The Mental Status Exam
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Introduction
The mental status exam (MSE) is akin to the psychiatric physical exam, with observations focused on visible the impact of the person's mind. Envision as approaching someone from far away - what do you notice first, and as they approach?
Make sure questions are tailored to people's educational level. Some questions here are for screening of cognition (ie dementia); use appropriately and inoffensively. Record the time the MSE was carried out, as things can change rapidly.
general appearance and behaviour
- clothing (appropriate to season?) hygiene
body weight, apparent vs chronological age, facial expression
- posture, gait
- movements: agitation? retardation? abnormal movements - tremors, akathesia, tardive dyskinesia, paralysis
- eye contact and attitude towards examiner
speech
All qualities of a patient's speech should be noted, including:
- rhythm/fluency, quantity, spontaniety
- prosody, dysarthria
- rate: pressured? slowed?
- volume, tone, articulation
- one-word answers or elaborative
- spontaniety vs paucity of thought
Language comprehension is also important. Assess repetition by picking a sentence which isn't affected by hearing loss - "today is a nice day". Also consider querying vocabulary by pointing to objects in the room. Reading and writing may also be relevant to assess.
emotional state
Mood is the sustained emotion a patient reports; "how's your mood?" or "how do you feel most days?" are good initial points. Record in patient's own words. Determine the intensity, duration, and frequency of any negative episodes, along with mood stability.
Affect is the observed emotion of the patient. Qualities include: euthymic (normal), depressed, elevated (hypomanic), anxious, expansive (contagiously cheerful). Range of emotions include: full, restricted, blunted, flat. stability: fixed, labile.
Mood congruence, appropriateness, and intensity
thought process
- coherence
- logic
- stream
- goal-directed
- circumstantial: indirect speech and delayed in reaching the goal, but eventually returns
- tangential: sppec is oblique or irrelevant, does not come back to the point
- loosening of associations: illogical shifting between topics
- flight of ideas: skipping verbally among marginally connected ideas
- word salad: jumble of words without logical coherence
- perseveration: repetition of the same verbal or motor response
- thought blocking: sudden cessation of flow of thought and speech
- clang associations - speech based on rhymes, puns, etc
- neologism: use of novel words, or of existing words in novel fashion
thought content
suicidal/homicidal ideation
- low, intermediate, high risk
obsessions: recurrent and persistent thoughts, impuses, or images which are intrusive or inappropriate
- cannot be stopped by logic or reason
- causes marked anxiety and distress
- common themes: contamination, orderliness, sexual, doubt, worry, guilt
pre-occupations or ruminations: throughts at length
overvalued ideas: unusal/odd beliefs that are not yet delusions
magical thinking: belief that thinking something will make it happen; normal in kids
ideas of reference: similar to delusions of reference, but reality of the belief is questioned
delusions: fixed, falsed belief out of keeping with a person's background and firmly held despite incontroverable evidence to the contrary
thought insertion/withdrawal/broadcasting, or delusions of control: first rank symptoms
perception
"any of those different experiences"
illusions: misinterpretation of a real, external stimulus
derealization - feeling that world is unreal
cognition
The mini-mental status exam (MMSE) is a common means of assessing cognitive function.
level of consciousness and orientation to time, place, and person.
attention and concentration: months of the year backwards is common.
memory: immediate, recent, and remote. If necessary, use cues to discover if the problem is with encoding or retrieval.
visuospatial capacity:
- interlocking pentagons
- ask the person to 'draw a house'; if they can't, ask them to 'copy this house'
- if they can copy the drawing, it means problem is in frontal systems
- if they cannot copy it, then problem is in parietal lobe (more likely Alzheimer's)
manipulation of acquired knowledge: look for abstract thought - ie "an apple and an orange are both..."
- they are both fruit = good
- they are both round = not enough
insight and judgment
Insight is the ability to realize one has a physical or mental illness and to understand its implications.
Judgment is the ability to understand relationships between facts and draw conclusions that determine one's action
other frontal lobe tests
- multiple loops
- alternate sequence
- problems = perseveration
- when " do this, you do that"
- then when I do this, you do nothing" and see if they 'stick'
Resources and References
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