Original subtitles

in the second section of the mental

status examination we will learn about

thought process my name is Tom field and

I produced and narrated this training

series let's look at the overview we

will learn via a scaffolding process in

this section we will learn about thought

process and review affect and mood in

the next section we will learn about

memory and view affect and mood and

thought

process in each section there are guided

practice activities at the end of the

eight sections there is an end of

training test I encourage you to follow

the handout as we progress you can use

scrap paper for guided practice if you'd

like there's also a sheet available for

this and as we view the video case

studies there are going to be times

occasions um during guided practice when

it's not going to be completely clear

whether the client is exhibiting one

aspect or element of the mental status

examination and in those occasions it's

okay to indicate unable to

assess the definition of thought process

is how a person makes sense of the world

and makes connections between

content thought process has three

elements form of thought attention and

speed of thought the last two are going

to be grouped together for this training

we'll look at form of thought

first form of thought exists on a

Continuum beginning at logical and

ending with flight of ideas logical is

considered normal or typical and flight

of ideas is considered abnormal or

atypical and as we progress from logical

to circumstantial to tangential to loose

associations and find finally to flight

of

ideas the client's connections made

between content becomes less strong uh

less

apparent in addition as we go through

form of thought it's important to

remember that thought process process in

general manifests in the content of the

client's speech so we often assess a

client's thought process based on their

verbal

content logical form of thought is

described as clear direct connections

made between content one idea flows

directly into

another after my mom left me that

message I thought you know I should call

her and just give her a piece of my mind

but but

then I started thinking and you know she

she's just so stubborn and I I just

don't think anything I say is going to

make a difference so um you know there

there's just no point in putting myself

through that I mean she's she's not

going to change so really the only thing

I have control over is how I respond to

her in this example if we listen closely

to the client's verbal content we will

see that clear Direct connections are

made between one idea and

another the client Begins by describing

how she was going to call her mother

then started thinking that anything she

said was not going to make a difference

that her mother was not going to change

and that the only thing she has control

over is how she responds to her mother

you can see here there is a logical flow

of ideas connections are made directly

between content this is known as a

logical form of of

thought circumstantial form of thought

is described as digressions to

unnecessary details in thought and

speech before communicating the central

idea let's watch an

example well I guess I should tell you

how I got fired from my job last week um

you know I went in last Monday and um

you know when I first came in saw my my

friend Lan sitting there and just she

had this kind of like daydreamy look on

her face that she gets when she's like

totally like not paying attention to her

work and um you know we we go back quite

a ways but um but anyway so like we had

some like filing to do that morning so

we went back in the file room and we

were kind of taking our time and and um

we were talking about like like both of

us like totally watch The Walking Dead

and the night before was like the

midseason Premiere so like we've been

like waiting for that show to come back

on since like December so you know like

you know like we're we're doing our work

and whatever but like we're totally

talking about that show because you know

you you totally like find out about like

what happened like with michon and like

that she had like this kid and like a

boyfriend and stuff that died and you

know she's having all this like drama

about whether she should still be part

of the group or not and then you've got

all this stuff with Rick and Carl and I

can't believe Carl ate 110 ounces of

chocolate pudding I mean I know it's

like the apocalypse and they don't like

have pudding anymore but it's just kind

of totally like gross I mean you'd think

he'd get diabetes or something and I

mean you don't want that you're not

going to be able to like run from

zombies if you're having like I don't

know like some kind of like blood sugar

problem or whatever um

you know so so we were like totally

talking about that and we talked about

the whole episode and like we were like

totally pissed that Daryl wasn't in the

episode because like let's be honest

he's like the hottest person on the show

and that's like you know and and plus

like you know he's just like you know

shooting zombies and stuff and it's just

really cool so so like we were like

doing our filing and whatever and then

um I got called into the office and it

turns out that like um the boss figured

out that I spend about 75% of my day on

like zombie blogs and you know instead

of doing my work so um he ended up

letting me go and that's kind of

that here the client takes a large

detour before getting to the central

point she's talking about why she was

fired and that's really what the what we

want to get to but the client uh kind of

derails and starts to talk about The

Walking Dead episode epod and uh and her

interest in that

show this uh detour is somewhat

connected to the central idea in that

her boss let her go for spending work

time trolling through zombie blogs and

for those not familiar The Walking Dead

is a television show about survivors of

a zombie apocalypse and so there is some

connection made to the central idea here

but the detour kind of detracts us

brings us away from the central idea

before eventually returning with a

circumstantial form of thought

eventually the central idea is

communicated but there's a detour made

before

then tangential form of thought is

described as oblique digressive and

irrelevant speech the central idea is

not communicated with tangential thought

in comparison with circumstantial

thought here's an

example so like I said I was really

hoping to hear from my daughter I

haven't heard from her o in over a year

and um I was uh going to call her on the

cell phone I have

AT&T um and actually you know I'm not

really been very happy with AT&T and I

was thinking about calling AT&T and

really getting into some conversation

with them about what kind of plans I

could do because I've heard there's a

lot of different plans out there that

might be better so that's something I

think I might

do in this example the client begins

with describing how they want to call

their daughter on a cell phone and soon

their verbal content takes a detour to

talk about AT&T and wanting to change

their cell phone plan or at least

explore their options unlike

circumstantial form of thought the

client does not return to the main topic

of wanting to talk to their daughter

they in clude with uh the discussion

around the cell phone plan and so

tangential form of thought is a detour

or digression from the central idea and

the central idea is never fully

communicated or

expressed loose associations are

described as little or vague connection

made between

Concepts this is uh familiar to some

some viewers the the idea of rabbit

hauling it's the idea that there there

are these continuous tangential links

made that never eventually get to the

central idea this can be a symptom of

schizophrenia let's watch an

example like I said I lost my job they

caught me drinking on

shift and uh I could go for a drink

right

now I think my favorite drink is

probably

scotch I drink it a lot I usually have a

couple of drinks when I go home I go

home and then I watch Late Night with

Jimmy Fallon have a couple drinks when

I'm watch Jimmy Fallon that guy's funny

he's not as good as Jay Leno though Jay

Leno uh that guy's a

legend seen his chin it's ridiculous I

don't have a chin like that I never

really liked my chin my mom used to tell

me that I had a kid's chin thought that

was kind my mom was always like that

though she always used to say stuff that

was sort of off

color

in this example the client continuously

makes tangential connections and rabbit

holes in a way um and doesn't return to

the central focus of the discussion they

begin with talking about how they lost

their job for drinking on shift and

never return to that instead they then

talk about how they could go for a drink

right now how their favorite drink is

scotch how they usually have a couple of

drinks when they get home home while

watching Late Night with Jimmy Fallon

then there's a comparison made to Jay

Leno and his his chin and how his mother

used to tell him that he had a kid's

chin and his mother used to say stuff

that was off color and so you can see

here that there are some connections

made between content but it just moves

the conversation further and further

away from the central

idea this is known as loose

associations f of ideas are described as

multiple thoughts and ideas generated

spontaneously without obvious connection

this often occurs in manic States and is

associated with bipolar disorder let's

watch an

example yeah I was thinking about my mom

was my mom was always a little weird

like that I'm not really sure what she

um she always I don't know you know

that's what I was thinking about that

the other day cuz she was in the in the

kitchen this one day and she was what

she was looking out the window and there

were all these little red glass vases

which um is uh you know I really need to

get a car if I had a car I'd be able to

make it easier to uh be able to make it

to counseling and um you know and that

that's another thing too I was actually

thinking about asking you a question

about something I wasn't really sure

whether or not I should talk to you

about it I've never I don't know

sometimes I feel like I can't really

talk about something and then Titans I

feel like I can I guess I'm not very

confident

um in this example the client does not

make clear connections between

ideas they begin with saying that their

mother was always a little weird or

strange then they describe a memory of

their mother being in the kitchen and

mention a glass vase which seems

unconnected and then mention they would

like to get a car which is completely

unconnected then there's a brief mention

about how it would help them attend

counseling sessions and there's a vague

connection there and then they speak

about how they have difficulties with

expressing their lack of

self-confidence this client's

connections are tenuous at best and

often there are there is no connection

made between content flight of

ideas um is best described as this these

spontaneous thoughts or ideas generated

without obvious

connection and so in comparison with

loose associations where there is

connections but it leads away from the

central idea in Flight of ideas those

connections are very tenuous or they

don't exist at

all it's now time for some guided

practice let's look at form of thought

and practice

together in the ensuing video case study

you are going to code affect and mood

and form of

thought here comes the first case study

so I guess I should tell you about how I

got fired last week um I went into work

on Monday as usual um and I sit with my

friend Lan and um usually on Monday I

bring Starbucks so you know like I had

you know like my normal size like hot

chocolate you know like whatever size it

is and

and I got her a caramel macchiato and

she likes the veny size which you know

kind of sketches me out because it's got

like a lot of sugar in it um and you

know this one time I was in

Starbucks um when I was ordering it and

like there was this like dude behind me

in line and he was like you know you

shouldn't get that size because I used

to drink those every day and then I

developed

diabetes um because you know like

there's like totally a lot of sugar

sugar in those um and you know like

diabetes is like pretty serious stuff I

mean like you can end up like having to

have your like feet amputated and all

this and um you know just having like

all these like crazy health problems and

you know like um but then like my

husband's got this friend who like his

son has diabetes and you know it's like

really expensive too like they have to

like drive like hours to the hospital

and all this but you know they do get to

like write off all those expenses on

their

taxes um you know which which could be

really helpful I wish I had more stuff I

could write off on my taxes um you know

like they just like screw me every year

and I just end up having to like pay all

this money I mean you know it's just

like such crap how like you know like

the government just keeps like taking my

money you know like if if you know if I

got like a refund this year I would

totally be going to Europe probably

Paris because

um you know it's just like romantic and

stuff and I've never been to the Eiffel

Tower um and you know there's some like

really cool stories about the Eiffel

Tower

too pause the video now and assess the

client for affect and mood and form of

thought let's look at the client's a

effect

first the client here appears to have a

full or broad a effect they don't seem

restricted in any way they don't seem to

have a blunted or flat

effect when talking about how they got

fired or even um how you can have things

amput your feet

amputated um for having diabetes the

client has this look of disgust on her

face when she says diabetes is serious

St stuff she also seems concerned and so

her affect would be full or broad since

it mirrors her internal emotional

state uh her affect is also congruent

for that reason she seems disgusted when

talking about feet being amputated she

seems concerned when saying diabetes is

serious

stuff her mood is dysphoric because she

talks about

her uh for example how they she gets

screwed every year in her taxes how and

how that's such a bunch of crap there's

an irritable Dimension there that's

that's uh a type of

dysphoria her in terms of her thought

process she makes loose

associations she begins with talking

about losing her job and then how she

often with her friend Luan goes into

Starbucks and then mentions meeting a

man in Starbucks who developed diabetes

and then talks about diabetes for a

while and then how they can uh her

friend can write off um their the

medications for diabetes on their taxes

and then how if she got a tax refund she

would go to Paris obviously those links

are fairly tenuous but they are linked

nevertheless um and so this is an

example of rabbit hauling known as loose

associations let's look at the next

example I'll tell you why I get so angry

at my neighbor if I tell you where I

live it might make some sense I live in

a huge apartment complex there are so

many people there are old

people PE families with children there

are a lot of dogs running

around but it's and the gardener mows

the lawn and makes noise but other than

that it's it's really quiet other than

the noise and and the loud

neighbor pause the video now and assess

the client for affect and mood and form

of

thought okay let's look at affect first

in this example the client's a effect is

blunted or flat if you replayed the

video without this the sound playing it

would be very hard to um to assess the

client's internal emotional state it's

not fully observable because the client

has a blunted or flat a effect in terms

of her mood she has a again a dysphoric

mood she seems irritable she talks about

some frustration at her neighbor and at

how how loud her neighbor is and her

thought process is

circumstantial she gets to the central

idea or the point eventually after

describing the apartment complex and the

central idea is that she lives with a

loud neighbor but she does take a

digression to get

there it's now time to look at attention

and speed of

thought attention has three elements

distractable preoccupied and

rumination speed of thought has two

elements latent thought and racing

thoughts distractable is described as

when Focus shifts quickly onto the

external environment this awareness

interrupts the present dialogue this is

an Associated symptom of anxiety and

attention deficit hyperactivity disorder

or

ADHD let's look at an

example I was talking to my dad last

night and we of course we got into

it he just you know it's the same old

stuff he just totally doesn't support

what I want to do with my life I mean I

just I just totally feel like you know

college isn't for me and I'm not going

to be really successful there so why

bother oh my gosh it's really raining

out there I'm not sure if I have an

umbrella in my

car so anyway

um in this example the client begins

with talking about an argument with her

father and becomes distracted by the

rain upside and that shifting of

attention to the external environment is

an example of distractable

attention preoccupied attention is

described as being inattentive to the

external environment being internally

focused and seeming to think deeply this

can be associated with depression

psychosis found in schizophrenia for

example and skeid

personality let's watch an

example so you were talking about some

problems you've been having with your

mother

H what what did you say you were talking

about your mother oh oh

yeah been having some problems I guess

mhm here the client seems lost in

thought the interviewer tries to ask

questions to to bring the client into

conversation but the client just

responds minimally just kind of

acknowledges and continues to be

immersed in thought and that degree of

inattention to the external

environment uh com in combination with

being very internally focused is an

example of preoccupied

attention rumination is described as a

preoccupation with a single idea or

theme this is associated with anxiety

obsessive compulsive disorder and can

lead to delusional thoughts in autism

this is known as

perseveration so I you know really been

waiting to hear from my daughter I

haven't heard from her in over a year

and you know I really miss

her so how was the the rest of your week

outside of

that uh you know it went pretty well

well but you know I really have been

thinking a lot about my daughter I'm

really missing her a lot and I sure wish

she would call

me yeah I know that bothers you a lot

you've been talking also about some

stress at your

work yeah work's been a little tough uh

there's been some things that have come

up but you know I really I I just really

wish I could talk to my daughter I

haven't heard from her for such a long

time and I really miss

her

this client seems to really miss their

daughter and any attempts by the

interviewer to move the conversation to

what happened this week or to work

stress are quickly brought back by the

client to the topic again of missing his

daughter this preoccupation with a

single idea or theme is an example of

rumination in autism by the way when a

client is preoccupied often they

topic of preoccupation is a preferred uh

idea or theme or character such as a

cartoon character and so the client will

continue to talk about that preferred

object or item or character um versus

talking about or maintaining another

conversation

topic latent speed of thought is

described as a prolonged period of time

between a thought and its verbal

expression this is associated with

depression anxiety and

schizophrenia so how was your date last

night it was okay I

guess and where did you

go we went

um we went to the Mexican restaurant

Clos what was the name of the

restaurant it was some tequila

name this client has long pauses between

when the interviewer asks a question and

when the client responds to the question

and those long pauses are examples of a

latent speed of

thought racing thoughts are described as

multiple thoughts occurring in a

seamless fashion these often occur in

list form these thoughts have a

pressured quality and are associated

with anxiety and manic States found in

bipolar

disorder you know I've been having kind

of kind of some trouble sleeping lately

with just these thoughts that just run

and cycle through my my brain and it's

just really hard to relax you know I'll

think about um stuff like you know what

if what if I what if I screw up at work

and I lose my job and then how am I

going to pay for my house and what if it

goes into foreclosure and you know I'm

just like really worried about my cat

she's been like puking up all these hair

balls and I don't know if I should take

her to the vet or maybe I need to be

like brushing her teeth more or

something and you know and then just

thinking about like this big project I

have to do and um you know and and just

you know it's it's to do with like the

war in Syria and like providing like Aid

and I just keep thinking about all the

things that are happening there and it

just like I just can't shut it

off when the client talks about thoughts

cycling through her brain she almost

gives it away racing thoughts are often

intrusive thoughts that Contin cons kind

of perpetuate themselves they're

difficult um to distract

from the client also provides a list of

thoughts that have been cycling through

her brain she mentions worries about

foreclosure of her house her cat puking

up hairballs a big project that's due

and the war in Syria and says that she

can't shut these thoughts

off as an aside in my clinical

experience racing thoughts often occur

at

bedtime it's now time for guided

practice for attention and speed of

thought in the first guided practice

video and the subsequent you're going to

code affect mood and form of thought in

addition to either attention or speed of

thought here's the first guided practice

video so so you know this this has just

been a bad week overall I mean to top it

off Friday was Valentine's Day and you

know like I just still can't believe you

know it's it's been a year since John

broke up with me on Valentine's Day and

it just it just ruined my day because

that was just all I could think about I

mean it just still makes me so

angry you said it had been a bad week

yeah I mean just it was just one of

those weeks you just can't wait for it

to get over you know things kept going

wrong at work you know I like misplaced

this important file and just totally got

like ringed out by the boss and then my

car broke down and then this crap with

John I

mean who breaks up with somebody on

Valentine's Day I mean we had been

dating for two and a half years I mean I

was expecting a ring and here he is oh

we're going to break up on Valentine's

Day I mean it's just

pause the video now and assess the

client for affect mood form of thought

attention and speed of

thought okay let's review a effect first

this client has a full and congruent a

effect they're obviously dysphoric or

irritable in addition in terms of

thought process or form of

thought they seem to have some a

tangential form of

thought there's some rumination about

this breakup with

John um and by the way she gives us a

clue when when the client says that it

was quote all I could think about when

referring to her breakup with John and

finally when she describes the stress

that she's been under in the past week

she provides a running list of stresses

that she's had to go through such as for

example being reamed out by her boss at

work and this is an example of racing

thoughts and so we have both tangential

atten uh tangential form of thought and

rumination in terms of attention and

also we have some racing thoughts in

terms of speed of

thought let's look at the next

example

I got this exam coming up and it's the

last exam of the year and I really need

to do well on it and I've been looking

at all the different things I need to do

well for the exam but I can't keep track

of it all I got to you know there like

essay questions and there multiple

choice questions and then after the

multiple choice questions there's this

big long written thing it's like two

pages or something like that I don't

know if I can do that I never been able

to write that well I was talking to the

teacher about it and she's not giving me

any help so I got no help and I got this

gigantic exam to do and a bunch of

different things I don't know how to do

I don't know how I'm going to deal with

it I'm going just drink lots of coffee

and stay up all night and study I guess

I don't

know pause the video now and assess the

client for affect mood form of thought

attention and speed of

thought okay in terms of affect the

client has a full or broad effect effect

um this is apparent for example when

they squint their eyes when talking

about how they had this exam is going

there's like two pages of essays they do

seem fairly anxious there and when they

talk about how they're not sure how

they're going to handle it um their eyes

grow wide and they mention going to stay

up all night and drink a lot of coffee

and do some review I guess and so that

indicates a full or broad effect they're

fairly worried or anxious IND indicative

of a dysphoric

mood in terms of their thought their

form of thought it's fair they have a

fairly logical form of thought there's a

obvious connection made between

Concepts in terms of their attention I

didn't notice anything in particular so

you could code this unable to assess and

regarding speed of thought there was an

obvious racing thought uh process going

on here whereby the client uh relates in

list form they're concerned about essay

questions and multiple choice questions

then an essay and the teachers no help

and so that degree of anxiety um and the

the list form indicates racing

thoughts so let's review today we

learned about form of thought and we

looked at logical also known as coherent

circumstantial tangential loose

associations and flight of

ideas we also looked at attention

distractable preoccupied and rumination

and speed of thought both latent and

racing thoughts and this concludes the

second section of the mental status

examination

training