me I know that they've put bugs in my in my apartment in my lights and things I just haven't found them yet they're they're really small and they're really difficult to find and and I know they're listening to my conversations I can hear that click when I pick up the telephone and and and and I know that they're they're tapping my phone and and and every time I leave the house a car follows me the car on the corner is not always the same car but I know I know that it's the FBI following me this client experiences a very common example of a persecution delution she believes the FBI are tapping her phones and following her in a parked car this kind of fear can have a large impact on a person's functioning clients with a this kind of persecution delusion May for example refuse to talk on the phone or refuse to leave the house a reference delusion is described as an individual's fixed belief that unrelated events in the external environment are special messages that have a direct personal significance and relevance to them I was watching the the news last night and there was a story on about um the war in Syria and they were talking to this Soldier about the war and then at the end of of the story the reporter said to him be careful out there and I knew that he was talking to me I knew that he was talking to me about work and that that meant that I need to watch my back because Joe is going to to try to to make it look like I'm not doing my job so that he can take my job this client infers that the news reporter statement be careful out there is directly related to their own personal life for example a warning that a coworker will try to take their job referenced delusions are also called ideas of reference in the literature erotomanic delusions are described as an individual's fixed belief that someone else is in love with them or wants to have sexual intercourse with them to be classified as a delusion this has to be unrequited let's watch an example so I noticed when I come in that your receptionist she's just really eyeing me up looking at me I think she really likes me I think she got a thing for me uh you know I can just tell that she's really attracted to me you know we have talked about this before um the she really doesn't have those kinds of feelings for you now how would you know that I I I beg to differ this client refers that a infers that a receptionist has made romantic feelings for him or has romantic feelings for him based on glances that she has given for example eyeing me up again attempts by the interviewer to interrogate this are met with resistance because of the strength of the client's belief responding to internal stimuli it's described as when an individual seems to be attentively listening and responding to sights and sounds in their external environment that others do not see or hear let's watch an example yeah yeah no I think [Laughter] [Music] so yeah this client seems to be having a conversation with someone not not in the room actions such as laughter nodding and shaking one's head independent of an interpersonal interaction may suggest that a person is hearing sensory input that others do not experience as an aside it is rare for clients to respond to internal stimuli that is not an auditory hallucination for example it is rare for a client to verbally respond to visual or factory gustatory or tactile hallucinations independent of interpersonal context it's now time for you to try your hand at coding for psychosis on the mental status examination in the following series of video case studies you are going to be coding for affect mood form of thought attention and speed of thought memory Consciousness speech interpersonal trap personal and appearance and remember for appearance you coding for both dress and grooming in addition you are also going to code for psychosis looking at delusions and responding to internal stimuli let's watch the first video I'm just so tired of my teacher making all of these tests hard just so that I will fail I know that's what he's doing it doesn't matter matter about the rest of the students but he makes the exams so difficult that all of the questions I can't even possibly pass the test because of how he tricks tricks us on the questions and I know he's doing it because he doesn't like me doesn't matter about the rest of the students pause the video now and assess the client for affect mood form of thought attention and speed of thought memory Consciousness speech interperson intrapersonal appearance and psychosis this client has a blunted or flat a effect their mood seems dysphoric in terms of thought process they have some loose associations there is a very vague connection made between the difficulty of a test and their teacher somehow wanting to persecute them in terms of attention there is some possible rumination here in terms of motor movement it seems relaxed not agitated despite the irritability we are unable to assess memory at this time speech seems regular rate and Rhythm we are unable to assess interpersonal issues the client may be cooperative defensive dismissive even contemptuous we don't know yet because we haven't seen the client's interaction with the interviewer the client appears to be catastrophizing somewhat her appearance seems well groomed with appropriate dress and she is experiencing a persecution delusion because she believes that the instructor is out to get her let's watch the second video case study I'll tell you how I know Donnie's been cheating on me when Donnie comes home the dog gives me a wink and when the dog gives me a wink I know Donnie's done something wrong and when the dog gives me a wink I know it's a sign he's giving me a sign that Donnie's done something wrong pause the video now and assess the client for affect mood form of thought attention and speed of thought memory Consciousness speech interpersonal intrapersonal appearance and psychosis this client has a blunted or flat effect their mood seems to be euic in terms of thought process they seem to have loose associations their form of thought we are unable to assess memory at this time their motor seems relaxed their speech is regular rate and rhythm there is some possible defensiveness although we could code unable to assess for interpersonal because the client starts with quote I'll tell you why no intra personal issues were apparent her appearance seems well groomed with appropriate dress and she is experiencing a reference delusion because she interprets the dog winking as a sign that Donnie has done something wrong let's watch the third video case study no no no pause the video now and assess the client for affect mood form of thought attention and speed of thought memory Consciousness speech interpersonal intrapersonal appearance and psychosis the client's affect here is again blunted and flat she seems concerned almost dysphoric for her mood we are unable to assess her form of thought and in terms of attentions she does seem preoccupied we are unable to assess memory her motor seems Restless we are unable to assess speech she may possibly be laconic there's also possible hypervigilance in terms of interpersonal because she looks around the environment a lot though this would be differentially uh diagnosed from responding to internal stimuli and so we I would code unable to assess here we are unable to assess inpersonal issues her appearance is well groomed with a appropriate dress and she is appears to be responding to internal stimuli as an aside her preoccupied attention seems to be linked to responding to the internal stimuli because she looks around the room and responds to what cannot be heard it she appears to be somewhat preoccupied in terms of her thought process let's watch the final video case study I started writing letters again this week to Leonardo DiCaprio I know that he he wants me to write these letters I I sent out maybe five a couple of weeks ago and and I didn't hear anything back but I know that he feels the same way and that he keeps all my letters and I know he wants me to keep writing to him pause the video now and assess the client for affect mood form of thought attention and speed of thought memory Consciousness speech interpersonal intrapersonal appearance and psychosis this client has a full and congruent affect their mood seems earmic they appear to have a somewhat logical form of thought in terms of room their attention they seem to have some possible rumination they seem to be a bit obsessional about Leonardo DiCaprio however we would need more information here their motor seems relaxed or even hypoactive their speech is regular rate and rhythm we are unable to assess memory although this might be intact she mentions keeping all of his letters we are unable to assess interpersonal issues there might be possible grandiosity here by the way in terms of intrapersonal because the client seems to have some feeling of perhaps specialness in terms of her relationship with a celebrity although we would need to investigate this further so unable to assess for in personal her appearance seems well groomed with appropriate dress and she is experiencing an erotomanic delusion because despite the lack of um reciprocity from Leonard DiCaprio her love is unrequited so to say she has a very firm belief that this celebrity is in love with her so let's review today we learned about psychosis and explored delusions bizarre control Grandeur infidelity persecution reference and aoom manic hallucinations responding to internal stimuli types of hallucinations that has to do with the five sensorium auditory visual olfactory gustatory and tactile hallucinations and appearance looking at both grooming and dress