Mental Status Examination

DR. REHAM ABDELSAMIE ALY

MD PSYCHIATRY
FELLOW OF THE ARAB BOARD OF
PSYCHIATRY
ACT DIPLOMATE & MEMBER
Oxford University Press

Psychiatric Mental Status

Examination, The, 1st Edition
 Sections of the mental status examination

 Appearance, Attitude, and Activity

 Mood and Affect

 Speech and Language

 Thought Process, Thought Content, and Perception

 Cognition

 Insight and Judgment

Appearance, Attitude, &
Psychomotor Activity
  Level of consciousness

 Apparent age
Appearance
Items included
 Position

 Attire

 Cleanliness and grooming

 Eye contact

 Evident physical abnormality

 Other striking or bizarre features

  Normal;
Level of  awake & alert, attentive to the examiner, &
Consciousness responsive to stimuli.
wakefulness or arousal  Hypervigilant; anxiously attentive,
do not relax, frequently scan the
room, & are easily startled;
 mania, anxiety, paranoia, hyperthyroidism
or ingestion of sympathomimetic drugs
(cocaine, amphetamines, etc.
 decreased arousal;
 Drowsy (sleepy), lethargic, stuporous, and
comatose.
 “clouding of consciousness” refer to all of
these degrees of diminished alertness.
  Position
 the location of the patient's body in
Appearance space
Position & Posture  lying, sitting, kneeling,


 Posture
 the arrangement of the patient's body
parts (e.g. cross-legged, leaning
uncomfortabily).
  socioeconomic status,
 occupation,
Appearance
 self-esteem,
Attire & Grooming
 interest in life,
 socialization, &
 the motivation or ability to
present oneself in an appropriate
way for the interview.
  tattoos,
 needle marks,
Appearance
 scars from prior suicide attempts
Physical Characteristics
or self-mutilation (particularly
common on the anterior
forearms),
 skin lesions or discoloration,
 unusual facial markings,
 obesity or thinness,
 sweating,
 handicaps, & amputated limbs
  indicates his or her level of comfort in
the interview.
 Suspicious persons avoid eye contact, as
Appearance will those who are coy, or wishing to
Eye Contact deny the situation or their emotions.
 Hostile patients stare to unnerve the
examiner,
 confused or intellectually impaired
patients may stare because of lack of
selfawareness.
 Depressed patients often look
downward.
 Hallucinating patients may look in
unexpected directions in response to
their own internally produced visual or
auditory stimuli.
  sad,
 happy,
Appearance
 angry,
Facial Expression
 surprised,
 bored,
 irritated,
 disgusted,
 confused,
 anxious,
 or pained.
  Along the course of the interview.
 includes facial expressions and posture,
completeness of answers, tone of voice,
Appearance willingness to cooperate, attentiveness,
Attitude degree of evasiveness in responses, and
the fantasies and wishes of the patient
as they relate to the interview process.
 friendly, trusting, preoccupied,
cooperative, suspicious, arrogant,
sarcastic, guarded, vigilant,
threatening, hostile, impatient,
regressed, childlike.
 Cooperative describes the individual
who is alert & attentive, & tries to
communicate relevant information to
the examiner, including by answering
questions.
  abnormalities in the level of
Psychomotor activity;
Activity
 any abnormal motor activity or
behavior;
 any excessive, repeated, or
distinctive activity or behavior.
 range from hyperactivity to
bradykinesia (slow movement, as
in parkinsonism), to virtually no
movement.
  Lack of movement;
Psychomotor  localized to an individual body part
Activity may indicate paresis or paralysis.
 or pseudoparalysis in conversion-
Movement
disordered patient.
 Cataplexy
 Akinesia; tendency toward lack of
motion.
 Masked facies.
 Psychomotor retardation
 Hyperactive.
 Restlessness; legs jiggling around
& fidgeting.
  oscillating movements occurring
Psychomotor in a relatively consistent rhythm
Activity
Tremors  Resting tremor

 Postural and action tremors

 Intention tremor
  snakelike writhings of the tongue,
Psychomotor face, or extremities.
Activity
Choreoathetoid
Movements  slow and twisting.

 TD.
  increases in muscle tone
Psychomotor  result in sustained contortions that
Activity
cause the patient to remain in a
distorted position such as a flexed
Dystonias back or twisted neck.

 Acute dystonias
 twisting of the neck & back,
 eyes rolling up under the upper eyelids
(oculogyric crisis),
 rotation & tilting of the head (torticollis),
 backward arching of the back and neck
(opisthofonos).
 Tongue and throat muscles may be
involved, leading to difficulty in talking,
swallowing, or even breathing.
  automatisms
Psychomotor  unconsciously initiated, involuntary
Activity movements
Automatic Movements  simple or complex,

 usually purposeless, &

 appear bizarre.

 Consciousness is impaired;

 Common automatisms include

 chewing, licking, lip smacking, or
clumsy movements of hands or feet.
 More complex examples are walking
from room to room, or pulling at
clothing or buttons.
  involuntary movements or
Psychomotor vocalizations
Activity
 simple to complex
Tics
  consistent,
Psychomotor  characteristic,
Activity
 distinctive,
Mannerisms
 apparently purposeful,
 highly stylized ways of doing
things.
 They may seem very exaggerated
or bizarre, as in schizophrenia.
  Perseveration
Psychomotor  incapacity for or difficulty in shifting
Activity from one task to another.
 typically verbal, as in inappropriate
Other Motor
Abnormalities repetition of a word or phrase (also
known as verbigeration),
 also physical (motor), such as
repeatedly performing a previously
requested task in the interview while
failing to initiate a more recently
requested task.
 Posturing
 sustaining an apparently purposeless,
nonresting position, such as with one
arm in the air for minutes to days.
  Echopraxia
Psychomotor  uncontrolled mimicking of another's
Activity movement & posture (as opposed to
Other Motor perseveration, the repeating of one's
Abnormalities own movements).
Cont…  In catalepsy (waxy flexibility) a limb or
other body part is kept in any position,
even ridiculous, in which another
person places them.

 Catatonic excitement
 Mood and Affect

A MOOD IS A PERSON'S PREDOMINANT

INTERNAL FEELING STATE AT A GIVEN TIME.
AFFECT IS THE EXTERNAL AND DYNAMIC
MANIFESTATION OF A PERSON'S INTERNAL
EMOTIONAL STATE,
  Euthymic
 Calm
Mood  Comfortable
Six clusters
 friendly

 normal

 pleasant

 unremarkable

 Apathetic:
 bland
 dull

 flat
  Dysphoric:
 Distraught
 grieving
 hopeless
Mood  lugubrious
 overwhelmed
Six clusters
 remorseful
Cont..  sad

 Angry:
 bellicose
 belligerent
 confrontational
 frustrated
 hostile
 impatient
 irascible
 irate
 irritable
 oppositional
 outraged
 sullen
  Apprehensive:
 Anxious
 fearful
Mood  frightened
 high-strung
Six clusters  nervous

Cont…  overwhelmed
 panicked
 tense
 terrified
 worried

 Euphoric:
 cheerful
 ecstatic
 Elated
 giddy
 happy
 jovial
 Terms to describe parameters of affect

Parameter of Affect Normal Abnormal

Appropriateness Appropriate Inappropriate

Congruent Incongruent

Intensity Normal Blunted

Exaggerated
Flat
Heightened
Overly dramatic

Mobility Mobile Constricted

Fixed
Immobile
Labile

Range Full range Restricted range

Reactivity Reactive Nonreactive

Responsive Nonresponsive
Speech & Language
  Fluency
Speech &
Language
 Prosody of Speech

 Quality of Speech
 Loudness

 Pitch

 Amount

 Spontaneity

 Articulation

 Phonation
  initiation & flow of language, as
Speech & heard in conversational speaking.
Language  Nonfluent language = Disrupted
Fluency flow of language
 whether expressed by speaking or by
writing.
 scanning speech in chronic abuse
alcohol & multiple sclerosis
 Stuttering; Are y-y-y-you go-go-
go-go-going
 Cluttering: abnormal bursts &
pauses in phrasing, & rapid speech.
Aphasias

Diagram Illustrating Differentiation

of Aphasias
  Anomia or dysnomia;
Speech &  after closed head injury,
Language
Alzheimer's dementia, sleep
Word-Finding
Difficulty deprivation, anxiety, delirium,
encephalitis, brain tumors, &
aphasias.

 When naming is deficient, assess

the patient's ability to recognize
the identity of an object & its use
or function (for agnosia and
apraxia).
  variations in rate, rhythm, & stress
Speech & in speech.
Language  includes musicality, intonation,
Prosody phrasing, & intervals.
 Prosody adds an emotional
dimension to conversation
 affected in aphasia, dementia, right
hemisphere lesions, & parkinsonism.
 Rate of speech vary from slow to
rapid.
 Anxious patients speak quickly, whereas
 depressed patients speak more slowly.
  intoxicated with alcohol may
become disinhibited & speak quickly
Speech & & forcefully.
Language
 Pressured speech when one is
Prosody of Speech trying to squeeze in a lot of words in
a given time period.
 In manic patients, who tend to be rambling
Cont… & have racing thoughts,
 pressured speech can be
accompanied by flight of ideas.
 In mania & severe anxiety, this urge
(pressure) to speak occurs without a
filter over whatever thoughts are
occurring, & nearly all thought
becomes verbalized, at the risk of
adverse social consequences.
  pauses between phrases or before
Speech & beginning sentences
Language  Long  prolonged
Speech latency  Depressed patients often speak slowly, &
sometimes softly, with longer than
normal pauses between words, phrases, &
sentences.
 Parkinsonian, mentally retarded, severely
demented, or intoxicated with drugs that
suppress the central nervous system (e.g.,
barbiturates) patients may speak slowly.
 Autistics can have difficulty initiating
speech & may exhibit aprosodia.
 Some people naturally speak slowly &
deliberately.
  Manic patients yell and raise their
voices inappropriately, such as when
Quality of telling jokes or making injudicious
Speech comments.
Loudness  Demented patients may scream
uncontrollably, much to the
consternation of caregivers such as
nursing home staff.
 delirious may also yell because they are
confused or may mumble unintelligibly.
 Persons in pain may (appropriately) yell
out.
 Psychotic patients in seclusion
frequently yell out.
 Many persons raise the loudness of
their voices when expressing anger or
irritation.
  Depressed patients may be soft-spoken,
 Suspicious persons may even whisper.
Quality of  Whispering in the absence of a laryngeal or
Speech related disorder may indicate conversion
disorder.
Loudness
 Persistent hoarseness may be related to
Cont… vocal cord injury or dysfunction, recent
intubation, influenza, or hypothyroidism.
 Straining or tremor in speech suggests
possible motor dysfunction, including
extrapyramidal disorders such as
parkinsonism.
 Vocal tics, analogous to motor tics, are
guttural sounds; alternatively, they may
manifest themselves as nonlinguistic
sounds (coughing, clearing the throat,
squeaking, etc.) that occur repetitively and
stereotypically in inappropriate contexts.
  pitch varies according to age and
Quality of sex.
Speech
 Children and females tend to have
Pitch
higher-pitched voices than males,
 Pitch vary with mood states, such
as in anger or agitation.
 Variation of pitch that occurs in
speaking phrases or sentences is
called intonation (considered
under Prosody).
  ranges from sparse to talkative.
 Loquacious persons may be manic,
Quality of anxious, or attempting to control the
Speech interview.
Amount  Depressed persons may feel socially
avoidant & speak very little.
 Mutism is the absence of speech.
 Mutism can be caused by a neurologic
disorder such as a complex partial
seizure or a mesial frontal infarction, or
be due to a psychiatric disorder such as
schizophrenia, other psychoses,
delirium, autism, severe depression,
catatonia, end-stage dementia,
conversion disorder, & factitious
disorder.
  is the degree to which the patient
initiates & engages in conversation.
Quality of
Speech
 Depressed patients commonly
demonstrate decreased spontaneity
Spontaneity of speech, which is consistent with
the associated paucity (amount),
slow rate, impaired prosody, &
reduced loudness.
 In contrast, manics are usually very
eager to speak & do so loquaciously.
 Paranoid or suspicious patients may
be hesitant to initiate conversation.
 Demented or delirious patients may
have a reduced spontaneity of
speech.
  Is the pronunciation of sounds (phonemes) that
comprise words. Dysarthria may be due to either
Quality of central nervous system or peripheral
dysfunction.
Speech
Articulation  Slurring of words may indicate
 intoxication from alcohol or
 motor dysfunction of the oral-pharyngeal area including
the tongue.

 Chorea or tardive dyskinesia can alter

articulation through abrupt interruptions of
coordinated muscle activity, including that of
the tongue & oropharynx.

 Drug side effects may impair articulation, such

as dry mouth secondary to the use of
anticholinergic drugs or sedation related to
pain-relieving or sleep-inducing medications.
  Resonance is the quality of speech
Quality of contributed by the oral cavity in
Speech relation to the palate.
Phonation

 Abnormality can contribute to

dysarthria and reduce the
intelligibility of speech.

 An example is hypernasality
resulting from paralysis of the soft
palate or cleft palate.
Thought Process, Thought
Content, & Perception
 Disordered Connectedness &
Thought Organization of Thought
Process  Circumstantiality
Important  Flight of ideas
abnormalities of
thought process
 Loose associations
 Tangentiality
 Word salad
Other Peculiarities of Thought Process
 Clang associations
 Echolalia
 Neologisms
 Perseveration
 Thought blocking
Thought Process

Excerpts from a letter by a

schizophrenic patient
demonstrating loose associations.
  Near-Delusional Beliefs
Thought  Overvalued idea
Content  Magical thinking

Important  Delusion
abnormalities of
thought content  Poverty of speech
 Obsession
 Preoccupation
 Rumination
 Violent Ideation
 Homicidal ideation
 Suicidal ideation

 Suspiciousness
  Autoscopy
 déjà vu
Perception
 Depersonalization
Important
abnormalities of  Derealization
perception
 Illusion
 Hallucination
 Jamais vu
 Definitions
 Autoscopy  Mood-congruent delusion
 Blocking  Neologisms
 Capgras' syndrome  Obsessions
 Circumstantiality  Overvalued idea
 Clang associations  Paranoia
 Delusional misidentification  Perseveration
 Déjà vu  Phobia
 Delusions  Poverty of speech
 Denial  Preoccupation
 Depersonalization  Projection
 Derailment  Psychosis
 Derealization  Racing thoughts
 Echolalia  Reduplicative paramnesia
 Erotomania  Referential thinking
 Flight of ideas  Rumination
 Formal thought disorder  Schneiderian symptom
 Guardedness  Suspiciousness
 Hallucination  Tangentiality
 Illusion  Thought content
 Jamais vu  Thought disorder
 Loose associations  Thought process
 Magical thinking  Word salad
Cognition
  Orientation to person, place, and
time
Cognition
 Attention and concentration
Cognitive testing
sequence  Registration and short-term
memory (verbal and nonverbal)
 Long-term memory (verbal and
nonverbal)
 Constructional and visuospatial
ability
 Abstraction and conceptualization
  digit span is a commonly used
attentional test.
Cognition  “repeat the following numbers after I
Attention say them: 5-2-9-4. Then the patient
should reply, 5-2-9-4”
 Digit span is impaired in delirious,
moderately demented, and
frontal/subcortical-lesionedpatients,
who may perform normally on the
forward span, but do poorly on
backward span. Left frontal-lobe
dysfunction can shorten the forward
digit span. Abulic patients perform
slowly and may not complete this task.
  ask the patient to count backward starting
at 65 & stopping at 49.
 Inattentive persons will continue counting beyond
49, or will lose track of the task during the
Cognition counting.
Concentration
 serial seven subtractions
(sustained attention)
 The patient should be asked to start at 100 &
subtract 7, then keep subtracting 7 from each
answer.
 Patients who have difficulty concentrating might
try to think out loud for example, 7 from 86: 6 from
86 is 80, then 1 from 80 is 79. Or they might try to
use their fingers (discourage this). Or they might
lose track of the task, or have long pauses between
numbers.

 For patients who are having trouble with

the arithmetic, substitute serial three
subtractions from 20.
 Educational or occupational background.
  On the MMSE,
 spelling the word WORLD backward is
Cognition used as an alternative to serial sevens.
Concentration  each letter should be scored as a point

(sustained attention) only if it is both in the correct order and

in the correct position. Thus, DLROW
Cont…
is correct for five points, whereas
DLOW is scored only two points.
 The word EARTH can also be used.

 Another simpler test of

concentration is to recite the days
of the week or months of the year
backward.
Memory

Types of memory
  Registration
 To learn and remember, one must first pay
attention. Assuming that attentional abilities are
intact, memory can be tested.
Cognition  assess registration via immediate recall (within
seconds) of the material presented to the patient.
Memory
 For example, the patient may be presented with
words to remember after a delay. Please repeat
them now so I shall know you heard them. If the
patient can repeat them, registration has
apparently occurred. If not, the examiner should
repeat them & ask the patient to recite them until
they are registered. The number of trials required
for registration should be noted; more than two
trials suggests inadequate registration.
 Impaired in inattentive, poorly motivated,
or depressed patients.
 Once attention and registration abilities
have been established, tests of shortterm
and long-term memory can be
administered
  Short-Term Memory
 present three or four unrelated words
Cognition to be remembered after a five-minute
Memory delay;
 check for adequate registration,
 One point is scored for each correctly
remembered word
 If recent memory deficit:
 cue for any missing words using a
category e.g. if “brown” then “it is a
color!”
 If category cues do not help, then give
several possible words, including the
correct one, from which the patient can
choose.
  Short-Term Memory
 Another test of short-term memory is
Cognition to read a paragraph-long vignette
Memory aloud.
 explain to the patient that he or she will
be expected to retell the story from
memory.
 When the patient retells the story, the
examiner counts the number of
important words or phrases
remembered.
 Short-term memory can be further
tested using a word-list learning task.
  Long-Term Memory
 recent or remote; depending on the
Cognition time period in question.
Memory  Episodic memory
 is time-tagged, personalized, and
experiential knowledge.
 patient is asked to describe important
personal events, such as a wedding,
entering college, past medical history,
and so on, & to identify when these
events happened.
 Verify the data from other sources.

 Be aware of confabulation:
 grandiose or unbelievable stories may
indicate spontaneous confabulation.
  Long-Term Memory
 Semantic memory
Cognition
 recall of general information.
Memory
 test it by asking Who were the last 3
presidents? Or When was the War? or
Where do Elkhateeb play?
 can also be tested by asking the patient
to list orally as many things as possible
in one minute that can be purchased in
a grocery store.
 Normal persons can list at least 18
different things.
  Essential to performing many
everyday activities; drive, maneuver
Cognition in the kitchen to cook, use a
Constructional Ability computer, vacuum a room, climb the
stairs, read maps, solve mazes, & get
around the environment without
becoming lost.
 In Deficits the patient may complain
of not recognizing previously
familiar faces of friends, leading to
frustration & depression, or may no
longer be capable of knitting or
doing puzzles with the children.
  Intact vision, motor coordination,
strength, praxis, and tactile
Cognition sensation.
Constructional Ability  Vision can be screened by using
an eye chart or by confrontational
visual field testing.
 The patient should be able to see &
identify the moving finger(s) in all
fields.
 Next, the examiner tests writing
using a pen to ensure that the
patient does not have a writing
apraxia.
  To assess constructional ability
have the patient copy a three-
Cognition dimensional square (block).
Constructional Ability
 MMSE uses intersecting
pentagons.
 If the patient cannot copy these
pentagons, simpler geometric
designs, like circles, triangles, or
squares, can be tried.
Constructional Ability

Intersecting pentagons and three patients'

attempts to copy them. Each patient (A, B, C)
had dementia, more severely in cases B and C,
both of whom made two attempts at drawing.
  Assessment of the ability to identify similarities
and interpret proverbs is a common approach to
testing abstraction.
Cognition  begin by explaining to the patient what is meant by
a proverb; it is a saying with a broader meaning.
Abstraction and
Conceptualization  An example should be found that the patient may
already have heard, such as Save for a rainy day.
 proceed with easy proverbs for interpretation.
 If patients can interpret simple ones, then one
progress to harder ones.
 possible explanations for an inability to interpret
proverbs abstractly:
 inadequate education (less than eight years),

 acute psychosis,

 dementia, delirium, head injury, frontal lobe

damage,
 low IQ (including mental retardation), &

 lack of cultural applicability of the proverb.

  Another aspect of conceptualization is the
ability to switch mental sets quickly
 for example, between letters and numbers
Cognition
(see the Trailmaking B Test ),
Abstraction and  or between symbols and numbers (Stroop
Conceptualization
Test),
 or between motor tasks.

 test by asking the patient to squeeze the

examiner's hand whenever he or she says
“green” & to relax whenever he or she says
“red” (a Go-No go paradigm).
 Impulsive and prefrontal cortex-lesioned
patients are particularly apt to make errors
of omission, commission, & perseveration
on such tasks.
Insight and Judgment
  Insight should be viewed along a
continuum, with many degrees
Insight between the extremes of insight
dulness & lack of insight.
 Anosognosia is an example of
extreme lack of insight, often the
result of nondominant parietal
lobe damage.
 Anosognosic patients typically deny
suffering the functional impairment
from their brain damage; when the
paralyzed left arm is held in front of
them, they may not recognize it as their
own arm.
  assessing the ability of the
patient’s to agree that they are
Insight  ill,
Evaluation  need further evaluation or testing,
 may benefit from treatment (including
medication), &
 that they may have a higher risk for
deterioration or relapse if they don't
comply with treatment.
  is the process of consideration &
formulation regarding a
Judgment particular issue or situation that
can lead to a decision or action.
 The better & more complete the
person's insight, the more likely
the judgment is to be sound.
 many psychiatric & neurologic
disturbances can reduce the
capacity for making judgments;
however, there are many degrees
of reduction in the capacity to
judgments.
Relationship among
insight, judgment,
decision and action

Insight and Judgment

  Questions to assess a patient's
judgment include:
Judgment  If you found a stamped, addressed
Evaluation letter on the street, what would you do
with it?
 If you were in a crowded movie theater
and you were the first one to notice a
fire, what would you do?
 inadequate to assess patients'
judgments regarding complex
situations!
THANK YOU