Mental Status Examination
There is no specific laboratory test, neuroimaging study, or clinical presentation of a patient that yields a definitive diagnosis of schizo-phrenia. Schizophrenia can present with a wide variety of symp-toms, and a longitudinal history of symptoms and comorbid clinical variables such as medical illness and a history of substance abuse are necessary before a diagnosis can be considered. The Mental Status Examination, much like the physical examination, is an ad-ditional clinical tool that aids the psychiatrist in generating a dif-ferential diagnosis and appropriate treatment recommendations.
Although a disheveled look is not pathognomonic for schizophre-nia, patients with this disorder often present, especially acutely, with a disordered appearance. The description of a patient’s ap-pearance is an objective verbal sketch, much like the description of a heart murmur, that can uniquely identify a particular patient.
A person with schizophrenia often has difficulty attending to activities of daily living, either because of negative symptoms (apathy, social withdrawal, or motor retardation) or because of the presence of positive symptoms, such as psychosis, disorgani-zation, or catatonia, that interfere with the ability to maintain personal hygiene. Also, schizophrenia patients often present with odd or inappropriate attire, such as a coat and hat worn dur-ing the summer or dark sunglasses worn during an interview. Itis generally thought that the inappropriate dress is a manifesta-tion of symptoms such as disorganization or paranoid ideation. It should be noted that some patients present quite neatly groomed. Thus appearance is noted but is not diagnostic.
Individuals with schizophrenia may be friendly and coopera-tive, or they may be hostile, annoyed and defensive during an interview. The latter may be secondary to paranoid symptoms, which can make patients quite cautious and guarded in their re-sponses to questions.
Schizophrenic patients can have bizarre mannerisms or stere-otyped movements that can make them look unusual. Patients with catatonia can stay in one position for weeks, even to the point of causing serious physical damage to their body; for ex-ample, a patient who stands in one place for days may develop stress fractures, peripheral edema and even pulmonary emboli. Patients with catatonia may have waxy flexibility, maintaining a position after someone else has moved them into it. Patients with catatonic excitement exhibit odd posturing or purposeless, repetitive, and often strange movements.
Behaviors seen in schizophrenia patients include chore-oathetoid movements, which may be related to neuroleptic expo-sure but have been reported in patients even before neuroleptic use. Other behaviors or movement disorders may be seen as parkinso-nian features, such as a shuffling gait or a pill-rolling tremor.
Psychomotor retardation may be present and may be a manifestation of catatonia or negative symptoms. On close ob-servation, it is usually characterized, in this group of patients, as a lack of motor movements rather than slowed movements.
Patients may present with agitation, ranging from minimal to extreme. This agitation is often seen in the acute state and may require immediate pharmacotherapy. However, agitation may be secondary to neuroleptic medications, as in akathisia, which is felt as an internal restlessness making it difficult for the person to sit still. Akathisia can manifest itself in limb shaking, pacing, or frequent shifting of position. Severely agitated patients may be unresponsive to verbal limits and may require measures to ensure their safety and the safety of others around them.
Paranoid patients may look hypervigilant, scanning a room or glancing suspiciously at an interviewer. Psychotic patients may make poor eye contact, looking away, or appear to stare vacu-ously at the interviewer, making a conversational connection seem distant. Characteristic responding to internal stimuli is seen when a patient appears to look toward a voice or an auditory hallucination, which the patient may hear. A nystagmus may also be observed. This clinical finding has a large differential diagno-sis, including Wernicke-Korsakoff syndrome; alcohol, barbitu-rate, or phenytoin intoxication; viral labyrinthitis; or brain stem syndromes including infarctions or multiple sclerosis.
In a Mental Status Examination, one usually comments on the rate, tone and volume of a patient’s speech, as well as any distinct dysarthrias that may be present. Pressured speech is usually thought of in conjunction with mania; however, it can be seen in schizo-phrenia patients, particularly on acute presentation. This is often difficult to assess, as it may be a normal variant or a cultural phe-nomenon, because some languages are spoken faster than others.
Tone refers to prosody, or the natural singsong quality of speech. Negative symptoms may include a lack of prosody, re-sulting in monotonous speech. Furthermore, odd tones may be consistent with neurological disorders or bizarre behavior.
Speech volume is important for a number of reasons. Loud speech can be a measure of agitation; it can occur in conjunc-tion with psychosis, or it could even be an indication of hearing loss. Speech that is soft may be an indication of guardedness or anxiety.
Dysarthrias are notable because they can be idiopathic and longstanding, or they can be an indication of neurological disturbance. In patients who have been exposed to neuroleptics, orobuccal tardive dyskinesia should be considered when there is evidence of slurred speech.
Affect, which is the observer’s objective view of the patient’s emotional state, is often constricted or flat in patients with schiz-ophrenia. In fact, this is one of the hallmark negative symptoms. Flattened affect may also be a manifestation of pseudoparkinson-ism, an extrapyramidal side effect of typical neuroleptics.
Inappropriate affect is commonly seen in patients with more predominant positive symptoms. A smile or a laugh while relat-ing a sad tale is an example. Patients with catatonic excitement or hebephrenia may have bizarre presentations or affective lability, laughing and crying out of context with the situation. Emotional reactivity must alert the clinician to the possibility of neurological impairment as well, as in the case of pseudobulbar palsy.
Mood is based on a patient’s subjective report of how he or she feels, emotionally, at the time of the interview. It is not uncom-mon for patients with schizophrenia to be depressed (especially patients with history of higher premorbid functioning who may have some insight into the losses they are facing) or to be indiffer-ent, with seemingly no emotional awareness of their situation.
Because actual thoughts cannot be measured, thought processes are assessed by extrapolation from the organization of speech. Thought disorders can be more or less obvious, and a trained lis-tener is one who appreciates the normal logical pattern of flow of words and ideas in speech and can thus sense abnormalities.
There are many different versions of thought disorders: lack of logical connections of ideas (looseness of associations); shift of the original theme because of weak connections of ideas (tangentiality); overinclusiveness to the point of loss of the theme (circumstantiality); use of words and phrases with no relation to grammatical rules (word salad); repetition of words spoken by others (echolalia); use of sounds of other words, such as “yellow bellow, who is this fellow?” (clang associations); use of made-up words (neologisms); and repetition of a particular word or phrase, such as “this and that, this and that” (perseveration).
Other thought disorders are part of a constellation of negative symptoms. Examples would be thoughts that appear to stop abruptly, either because of interruption by an auditory hallucination or because the thought is lost (thought blocking); absence of thoughts (paucity of thought content); and a delayed response to questions (increased latency of response).
Although not necessarily present in every patient, characteristic symptoms of schizophrenia include the belief that outside forces control a person’s thought or actions. A patient might report that others can insert thoughts into her or his head (thought inser-tion), broadcast them to others (thought broadcasting), or take thoughts away (thought withdrawal). Other delusions, or fixed false beliefs, may also be prominent. Patients may describe ideas of reference, which is the phenomenon of feeling that some exter-nal event or report relates to oneself specifically; for example, a patient may infer special meaning from an image seen on televi-sion or a broadcast heard on the radio.
Paranoid ideation may be manifested as general suspicious-ness or frank, well-systematized delusions. The themes may be considered bizarre, such as feeling convinced that aliens are send-ing signals through wires in the patient’s ear, or nonbizarre, such as being watched by the Central Intelligence Agency or believing that one’s spouse is having an affair. These symptoms can be quite debilitating and lead to a great deal of personal loss, which pa-tients may not understand because the ideas are so real to them.
Patients with schizophrenia commonly express an abun-dance of vague somatic concerns, and a particular patient might develop a delusion around a real physiological abnormality. Therefore, somatic symptoms should be evaluated appropriately in their clinical context without automatically dismissing them as psychotic. Preoccupations and obsessions are also seen com-monly in this population, and certain patients have comorbid ob-sessive–compulsive disorder.
The mortality rate for suicide in schizophrenia is approxi-mately 10%. It is therefore imperative to evaluate a patient for both suicidal and homicidal ideation. Patients of all diagnoses, and par-ticularly schizophrenia, may not spontaneously articulate suicidal or homicidal ideation and must therefore be asked directly about such feelings. Moreover, psychotic patients may feel compelled by an auditory hallucination telling them to hurt themselves.
Perceptual disturbances involve illusions and hallucinations. Hal-lucinations may be olfactory, tactile, gustatory, visual, or audi-tory, although hallucinations of the auditory type are more typical of schizophrenia. Hallucinations in the other sensory modalities are more commonly seen in other medical or substance-induced conditions. Auditory hallucinations can resemble sounds, back-ground noise, or human voices. Auditory hallucinations that con-sist of a running dialogue between two or more voices or a com-mentary on the patient’s behavior are typical of schizophrenia. These hallucinations are distinct from verbalized thoughts that most humans experience. They are often described as originating from outside the patient’s head, as if they were emanating from the walls or the radiators in the room. Less commonly, a patient with schizophrenia describes illusions or misperceptions of a real stimulus, such as seeing demons in a shadow.
Patients with schizophrenia most likely have a clear sensorium unless there is some comorbid medical illness or substance- related phenomenon. A schizophrenia patient may be disori-ented, but this could be a result of inattentiveness to details or distraction secondary to psychotic preoccupation.
Studies utilizing continuous performance task paradigms have demonstrated repeatedly that schizophrenia patients have pervasive deficits in attention in both acute and residual phases. On a Mental Status Examination, these deficits may present themselves as the inability to perform mental exercises, such as spelling the word “earth” backward or serial subtractions.
Careful assessment of memory in patients with schizophrenia may yield some deficits. Acquisition of new information, imme-diate recall, and recent and remote memory may be impaired in some individuals. Furthermore, answers to questions regarding memory may lead to idiosyncratic responses related to delusions, thought disorder, or other overriding symptoms of the illness. In general, schizophrenia patients do not show gross deficits of memory such as may be seen in patients with dementia or head trauma.
Schizophrenia is not the equivalent of mental retardation, al-though these syndromes can coexist in some patients. Patients with schizophrenia generally experience a slight shift in intellec-tual functioning after the onset of their illness, yet they typically demonstrate a fund of knowledge consistent with their premorbid level. Schizophrenia patients manifest a characteristic discrep-ancy on standardized tests of intelligence, with the nonverbal scores being lower than the verbal scores.
A classical aberration of mental function in a patient with schizo-phrenia involves the inability to utilize abstract reasoning, which is similar to metaphorical thinking, or the ability to conceptual-ize ideas beyond their literal meaning. For example, when the patient is asked what brought him or her to the hospital, a typical answer might be “an ambulance”. On a Mental Status Examina-tion, this concrete thinking is best elicited by asking a patient to interpret a proverb or state the similarities between two objects. For example, “a rolling stone gathers no moss” may mean, to the patient with schizophrenia, that “if a stone just stays in one place, the moss won’t be able to collect”. More profound difficulties in abstraction and executive function, often seen in schizophrenia, such as inability to shift cognitive focus or set, may be assessed by neuropsychological tests.
Individuals suffering from schizophrenia often display a lack of insight regarding their illness. Whether it is a reflection of a nega-tive symptom, such as apathy, or a constricted display of emotion, patients often appear to be emotionally disconnected from their illness and may even deny that anything is wrong. Poor judg-ment, which is also characteristic and may be related to lack of insight, may lead to potentially dangerous behavior. For example, a patient walking barefoot in the snow because of the feeling that her or his shoes could be traced by surveillance cameras would be displaying both poor judgment and poor insight. On a formal Mental Status Examination, judgment is commonly assessed by asking patients what they would do if they saw a fire in a movie theater or if they saw a stamped, addressed envelope on the street. Insight can be ascertained by asking patients about their under-standing of why they are being evaluated by a psychiatrist or why they are receiving a certain medication.
Although there are no pathognomonic physical signs of schizo-phrenia, some patients have neurological “soft” signs on physical examination. The neurological deficits include nonspecific ab-normalities in reflexes, coordination (as seen in gait and finger-to-nose tests), graphesthesia (recognition of patterns marked out on the palm) and stereognosis (recognition of three-dimensional pictures). Other neurological findings include odd or awkward movements (possibly correlated with thought disorder), altera-tions in muscle tone, an increased blink rate, a slower habituation of the blink response to repetitive glabellar tap and an abnormal pupillary response.
The exact etiology of these abnormalities is unknown, but they have historically been associated with minimal brain dys-function and may be more likely in patients with poor premorbid functioning. These neurological abnormalities have been seen in neuroleptic-naive patients as well as those with exposure to tra-ditional antipsychotic medication. Overall, the literature suggests that these findings may be associated with the disease itself.
Neuroophthalmological investigations have shown that patients with schizophrenia have abnormalities in voluntary sac-cadic eye movements (rapid eye movement toward a stationary object) as well as in smooth pursuit eye movements. The influ-ence of attention and distraction, neuroleptic exposure and the specificity of smooth pursuit eye movements for schizophrenia have raised criticisms of this area of study, and further investiga-tion is necessary to determine its potential as a putative genetic marker for schizophrenia.