Mental status examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]

Overview

Mental status examination, or MSE, is a medical process where a clinician working in the field of mental health (usually a psychotherapist, social worker, psychiatrist, psychiatric nurse or psychologist) systematically examines a patient's mind. Each area of function is considered separately under categories in a way similar to a physical examination performed by physicians. However, much of the material for the mental status examination is gathered during psychiatric history taking. The result of this examination is combined with the psychiatric history to produce a "psychiatric formulation" of the person being examined. The purpose of the mental status examination is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning.

Neurologist, emergency physicians, and other physicians perform mental status examinations from different perspectives. In general, the neurological exam seeks evidence of localizable brain anomaly; the emergency physician may wish to quickly discover the effects of head trauma or intoxication (poisoning).

It is a structured way of observing and describing a patient's current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment. There are some minor variations in the subdivision of the mental status examination and the sequence and names of mental status examination domains. The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests. The mental status examination is not to be confused with the mini-mental state examination (MMSE), which is a brief neuro-psychological screening test for [[dementia]}

Definition

The mental status examination accesses behavioral and cognitive functioning. Behavioral components include, appearance and general behavior, level of consciousness and attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight, and the reaction evoked in the examiner. Cognitive components include alertness, language, memory, constructional ability, and abstract reasoning.

There are many versions of mental status examination, which differ around the world but there is a broad commonality. Some schemes look at ego psychology and defence mechanisms while others are more concise.

▸ Click on the following categories to learn more.

Mental Status Exam   ▸  Components   ▸  Role of the Examiner   ▸  Mini mental state examination   ▸  MoCA

Behavioral ▸ Appearance ▸ Behavior ▸ Mood and affect ▸ Thought ▸ Speech ▸ Perceptions ▸ Consciousness ▸ Cognition ▸ Attention ▸ Orientation ▸ Memory ▸ Judgment ▸ Insight ▸ Constructional Ability

Role of the Examiner ▸ Transference in an Examiner ▸ Instructions to the Examiner

Components of the Exam

Appearance

This category covers the physical aspects of the person. This includes his/her physical appearance such as age, height and weight, how he/she is dressed and groomed, and the dominant attitude presented in the interview. Some include factors like the degree of poise or comfort in the interview, and the degree of anxiety and how it is expressed in this category.

1. Clothing:
   • Colorful or bizarre clothing : Mania, schizotypical personality
   • Unkempt grooming, dirty clothes : Schizophrenia, depression
   • Clothing and accessories of a particular subculture, body modifications
   • Clothing not typical of the patient's gender, may give clues to personality disorders
   • Provocative clothing may suggest bipolar disorder or histrionic personality disorder
2. Hygiene: Odor, which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication.
3. Attitude towards interviewer: Cooperative, uncooperative, hostile, guarded, suspicious or regressed. The most subjective element of the mental status examination, attitude depends on the interview situation, the skill and behavior of the clinician, and the pre-existing relationship between the clinician and the patient. However, attitude is important for the clinician's evaluation of the quality of information obtained during the assessment. Attitude, also known as rapport, refers to the patient's approach to the interview process and the interaction with the examiner.
4. Age: If apparent age is greater than the chronological age, it may be indicative of chronic illness or chronic poor self care.
5. Weight loss: This could signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety.

Behavior

Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait.

1. Psychomotor agitation: An increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium
2. Psychomotor retardation: A global decrease in arousal and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression, negative symptoms of schizophrenia or a medical condition such as parkinson's disease, dementia or delirium
3. Akinesia: Absent physical movement, seen in the catatonic schizophrenia; and extrapyramidal side effect of antipsychotic medications.
4. Akathisia: A compulsive feeling to move and inability to sit still because of a subjective feeling of motor restlessness, a side effect of antipsychotic medication. It can be confused with psychomotar agitation
5. Tics: Involuntary but quasi-purposeful movements or vocalizations, which may be a symptom of tourette's syndrome
6. Dystonia, Tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medications
7. Chorea, athetoid or choreoathetoid movements may indicate a neurological disorder
8. Catalepsy or waxy flexibility: It is seen in catatonic schizophrenia, person remains the position they were given
9. Stereotype and Mannerisms: Stereotype is repetitive purposeless movements such a rocking or head banging. Mannerisms are repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait. They may be a feature of chronic schizophrenia or autism
10. Tardive diskinesia: It is extra-pyramidal side effect of antipsychotics
11. Echopraxia: In spite of instructions, interviewer's actions are repeated by the patient, it is seen in tourret's syndrome
12. Eye contact:
    • Repeatedly glancing to one side can suggest that the patient is experiencing hallucinations, and the quality of eye contact can provide clues to the patient's emotional state
    • Lack of eye contact may suggest depression or autism.

Mood and affect

The distinction between mood and affect in the MSE is subject to some disagreement. Mood is regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation. Cultural considerations are important in this and many other aspects of the mental status examination.

• Affect is "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time." Affect is described by labeling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. While evaluating affect, baseline of the patient and other context should be considered e.g. parkinson's disease has paucity of movements and can be mistaken as a blunt affect.

1. Appropriate or inappropriate: The relation between what the patient is experiencing or describing and the emotion exhibited at the same time, in other words, as congruent or incongruent with their thought content.
2. The intensity described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic
   • A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder
   • Heightened affect may suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorder
3. The range of the affect describes whether the person shows a full or an expanded range or blunted or restricted
4. Reactive or non reactive: The flexibly and appropriate with the flow of conversation, is termed as reactive. A bland lack of concern for one's disability may be described as showing la belle indifférence, a feature of conversion disorder, which is historically termed hysteria.
5. Mobility refers to the extent to which affect changes during the interview. It can be described as mobile, constricted, fixed, immobile or labile.

• Mood: Mood is described using the patient's own words, and can also be described in summary terms such as,

1. Neutral
2. Euthymic (normal)
3. Dysphoric(depression, anxiety, guilt)
4. Euphoria(implying a pathologically elevated sense of well-being)
5. Angry
6. Anxious
7. Apathetic.

Alexithymic individuals are unable to describe their subjective mood state. Anhedonia is inability to experience any pleasure, it is seen in depression. Examiner should inquire about mood over period of past few weeks instead of the mood at that moment. An objective way of evaluation is asking patients to calibrate their mood over scale of 1 to 10, 1 being sad and 10 being happy. One should also note if mood fluctuates or remains constant on each visit.

Thought

Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. A description of thought content would describe a patient's delusions, overvalued ideas, obsessions, phobias and preoccupations. Abnormalities of thought content are established by exploring individual's thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts. Thought is described into two virtues, form and content. Process/Form: Quantity.

Tempo (rate of flow)

1. Flight of ideas, when their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a chain of poetic associations in the patient's speech. Flight of ideas is typical of mania.
2. Retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Depression, dementia, negative symptom of schizophrenia may have retarded or inhibited thinking.
3. Poverty of thought is a global reduction in the quantity of thought
4. Thought perseveration: Thought perseveration refers to a pattern where a person keeps returning to the same limited set of ideas. A patient with dementia might also experience thought perseveration.
5. Formal thought disorder: A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight's move thinking. Formal thought disorder is a common feature of schizophrenia.
6. Circumstantial thinking: Thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders.

Form (or logical coherence) of thought

This looks at features like the rate of thoughts and how they flow and are connected. Formal thought disorder comprises processes such as pressure of thought (excessively rapid), flight of ideas, thought block, disconnected thoughts (loosening of association and derailment and Knight's move), tangentiality and circumstantial thoughts (over inclusive and slow to get to the point).

1. Obsession:
   • An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences, they are not experienced as imposed from outside the patient's mind.
   • Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes.
   • A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes).
2. Phobia:
   • A phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a delusion in that the patient is aware that the fear is irrational.
   • A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview.
3. Suicidal ideation, homicidal thoughts and other preoccupations:
   • Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include suicidal ideation, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortion of anxiety and depression.
   • The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life.

Content

Thought content includes things discussed in the interview and the beliefs. The preoccupying thoughts such as ideas of reference, obsessions, ruminations or phobia. The patient may have overvalued ideas, first rank symptoms - delusions of control, thought alienation comprising of thought insertion, withdrawal and broadcast, delusional perception, somatic passivity or delusion.

Perceptions

This covers the area of the senses and describes any distortions such as illusion, hallucination or delusion .

Illusions

• Optical Illusions: An optical illusion is characterized by visually perceived images that are deceptive or misleading. Therefore, the information gathered by the eye is processed by the brain to give, on the face of it, a percept that does not tally with a physical measurement of the stimulus source.
• Auditory illusions: An auditory illusion is an illusion of hearing, the listener hears either sounds which are not present in the stimulus, or "impossible" sounds.
• Tactile illusions: Examples of tactile illusions include phantom limb Tactile illusions can also be elicited through haptic technology. These "illusory" tactile objects can be used to create "virtual objects".
• Other senses: Illusions can occur with the other senses including those involved in food perception. Here both sound and touch have been shown to modulate the perceived staleness and crispness of food products. It was also discovered that even if some portion of the taste receptor on the tongue became damaged that illusory taste could be produced by tactile stimulation. Evidence of olfactory (smell) illusions occurred when positive or negative verbal labels were given prior to olfactory stimulation.

Hallucination

• Hallucinations may be manifested in a variety of forms. They affect different senses, sometimes occurring simultaneously, creating multiple sensory hallucinations for those experiencing them. These are visual, auditory, gustatory, olfactory, tactile , somatic and kinaesthetic hallucinations.
• Some of the Schneiderian first rank symptoms are also hallucinatory in nature such as thought echo, gedankenlautwerden, thought insertion, thought withdrawal and somatic passivity.
• Depersonalization, where the person feels unreal, and derealization, where the person feels that the surroundings are unreal, are also described here.
• Evaluate if the patient harbor realistic concerns, or they are irrational.
• Inquire about functional and reflex hallucinations. It should be acknowledged how a person copes with these hallucinations and whether they are pleasant, unpleasant or terrifying for him. It is also important to explore and comment on hallucinatory behavior for example if the person is looking back again and again or gesturing or self talking.
• Visual:

• Visual hallucination is the 'seeing of things that are not there', which can also (according to some definitions) include 'seeing things that are there, incorrectly' (Illusion). Most users describe it by the "Third Eye", by which they can see things others cannot.
• Sometimes patients may see vague things like halos or colours which are difficult to describe.
• Stronger hallucinogenics have been reported to have an effect leading the user to see oneself in a different world and having a different life.

• Auditory:

• Auditory hallucinations (paracusia) are the perception of sound without outside stimulus. Auditory hallucinations are common in schizophrenia while visual disturbances are more common in organic problems.Auditory hallucinations can be divided into two categories:

1. Elementary: Elementary hallucinations are the perception of sounds such as hissing, whistling, an extended tone, and more. In many cases, tinnitus is an elementary auditory hallucination. However, some people who experience certain types of tinnitus, especially pulsatile tinnitus, are actually hearing the blood rushing through vessels near the ear. Because the auditory stimulus is present in this situation, it does not qualify as a hallucination.
2. Complex:
   • Complex hallucinations are those of voices, music, or other sounds that may or may not be clear, may be familiar or completely unfamiliar, and friendly or aggressive, among other possibilities. Hallucinations of one or more talking voices are particularly associated with psychotic disorders such as schizophrenia, and hold special significance in diagnosing these conditions.
   • Musical hallucinations are also relatively common in terms of complex auditory hallucinations and may be the result of a wide range of causes ranging from hearing-loss (such as in musical ear syndrome, the auditory version of Charles Bonnet syndrome), lateral temporal lobe epilepsy, arteriovenous malformation, stroke, lesion, abscess, or tumor.

• Many people not suffering from diagnosable mental illness may sometimes hear voices as well. One important example to consider when forming a differential diagnosis for a patient with paracusia is lateral temporal lobe epilepsy. Despite the tendency to associate hearing voices, or otherwise hallucinating, and psychosis with schizophrenia or other psychiatric illnesses, it is crucial to take into consideration that, even if a person does exhibit psychotic features, he/she does not necessarily suffer from a psychiatric disorder on its own. Disorders such as Wilson's disease, various endocrine diseases, numerous metabolic disturbances, multiple sclerosis, systemic lupus erythematosus, porphyria, sarcoidosis, and many others can present with psychosis.
• It is also important to ascertain whether hallucinations are in second person or third person; if in second person whether they command the subject to do anything especially suicidal or homicidal acts.
• Hallucinations can be in the form of a running commentary, whether in second person or third person.
• Hallucinations may be of any gender, known or unknown person(s)

• Extracampine hallucinations: Hallucinations in which the person does see things or hear voices outside his sensory field like hearing voice of a friend sitting 5 miles away or seeing things behind the head or inside the body.
• Lilliputian hallucinations: Sometimes the patient may see very small people around him, a phenomenon called Lilliputian hallucinations.
• Palinopsia: The patient experiences a trail of objects moving around termed as Palinopsia
• Command hallucinations:

• Command hallucinations are hallucinations in the form of commands; they can be auditory or inside of the person's mind and/or consciousness. The contents of the hallucinations can range from the innocuous to commands to cause harm to the self or others. Command hallucinations are often associated with schizophrenia. People experiencing command hallucinations may or may not comply with the hallucinated commands, depending on circumstances. Compliance is more common for non-violent commands.
• Some helpful questions that can assist one in figuring out if he/she may be suffering from this includes: "What are the voices telling you to do?", "When did your voices first start telling you to do things?", "Do you recognize the person who is telling you to harm yourself (others)?", "Do you think you can resist doing what the voices are telling you to do?"

• Olfactory:

• Phantosmia is the phenomenon of smelling odors that are not really present. The most common odors are unpleasant smells such as rotting flesh, vomit, urine, feces, smoke, or others.
• Phantosmia often results from damage to the nervous tissue in the olfactory system. The damage can be caused by viral infection, brain tumor, trauma, surgery, and possibly exposure to toxins or drugs. Phantosmia can also be induced by epilepsy affecting the olfactory cortex and is also thought to possibly have psychiatric origins. Phantosmia is different from parosmia, in which a smell is actually present, but perceived differently from its actual smell. Smelling colors is also reported in some cases of serious hallucinations.
• Olfactory hallucinations can also appear in some cases of associative imagination, for example, while watching a romance movie, where the man gifts roses to the woman, the viewer senses the roses' odor (which in fact does not exist).
• Olfactory hallucinations have also been reported in migraine, although the frequency of such hallucinations is unclear.

Tactile hallucinations:

Tactile hallucinations are the illusion of tactile sensory input, simulating various types of pressure to the skin or other organs. One subtype of tactile hallucination, formication, is the sensation of insects crawling underneath the skin and is frequently associated with prolonged cocaine use. However, formication may also be the result of normal hormonal changes such as menopause, or disorders such as peripheral neuropathy, high fevers, lyme disease, skin cancer, and more.

• Gustatory:

This type of hallucination is the perception of taste without a stimulus. These hallucinations, which are typically strange or unpleasant, are relatively common among individuals who have certain types of focal epilepsy, especially temporal lobe epilepsy. The regions of the brain responsible for gustatory hallucination in this case are the insula and the superior bank of the sylvian fissure.

• General somatic sensations:

General somatic sensations of a hallucinatory nature are experienced when an individual feels that his body is being mutilated, i.e. twisted, torn, or disembowelled. Other reported cases are invasion by animals in the person's internal organs such as snakes in the stomach or frogs in the rectum. The general feeling that one's flesh is decomposing is also classified under this type of hallucination.

Delusion

A delusion is a belief held with strong conviction despite superior evidence to the contrary. It can also beIt can also be defined as "a false, unshakeable idea or belief which is out of keeping with the patient's educational, cultural and social background. The patient held with extraordinary conviction and subjective certainty", and is a core feature of psychotic disorders. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, or other effects of perception. Delusions typically occur in the context of neurological or mental illness, although they are not tied to any particular disease and have been found to occur in the context of many pathological states (both physical and mental). However, they are of particular diagnostic importance in psychosis or psychotic disorders including schizophrenia, paraphrenia, manic episodes of bipolar disorder, and psychotic depression. Delusions are categorized into following different groups:

• Bizarre delusion: A delusion that is very strange and completely implausible; an example of a bizarre delusion would be that aliens have removed the reporting person's brain.
• Non-bizarre delusion: A delusion that, though false, is at least possible, e.g., the affected person mistakenly believes that he is under constant police surveillance.
• Mood-congruent delusion: Any delusion with content consistent with either a depression or mania, e.g., a depressed person believes that news anchors on television highly disapprove of him, or a person in a manic state might believe she is a powerful deity.
• Mood Incongruent delusion: Delusions not consistent with mood, commonly seen in schizophrenia.
• Mood-neutral delusion: A delusion that does not relate to the sufferer's emotional state; for example, a belief that an extra limb is growing out of the back of one's head is neutral to either depression or mania.

In addition to these categories, delusions often manifest according to a consistent theme. Although delusions can have any theme, certain themes are more common. Some of the more common delusion themes are:

1. Delusion of control or or passivity experiences : This is a false belief that another person, group of people, or external force or agency controls one's general thoughts, feelings, impulses, or behavior. Seen in schizophrenia.
2. Cotard delusion or nihilistic delusions : This is a false belief that one does not exist or has died. Seen in depression with psychotic features.
3. Delusion of guilt or sin (or delusion of self-accusation): This is an ungrounded feeling of remorse or guilt of delusional intensity. Seen in depression with psychotic features.
4. Delusion of poverty: The person strongly believes that he is financially incapacitated. Although this type of delusion is less common now, it was particularly widespread in the days before state support. Seen in depression with psychotic features
5. Delusional jealousy: A person with this delusion falsely believes that a spouse or lover is having an affair, with no proof to back up their claim.
6. Delusion of reference: The person falsely believes that insignificant remarks, events, or objects in one's environment have personal meaning or significance. Examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity.
   • Delusion of mind being read: The false belief that other people can know one's thoughts.
   • Delusion of thought insertion: The belief that another thinks through the mind of the person.
7. Erotomania or Erotomanic delusions: A delusion in which someone falsely believes another person is in love with them.
8. Grandiose delusions:
   • Grandiose delusions are distinct from grandiosity, in that the sufferer does not have insight into his loss of touch with reality. An individual is convinced he has special powers, talents, or abilities. Sometimes, the individual may actually believe they are a famous person or character.
   • Grandiose delusions or delusions of grandeur are principally a subtype of delusional disorder but could possibly feature as a symptom of schizophrenia and manic episodes of bipolar disorder.
   • Grandiose delusions are characterized by fantastical beliefs that one is famous, omnipotent, or otherwise very powerful
   • The delusions are generally fantastic, often with a supernatural, science-fictional, or religious bent
   • Grandiose delusions or delusions of grandeur can also be associated with megalomania
     1. Grandiose religious delusion: The belief that the affected person is a god, or chosen to act as a god.
9. Somatic delusion: A delusion whose content pertains to bodily functioning, bodily sensations, or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal, or changed.
   • Delusional parasitosis: A delusion in which one feels infested with insect, bacteria, mite, spiders, lice, fleas, worms, or other organisms. Affected individuals may also report being repeatedly bitten. In some cases, entomologists are asked to investigate cases of mysterious bites. Sometimes physical manifestations may occur including skin lesions.
10. Delusional misidentification
11. Persecutory delusions or Paranoid delusions: Persecutory delusions are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or otherwise obstructed in the pursuit of goals. Persecutory delusions are a condition in which the affected person wrongly believes that they are being persecuted. The individual thinks that,

1. Harm is occurring, or is going to occur
2. the pPersecutor(s) has(have) the intention to cause harm
3. Constantly being prejudged or profiled.

Speech

It is customary to separate speech from thought in the mental status examination, although this is rather artificial. In general, aspects of the speech that will not be part of the section on thought are covered here. The patient's speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions. This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought form and thought content. This includes general and paralinguistic features the following,

• Volume or quantity
• Rate and flow of speech.
• Loudness, garrulous, monotonous, labored, emotional
• Rhythm
• Prosody
• Intonation

• Pitch
• Phonation
• Articulation
• Rate
• Spontaneity
• Latency of speech mannerisms, accent, and stuttering

Evaluating spontaneous speech while asking open ended questions may provide better assessment of the speech. A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under cognition.

• Aphonia or dysarthria can be seen in stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism
• Paralinguistic and pragmatic aspects of their speech.may be impaired in the autism spectrum disorders like asperger syndrome
• Echolalia (repetition of another person's words) and palilalia (repetition of the subject's own words) seen in autism, schizophrenia or alzheimer's disease.
• Neologisms, which are made-up words which have a specific meaning to the person using them in schizophrenia.
• Rapid, loud and pressured speech in mania or anxiety or amphetamine intoxication;
• Prolonged speech latency and a slow, quiet and hesitant manner in depression.
• Slowness and loss of spontaneity in movement may characterize a subcortical dementia or depression
• Hypophonia in Parkinson's disease
• Halting speech of the patient with word-finding difficulties
• Akathisia (motor restlessness) in extrapyramidal syndrome secondary to antipsychotic use.

[Set generation] [Set generation]

Consciousness

Levels of consciousness are described on the basis of the strength of stimuli needed to elicit responses. It depends on cortical and brainstem components. The following are levels of consciousness,

1. Conscious
2. Hyperalert
3. Confusion
4. Delirious
5. Lethargy
6. Somnolent
7. Obtunded
8. Stupor
9. Coma

Recording type of stimulus needed to elicit response in the patient and the response can prove useful evaluation of the patient.

Cognition

This looks at a number of areas such as the level of abstract thought (which declines or is absent in a number of conditions such as dementia and schizophrenia), the level of general education and intelligence, and the degree of concentration which is often tested by digit span recall or an ability to serially subtract seven starting at 100. Folstein's mini mental state examination is often used to more formally assess cognition. This section of the MSE covers the patient's level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation.

• Attention and concentration are assessed by the serial sevens test (or alternatively by spelling a five-letter word backwards), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. Executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter F, in one minute"). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE.
• Mild impairment of attention and concentration may occur in any mental illness where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain functioning such as delirium, dementia intoxication. Specific language abnormalities may be associated with pathology in Wernicke's area or Broca's area of the brain. In Korsakoff's syndrome there is dramatic memory impairment with relative preservation of other cognitive functions.
• Visuospatial or constructional abnormalities here may be associated with parietal lobe pathology, and abnormalities in executive functioning tests may indicate frontal lobe pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing.
• The mental status examination may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-stone").
• The posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed.
• A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again.
• Pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements.
• A lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (Parinaud's syndrome).

Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders.

Attention

Attention can be evaluated by many tests. Tests focuses on simple tasks without stressing on other faculties like language, motor or spatial conceptions. However, these tests can not differentiate between toxic and metabolic states, diffuse cortical dysfunction, or psychiatric dysfunction.

• One commonly used test have patients to listen to digit spans of increasing length and tell them back in same order or in reverse order to the examiner.
• In an another test patient is asked to tap on a repeating letter in a randomly written series of letter on paper. Reduced attention will reduce attention span and increase the number of errors.

e.g. tap on letter Q W Q B K L N Q Q Q N N Q O H V Q J N B K J Q Q J Q K Q B B Q

• Cortical and brainstem functioning is essential to have optimal attention span. Reticular activating system contributes to arousal.
• A dysfunction in the ascending biogenic amine pathways can cause reduced attention, which is seen in depression and dementia.
• An unilateral spatial neglect is seen in lesion of the contra-lateral parietal lobe.

Orientation

This frequently looks at whether the person knows the time (including the date), place (where he/she are), person (who he/she is), and situation (that he/she is in). Broadly orientation indicates recent memory function. [& Memory] [& working memory]

Memory

Memory is tested by looking for immediate recall, short-term memory (an ability to remember several things after five minutes) and long-term memory (an ability to remember distant events such as the years of World War II). [Normal orientation & memory] [Attention working memory ]

Judgment

This looks at how the person makes judgments about events. Is it logical or idiosyncratic? Is it reasoned? Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. Traditionally, the mental status examination included the use of standard hypothetical questions such as "what would you do if you found a stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual's executive system capacity in terms of impulsiveness, social cognition, self-awareness and planning ability. Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others. [reasoning] [reasoning]

Insight

This describes how much understanding or awareness the person has of his/her own psychological functioning or disturbance. The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context, insight can be said to have three components: recognition that one has a mental illness, compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively. Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment.

Constructional Ability

Dysfunction in the function of both hemispheres can cause impairment in the constructional ability. Progressive diseases like alzhimer can be monitored by the serial evaluation constructional ability. Most of the times dysfunction is present in the posterior to the Roland sulcus, if there is no aphasia the lesion is in the nondominant hemisphere. This faculty requires integration of occipital, parietal, and frontal lobe. Apraxia is not a weakness, but an inability to do the task like drawing a line drawing, manipulation of the block design. Ask the patient to draw a picture from memory, eg. draw a clock shoing time 12 o'clock or manipulate blocks (multicolored cubes from WAIS-R) to reproduce stimulus designs or reproduce a drawing from a memory.

Ideomotor apraxia: In ideomotar apraxia, there is an impairment in the orderly command required to manipulate real objects. The patient suffering from ideomotar apraxia is unable to do a pretend action with imaginary objects. This can be tested by asking the patient to do imaginary tasks like, button an imaginary t shirt.

Theoretical foundations

The mental status examination derives from an approach to psychiatry known as descriptive psychopathology or descriptive phenomenology which developed from the work of the philosopher and psychiatrist Karl Jaspers. From Jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives. In practice, the mental status examination is a blend of empathic descriptive phenomenology and empirical clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient signs and symptom, is incompatible with the original meaning which was concerned with comprehending a patient's subjective experience.

Application

The mental status examination is a core skill of qualified (mental) health personnel. It is a key part of the initial psychiatric assessment in an out-patient or psychiatric hospital setting. It is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The mental status examination can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief mental status examination checklists are available for use in emergency situations, for example by paramedics or emergency department staff. The information obtained in the mental status examination is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.

Role of the Examiner

Transference in an Examiner

Transference in an examiner can give a subtle clues to the diagnosis. In efforts to remain non judgmental the feelings aroused in an examiner are overlooked.

1. Depressed patient can evoke feelings of dysphoria
2. Frustration may be felt by help rejecting attitude seen in many psychiatric disorders.
3. Feelings of being off balance and being disconnected to conversation may be an indicative of schizophrenia.

Instructions to the Examiner

1. Mental status examination requires a good rapport between the patient and the examiner. If mental status examination is left towards end of interview the patient can be more comfortable at the time of mental status examination. Some clinicians prefers to administer mental status examination at the begining of the clinical evaluation because it helps to direct rest of clinical encounter and provides rough estimate to the sensitivity and accuracy of the clinical history. Examiner must develop a technique to incorporate aspects of mental status examination in routine history taking, in which the patient can relate and will reveal aspects like general appearance and behavior, alertness, speech, activity, affect, and attitude.
2. If there is a suspicion of a psychiatric illness, positive findings in a neurological examination or problems in conduction ADLs by the patient, a formal testing of cognitive impairments is mandated. Examiner must explain about need of cognitive testing to gain cooperation rather than resistance.

Cultural considerations

There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations - without understanding may seem similar though they have different roots. Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder.

Children

There are particular challenges in carrying out an MSE with young children and others with limited language such as people with intellectual impairment. The examiner would explore and clarify the individual's use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner. In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences.

Mental Health Examination in the preschool Child

• In a preschool child mental status examination, observation of play activities are helpful. Following things should be observed,

intial reaction of a child after greeting, eye contact, cooperativeness, social engagement, features of speech, child's interaction with primary caregiver, repeating of play or phrases, disorganization in play, complexity and thematic content of play, ability to sustain interest.

• ITMSE, Infant and Toddler Mental Exam is modified mental status exam for infant and young child.

Controversy

The article so far has described how a clinician usually goes about the task of performing a mental status examination. There is controversy both within the profession about this and also controversy from without.

Within the profession

There are many gaps in the traditional mental status examination that have been pointed out. The areas of impulse control, ego psychology and defense mechanisms are among them. Cultural concerns and knowledge of the facts can skew the assessment. A clinician who does not know that the person he/she is examining is who he/she claims to be may interpret information given as a delusion. The examination is inherently flawed because it relies on the clinician's inferences about what he/she observes. Any individual's observations and inferences, including those of the clinician, are based upon one's cultural background, education, expectations, belief system, etc. One attempt to reduce the impact of these inherent distortions is to use so-called "objective" testing of personality such as the Minnesota Multiphasic Personality Inventory or "projective" techniques such as the Rorschach inkblot test. These methods, however, have their own issues with reliability, validity, cultural influences, and possible conscious or unconscious distortion. Integration and/or comparison of clinical observations, such those in an mental status examination, with objective and projective test data may provide the clinician with an improved basis for clinical inferences about a patient.

Outside the profession

The mental status examination is one of the more subjective parts of the work of psychiatrists and psychologists. It thus attracts significant criticism from antipsychiatry and related groups.

Further reading

• Recupero, Patricia R (2010). "The Mental Status Examination in the Age of the Internet". Journal of the American Academy of Psychiatry and the Law. 38 (1): 15–26. PMID 20305070. Retrieved 20 November 2010
• MSE Rapid Record Form

External links

• The Mental State Examination Rapid Record Form (free)
• Psychskills.co.uk - The Mental State Examination (MSE)
• MED/3358 at eMedicine
• University of Utah Medical School: Video clips demonstrating cognitive assessment

See also

• Mental illness for an introduction into the various disorders
• Thought disorder