Outline of Topics

General Overview

Summary of Exam

I. Level of Consciousness

II. Attention

III. Memory

IV. Intellectual Functions

V. Language Functions

VII. Psychosensory Functions VIII. Psychomotor Functions

IX. Constructional Ability

X. Higher Cognitive Functions

XII. Related Cortical Functions

XII. Thought Content

XIII. Behavioral Observations

XIV. Mood & General Emotional Status

XV. Emotional Reactions

1. Aids in identifying or ruling out gross cerebral dysfunction.
2. Careful observations may raise questions which warrant closer investigation.
3. Impaired behavior may be the result of physical or psychological factors or some combination thereof.

a. if physical may be lateralized and/or focal.

4. Mental functions are commonly disturbed by neurologic disorders.

a. May reflect brain damage
b. Emotional threat of illness
c. Maladjustment
d. Interaction

(1) psychological factors can augment physical symptoms.
(2) same for generalized systemic disorders.

e. Mental functions reflect the state of the entire .organism.

(1) brain more sensitive.

f. Many functions may be disturbed by involvement anywhere in the brain, however, there are "essential areas" which are of greatest sensitivity to loss.
g. Complex integrative areas are most sensitive to damage.
h. Loss results in adaptive strategies, such strategies may be so effective as to mask the deficit for a time.

(1) Flexibility reduced and tolerance to stress is decreased.
(2) Alcohol, drugs, systemic infection, aging, etc. can serve to render compensated losses more visible.

i. Dissolution of Mental functions.

(1) implies loss from complex to simple behaviors.
(2) continuum.

1. Be alert for cues as to Mental Function.

a. Language
b. History
c. Symptom description
d. Jocularity and/or impatience - cover up?
e. Dress

2. Relate behavior to educational and socioeconomic background.
3. Consensual validation from friends.
4. Look for change and investigate.
5. Remember - all behavior is composed of the results of the total functioning organism.

1. OBS - little clinical utility - vague and overly inclusive.
2. Neuro-behavioral assessment - becoming more common.
3. Dementia, aphasia, confusional states, and learning disabilities.
4. Dementia - 3rd most frequent in all neurology patients.

1. Patients with documented brain lesions such as tumors, trauma, vascular accident, etc., should minimally have screening mental status exam to document cognitive or emotional changes.
2. Many patients unfortunately released from the hospital without clear picture of functions.
3. Patients with suspected brain lesion because of recent seizure, headache, behavioral change, or head trauma.
4. Cerebral dysfunction frequently presents initially as emotional and behavioral change.
5. All psychiatric patients should have mental status exam.

a. Depression most commonly seen with frontal and temporal tumors, hydrocephalus, or cortical atrophy.
b. Particularly important in patients late in life without reactive events.

6. Patients have vague complaints - memory, concentration, declining interests, various physical complaints without organic etiology.

SUMMARY OF MENTAL STATUS EXAM

1. Level of Consciousness

a. Reaction to Stimuli

(1) Verbal (auditory)
(2) Visual
(3) Tactile
(4) Painful

b. Attention Span
c. Confusion
d. Drowsiness
e. Stupor
f. Semi-coma
g. Deep-coma

2. Attention

a. Alertness
b. Shifting attention
c. Sustained attention
d. Directed attention
e. Vigilance
f. Inattention
g. Neglect

3. Memory

a, Acquisition
b. Retention
c. Recall

(1) spatial (visual)
(2) digits
(3) paired associates
(4) prose

(a) short-term
(b) long-term

d. Past memory

4. Intellectual Performance

a. Orientation

(1) Person
(2) Place
(3) Time

b. General Information
c. similarities
d. Arithmetic calculation
e. Vocabulary usage
f. Spatial perception

5. Language function

a. Comprehension
b. Speech
c. Reading
d. Writing
e. Writing from dictation
f. Naming objects
g. Spelling
h. repetition of verbal statements

6. Expressive Language Functions

a. Respiration
b. Phonation
c. Articulation
d. Resonance
e. Melody
f. Spontaneous level

7. Psychosensory Functions

a. Agnosias
b. Body scheme
c. Time perception
d. Space perception

8. Psychomotor Functions

a. Apraxia
b. Perseveration (type)
c, Compulsive acts
d. General motility
e. fine motor functions
f. grip
g. Motor sequencing
h. balance

9. Constructional Ability

a. Visual/motor functions (eye-hand coordination)
b. reproduction of 3-D blocks
c. Block designs
d. Reproduction of drawings
e. drawings on command

10. Thought Content

a. Mood
b. -worries
c. Fears
d. Pre-occupations
e. Somatic concerns
f. Insight
g. Fixed ideas
h. Delusions
i. Illusions
j. Hallucinations

11. Emotional Reaction

a. Tense
b. Hostile
c. Depressed
d. Euphoric
e. Inappropriate
f. Negativistic
g. Bizarre
h. Outbursts

12. Dominance
13. Handwriting

I. Level of Consciousness

1. Consciousness determines patient's ability to relate to environment.
2. Difference between content of consciousness and basic arousal:

a. Content - higher cortical functions.
b. Basic arousal - RF activation of cortex.

3. Awareness of Surroundings;
4. Key is responsiveness to stimuli.
5. ARAS and DTPS
6. Coma may result from biochemical changes without cor-responding tissue destruction.
7. General observations.

a. level of consciousness may be reduced by neurologic psychological factors.

somnolence
stupor
semicoma
deep coma

Deep coma (Grade 4)

a. Little or no response to any stimulus
b. generally limited to deep pain
c. Flaccid musculature
d. incontinent
e. Stretch reflex, Babinski and corneal reflex disappear
f. respiration are periodic and pulse rapid.

Semicoma (Grade 3)

a. Organized withdrawal to painful stimuli
b. Similar response to persistent tactile stimuli.
c. Stimulus bound responding.
d. Incontinence
e. Reflexes present
f. Spontaneous movements are uncommon unless patient is aroused.

Stupor (Grade 2)

a. Considerable spontaneous movement.
b. Respond to pain and intense stimuli.
c. May give combative response or withdrawal.

Somnolence (Grade 1)

a. Roused by various stimuli and make appropriate motor and verbal responses.
b. May be clear mentally but often confused.
c. Illusions, delusions, hallucinations or delirium is common.

Confusion

a. Impaired responses to environment.
b. Responses are slower, restricted and less adaptive.
c. Thinking and memory impaired.
d. Delirium - condition in which illusions, hallucinations and panic are combined with confusion.
e. May be hyper-reactive or apathetic-
f. disoriented as to time, placer person.

Motor Status

a. Highly variable
b. Hyperkinetic activity seems more common in acute febrile or toxic diseases than with increased intracranial pressure.

Vegetative Activity

a. ANS - most intensely disturbed in deep coma. (BS-lesion).
b. Body temperature frequently elevated
c. Hypothermia frequent with toxic origin.

Pseudo-wakeful states

a. Mute, fails to orient to stimuli
b. Toxic origin or focal lesions.

1. Call name.
2. Call name in loud voice.
3. Light touch to arm.
4. Vigorous shaking of shoulder.
5. Painful stimulation.
6. Record:

a. Degree and quality of movement,
b. Content and coherence of speech.
c. Presence of eye opening and eye contact.
d. Response to cessation of stimulation.

1. Parimedian portion of brain stem of RF.
2. Reticulo-cortical damage - coma but brain stem nuclei intact - eyes open.

a. Occlusion of brain stem vessels from basilar artery.
b. Orbital and cingulate lesions - akinetic and mute but appear much more alert.

3. Locked-in syndrome - damage of upper pontine tegmentum - separates cortex from motor cortex.
4. 1%-of coma cases hysterical.

II. Attention

1. Alertness - basic arousal
2. Attention - ability to attend to a specific stimulus.

a. Alert but inattentive patient will be easily distracte6.

1. observation - check alertness and behavior.
2. History
3. Digit Repetitions

a. Forward (5-7)
b. Backward (3-4)

4. Vigilance

a. Read long series of letters, Whenever you hear the letter A indicate by tapping desk with pencil.

5. Inattention and Neglect (suppression or extinction).

a. -Test in sensory examination.

1. ARAS and DTPS - (Arousal) or Activation
2. Attention may be balance between ARAS and Cortical inhibition of ARAS.
3. Diffuse Brain Dysfunction is major cause of inattention
4. Korsakoff's may do digits but have trouble with vigilance task.
5. Right hemisphere lesions have greater effect on attention than left hemisphere lesions.
6. Parietal damage causes suppression probably due to the reduced reticulo-cortical interaction on the damaged side.

III. Memory

1. Most common initial complaint of cerebral dysfunction.

a. Also associated with depression.

1. Registration or reception ( and short-term storage).
2. Retention or storage (enhanced by repetition).
3. Recall or retrieval.
4. Immediate - digits.
5. Recent - day-today events.
6. Remote - long-term.

1. WAIS digits - short-term memory (immediate recall).
2. Orientation - WAIS
3. Remote memory
4. New learning

a. 4 unrelated words (brown, honesty, tulip, eyedropper)
b. Verbal stories for immediate recall.
c. Visual memory (hidden objects).
d. Visual memory for designs.
e. Paired associate learning.

1. Immediate recall - language cortex or basic processing area in cortex.
Digits - requires language cortex.

(a) Any aphasia will disrupt.

1. Hippocampus, mammillary bodies, and thalamus important subcortical links.

(a) Limbic damage disrupts storage.
(b) Secondary to bilateral temporal lobectomy herpes simplex encephalitis and bilateral hippocampal infarction.
(c) Korsakoff's syndrome.

2. Presenile dementia.
3. Traumatic injury.

(a) Retrograde amnesia.
(b) Temporal lobes frequently concussed against the bony confines of the middle fossa.

4. Most episodes of transient global amnesia are temporary.

1. Hysterical Neurosis - can learn new material.
2. Ganser syndrome - pseudo-dementia, prisoners and psych. patients with head trauma.

(a) approximate answers to questions.
(b) Characterized by inconsistent responses.

IV. Intellectual Functions

1. Limited attention span
2. Difficulty answering specific questions
3. General observations

a. Establish estimate of premorbid level.

(1) school
(2) employment

b. Difficulty following directions.
c. Perseveration.

4. Memory

a. Recent
b. Past

5. General Information
6. Retention (digits).
7. Calculation

a. 7 from 100..
b. x without carry
c. x with carry

8. Similarities
9. Judgment

a. Proverbs
b. Oral or written story

V. Language Functions

1. Four major components - listening, speaking, reading, and writing.
2. linguistic vs.- Non-language
3. Emotional speech - often relatively automatic.
4. Propositional speech - expression of ideas.

1. Ability to recognize, retain and comprehend language.
2. Association learning.

1. Second language component developed by the child.
2. Propositional speech - most likely impaired by brain dysfunction.

1. Specific language disturbance is pathonomic for cerebral damage.
2. Language disturbance can impair many secondary behaviors (i.e. calculation, digits, verbal memory).

1. Dysarthria - disorder of articulation in which basic language (grammar and word choice) is intact.
2. Dysprosody - interruption of speech melody.

a. Resulting speech - monotonal, halting, mimic foreign accent at times.

3. Buccofacial apraxia (oral) - inability to carry out skilled movements of the face and speech apparatus but with normal comprehension and muscle strength.
4. Aphasia 7 language disturbance with error of grammar and word choice.
5. Alexia - reading inability.

a. Loss in previously literate person.
b. Dyslexia - specific developmental learning disorder.

6. Agraphia - acquired disturbance in writing.

1. observe spontaneous speech, comprehension, repetition and naming.
2. Reading and writing - evaluated next.

1. Ask which hand is dominant.
2. Check early history.
3. Get responses on lateral dominance exam.

1. Elicit responses to general questions, "Why in hospital?", "Tell about your work."

a. Is speech output present?
b. Is speech dysarthric or dysprosodic?
c. Any evidence of specific aphasia errors.

2 . Types of errors

a. Non-fluent aphasia b. Paraphasia - abnormal words

(1) word substitution - pen for car.
(2) literal paraphasia - lar for car

1. Ask yes-no questions.
2. 'Point to single objects in the room.
3. Aphasia screening test.
4. Token test.

1. Ask patient to repeat:

a. Ball
b. Help
c. Airplane
d. Hospital
e. Mississippi River
f. The little boy went home.
g. We all went over there together.
h. Let's go downtown for ice-cream.
i. The fat short boy dropped the china vase.
j. Each fight readied the boxer for the championship bout.

1. Confrontational naming - colors, body parts, room objects, clothing, parts of objects.

a. Some aphasics have difficulty naming objects in a specific category.

1. Strongly related to educational background.
2. Test both oral reading and comprehension.

1. Write letters and numbers to dictation.
2. Names of common objects.

Clinical Implications

A Cerebral Dominance

1. 90% population - right handed (99% L.H. dom.)
2. 40% Left handed - Left hemisphere dominant.

1. Global Aphasia - few words or sounds

(a) Comprehension absent or reduced.
(b) Large lesion.
(c) Hemiplegia - associated with it.

2. Broca's Aphasia

(a) Non-fluent, dysarthric, effortful speech.
(b) Utters mostly nouns and verbs. (telegraphic or agrammatic speech)
(c) Usually right hemiplegia.
(d) Significant emotional change, frustration, aggravation and depression.
(e) Adjust better due intact comprehension.

3. Wernicke's Aphasia -

(a) Fluent, effortless, well articulated speech with paraphasia, and often devoid of substantive words.
(b) Severe disturbance in auditory comprehension
(c) The more severe the auditory comprehension-the more likely that the lesion involves Wernicke's area.
(d) If single word comprehension is good yet complex is impaired-lesion more likely in parietal cortex.
(e) No hemiplegia.
(f) Often thought initially to be psychotic.
(g) Often unaware of deficit and talk endlessly.

1. Fluent yet halting speech, word finding pauses, and literal paraphasia.
2. Reading good but writing shows errors in spelling, word choice, and syntax.
3. Lesion in arcuate fasciculus.

1. Word finding difficulties.
2. Limited localizing significance.
3. Most severe in patients with lesions in 2nd and 3rd temporal gyri.

1. Intact repetition of spoken language but disturbance of other language functions.

(a) Can comprehend and read well with transcortical motor aphasia but restricted speech.
(b) Transcortical sensory aphasia-repeats but doesn't comprehend.
(c) Tendency to be echolalic.

2. Caused by infarcts within the border zones between major vessels.

(a) Sensory-posterior border zone infarct (inverse C).
(b) Spare superior temporal and inferior frontal and parietal perisylvian.
(c) Spared perisylvian cortex is all that is necessary for accurate language repetition.

3. Most common causes:

(a) Anoxia secondary to decreased circulation as seen in cardiac arrest.
(b) Occlusion of carotid artery.
(c) Anoxia due to carbon monoxide poisoning.

1. Patients don't have aphasic speech, agraphia, or alexia but have total lack of comprehension for speech.
2. Wernicke's area alone is damaged.

1. Caused by lesions to muscles of articulation, Broca's area, basal ganglia, striate or pontine lesions bilaterally or bulbar lesions.
2. Can communicate via reading and writing.
3. Buccofacial apraxia may be caused by various lesions between the supra-marginal gyrus and frontal cortex.

(a) Lesions disrupt motor sequencing.

4. Dysfluency (stuttering) not aphasia, apraxia, or dysarthria (etiology unknown).

1. Angular gyrus.

1. Caused by lesions in Wernicke's, angular, Broca's areas.

1. Rambling, disjointed, neologistic language seen in psychosis, dementia (organic) and fluent jargon aphasia.
2. History important.
3. Refer for complete language testing.
4. Ideational apraxia present in demented not psychotic.

1. Neurotics - convert anxiety into halting, effortful telegraphic speech.
2. Acute aphonia - no speech. Gesture, mouth words, write.
3. Elective mutism - refusal to speak.

VII. Psychosensory Functions

1. Agnosia - failure to recognize familiar objects

a. Association areas required for recognition.
b. Sensory area receives stimulation which has no meaning
c. Stereognosis
d. Agnosia for body parts
e. May recognize total object but not parts.

2. Agnosia - denial of disease.

a. Inferior parietal - body sense.

3. Autotopagnosia - disturbance in recognition of body parts.

VIII. Psychomotor Functions

1. Examine patient's ability to conceive, formulate and execute complex, purposive, skilled, volitional acts.
2. Such behavior requires 3 steps

a. Develop concept or idea as to what is desired and retain it to completion.
b. formulation of organizes plan to accomplish the desired act.

(1) knowledge of location of body parts
(2) relationship to surroundings
(3) mental image formed which is transmitted to motor system.

c. Execution of the details of the plan

(1) requires skilled movements

3. Ideational Apraxia

a. Inability or failure to comprehend, develop or retain the concept of what is desired (resembles extreme absent mindedness).
b. difficulty with sequential ideas (Token).

4. Ideokinetic Apraxia (Ideomotor)

a. Break in transmitting idea into appropriate motor act.
b. lesion in temporal, parietal, occipital area.

5. Kinetic Apraxia

a. Premotor cortex lesion
b. No weakness but loss of sequential responses.
c. Luria's tests.

6 . Testing

a. Touch own nose (gesture)
b. Drink from cup (gesture)
c. use match6s (gesture)
d. Close eyes
e. Point to nose or chin
f. Repeat instructions (Aphasia ST)

IX. Constructional Ability

1. (Constructional praxis - ability to construct 2 or 3 dimensional figures from I and 2 dimensional units.)
2. Not used in most mental status exams probably because not a common complaint.

1. Types of tasks

(a) 2-dimen;ionaal block designs.
(b) Copying of geometric shapes.
(c) Spontaneous drawings.
(d) Stick pattern reproduction.
(e) 3-D block construction.
(f) Spatial analysis requiring patient to shade in comnon portion.

2. Deficits in visual and motor functions will impair.
1. Reproduction Drawings - 2 aid 3-D

(a) Perseveration, closing in. rotation.

2. Drawings to command

a. Draw clock, house, flower

3. Block Designs

1, Parietal cortex primary area.

(a) Postulated visual info from 17 to 18t 19 where perception is elaborated and compared to previous experience.
(b) Stimuli then spread to tertiary areas of inferior parietal, lobe (39, 40) where visual, somatosensory, and auditory are integrated.
(c) Then translated into motor patterns at perirolandic cortex?

1. Constructional apraxia can occur following damage to either parietal cortex.

(a) Greater deficit with right.

2. Right parietal on block designs frequently lose the gestalt and string out blocks.
3. Left parietal - better gestalt but loss of internal detail!
4. Greatest impairment seen in patients with bilateral damage.

(a) one of earliest signs of presenile dementia.
(b) Toxic state - impaired but clear up.

5. Also good for I.Q. and developmental progress of children.
6. Pathognomic signs

(a) 450 plus rotation or loss of orientation.
(b) perseveration.
(c) Fragmentation - omission of parts,
(d) Difficulty in integrating parts.
(e) Difficulty with angles.

X. Higher Cognitive Functions

1. Attention language and memory are building blocks for the development of higher intellectual abilities.
2. HCF may show deterioration before more basic systems are involved.
3. Reveal ability of patient to function in his environment.

1. Groups:

(a) Fund of information (WAIS)
(b) Manipulation of old knowledge (WAIS)
(c) Social awareness and judgment (History)
(c) Abstract thinking; proverbs, analogies, category.
(d) Whole body commands frequently are intact in the presence of limb apraxia.
(e) Under extrapyramidal control.

1. Breakdown in performance of a task involving a series of steps (folding a letter, put in envelope, seal, mail it).
2. More complex than ideomotor,
3. Patient can do each step separately, but not in sequence.
4. Usually seen with bilateral disease.

(a) Parietal
(b) Inability to recognize use of objects.
(c) Associated with widespread intellectual deterioration.

1. Patients usually have lesions in dominant hemisphere.

XII. Related Cortical Functions

1. Disorder of learned movements which can't be accounted for by motor or comprehension.

a. Defect in motor planning.

2. Ideomotor Apraxia

a. Fail to carry out previously learned motor act upon command.
b. Measure by gestural commands.
c. Instruction to Wernicke's area.

(1) To supramarginal for association with kinesthetic memories.
(2) To premotor cortex where memory for motor patterns is evoked.
(3) To motor strip to perform output.

d. Equivalent sequence in right hemisphere where Wernicke's area projects.
e. Anterior corpus callosum lesions cause isolated apraxia of the left hand.

(1) Posterior corpus callosum could transmit information but does not.
(2) Lesions of right hemisphere almost never result in apraxia of either hand.
(3) Left hemisphere lesions may cause disturbance in both hands.

f. Presence of involuntary but not voluntary apraxia suggest disconnection syndrome.

(1) Can use visual to motor input to allow patient to imitate.
(2) Most regular patients also can't imitate.
(3) Extrapyramidal system exerts major influence on gross body functions.

3. Ideational Apraxia.

a. Higher order disturbance of complex motor planning.
b. Involves breakdown in sequential movements.
c. Can perform each individual step.
d. Inability to recognize the use of objects.
e. Associated with widespread intellectual deterioration.

1. Important to determine if patient ever had good right-left discrimination.
2. Most frequently associated with lesion in the parieto-temporo-occipital cortex of dominant hemisphere.

1. Identify named fingers of examiner.
2. identify named fingers of own hand.
3. Associated with parieto-occipital lesions most frequent in left hemisphere.

1. Questionable validity.
2. 4 components

a. Finger agnosia
b. Right-left disorientation
c. Dysgraphia
d. Dyscalculia

1. Rare - no aphasia, good comprehension but patient cant recognize objects visually.

a. Can't tell use of object. 1

2. Actual Visual Perception - distorted (easy if in their-hand),

a. Damage - visual assoc. cortex bilaterally (13, 19).

3. Associative visual agnosia

a. Demonstrate use but can't name.
b. Adequate visual function.
c. Damage left occipital lobe and corpus callosum.
d. Also alexia without agraphia.

1. Disease right temporo-occipital.

1. Right temporo-occipital cortex.

1. History of orientation
2. Locating places on map.

1. Parietal lobe disease.

XII. Thought Content

1. Subjective experiences of patient ? ? (can't be measured objectively ? ? ?).

a. Repeatedly returning to a topic
b. Avoiding a topic.
c. Unwillingness to leave (idea to be expressed).

2. Specific testing

a. Mood - questions related to feelings.
b. Pre-occupations or somatic concerns - health.
c. Insight - What do you think about problem?
d. Fixed ideas, delusions, hallucinations, illusions.

XIII. Behavioral Observations

1. Before testing make specific and systematic observations of the patients' appearance, mood, and behavior.
2. Careful behavioral assessment is important because:

a. There are specific behaviors associated with Neurologic disease entities.
b. Data crucial to differential diagnosis between organic and functional disorders.
c. Test results must be interpreted in the context of basic behavioral data.
d. A significant behavioral disturbance may hamper formal testing.

History

1. Family history

a. Neurologic and psychiatric disorders.
b. Familial prediction of disease process (hypertension, stroke).

2. Birth and developmental history

a. Brain damage from birth
b. Developmental delays.

(1) Motor
(2) Language
(3) Intellectual
(4) Academic

3. Past history

a. Previous Neurological disease.
b. CNS infections.
c. Significant head trauma.
d. Seizures.

4. Description of present illness.

a. Nature of onset.
b. Duration of illness.
c. Description of behavioral change associated with illness.

5. other relevant Neurobehavioral Data.

a. Memory difficulty.
b. Orientation.
c. Reading, writing, or calculations - difficulties of recent onset.
d. Attention and concentration problems.
e. Recent onset of language problems.
f. Unusual or bizarre behavior.

6. Educational and Vocational history.

a. Highest grade attained.
b. Adequacy as a student.
c. Vocation.

(1) Type of jobs.
(2) Frequency of job changes.
(3) Recent problems with job.

1. General Appearance

a. Description Data

(1) Age
(2) Sex
(3) Height and Weight

b. General impression of appearance.

(1) Appearance for chronological age.
(2) Posture.
(3) Facial expression.
(4) Eye contact.

2 . Personal Cleanliness

a. Skin
b. Hair
C. Nails
d. Teeth
e. Beard
f. Indications of unilateral neglect.

3. Habits of dress

a. Type clothing.
b. Cleanliness of clothing.
c. Sloppiness in dressing.
d. Overly fastidious in dress and grooming.
e. Indications of unilateral neglect.

4. Motor Activity

a. Level of general activity

(1) Placid vs. tense.
(2) Hyperkinetic vs. Hypokinetic.

b. Abnormal Posturing

(1) Tics
(2) Facial Grimaces
(3) Bizarre Gestures
(4) other involuntary movements

XIV. Mood and General Emotional Status

1. Mood - more persistent and less intense than specific emotional responses.

a. Mood normal to situation.
b. Feeling of sadness (hopelessness, grief).
c. Feeling of 6lation.(inappropriate optimism or boasting).
d. Apathy or lack of concern.
e. Constantness or fluctuations in mood.
f. Inappropriate affect.

2. Emotional status

a. Cooperation
b. Anxiety
c. Depression
d. Suspiciousness
e. Anger
f. Specific inappropriate emotional responses.
g. Reality testing

(1) Delusions
(2) Illusions
(3) Hallucinations
(4) Paranoid thinking

h. Indications of specific neurotic symptoms.

(1) Phobias
(2) Chronic anxiety
(3) Obsessive-Compulsive
(4) Depression

i. Abnormalities in language

(1) Neologisms - new words
(2) Flight of ideas in thinking and speaking.
(3) Loose associations in thinking and speaking.

1. Luria's drawing.
2. Premotor sequencing.

1. Acute onset
2. Fluctuations in consciousness.
3. Visual hallucinations
4. Disoriented
5. Confusional state becomes exaggerated at night.
6. Confusional state is important and points toward medical disorder.

a. Generalized brain dysfunction
b. Further testing would be invalid.
c. Testing could lead to a misdiagnosis of dementia.
d. Alternations in consciousness are almost always associated with organic brain dysfunction.

1. Won't normally show dramatic cognitive deficits on formal mental status testing but will demonstrate personality changes.

a. Some predominantly apathetic (may be misconstrued as depression).
b. Some are manic.

2. Most patients have lost both interest in his environment and social drive.
3. Major finding is less cognitive loss with frontal lesions as opposed to equivalent lesions elsewhere.

1. ictal phenomena - Deja vu, transient visual and auditory hallucinations, feelings of depersonalization, fear, anger, delusions or illusions, sexual feelings, paranoia.
2. Religiosity

1. Apathy disorder of mood - characterized by significant indifference and emotional blunting.

a. Seen with frontal, right hemisphere and bilateral disease.
b. Common symptom of brain damage and also in depression.

2. Primary depression

a. May appear demented.

1. Make excuses for loss.
2. Unilateral inattention.

a. Most frequently right hemisphere
b. And most frequently vascular.
c. Parietal lesions.

1. Behavior which reflects feeling or mood.
2. BD - often lack of sustained effort.

a. Concentration difficulty
b. Easily distracted.
c, irritable and tense.
d. Emotional lability.

3. Exaggerates general or basic tendencies.
4. General observations

a. Tension and anxiety noted in general attitudes, sweating, tremor, tachycardia.
b. Unconcern for problems
c. Depression
d. Bizarre responses