Mental Status Examination

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 outpatient or
psychiatric hospital/clinic 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 MSE
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 MSE checklists are available
for use in emergency situations, for example by paramedics or emergency
department staff. The information obtained in the MSE is used, together with the
biographical and social information of the psychiatric history, to generate a
diagnosis, a psychiatric formulation and a treatment plan. The mental status
examination is a structured assessment of the patient's behavioral and cognitive
functioning. It includes descriptions of the patient's appearance and general
behavior, level of consciousness and attentiveness, motor and speech activity,
mood and affect, thought and perception, attitude and insight, the reaction evoked
in the examiner, and, finally, higher cognitive abilities. The specific cognitive
functions of alertness, language, memory, constructional ability, and abstract
reasoning are the most clinically relevant.

Domains

Appearance

Clinicians assess the physical aspects such as the appearance of a patient,

including apparent age, height, weight, and manner of dress and grooming. Colorful
or bizarre clothing might suggest mania, while unkempt, dirty clothes might
suggest schizophrenia or depression. If the patient appears much older than his or
her chronological age this can suggest chronic poor self-care or ill-health. Clothing
and accessories of a particular subculture, body modifications, or clothing not
typical of the patient's gender, might give clues to personality. Observations of
physical appearance might include the physical features of alcoholism or drug
abuse, such as signs of malnutrition, nicotine stains, dental erosion, a rash around
the mouth from inhalant abuse, or needle track marks from intravenous drug
abuse. Observations can also include any odor which might suggest poor personal
hygiene due to extreme self-neglect, or alcohol intoxication. Weight loss could also
signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety.

Attitude

Attitude, also known as rapport or cooperation, refers to the patient's approach to

the interview process and the quality of information obtained during the
assessment.

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. A tremor or dystonia (a neurological movement disorder syndrome in
which sustained or repetitive muscle contractions result in twisting and repetitive
movements or abnormal fixed postures) may indicate a neurological condition
or the side effects of antipsychotic medication. The patient may have tics
(involuntary but quasipurposeful movements or vocalizations) which may be a
symptom of Tourette's syndrome. There are a range of abnormalities of
movement which are typical of catatonia (a state of psycho-motor immobility and
behavioral abnormality manifested by stupor--the lack of critical mental function
and a level of consciousness wherein an affected person is almost entirely
unresponsive), such as echopraxia (is the involuntary repetition or imitation of
another person's actions), catalepsy(muscular rigidity), waxy flexibility (a tendency
to remain in an immobile posture) and paratonia ( inability to relax muscles).
Stereotypies (repetitive purposeless movements such as rocking or head banging)
or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture
or abnormal gait) may be a feature of chronic schizophrenia or autism. More global
behavioural abnormalities may be noted, such as an increase in arousal and
movement (described as psychomotor agitation or hyperactivity) which might
reflect mania or delirium(acute confusional state).

Similarly, a global decrease in arousal and movement (described as psychomotor

retardation, akinesia or stupor (the lack of critical mental function and a level
of consciousness wherein an affected person is almost entirely
unresponsive and only responds to intense stimuli such as pain.)) might
indicate depression or a medical condition such as Parkinson's disease, dementia or
delirium. The examiner would also comment on eye movements (repeatedly
glancing to one side can suggest that the patient is experiencing hallucinations),
and the quality of eye contact (which can provide clues to the patient's emotional
state). Lack of eye contact may suggest depression or autism.
Mood and affect

Mood is the pervasive feeling tone which is sustained (lasts for some length of
time) and colours the total experience of the person. Affect, on the other hand, is
the outward objective expression of the immediate, cross-sectional experience of
emotion at a given time. The assessment of mood includes testing the quality of
mood, which is assessed subjectively (‘how do you feel’) and objectively (by
examination). The other components are stability of mood (over a period of time),
reactivity of mood (variation in mood with stimuli), and persistence of mood (length
of time the mood lasts).

Mood is described as general warmth, euphoria, elation, exaltation and/or ecstasy

(seen in severe mania) in mania; anxious and restless in anxiety and depression;
sad, irritable, angry and/or despaired in depression; and shallow, blunted,
indifferent, restricted, inappropriate and/or labile in schizophrenia. Anhedonia may
occur in both schizophrenia and depression.

The affect is similarly described under quality of affect, range of affect (of emotional
changes displayed over time), depth or intensity of affect (normal, increased or
blunted) and appropriateness of affect (in relation to thought and surrounding
environment).

A flat or blunted affect is associated with schizophrenia, depression or

post-traumatic stress disorder; heightened affect might suggest mania,
and an overly dramatic or exaggerated affect might suggest certain
personality disorders.

Speech

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.

When observing the patient's spontaneous speech, the interviewer will note and
comment on paralinguistic features such as the loudness, rhythm, prosody,
intonation, pitch, phonation, articulation, quantity, rate, spontaneity and
latency of 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.

Language assessment will allow the recognition of medical conditions presenting

with aphonia (inability to produce voiced sound)or dysarthria (poor articulation),
neurological conditions such as stroke or dementia presenting with aphasia (an
inability to comprehend or formulate language), and specific language disorders
such as stuttering (stammering), cluttering (rapid rate of speech) or mutism.

Echolalia (repetition of another person's words) and palilalia (repetition of

the subject's own words) can be heard with patients with autism,
schizophrenia or Alzheimer's disease. A person with schizophrenia might
use neologisms, which are made-up words which have a specific meaning
to the person using them. Speech assessment also contributes to assessment of
mood, for example people with mania or anxiety may have rapid, loud and
pressured speech; on the other hand depressed patients will typically have
a prolonged speech latency and speak in a slow, quiet and hesitant
manner.

Thought process

Thought process in the MSE refers to the quantity, tempo (rate of flow) and form
(or logical coherence) of thought. Thought process cannot be directly observed but
can only be described by the patient, or inferred from a patient's speech. ‘Thought’
is discussed here under the following two headings of ‘stream and form’, and
‘content’.

Stream and form of thought

The ‘continuity’ of thought is assessed; Whether the thought processes are relevant
to the questions asked; Any loosening of associations, tangentiality,
circumstantiality, illogical thinking, perseveration, or verbigeration, derailment of
thought, or knight's move thinking (discourse consisting of a sequence of
unrelated or only remotely related ideas.- loosing of association ) is noted.

Thought content

A description of thought content would be the largest section of the MSE report. It
would describe a patient's suicidal thoughts, depressed cognition, delusions,
overvalued ideas, obsessions, phobias and preoccupations. One should
separate the thought content into pathological thought, versus nonpathological
thought.

Abnormalities of thought content are established by exploring individuals' 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.

Delusions
A delusion has three essential qualities: it can be defined as "a false, unshakeable
idea or belief (1) which is out of keeping with the patient's educational, cultural and
social background (2) held with extraordinary conviction and subjective certainty
(3)",and is a core feature of psychotic disorders. For instance an alliance to a
particular political party, or sports team would not be considered a delusion in some
societies.

The patient's delusions may be described within the SEGUE PM mnemonic as

somatic, erotomanic delusions, (is characterized by an individual's delusions of
another person being infatuated with them.) grandiose delusions, unspecified
delusions, envious delusions (c.f. delusional jealousy), persecutory or paranoid
delusions, or multifactorial delusions. There are several other forms of delusions,
these include descriptions such as: delusions of reference, or delusional
misidentification, or delusional memories (i.e. I was a goat last year) among others.

Delusions should be reported as primary (coming from no particular source),

secondary (sourced from another delusion or hallucinations), tertiary (sourced from
a secondary delusion), or a delusional system (a network of associated delusions).

Delusional symptoms can be reported as on a continuum from: full symptoms (with

no insight), partial symptoms (where they may start questioning these delusions),
nil symptoms (where symptoms are resolved), or after complete treatment there
are still delusional symptoms or ideas that could develop into delusions you can
characterize this as residual symptoms.

Delusions can suggest several diseases such as schizophrenia,

schizophreniform disorder, a brief psychotic episode, mania, depression
with psychotic features, or delusional disorders.

Delusions of control, or passivity experiences (in which the individual has

the experience of the mind or body being under the influence or control of
some kind of external force or agency), are typical of schizophrenia.
Examples of this include experiences of thought withdrawal, thought insertion,
thought broadcasting, and somatic passivity.

Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that

one has no mind or is already dead) are typical of depressive
psychoses/unipolar disorder.

Overvalued Ideas refers to a solitary , abnormal belief that is neither delusional

nor obsessional in nature , but which is preoccupying to the extent of dominating
the sufferer's life.
Hypochondriasis is an overvalued idea that one is suffering from an illness,
dysmorphophobia that a part of one's body is abnormal, and anorexia
nervosa that one is overweight or fat.

Obsessions

An obsession is an "undesired, unpleasant, intrusive thought that cannot

be suppressed through the patient's volition". 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.

Phobias

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.

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 thoughts of suicide, 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
distortions of anxiety and depression.

Suicidal thoughts

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. The most important questions to ask are:
Do you have suicidal feeling now; have you ever attempted suicide (highly
correlated with future suicide attempts); do you have plans to commit suicide in the
future; and, do you have any deadlines where you may commit suicide.

Perceptions
 A perception in this context is any sensory experience, and the three
broad types of perceptual disturbance are hallucinations,
pseudohallucinations (an involuntary sensory experience vivid enough to
be regarded as a hallucination, but considered by the person as subjective
and unreal,)and illusions. A hallucination is defined as a sensory perception in
the absence of any external stimulus, and is experienced in external or objective
space (i.e. experienced by the subject as real).

An illusion is defined as a false sensory perception in the presence of an external

stimulus, in other words a distortion of a sensory experience, and may be
recognized as such by the subject. A pseudohallucination is experienced in
internal or subjective space (for example as "voices in my head") and is regarded
as akin to fantasy. Other sensory abnormalities include a distortion of the patient's
sense of time, for example déjà vu, or a distortion of the sense of self
(depersonalization) or sense of reality (derealization--alteration in the perception or
experience of the external world so that it seems unreal).

Hallucinations can occur in any of the five senses, although auditory and
visual hallucinations are encountered more frequently than tactile (touch),
olfactory (smell) or gustatory (taste) hallucinations. Auditory
hallucinations are typical of psychoses: third-person hallucinations (i.e.
voices talking about the patient) and hearing one's thoughts spoken aloud
are among the Schneiderian first rank symptoms indicative of
schizophrenia, whereas second-person hallucinations (voices talking to the
patient) threatening or insulting or telling them to commit suicide, may be
a feature of psychotic depression or schizophrenia. Visual hallucinations
are generally suggestive of organic conditions such as epilepsy, drug
intoxication or drug withdrawal. Many of the visual effects of
hallucinogenic drugs are more correctly described as visual illusions or
visual pseudohallucinations, as they are distortions of sensory
experiences, and are not experienced as existing in objective reality.
Auditory pseudohallucinations are suggestive of dissociative disorders.

Cognition (Neuropsychiatric) Assessment

Assessment of the cognitive or higher mental functions is an important part of the

MSE. A significant disturbance of cognitive functions commonly points to the
presence of an organic psychiatric disorder. It is usual to use Folstein’s mini mental
state examination (MMSE) for a systematic clinical examination of higher mental
functions.

Consciousness - 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. Alertness is a global observation of
level of consciousness i.e. awareness of, and responsiveness to the environment,
and this might be described as alert, clouded, drowsy, or stuporous.

Orientation is assessed by asking the patient where he or she is (for example

what building, town and state) and what time it is (time, day, date).

Attention and concentration are assessed by several tests, commonly serial

sevens test subtracting 7 from 100 and subtracting 7 from the difference 5 times.
Alternatively: spelling a five-letter word backwards, saying the months or days of
the week in reverse order, serial threes (subtract three from twenty five times),
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 or
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 MSE 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 parietal lobe can be assessed by the person's ability to identify objects by touch
alone and with eyes closed.

Insight

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/major mental disorder and

dementia, and is an important consideration in treatment planning and in
assessing the capacity to consent to treatment.

Judgement

Judgement is the ability to assess a situation correctly and act appropriately within
that situa tion. Both social and test judgement are assessed. i. Social judgement is
observed during the hospital stay and during the interview session. It includes an
evaluation of ‘personal judgement’. ii. Test judgement is assessed by asking the
patient what he would do in certain test situations, such as ‘a house on fi re’, or ‘a
man lying on the road’, or ‘a sealed, stamped, addressed envelope lying on a
street’. Judgement is rated as Good/Intact/Normal or Poor/ Impaired/Abnormal.

Assessment would take into account the individual's executive system capacity in
terms of impulsiveness, social cognition, self-awareness and planning ability.

Limitations--The MSE is only one component needed to assess competency.

Medical condition, current ability for self-care, and corroborating information from
family or friends must be taken in consideration.

Mini-Mental State of Examination Folstein et al. (1975) is perhaps the most

widely used "short, portable" mental status test. This is a 30-point test with 10
points devoted to orientation, 3 to registration, 5 to calculation, 3 to shortterm
memory, 8 to language function, and 1 to constructional ability. Much of the
criticism levelled against short screening instruments is obviated if the user realizes
the limitations of a screening test and does not over interpret results.