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Mental Status Examination

Oct 03, 202413 min read

Overview

The sum total of the examiner’s observations and impressions of the psychiatric patient at the time of the interview. Various methods and techniques exist to allow for examination even for incoherent, apprehensive, or disabled patients. Mental status can change from hour to hour.

  1. Appearance:
    • Overt behavior
    • Attitude
      • Cooperative, friendly, attentive, interested, frank, seductive, defensive, contemptuous (scornful), perplexed (unsure), apathetic (uninterested), hostile, playful, ingratiating (attempting to gain favor), evasive or guarded, among many other adjectives.
    • Speech
      • Quantity: talkative, taciturn, normal, alogia, etc.
      • Rate of Production: rapid, slow, pressured (hard to interrupt), emotional, monotonous, mumbled, etc.
      • Quality: stuttering, tics, dysprosody, etc.
    • Psychomotor Agitation
      • Mood
        • Depressed, anxious, angry, expansive, euphoric, perplexed.
      • Affect
        • Dysphoric, Euthymic, Anxious, Elevated/Euphoric, Labile
        • Normal, Constricted, Blunted, Flattened
  2. Thinking
    • Thought Process/Form (Disorganized Thought; Flight of Ideas, Associative Looseness, Perseveration Phenomenon, etc.)
    • Thought Content (Illusions, Delusions, Hallucinations)
    • Perceptions
  3. Sensorium
    • Alertness: Clouding (“Clouded Sensorium”), Somnolence (Excessive Drowsiness), Stupor, Coma, Lethargy, Alertness
    • Orientation (Person, Place, Time, Situation)
    • Concentration
    • Memory: immediate (minutes), recent (days), recent past (months), remote (distant past)
    • Calculations
    • Fund of Knowledge
    • Abstract Reasoning
  4. Insight/Intellect
    • Judgement
    • Cognition: “intact”

Appearance

The patient’s body type, posture, poise, clothes, grooming, hair, nails, etc. qualitative descriptions for appearance include:

  • Healthy, sickly, ill, at ease, older or younger than stated age, disheveled, child-like, bizarre
  • Signs of anxiety are noted: moist hands, perspiring forehead, tense posture, and wide eyes.

Example

The patient is a 23 year old male who appears his age. There is poor grooming and personal hygiene evidenced by foul body odor and long unkempt hair. The patient is wearing a worn T-shirt with an odd shield-like symbol. It appears to be related to the patient’s delusion of needing ‘antivirus’ protection for mind-readers.

Attitude

  • Cooperative, friendly, attentive, interested, frank, seductive, defensive, contemptuous (scornful), perplexed (unsure), apathetic (uninterested), hostile, playful, ingratiating (attempting to gain favor), evasive or guarded, among many other adjectives.
  • Record established level of rapport.
  • Note an apathetic and/or non-cooperative attitude towards the examiner.

Speech

  • Quantity: talkative, garrulous (excessively talkative), voluble (continuous speech), taciturn (untalkative), non-spontaneous (only answers in prepared speech), normally responsive to cues from the interviewer, alogia (poverty of speech; found in schizophrenia), aphasia.
  • Rate and Volume of Production: rapid, slow, pressured (hard to interrupt), hesitant, emotional, dramatic, monotonous, loud, whispered, slurred, staccato (shortened syllables/words production), mumbled
  • Quality: speech impairments such as stuttering, tics e.g. from Tourette’s Disorder, dysprosody (unusual speech rhythm/intonation), etc.
  • Response Latency: how long the patient takes to respond.

Behavior and Psychomotor Activity

  • Mannerisms, tics, gestures, twitches, stereotyped behavior, echopraxia, hyperactivity, agitation, combativeness, flexibility, rigidity, gait, agility.
  • Movements which may result from drug side effects e.g. tardive dyskinesia, extrapyramidal symptoms, or tremors.
  • Restlessness, wringing of hands, pacing, among other physical manifestations.
  • Psychomotor retardation or generalized slowing of body movements.
  • Describe any aimless, purposeless activity.

Mood

  • A pervasive and sustained emotion that colors a person’s perception of the world. It often refers to the patient’s self-reported mood. It should involve the depth, intensity, duration, and fluctuations (whether labile or stable) of the individual’s mood, and whether or not their mood was remarked voluntarily or was it necessary to ask first?
  • Depressed, despairing, irritable, anxious, angry, expansive, euphoric, empty, guilty, hopeless, futile, self-contemptuous, frightened, and perplexed.

Affect

  • The present emotional responsiveness inferred from facial expression and expressive behaviors.
  • Quality: dysphoric (e.g. in depression), euthymic (normal state), anxious, elevated/euphoric (e.g. in mania), flat (e.g. in schizophrenia), labile (easily changed), and irritable.
  • Congruency: the appropriateness of the affect in relation to the mood e.g.
    • Persecutory delusions should result in being upset or afraid
    • Flattened affect when speaking about murderous impulses in schizophrenic patients
  • Range: normal, constricted (reduced range of expression), blunted (decreased intensity of emotional expression), or flat (severe reduction or absence of emotional expression i.e. monotony, immobile facial expressions).

Appearance/Behavior

The patient is an 18 year old male who looks his stated age, 163 cm tall, wearing a plain black shirt with shorts and slippers. He has black hair and dark brown eyes, which appear sunken and drowsy. He has noticeable bruises on the knuckles, arms, and presence of scars on the face. The client has difficulty communicating and did not maintain eye contact during NPI. He has a blunt affect and manifested alogia. He also showed signs of aggressive and impulsive behavior.

Thinking

Perception

Disturbances such as illusions, hallucinations, and delusions may be experiences in reference to the self or the environment. This may also involve depersonalization and derealization.

  • May be inferred when the patient respond to their internal stimuli.
  • Describe the sensory system involved in the disturbance (visual, olfactory, gustatory, auditory, tactile) and the content of the experience.
  • Illusions: false interpretations of external or a real environmental stimulus involving any sense e.g. a tube is perceived as a snake, or the smell of chlorine is perceived as the smell of decay.
  • Hallucinations: false sensory perceptions that occur in the absence of an actual external stimuli. These may also involve any sense.
    • From most common to least: auditory, visual, tactile, olfactory, gustatory
  • Depersonalization: detachment from the environment and self e.g. standing outside oneself as an outside observer.
  • Derealization: a feeling of altered reality, also detached from the environment, but happenings in the environment are distorted or unreal.

Thought

Thought is divided into the form or process (the production and associations used in thought) which may be logical, illogical, or even incomprehensible and its content (ideas, beliefs, preoccupations, obsessions).

Thought Form/Process

  • Flight of Ideas: extreme rapid thinking resulting to quickly changing courses in conversation e.g. in mania.
  • Associative Looseness: “Derailment*”, the lack of coherence in conversation and ideas e.g. in schizophrenia.
  • Tangentiality: appropriate answer in relation to the topic, not as an answer to questions.
  • Circumstantiality: Overinclusion of trivial or irrelevant details that impede the sense of getting to the point.
  • Word Salad: incoherent or incomprehensible connections of thoughts (most severe form of disorganized thought)
  • Clang Association: the use of rhyming words in speech (also of assonance and consonance)
  • Neologisms: the creation of new words or phrases (or even conventional words) in idiosyncratic ways.
  • Perseveration Phenomenon: the repetition of words or phrases in sentences, often out of context.
  • Thought-Blocking: interruption of thoughts before an idea is completed. It may manifest as forgetting what the patient was just talking about.
  • Do the patient’s replies answer the questions asked to an appropriate degree?
  • Does the patient have the capacity for goal-directed thinking?
  • Is there a clear cause-and-effect relation in the patient’s explanations?

Thought Content

Disturbance of thought content would result in delusions, preoccupations (may involve their illness), obsessions, compulsions, phobias, plans, intentions, hypochondriacal symptoms, and specific antisocial urges.

  • Delusions: fixed, false beliefs. This may be mood congruent or mood incongruent.
    • Describe content and evaluate its organization. Identify the patients’ conviction about the delusion’s validity.
    • External Control Delusions: thought insertion, similar to introjection; thought withdrawal, where one believes their thoughts are being taken from them (may result in thought blocking); thought broadcasting, where one believes their thoughts are being projected to others.
    • Persecutory Delusions: false beliefs that one is about to be harmed or being mistreated by others in some way.
    • Paranoid Delusions: a weaker form of persecutory delusions that may be still be amended by opposing evidence.
    • Grandiose Delusions: unfounded beliefs of special powers, wealth, missions, or identity.
    • Jealous Delusions: delusions of significant others being unfaithful or traitorous.
    • Somatic Delusions: delusions related to the body of the individual.
    • Guilty Delusions: unwarranted or extreme feelings of remorse of doing something wrong.
    • Nihilistic Delusions: delusions of being dead, decomposed or annihilated, having lost one’s own internal organs or even not existing entirely as a human being. It may also relate to delusions of future events that cause those things, such as Armageddon.
    • Erotic Delusions: (erotomania) a false belief that one is romantically loved by another (often public figures or those in a higher position).
    • Ideas of Reference Delusions: the false belief that unrelated things are directly related to the individual; that their thoughts caused something to happen.
    • Ideas of Influence Delusions: the false belief that unrelated things are exerting an influence over the individual.
  • Does the patient have thoughts of harm to self (suicidal ideation) or to others? Have they formulated plans (suicidal planning)?

Thinking

The patient only talked minimally and showed signs of alogia (responding “whatever”, or “nothing” to most questions). Unable to maintain a linear train of thought with apparent disorganization or irrational connections during expression. He keeps blaming those around him for not providing him support. He denied any thoughts of suicide and hallucinations. He has impaired thought content of what is right and wrong; the patient believes stealing is not wrong as it alleviates his hunger.

Sensorium

Level of Consciousness

  • Clouding, Somnolence, Stupor, Coma, Lethargy, Alertness

Orientation

Awareness or knowledge of the varying levels of orientation: person, the self e.g. the ability to recall one’s own name, only lost in very severe dementia or during psychosis; place, the ability to name where one’s location or at least their city or country; time includes the date (may one or two days as room for error), day of the week, year, and season; situation is the ability to describe global circumstances e.g. their condition and the context of their inpatient status.

  • Three Spheres: Person, Time, Place (in order)
  • Four Spheres: Person, Time, Place, Situation.
  • In certain health assessments, these are referred to as “Alert and Oriented” followed by the level of orientation the patient displays; “AOx4” refers to being oriented to all four spheres. In cases where healthcare providers only require three levels of orientation, AOx3 is considered the highest score.

Example

The patient is oriented to the three spheres. He stated he was incarcerated in a psychiatric facility (place). He was aware with whom he interacted with as he was able to recall the name of the student nurse who looked after him but did not remember all of them. He was also time-oriented, as he was able to tell the time and date of the day.

Levels of Memory

  • Immediate Memory: recalling perceived stimuli within seconds to minutes.
  • Recent Memory: recalling perceived stimuli within the past few days. Anterograde Amnesia
  • Recent Past Memory: recalling perceived stimuli within the past few months.
  • Remote Memory: recalling perceived stimuli in the distant past. Retrograde Amnesia

Memory

The patient can remember recent events. He was able to report on his activities from the previous day but with minimal use of words. His long-term memory is intact and he can recall the day that they transferred here in Manila. During my interview, he was able to remember the day that his father was arrested. He was able to able to remember his experiences at the warzone in Isabela, Basilan.

Insight/Intellect

Insight is the degree of awareness a patient has about their state of illness. They may exhibit complete denial of their situation (i.e. complete denial of illness), acknowledge it but place the blame on other factors, or ascribe it to something unknown or mysterious in themselves.

  • To assess, identify the patient’s understanding of the world around them and their illness; their ability to reality-test, which allows them to see the situation as it is; and their willingness to seek for help.

Levels of Insight

  1. Complete denial of illness
  2. Slight awareness and simultaneous denial of being sick and needing help.
  3. Awareness of illness but blaming external or organic factors.
  4. Awareness of illness but blaming something unknown in the patient.
  5. Intellectual: admission of illness, their thoughts, and its causal relationship with failure in societal roles, yet without proper application of this knowledge in future experiences.
  6. True Emotional Insight: emotional awareness of internal motives and feelings, and significant others. This may result in basic changes in behavior.

Cognition

Often not extensively reported (e.g. “intact cognition”), but is inferred from the interview. If indicated, a Mini-Cog test may be done. This involves concentration, attentiveness, comprehension, interpreting information, problem-solving, decision-making, learning, and perception.

  • Test for orientation. Make sure the patient is paying attention to you.
  • 3-Word Recall Test:
    • Choose three words (e.g. Banana, Sunrise, Chair), and let the patient repeat them (if they can’t, continue to clock drawing).
    • Afterwards, have them draw a clock. The sheet of paper may already have a circle drawn in, or not. Have them write all the numbers, and ask them to draw the hands pointing to an arbitrary time (e.g. 10:30).
    • After they are done, ask them to recall the three words.
  • Scoring: one point for each word recalled and two points for a normal clock, and no points for an abnormal clock (wrong clock hands, missing/misplaced numbers)
    • 0 - 2: a higher likelihood of clinically important cognitive impairment.
    • 3 - 5: lower likelihood of clinically important cognitive impairment.
  • Test for concentration:
    • Serial Sevens: ask the patient to subtract 7 continuously from 100.
    • Backward Spelling: ask the patient to spell five-letter words backwards. If, after the test, impairment is suspected, an MMSE may be performed. This test among other tests may be used to test memory, calculations, fund of knowledge, and abstract reasoning.
  • Abstract Reasoning may be tested with the ability to interpret or associate situations, proverbs, or comments.

Intellect/Insight

During the NPI, when the client was asked to solve arithmetic (5 times 3), they answered 2. However, when asked to try again, they used their fingers and answered 15; able to answer basic math problems with sufficient time to respond. Counting backwards by 3 from 20 also required ample time, but was done. When asked about their condition, denial of the illness and avoidance coping were displayed: “I barely steal anything.”

Cognition

Due to mental incapacity or neurological disorder, the patient’s cognitive ability may be impaired. However, during the therapeutic activities, the client was participative but at times was stubborn. The client was able to understand and follow instructions in our therapeutic activities. He needed sufficient time to provide answers to my questions. He has little to no difficulty remembering previous therapeutic activities.

Judgment

The patient’s capability for social judgment; the ability to predict or understand the outcomes of one’s behaviors. If impaired, safety issues arise. This is an important aspect of the MSE.

Sample MSE

Mania

Mania: Ms. Joanna Doe is a 34 year old female who appears to be her stated age. Appearance is remarkable for wearing revealing and likely designer clothes with excessive makeup. Behavior is hyperactive and agitated at times. Speech is pressured and with an increased rate, often loudly. Mood is described as ‘happy and on top of the world’ and affect is elevated and euphoric; not appropriate to the situation. She is also irritable in parts and quite labile. Her thought process is disorganized with apparent flight of ideas connected to grandiose delusional themes. There is no suicidal or homicidal ideation. Thought content includes grandiose delusional themes. Perception appears normal. Insight is poor. Judgment is poor; she wishes to fly to Milan and exercises poor financial decisions.

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