Mental Status Exam (MSE) — Factors and Definitions
Table of Contents
Image: “Blue” by Omer Unlu. License: CC BY-SA 2.0
Overview
A mental status examination, just like a physical examination, is an intrusion on the patient’s rights and should not be conducted against the patient’s will. Before performing a mental status examination, the patient should consent to the procedure. Additionally, the patient should understand that the results of such an exam are going to be documented and he should agree on that. If a mental status examination is needed in an emergency setting where the patient cannot give consent, it should be documented that the patient did not agree on this mental status examination.
Patient’s Appearance
The patient’s general appearance should be noted and documented. The patient’s sex, apparent age, stated age, race, and ethnicity should be documented. The patient’s nutritional status should be also documented. Anorexia nervosa is characterized, for example, by severe low weight.
- The patient’s entrance to your office should be noted. A highly suspicious patient, for instance, might have paranoia.
- The patient’s posture and motor activity should be noted. It should also be noted whether the patient appears relaxed or anxious.
- Patient’s grooming and hygiene can give important clues to the psychiatrist.
- Patient’s eye contact is also part of the patient’s appearance and should be noted here.
- Avoidance of eye contact should be noted and should be detailed as whether it happened most of the time or during certain topics.
- Staring at the floor or ceiling or scanning the room should be documented if present.
Patient’s Attitude towards the Psychiatrist
The patient’s facial expressions and attitudes towards the interviewer should be documented. The patient’s interest and degree of engagement during the interview are vital and should be included in the mental status exam. Hostility is usually seen in bipolar or psychotic patients and should be documented if present. If the patient is overly friendly, that should also be documented.
Patient’s Mood
The patient’s current and sustained emotion should be inquired about and noted in your mental status examination.
Sometimes, patients give vague answers such as OK or don’t know. In that case, further questioning is needed to document the patient’s mood accurately.
Once the current mood of the patient is established, questions about the length of that specific mood are needed. When mood changes over time or is unstable, a bipolar disorder is more likely for instance.
Patient’s Affect
The patient’s affect reflects how the patient currently feels. The patient might have an expansive mood with a lot of laughter when he or she is in a manic episode. A euthymic or normal affect is appropriate to the patient’s current mood. Sometimes, the patient’s affect is constricted and limited. This is commonly seen in depressed patients.
A blunted affect is characterized by a very minor variation during the interview. Such a patient might be severely depressed or might have a thought disorder. A patient with a flat affect shows no variation whatsoever in relation to the patient’s current emotion.
The patient’s affect should also be documented if it agrees with the current expressed emotion by the patient. For instance, a cheerful patient who has just been diagnosed with cancer might be in denial.
Patient’s Speech
The patient’s quality, rate, and quantity of speech should be documented. The patient’s responses to open-ended and close-ended questions should be noted. Patients who provide too much detail to a close-ended question might be trying to divert the conversation to something else they are more comfortable with.
One-word answers are also troubling as they can hint towards the possibility of withholding information from the psychiatrist. A depressed patient might have a slow speech rate when an open-ended question is asked.
Thought Process
The status of thought process should be noted as this is vital for a thought disorder diagnosis such as schizophrenia. The process of thoughts might be described as without association, with a flight of ideas, rapid thoughts, tangential, circumstantial, word salad, derailment, neologism, clanging, punning, thought blocking or thought poverty.
Loss of association between thoughts and flight of ideas are characterized by the rapid movement of one topic to another. This might be seen in a bipolar patient in the manic phase. In patients with flights of ideas, a previous topic might be re-visited again. Patients with tangential thought processing tend to switch from topic to another without ever returning to the previous topic. Racing of ideas is similar to flights of ideas but the topics might be more rapidly provided. A complete word salad is seen in psychotic patients. This word salad can include known words or newly invented words known as neologism. The use of rhyming words is known as clanging.
Some Disorders that Affect the Thought Process
Thought Content
In addition to the thought process, the content of the thoughts should also be noted.
Hallucinations
The content might include hallucinations. Documentation of auditory or visual hallucinations in a patient with a word salad or neologism provides stronger evidence for a possible psychotic disorder. If hallucinations are present, inquiry about command-type hallucinations is necessary. Open-ended questions should be used here. For instance, ask the patient if the voices are telling him to do something.
Obsessions and compulsions
Obsessions and compulsions are also part of the thought content one should ask about. If the patient shows evidence for possible obsessions or compulsions, close-ended questions should be used.
Phobias
Phobias should be also inquired about and any specific phobias should be documented in the mental status examination.
Suicidal ideation
Suicidal ideation should be documented during your mental status examination. Direct inquiry about suicidal ideation is recommended. If the patient has a positive suicidal ideation, specific inquiry about any suicidal plans should be done. If a plan is put, the patient’s readiness for that plan should be assessed. These are the main risk factors for a true suicidal attempt. Homicidal ideation should be also inquired about, especially in psychotic patients or those with suicidal ideation. Patients who blame someone for their depression might eventually become homicidal instead of suicidal.
Comprehension
The patient’s comprehension should be checked. Ask the patient a direct question such as squeeze my fingers. A patient in delirium might fail to follow commands. The level of consciousness should also be noted.
Orientation
Orientation to time, person, place and situation should be documented. Ask the patient about his or her full name, do they know where they are, what is the date today and the current time, and why do they think they are here or if they know why they are here.
Ask the patient to subtract 7 from 100 sequentially. This tests the patient’s ability to concentrate and pay attention. An easy word such as “world” should be spelled by the patient forward and backward to further test the patient’s concentration.
The patient’s ability to draw interlocking pentagons should be checked. A patient unable to perform this task is said to have constructional apraxia. This can be seen in neurologic diseases such as a stroke.
Memory
The patient’s ability to determine similarities between two things is known as abstract thought. If a plane and a bus are presented to the patient and the patient is asked what is common between the two, a satisfactory answer would be both are modes of transportation. Someone with impaired abstract thoughts might say that both are rectangular.
Based on this information, one should determine the patient’s intelligence level as below average, average or above average.
Patient’s Insight
When obtaining your psychiatric history, you should document whether the patient has a good understanding of their illness and acknowledge that they need help or not. A patient with a mood disorder might have a good insight, whereas someone with psychosis is very unlikely to have a good insight.
Judgement
The patient’s judgment should also be evaluated. Ask the patient about their response to an imaginary situation or scenario and evaluate their response to what they would do in that scenario. The response behavior might be considered as appropriate or inappropriate to the situation.
Impulsivity
Inquiry should be made about whether the patient might engage in certain activities without thinking or planning. This is known as impulsivity.
Reliability
Once you have finished your mental status examination of the patient, you should determine whether the patient was reliable, unreliable or not possible to tell. This is important as it increases the credibility of the obtained history and can determine the necessity for interviewing other individuals close to the patient in addition to the patient. The patient’s reliability can be assessed from your mental status examination, and can be determined from the patient’s compliance with your treatment plan.
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