The Mental State Examination in Early Psychosis

• The mental state can vary considerably in response to different settings and to different staff members.

• Some patients retain a considerable ability to control their symptoms.

• Patients can learn quickly to conceal some psychotic phenomena - for example, to avoid treatment or a prolonged stay in hospital.

• Patients with paranoid psychosis may be more willing to reveal information to visiting clinicians or research staff than their treating clinicians.

• Clinical signs can vary significantly depending on the time of day, with signs of depression being more common in the morning and mania escalating in the late evening.

For these reasons, it is useful to conduct a series of assessments by different clinicians, each contributing to a comprehensive assessment summary. This should be arranged in a way that maintains the patient's sense of continuity of care and preserves one or two clinicians as primarily responsible for care.

Regular formal reviews of mental state should be undertaken during an episode of acute psychosis. Most of the mental state examination can be conducted in a routine manner, except that patients with a first episode of psychosis may describe phenomena that are less well formed than in patients with chronic disorders, especially if they are of recent onset, and may be less well ''schooled'' in providing descriptions.

Phase of Psychosis

It is useful to determine the rate of emergence of the psychosis and where in the cycle the patient is being assessed. In the early phase of a rapidly developing florid psychosis, patients are often perplexed and frightened and have fleeting and poorly formed delusions. Patients presenting for the first time after a prolonged episode of untreated psychosis often have clearly formed delusions or interpretations of psychotic phenomena.

Insight

The level and quality of insight should be explored [45]. Insight is a complex and somewhat controversial feature which involves several elements, including:

• awareness of changes in mental functioning;

• awareness that the changes are the symptoms of a mental illness;

• awareness that the illness requires treatment.

Insight varies markedly between patients and seems to have only a partial association with the severity or phase of psychosis. Insight can vary in a patient within a single interview, depending on the level of arousal and mood state. A suspicious guarded presentation may imply reduced insight, while a frank denial of symptoms may reflect a complete lack of awareness of any change, or merely concealment in the context of fear of the consequences of disclosure.

Negative Symptoms

Negative symptoms in first-episode psychosis appear to be more responsive to treatment than in subsequent episodes. Many are secondary (a response to symptoms) rather than primary (an inherent part of the illness). Assessment of negative symptoms is important in determining the treatment and the prognosis.

Cognitive Function

Careful serial assessment of cognitive function should be performed both in the acute phase and later recovery, because it is closely correlated with level of psychosocial function.

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