Mental Status Examination

The Mental Status Exam (MSE) is a systematic way of describing a patient’s mental state at the time you were doing a psychiatric assessment.

The Mental Status Exam is analogous to the physical exam: it is a series of observations and examinations at one point in time. Focused questions and observations can reveal “normal” or pathological findings. Although our observations occur in the context of an interview and may therefore be ordered differently for each patient, the report of our findings is ordered and “paints a picture” of a patient’s appearance, thinking, emotion and cognition. The data from the Mental Status Exam, combined with personal and family histories and Psychiatric Review of Systems, form the database from which psychiatric diagnoses are formed.

The mental status examination is a useful tool to assist physicians in differentiating between a variety of systemic conditions, as well as neurologic and psychiatric disorders ranging from delirium and dementia to bipolar disorder and schizophrenia. The examination itself may comprise a few brief observations made during a general patient encounter or a more thorough evaluation by the physician. It also may include the administration of relatively brief standardized tools such as the Mini-Mental State Examination (MMSE) and Mini-Cog.

Culture, native language, level of education, literacy, and social factors such as sleep deprivation, hunger, or other stressors must be taken into account when interpreting the examination, because these factors can affect performance. Language skills of the physician and patient are critical; the patient must be able to understand the questions and communicate his or her answers, and the physician must be able to interpret the examination results. If possible, the mental status examination should occur when the physician is alone with the patient and again in the presence of the patient’s friends or family members who can provide more longitudinal insight into problems the patient may be having. The physician should maintain a nonjudgmental, supportive attitude during the encounter.

Why write down a mental status exam over and over again?

Oftentimes, the MSE can seem redundant. As a single data point in time, the MSE can sometimes be of limited clinical utility. However, with repeated MSEs, you can begin to develop a picture of how a patient’s mental status is changing over time. It is especially helpful when other clinicians read the MSE of a patient in the past and compare it to the current presentation. The Mental Status Exam is a “snapshot” of a patient, that describes their behaviors and thoughts at the time you interviewed them. Think about how a psychotic individual’s MSE might change over the course of a few hours, or how a manic patient might similarly fluctuate

General Observations

  • Appearance & behaviour :

A general description of how the patient looks and acts during the interview.

Does the patient appear to be his or her stated age, younger or older?

Is this related to the patient’s style of dress, physical features, or style of interaction?

Items to be noted include what the patient is wearing, including body jewelry, and whether it is appropriate for the context.

For example, a patient in a hospital gown would be appropriate in the emergency room or inpatient unit but not in an outpatient clinic.

Distinguishing features, including disfigurations, scars, and tattoos, are noted.

Grooming and hygiene also are included in the overall appearance and can be clues to the patient’s level of functioning.

The description of a patient’s behavior includes a general statement about whether he or she is exhibiting acute distress and then a more specific statement about the patient’s approach to the interview. The patient may be described as cooperative, agitated, disinhibited, disinterested, and so forth. Once again, appropriateness is an important factor to consider in the interpretation of the observation.

If a patient is brought involuntarily for examination, it may be appropriate, certainly understandable, that he or she is somewhat uncooperative, especially at the beginning of the interview.

  • Motor Activity. Motor activity may be described as normal, slowed (bradykinesia), or agitated (hyperkinesia).

This can give clues to diagnoses (e.g., depression vs. mania) as well as confounding neurological or medical issues.

Gait, freedom of movement, any unusual or sustained postures, pacing, and hand wringing are described.

The presence or absence of any tics should be noted, as should be jitteriness, tremor, apparent restlessness, lip-smacking, and tongue protrusions.

These can be clues to adverse reactions or side effects of medications such as tardive dyskinesia, akathisia, or parkinsonian features from antipsychotic medications or suggestion of symptoms of illnesses such as attention-deficit/hyperactivity disorder.

  • Speech. Evaluation of speech is an important part of the MSE.

Elements considered include fluency, amount, rate, tone, and volume. Fluency can refer to whether the patient has full command of the English language as well as potentially more subtle fluency issues such as stuttering, word finding difficulties, or paraphasic errors.

The evaluation of the amount of speech refers to whether it is normal, increased, or decreased. Decreased amounts of speech may suggest several different things ranging from anxiety or disinterest to thought blocking or psychosis. Increased amounts of speech often (but not always) are suggestive of mania or hypomania. A related element is the speed or rate of speech. Is it slowed or rapid (pressured)? Finally, speech can be evaluated for its tone and volume. Descriptive terms for these elements include irritable, anxious, dysphoric, loud, quiet, timid, angry, or childlike.

  • Mood  : The terms mood and affect vary in their definition, and a number of authors have recommended combining the two elements into a new label “emotional expression.”  Traditionally, mood is defined as the patient’s internal and sustained emotional state. Its experience is subjective, and hence it is best to use the patient’s own words in describing his or her mood. Terms such as “sad,” “angry,” “guilty,” or “anxious” are common descriptions of mood. Affect. Affect differs from mood in that it is the expression of mood or what the patient’s mood appears to be to the clinician.

Affect is often described with the following elements: quality, quantity, range, appropriateness, and congruence. Terms used to describe the quality (or tone) of a patient’s affect include dysphoric, happy, euthymic, irritable, angry, agitated, tearful, sobbing, and flat. Speech is often an important clue to the assessment of effect but it is not exclusive. Quantity of affect is a measure of its intensity. Two patients both described as having depressed affect can be very different if one is described as mildly depressed and the other as severely depressed. Range can be restricted, normal, or labile. Flat is a term that has been used for a severely restricted range of effects that is described in some patients with schizophrenia.

Appropriateness of affect refers to how the affect correlates to the setting. A patient who is laughing at a solemn moment of a funeral service is described as having an inappropriate affect. Affect can also be congruent or incongruent with the patient’s described mood or thought content. A patient may report feeling depressed or describe a depressive theme but do so with laughter, smiling, and no suggestion of sadness.

  • Thought Content : Thought content is essentially what thoughts are occurring to the patient.  This is inferred by what the patient spontaneously expresses, as well as responses to specific questions aimed at eliciting particular pathology. Some patients may perseverate or ruminate on specific content or thoughts. They may focus on material that is considered obsessive or compulsive. Obsessional thoughts are unwelcome and repetitive thoughts that intrude into the patient’s consciousness. They are generally ego alien and resisted by the patient. Compulsions are repetitive, ritualized behaviors that patients feel compelled to perform to avoid an increase in anxiety or some dreaded outcome. Another large category of thought content pathology is delusions.

Delusions are false, fixed ideas that are not shared by others and can be divided into bizarre and non-bizarre (non-bizarre delusions refer to thought content that is not true but is not out of the realm of possibility).  Common delusions include grandiose, erotomanic, jealous, somatic, and persecutory. It is often helpful to suggest delusional content to patients who may have learned to not spontaneously discuss them. Questions that can be helpful include, “Do you ever feel like someone is following you or out to get you?” and “Do you feel like the TV or radio has a special message for you?”

An affirmative answer to the latter question indicates an “idea of reference.” Paranoia can be closely related to delusional material and can range from “soft” paranoia, such as general suspiciousness, to more severe forms that impact daily functioning.

  • Thought Process : Thought process differs from thought content in that it does not describe what the person is thinking but rather how the thoughts are formulated, organized, and expressed. A patient can have normal thought process with significantly delusional thought content. Conversely, there may be generally normal thought content but significantly impaired thought process. Normal thought process is typically described as linear, organized, and goal directed.

With the flight of ideas, the patient rapidly moves from one thought to another, at a pace that is difficult for the listener to keep up with, but all of the ideas are logically connected.

The circumstantial patient over-includes details and material that is not directly relevant to the subject or an answer to the question but does eventually return to address the subject or answer the question. Typically the examiner can follow a circumstantial train of thought, seeing connections between the sequential statements.

The tangential thought processes may at first appear similar, but the patient never returns to the original point or question. The tangential thoughts are seen as irrelevant and related in a minor, insignificant manner. Loose thoughts or associations differ from circumstantial and tangential thoughts in that with loose thoughts it is difficult or impossible to see the connections between the sequential content.

Perseveration is the tendency to focus on a specific idea or content without the ability to move on to other topics. The perseverative patient will repeatedly come back to the same topic despite the interviewer’s attempts to change the subject.

Thought blocking refers to a disordered thought process in which the patient appears to be unable to complete a thought. The patient may stop midsentence or mid-thought and leave the interviewer waiting for the completion. When asked about this, patients will often remark that they don’t know what happened and may not remember what was being discussed.

Neologisms refer to a new word or condensed combination of several words that are not a true word and is not readily understandable, although sometimes the intended meaning or partial meaning may be apparent.

Word salad is speech characterized by confused, and often repetitious, language with no apparent meaning or relationship attached to it.

Clang association: thoughts are associated with sound rather than by its meaning.

Derailment: a breakdown in both the logical connection between ideas and the overall sense of goal-directedness. The words make sentences but do not make sense.

  • Perceptual Disturbances : Include hallucinations, illusions, depersonalization, and derealization. Hallucinations are perceptions in the absence of stimuli to account for them. Auditory hallucinations are the hallucinations most frequently encountered in the psychiatric setting. Other hallucinations can include visual, tactile, olfactory, and gustatory (taste). The interviewer should make a distinction between a true hallucination and a misperception of stimuli (illusion). Hypnagogic hallucinations (at the interface of wakefulness and sleep) may be normal phenomena.

Hypnopompic hallucinations refer to bizarre sensory experiences that occur during the transitory period between a sleeping state and wakefulness.

In describing hallucinations the interviewer should include what the patient is experiencing when it occurs, how often it occurs, and whether or not it is uncomfortable (ego-dystonic). In the case of auditory hallucinations, it can be useful to learn if the patient hears words, commands, or conversations and whether the voice is recognizable to the patient.

Depersonalization is a feeling that one is not oneself or that something has changed.

Derealization is a feeling that one’s environment has changed in some strange way that is difficult to describe.

  • Cognition – The elements of cognitive functioning that should be assessed are alertness, orientation, concentration, memory (both short and long term), calculation, fund of knowledge, abstract reasoning, insight, and judgment.
  • Abstract Reasoning – Abstract reasoning is the ability to shift back and forth between general concepts and specific examples. Having the patient identify similarities/differences between objects or concepts (apple and pear, bus and airplane, or a poem and a painting) as well as interpreting proverbs can be useful in assessing one’s ability to abstract. Cultural and educational factors and limitations should be kept in mind when assessing the ability to abstract.
  • Insight : Insight, in the psychiatric evaluation, refers to the patient’s understanding of how he or she is feeling, presenting, and functioning as well as the potential causes of his or her psychiatric presentation.
    1. Complete denial of illness.
    2. Slight awareness of being sick and needing help but denying it at the same time.
    3. Awareness of being sick but blaming it on others, on external events, on medical or unknown organic factors.
    4. Intellectual Insight- Admission of illness and recognition that symptoms or failures in social judgment are due to irrational feelings or disturbances; without applying that knowledge to future experiences.
    5. True Emotional Insight- Emotional awareness of the motives and feelings within, of the underlying meaning of symptoms; and whether this awareness leads to changes in personality and future behavior, openness to new ideas and concepts about self.
    6. Impaired Insight- -Diminished ability to understand the objective reality of a situation. -A person with very poor recognition or acknowledgement is referred to as having „poor insight‟ or „lack of insight‟. 
  • Judgment : Judgment refers to the person’s capacity to make good decisions and act on them. The level of judgment may or may not correlate to the level of insight. A patient may have no insight into his or her illness but have good judgment. It has been traditional to use hypothetical examples to test judgment, for example, “What would you do if you found a stamped envelope on the sidewalk?” It is better to use real situations from the patient’s own experience to test judgment.
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