Mental status examination

Source: Wikipedia, the free encyclopedia.
Not to be confused with Mini–mental state examination.
This page is about an exhaustive mental status examination. For a more brief assessment, used in emergency situations, see Orientation (mental).
Mental status examination
ICD-9-CM94.09, 94.11

The mental status examination (MSE) is an important part of the clinical

judgment.[1]
There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's

formulation
, which are required for coherent treatment planning.

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.[2]

The MSE is not to be confused with the

screening test for dementia
.

Theoretical foundations

The MSE derives from an approach to

psychoanalytic
approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives.

In practice, the MSE is a blend of empathic descriptive phenomenology and

subjective experience.[6][7]

Application

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
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.[8] 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.
paramedics or emergency department staff.[12][13]
 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.

Domains

The mnemonic ASEPTIC can be used to remember the domains of the MSE:[14]

  • A - Appearance/Behavior
  • S - Speech
  • E - Emotion (Mood and Affect)
  • P - Perception
  • T - Thought Content and Process
  • I - Insight and Judgement
  • C - Cognition

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

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.[15] Weight loss could also signify a depressive disorder, physical illness, anorexia nervosa[14] or chronic anxiety.[16]

Attitude

Attitude, also known as rapport or cooperation,[17] refers to the patient's approach to the interview process and the quality of information obtained during the assessment.[18] Observations of attitude include whether the patient is cooperative, hostile, open or secretive.[14]

Behavior

Abnormalities of behavior, also called abnormalities of activity,

autism
.

More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as

akinesia or stupor) 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.[21][22][23]

Mood and affect

The distinction between mood and affect in the MSE is subject to some disagreement. For example, Trzepacz and Baker (1993)[24] describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims (1995)[25] refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation.[26][14]

Mood is described using the patient's own words, and can also be described in summary terms such as neutral,

Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may have anhedonia
.

Vincent van Gogh's 1889 Self Portrait suggests the artist's mood and affect in the time leading up to his suicide.[citation needed]

Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as

labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one's disability may be described as showing la belle indifférence,[27] a feature of conversion disorder, which is historically termed "hysteria" in older texts.[28][29][30]

Speech

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, which is addressed under thought process and thought content (see below). 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.[14] Many acoustic features have been shown to be significantly altered in mental health disorders.[31] 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 also form part of the

mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see below).[32]

Language assessment will allow the recognition of medical conditions presenting with

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
pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.[33][34][35]

Thought process

The paintings of the outsider artist Adolf Wölfli could be seen as a visual representation of formal thought disorder.[citation needed]

negative symptoms of schizophrenia. It can also be a feature of severe depression or dementia. A patient with dementia might also experience thought perseveration. Thought perseveration
refers to a pattern where a person keeps returning to the same limited set of ideas.

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,

phobias and preoccupations. One should separate the thought content into pathological thought, versus non-pathological thought. Importantly one should specify suicidal thoughts as either intrusive, unwanted, and not able to translate in the capacity to act on these thoughts (mens rea), versus suicidal thoughts that may lead to the act of suicide (actus reus
).

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.[39][40][41]

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)",

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,

delusions of reference, or delusional misidentification
, or delusional memories (e.g., "I was a goat last year") among others.

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

delusional disorders
. One can differentiate delusional disorders from schizophrenia for example by the age of onset for delusional disorders being older with a more complete and unaffected personality, where the delusion may only partially impact their life and be fairly encapsulated off from the rest of their formed personality—for example, believing that a spider lives in their hair, but this belief not affecting their work, relationships, or education. Whereas schizophrenia typically arises earlier in life with a disintegration of personality and a failure to cope with work, relationships, or education.

Other features differentiate diseases with delusions as well. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychosis, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. 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. Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychosis.

Overvalued Ideas

An overvalued idea is an emotionally charged belief that may be held with sufficient conviction to make believer emotionally charged or aggressive but that fails to possess all three characteristics of delusion—most importantly, incongruity with cultural norms. Therefore, any strong, fixed, false, but culturally normative belief can be considered an "overvalued idea".

dysmorphophobia that a part of one's body is abnormal, and anorexia nervosa
that one is overweight or fat.

Obsessions

An

obsessive-compulsive disorder
, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes).

Phobias

A phobia is "a dread of an object or situation that does not in reality pose any threat",[44] 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 (e.g., numerology calculation, doomsday belief, Mother's Day, anniversary, Christmas).[45]

Perceptions

A

hallucinations, pseudohallucinations 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).[14]

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

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. Déjà vu, derealization and depersonalization are associated with temporal lobe epilepsy and dissociative disorders.[46][47]

Cognition

Further information: Cognitive test

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

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

Korsakoff's syndrome
there is dramatic memory impairment with relative preservation of other cognitive functions. Visuospatial or constructional abnormalities here may be associated with
neuropsychological testing.[48]

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-rock"). The

posterior columns
are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed. A
cerebellar
disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. Pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. A lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (Parinaud's syndrome). Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders.[49][50][51][52][53]

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,

compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological.[54] 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.[55]

Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment.[56] Anosognosia is the clinical term for the condition in which the patient is unaware of their neurological deficit or psychiatric condition.[14][57]

Judgment

Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. One should frame judgement to the functions or domains that are normal versus impaired (e.g., poor judgement is isolated to petty theft, able to function in relationships, work, academics).

Traditionally, the MSE included the use of standard hypothetical questions such as "what would you do if you found a stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual's

executive system capacity in terms of impulsiveness, social cognition
, self-awareness and planning ability.

Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others.[58]

Cultural considerations

There are potential problems when the MSE is applied in a cross-cultural context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations — these may seem similar to one who does not understand that they have different roots. Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder. Consultation with cultural leaders in community or clinicians when working with Aboriginal people can help guide if any cultural phenomena has been considered when completing an MSE with Aboriginal patients and things to consider from a cross-cultural context.[59][60][61]

Children

There are particular challenges in carrying out an MSE with young children and others with limited language such as people with

intellectual impairment. The examiner would explore and clarify the individual's use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner. In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences.[62]

See also

Footnotes

  1. ISBN 0-19-506251-5
    .
  2. ^ Trzepacz & Baker (1993) Ch 1
  3. ^ Sims (1995) Ch 1
  4. S2CID 145391880
    .
  5. PMID 17108232
    .
  6. PMID 2685304
    .
  7. S2CID 20791751
    .
  8. ^ Vergare, Michael; Binder, Renee; Cook, Ian; et al. (June 2006). "Psychiatric Evaluation of Adults, Second Edition". American Psychiatric Association Practice Guidelines. PsychiatryOnline. Archived from the original on 2008-10-03. Retrieved 2008-07-30.
  9. ^ "History and Mental Status Examination". eMedicine. February 4, 2008. Archived from the original on June 17, 2008. Retrieved 2008-06-26.
  10. ^ Trzepacz & Baker (1993) Preface
  11. ^ "Mental state examination examples". Monash University learning support. Archived from the original on 2008-06-16. Retrieved 2008-06-27.
  12. PMID 7594361
    .
  13. ^ "Brief Mental Status Examination" (PDF). Archived from the original (PDF) on 8 October 2013. Retrieved 20 August 2013.
  14. ^ a b c d e f g h i "Mental Status Exam (MSE)". PsychDB. 2022-01-21. Retrieved 2023-10-26.
  15. ^ Trzepacz & Baker (1993) p. 13-19
  16. ^ Gelder, Mayou & Geddes (2005)
  17. ^ Sims (1995) p. 13
  18. ^ Trzepacz & Baker (1993) p. 19-21
  19. ^ Trzepacz & Baker (1993) p 21
  20. ^ German: holding against
  21. ^ Hamilton (1985) p 92-114
  22. ^ Sims (1995) p 274
  23. ^ Trzepacz & Baker (1993) p 21-38
  24. ^ Trzepacz & Baker (1993) p 39
  25. ^ Sims (1995) p 222
  26. ^ Supported for example by "Mental state examination: Mood and affect". Psychskills. Archived from the original on 2008-06-13. Retrieved 2008-06-26.
  27. ^ French: beautiful indifference "la belle indifference". Retrieved 2008-06-26.
  28. ^ Hamilton (1985) Ch 6
  29. ^ Sims (1995) Ch 16
  30. ^ Trzepacz & Baker (1993) Ch 3
  31. PMID 32128436
    .
  32. ^ See for example "Mental state examination: Cognitive function". Psychskills. Archived from the original on 2008-06-01. Retrieved 2008-06-26.
  33. ^ Hamilton (1985) p 56-62
  34. ^ Sims (1995) Ch 9
  35. ^ Trzepacz & Baker (1993) Ch 4
  36. ^ Hamilton (1985) Ch 4
  37. ^ Sims (1995) Ch 8
  38. ^ Trzepacz & Baker (1993) p 83-91
  39. ^ Hamilton (1985) p 41-53
  40. ^ Trzepacz & Baker p 91-106
  41. ^ Sims (1995) p 118-125
  42. ^ Sims (1995 p 82)
  43. ^ Trzepacz & Baker p 101
  44. ^ Trzepacz & Baker p 103
  45. ^ Jacobs, Douglas; Baldessarini, Ross; Conwell, Yeates; et al. (November 2003). "Assessment and Treatment of Patients With Suicidal Behaviors". American Psychiatric Association Practice Guidelines. PsychiatryOnline. Archived from the original on 2008-08-28. Retrieved 2008-07-30.
  46. ^ Sims (1995) Ch 6
  47. ^ Trzepacz & Baker (1993) p 106-120
  48. ^ Trzepacz & Baker (1993) Ch 6
  49. ISBN 0-87488-449-7
    .
  50. ISBN 0-87488-596-5
    .
  51. ISBN 0-87488-699-6
    .
  52. ^ RB Taylor. Difficult Diagnosis Second Edition. New York, WB Saunders Co., 1992.
  53. ^ JN Walton. Brain's Diseases of the Nervous System Eighth Edition. New York, Oxford University Press,1977
  54. S2CID 25934331
    .
  55. PMID 8494061.{{cite journal}}: CS1 maint: multiple names: authors list (link
    )
  56. ^ Trzepacz & Baker (1993) p 167-171
  57. PMID 30020733
    , retrieved 2023-10-26
  58. ^ Trzepacz & Baker (1993) Ch 7
  59. ^ "Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Indigenous Justice Clearinghouse". www.indigenousjustice.gov.au. Australian Government Department of the Prime Minister and Cabinet. Retrieved 9 November 2023.
  60. ^ Bhugra D & Bhui K (1997) Cross-cultural psychiatric assessment. Advances in Psychiatric Treatment (3):103-110
  61. ^ Sheldon M (August 1997). "Mental State Examination". Psychiatric Assessment in Remote Aboriginal Communities of Central Australia. Australian Academy of Medicine and Surgery. Archived from the original on 2008-07-19. Retrieved 2008-06-28.
  62. ISBN 0-632-05361-5
    . pp 43-44

References

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Further reading

External links
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