Which of the following is commonly assessed as part of a mental status exam?
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2] Show OverviewMental 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 one of the more subjective parts of the work of psychiatrists and psychologists. It thus attracts significant criticism from antipsychiatry and related groups. The mental state examination [MSE] is an integral, and essential, skill to develop in a psychiatric evaluation. The undertaking of an accurate MSE helps elicit signs and symptoms of apparent mental illness and associated risk factors.
Key principles in the approach to MSE:
1. APPEARANCEObserving a patient’s appearance can help you identify clues about their mental status. It is important to recognise that if a patient appears ‘well-groomed’, this does not mean that their mental state is well. It is also important to ask the patient if they find attending to their personal care difficult in any way, if they need prompting or if they require help physically doing so. Patient demographics:
Clothing type:
Posture:
Gait:
Grooming, self-care and hygiene:
Physical Health:
Alcohol & Substances:
2. BEHAVIOURA patient’s non-verbal communication may indicate some insight into their current mental state. Behaviour is commonly misinterpreted in mental health services and should never be described in a stigmatising or patronising way such as ‘good’, ‘odd’ or ‘attention-seeking’. Use language that is constructive, useful and specific. In addition, it is good to observe ‘Attitude’ – e.g. Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, distracted, focused, defensive. Gestures:
Mannerisms:
Eye contact & body language:
Facial expressions:
Psychomotor activity:
Disinhibited behaviour:
Engagement & Rapport:
Level of arousal:
Abnormal movements: They may indicate underlying organic conditions or medication-related side effects. if patients are on antipsychotic medications a full extrapyramidal side effect exam should be carried out. (See videos at the end)
3. SPEECHSpeech is assessed by observing and listening to the patient’s spontaneous speech. Note any paralinguistic features such as volume, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate and latency of speech.
Neurological conditions such as stroke or dementia can present with aphasia (the inability to comprehend or formulate language because of damage to specific areas of the brain.) Aphasia can also be a result of brain tumours, infections or neurodegenerative diseases). People with autism spectrum disorders may have abnormalities in paralinguistic and pragmatic aspects of their speech. 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. Are any of the words used ‘made up’ [neologisms]? Gross disorganisation of speech could indicate a psychotic disorder. Speech content should be noted in the thoughts section of this MSE. 4. MOODMood and affect are both related to emotion, but they are different. Both the subjective and objective aspects of mood should be assessed. The mood is the patient’s pervasive and sustained emotional state and usually shows the underlying emotion of the person. Objective (How we observe and describe their mood):
Subjective (As reported by the patient and observed by the examiner): Ask the patient to describe how they are feeling and if they are experiencing any biological symptoms as a result of their mood-for example, insomnia or appetite. Make sure you note their exact words and verbatim. Example questions to encourage a subjective answer:
5. AFFECTAffect is a patient’s moment to moment expression. This is assessed through posture, movements, body, facial expressions and tone of voice. You do not ask any questions in this section; it’s purely observational. Descriptors include:
6. THOUGHTSExample questions to assess thought include:
Stream of thought:
Form of thought:
Possession of thought:
Content of thought:
Phenomenology of Thought Form: Flight of ideas:
Tangentiality:
Poverty of Thought Word Salad:
Derailment (“loosening of associations”):
Clang Associations:
Pressure of speech:
Poverty of thought:
Blocking:
Mutism:
Echolalia:
Neologisms:
Phenomenology of Thought content: Suicidal and Homicidal ideation (Risk assessment) Obsessions:
Compulsions:
Preoccupation / Worry:
Rumination:
Overvalued ideation:
It tends not to have a bizarre quality. Seen in:
Delusions:
Ideas of reference and Delusions of Reference:
Examples include:
Obsessions vs Overvalued ideas vs Delusions:
7. PERCEPTIONThe process of becoming aware of what is presented to the body through the body’s sense organs. It is also important to consider other health conditions such as autoimmune diseases, which can mimic mental illness and can change a person’s perceptions. [Autoimmune conditions masquerading as psychiatric illness] Consider the presence of hallucinations and illusions here [a hallucination can be defined as perception in the absence of stimulus; illusions are defined as a misinterpretation of stimulus]. Hallucinations can be divided based on Complexity:
Sensory Modality involved:
P = Perception:
E = Encephalitis:
R = Reflex Hallucinations and further types of perceptual abnormalities:
C =Concentration:
E = Experience:
P = Pseudohallucinations:
T = Tactile, Auditory, Visual, Gustatory, Olfactory Hallucinations:
I = Ipseity Disturbance:
O = Organic States:
N = Negative Symptoms:
S = Sensory Distortions and Deceptions:
A recent work by Wearne and Genetti recommends that ‘pseudohallucinations’ or hallucinations described in non-psychotic illness like PTSD and complex trauma are often difficult to differentiate from hallucinations in Schizophrenia phenomenological. [Wearne & Genetti, 2015] However, hallucinations in Schizophrenia are more likely accompanied by a complex delusional system. The voices were also more likely to be critical and negative towards the individual, consistent with the experience of abuse in people with PTSD. 8. COGNITIONThis section of the MSE covers the patient’s level of orientation, attention, memory, alertness and visuospatial functioning. The cognition section assesses their awareness of self, their environment, higher cortical functioning, frontal functioning, language, mental calculation, drawing and copying. Very Important: Please ensure that you are mindful of language barriers, age and ability for accurate and fair testing. Orientation:
Clouding of Consciousness:
Stupor:
Memory:
1.Recent memory:
2. Long term memory:
3. Immediate memory: Give the patient objects to remember and then ask them to repeat them back to you (Refer to the Mini-Mental state examination or MoCA for detailed assessing).
MMSE: Visuospatial Functioning:
Frontal Lobe Examination:
9. INSIGHT AND JUDGEMENTThe patient’s understanding of their mental health problem is evaluated by gathering as much information as possible from their perspective. Judgement is assessing the patient’s general problem-solving ability. Important: Having insight into a problem does not necessarily mean that their mental health is okay.
Six levels of insight have been described:
Determining the degree of insight helps in predicting likelihood of compliance with treatment. 10. CLINICAL JUDGEMENT AND RISK ASSESSMENT
Key aspects of a risk assessment:
CONCLUSIONAND LAST, BUT NOT LEAST…. VERY IMPORTANT: Thank the person for their time meeting you today and for being open with you. Explain what will happen next!
Click the Image to Download the Infographic PDF QUIZLoading Ten Point Guide to Mental State Examination (MSE) in Psychiatry USEFUL READING
EDUCATIONAL VIDEOSThe following videos are sources from psychinterview.com, which is an educational website with 90+ videos that specialises in enhancing psychiatric interviewing, psychoeducation and diagnostic skills. MENTAL STATE EXAMINATION
MOTIVATIONAL INTERVIEWING TECHNIQUES IN ALCOHOL DEPENDENCE
EXTRAPYRAMIDAL SIDE EFFECT EXAMINATION ReferencesThe psychopathology of NMDAR-antibody encephalitis in adults: a systematic review and phenotypic analysis of individual patient data Al-Diwani, A., Handel, A., Townsend, L., Pollak, T., Leite, M.I., Harrison, P.J., Lennox, B.R., Okai, D., Manohar, S.G., Irani, S.R. (2019) ‘The psychopathology of NMDAR-antibody encephalitis in adults: a systematic review and phenotypic analysis of individual patient data’, The Lancet Psychiatry, 6 (3), pp. 235-246. Validation of the Brief Assessment of Impaired Cognition and the Brief Assessment of Impaired Cognition Questionnaire for identification of mild cognitive impairment in a memory clinic setting Jorgensen, K., Nielsen, T.R., Nielsen, A., Waldorff, F.B., Waldemar, G. (2020) ‘Validation of the Brief Assessment of Impaired Cognition and the Brief Assessment of Impaired Cognition Questionnaire for identification of mild cognitive impairment in a memory clinic setting’, International Journal of Geriatric Psychiatry. The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment Nasreddine Z.S., Phillips N.A., Bedirian V. (2005) ‘The Montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment’, Journal of American Geriatric Society, (53) pp. 695-699. Mental State Examination and Its Procedures—Narrative Review of Brazilian Descriptive Psychopathology Neto, H.G.R., Estellita-Lins, C.R., Lessa, J.L.M., Cavalcanti, M.T. (2019) ‘Mental State Examination and Its Procedures—Narrative Review of Brazilian Descriptive Psychopathology’, Frontiers in Psychiatry. A ‘symptom-triggered’ approach to alcohol withdrawal management Murdoch, J., Marsden, J. (2014) ‘A ‘symptom–triggered’ approach to alcohol withdrawal management’, British Journal of Nursing, 23 (4), pp. 198-202. Pseudohallucinations as functional cognitive disorders Mustafa, F.A. (2020) ‘Pseudohallucinations as functional cognitive disorders’, The Lancet Psychiatry, 7 (3), pp. 230. Pseudohallucinations versus hallucinations: wherein lies the difference? Wearne D, Genetti A. Pseudohallucinations versus hallucinations: wherein lies the difference? Australasian Psychiatry. 2015 Jun; 23(3):254-7. Study of visuospatial skill in patients with dementia Pal, A., Biswas, A., Pandit, A., Roy, A., Guin, D., Gangopadhyay, G., Senapati, A.K. (2016) ‘Study of visuospatial skill in patients with dementia’, Annals of Indian Academy Neurology, 19 (1), pp. 83–88. EASE: Examination of Anomalous Self-Experience Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., Zahavi, D., Karakuła-Juchnowicz, H., Morylowska- Topolska, J., Juchnowicz, D. (2017) ‘EASE: Examination of Anomalous Self–Experience’, Current Problems of Psychiatry, 18 (3), pp. 217-241. Mental State Examination (MSE) – OSCE Guide Potter, L. (2010) Mental State Examination (MSE) – OSCE Guide. Available at: https://geekymedics.com/mental-state- examination/ (Accessed 21/07/2020). The use of MMSE and MoCA in patients with acute ischemic stroke in clinical Shen Y.J., Wang W.A., Huang F.D. (2016) ‘The use of MMSE and MoCA in patients with acute ischemic stroke in clinical’, International Journal of Neuroscience, (126), pp. 442-447. How to approach the mental state examination Soltan, M., Girguis, J. (2017) ‘How to approach the mental state examination’, BMJ (online), 357 Pseudohallucinations versus hallucinations: wherein lies the difference? Wearne, D., Genetti, A. (2015) ‘Pseudohallucinations versus hallucinations: wherein lies the difference?’ Australasian Psychiatry, 23 (3), pp. 254-257. Olfactory and Gustatory Hallucinations Presenting as Partial Status Epilepticus Because of Glioblastoma Multiforme Capampangan, Dan J., et al. “Olfactory and gustatory hallucinations presenting as partial status epilepticus because of glioblastoma multiforme.” Annals of emergency medicine56.4 (2010): 374-377. Olfactory Auras in Patients with Temporal Lobe Epilepsy Chen, Chien, et al. “Olfactory auras in patients with temporal lobe epilepsy.” Epilepsia 44.2 (2003): 257-260. What should be included in a mental status exam?A mental status exam (MSE) must accompany all Mental Incapacity Evaluations, including narrative reports and DSHS form 13-865. The MSE must include detailed observations regarding the person's appearance, speech, attitude, behavior, mood, and affect.
Which are the 5 major areas of the mental status examination?The MSE can be divided into the following major categories: (1) General Appearance, (2) Emotions, (3) Thoughts, (4) Cognition, (5) Judgment and Insight.
Which is typically assessed in a mental status examination quizlet?Select behaviors that are assessed with a mental status examination include: memory, attention, thought content, and perceptions.
What are the four main domains of the mental status exam?The mnemonic ASEPTIC can be used to remember the components of the Mental Status Examination.. A - Appearance/Behaviour.. S - Speech.. E - Emotion (Mood and Affect). P - Perception (Auditory/Visual Hallucinations). T - Thought Content (Suicidal/Homicidal Ideation) and Process.. I - Insight and Judgement.. C - Cognition.. |