MENTAL STATUS EXAM

The Mental Status Exam (MSE) is an assessment of the individual s current state of mind. It assesses the range, quality, and depth of perception, thought processes, feelings, and psychomotor actions. Direct observation of the individual is required for the completion of the MSE. The observation occurs before, during and after the formal clinical interview while the clinician is in direct view of the individual. Specific questions to assess certain domains of the MSE are also required. The following information is included as a guide only. Clinic al judgment regarding a MSE is paramount in completing this exam.

MENTAL STATUS EXAMINATION DEFINITIONS

I. LEVEL OF COOPERATION

Pleasant: Agreeable manners, behavior Cooperative: Willingness and ability to work with others in a common effort. Attentive: Ability to sustain focus on one activity. Disturbance: difficulty finishing tasks, easily distracted or having difficulty in concentration.

II. GENERAL APPEARANCE

Appears to be Stated Age General State of Physical Health Dress: Neat, clean or disheveled Hygiene: Bathed, groomed, shaved or not.

III. ATTITUDE

The position or posture that an individual presents to others.

Sensitivity: Easily hurt or damaged, delicate, susceptible. Passive: Inactive submissive, no opposition. Dependent: Requires assistance from others. Dramatic: Vivid, emotional, with flair. Entitlement: Exaggerated sense of importance. Perfectionist: Demands higher quality of performance from self and others more than is required by the situation.

Anti-authority: Hostile to or opposes social establishments, legal authorities, etc. Eccentric: Odd, deviation from established norms. Manipulative: Self-serving, controlling for own advantage. Suspicious: Distrustful, guarded. Impulsive: Prone to act spontaneously. Aggressive: Forceful, ready, pushy.

IV. FACIAL EXPRESSIONS

Normal: Appropriate to the situation Happy: Content, enthusiastic SAD: down and out, frowning Anxious Worried: Uncertain, apprehensive Silly: Trivial, frivolous Embarrassed: Self-conscious Angry: Irritation, resentment, rage Expressionless: Lacks facial tone Avoid Direct Eye Contact: Avoids contact with examiner Stares into Space: Disinterested, distracted, lost in space Omega Sign: Furrowed brow (sustained contraction of corrugator muscle)

V. Speech

Normal: In rate, tone, volume

Slow: Rate less than average Fast pressured: Rate greater than average Soft: Decreased volume Loud: Increased volume Monotone: No fluctuation in tone Slurred: omission, reduction or substitution of sounds Stuttering: Involuntary disruption or blocking of speech Mutism: Inability to speak Poverty of Speech: Restricted amount of speech, monosyllables Logorrhea: copious, logical speech Echolalia: repetition of one person s words by another. Motor Aphasia: Ability to speak is lost but understanding remains

VI. BEHAVIOR AND PSYCHOMOTOR ACTIVITY

Normal: Increased Amount: Excessive body movement. A.Hyperactivity: Supranormal amount of purposeful, goal directed activity. B. Agitation: Increased purposeless, goalless behavior Decreased Amount: (Psychomotor Retardation) Diminution or poverty of movement, lethargic Tic: Twitching or spasmodic movement Tremor: Trembling, shaking

Trichotillomania: The unnatural impulse to pull out one s own hair Pacing: Walking back and forth Alexia: failure of muscle coordination; Irregularity of muscle action Akathisia: Motor restlessness, inability to sit still Dystopia: Involuntary, irregular chronic contortions of the muscles of trunk and extremities Dyskinesia: Involuntary bucco-facial movements Catatonia: motor anomalies A. Mannerisms: Odd, repetitive movements, goal- directed B. Stereotype: Odd repetitive movements. Not goal directed. C. Echopraxia: Automatic copying of examiner s movements or posture D. Catalepsy: Awkward posture or position for prolonged period E. Flexibilities (Waxy Flexibility) Encountering resistance when moving extremity which is maintained in an odd position.

VII. AFFECT (Objective)

The children s observation/evaluation of the patient s feelings state (during the interview) Appropriate: Emotional tone consistent with content of speech, thought and ideas. Inappropriate: Emotional tone inconsistent with content of speech, thought of ideas Expanded: Excess of joy or sadness, a wide range Labile: Rapid, abrupt changes in feeling tone Constricted: impoverished, inhibited, a spectrum of feelings not elicited

Blunted: A severe reduction in the intensity of feeling tone Ambivalence: Contradictory feelings present at the same time.

VIII. MOOD (Subjective)

The patient s report of his/her feeling state over the past several weeks.

Euthymic: Normal, level range of mood, implying absence of depression or elation Irritable: Easily annoyed and provoked to anger. Dysphoria: An unpleasant, painful or anguished state Euphoria: intense elevation with feelings of grandeur Apathetic: Lack of feeling or emotion Grief: Sadness appropriate to real loss Depressed: Spirits low Anhedonia: Loss of interest in and withdrawal from all regular and pleasurable activities. Alexithymia: Inability or difficulty in describing or being aware of one s moods or emotions Diurnal Variation: Consistent shift in feeling during 24-hour period. Ex: Better morning, worse as day progresses Mood-Congruent: Content of thoughts, feelings, mood appropriate Mood-Incongruent: Content of thoughts, feelings has no association with mood.

X. THOUGHT CONTENT

The specific topics, details or matters presented during the interview.

Ego-syntonic: Ideas that are in harmony with an individual s concept of self. Guilt: Self-reproach, responsibility for imagined offenses Anomia: Alienation, lack of direction Unworthiness: Critical of one s worth or ability Helplessness: Incapable of assisting one s self. Hopelessness: utter despair, problems can t be solved Somatic Preoccupation: Overly concerned with body functions Obsessions: Persistence of an unwanted thought that cannot be eliminated from consciousness Compulsion: Pathological need to act on an

impulse which, if resisted anxiety Ruminations: Excessive worry, repetitive or continuous speculation

Doubting/Indecision: Uncertainty Grandiosity: Exaggeration of one s worth

Ideas of Reference: incorrect assumption that real events or incidents have direct reference to one s self Overvalued Ideas: Fanatically maintained notions, such as the superiority of one s sex, nation, or race over others Paranoid Ideation: Belief that one is singled out for unfair treatment Hyper-Religiosity-Excessive concern with spiritual matters Phobic Thoughts: Irrational, unrealistic fears. A. Specific-Circumscribed dread of discreet object or situation. (Ex-spiders, snakes); B. SocialDread of public humiliation(public speaking, performing, eating in public) Delusion: A fixed false belief A. Persecution: false belief that one is being harassed or cheated B. Grandeur: false belief of one s importance, power, or identity C. Reference: False belief that behavior of others, events, or objects refers to one s self. D. Control: False belief that one s will, thoughts and feelings are controlled by external forces 1) Thought Withdrawal: Thoughts are being removed by external forces 2) Thought Insertion: Thoughts are being implanted by external forces. 3) Thought Broadcasting: thoughts can be heard by others Suicidal Ideation: Desire to harm oneself or end

one s life Homicidal Ideation: Desire to do serious harm to or take the life of another person.

XL. DISORDER OF PERCEPTION

Perception: The mental registration or meaning interpretation of the sensory stimulus.

Not Present Illusion: Misinterpretation of a real, sensory experience Agnosia: Inability to recognize and interpret the significance of sensory stimuli (auditory, visual, olfactory, gustatory, facile) Hysterical Anesthesia: Loss of sensory modalities from internal conflicts. Dysmegalopsia: Objects seem larger and closer than they are B. Micropala: Objects seem smaller and receded into space Depersonalization: A subjective sense of being unreal, strange, or unfamiliar to oneself Derealization: A subjective sense that the environment to strange or unreal Jamais VU: False feeling of unfamiliarity with a real situation one has experienced Hallucination: An incorrect sensory perception in the absence of actual external stimulus A. Auditory: False perception of sound 1)Elementary Noises 2) Complete: Voices or words B. Visual: False perception of eight consisting of formed and unformed images. C. Olfactory: False perception of smell D. Gustatory: False perception of taste E. Tactile: False perception of touch or surface

sensation F. Somatic: False perception of things occurring to one s body G. Extracampine: Sees objects outside the sensory field. Ex: Behind his back H. Kaleidoscopic: Vivid colors with geometric patterns Hypnagogic: False perception occurring while falling asleep Hypnopompic: False perception occurs while awakening from sleep Synesthesia: A perceptual disturbance in more than one modality. Hearing colors, smelling music.

XII. SOMATIC COMPLAINTS

Sleep: Normal, Difficulty getting to sleep, diminished amount of sleep, early morning awakening(terminal insomnia) Eating Habits: Appetite-normal, increased, decreased. Unusual food cravings, binge eating, self-induced vomiting. Weight: Normal, increased, decreased Crying Spells, Decreased Energy Loss of Interest Diminished Libido Tachycardia Sweating Shortness of Breath

XIII. SENSORIUM COGNITIVE FUNCTION INSIGHT AND JUDGEMENT

Sensorium: The level of consciousness or mental clarity Alert: Quick to perceive and respond, ready Delirium: Bewildered, restless, confused Somnolence: Abnormal drowsiness; Lethargy, obtunded. Stupor: Lack of reaction to and unawareness of surroundings. Aroused by intense stimuli only Coma: prolonged degree of unconsciousness Orientation: Time-Year, season, date, day of week, month, approximate time of day Place: Knows where he/she is: state, city, county(town)street, name of hospital Person: Knows own name. Situation: Why he/she is here, with whom he/she is interacting Memory: Immediate Recall-3 items; recall in 120 seconds. Short Term: Events of past 5-10 minutes. Recent-Events or items of day, week, or month. Past-Birthdate, anniversaries, significant past experiences A. Amnesia: Partial or total inability to recall past experiences B. Fugue: Amnesia, then assuming a new identity C. Confabulation: Unconscious filling of gaps in memory with imagined or untrue experiences Attention and Calculation A. County by threes-1,4,7,---(1-40) B. County backwards from 21-1, 20-19, 18, C. Process Digits: Forward-Three (6-35) to eight (82673829)backwards-Three(183)to eight (72485136) D. Simple arithmetic: 6+8, 50-12; 8x9 E. Spell Words: World, State (Forward, Backwards) F. Sentence Learning: No ifs, ands, or buts (Repeat)

G. Identity Objects: (Dystopia) Example: Pen, watch, shoe. H. Copy Design: Visual Motor Integrity(Draw two triangles which must connect at one point)

Fund of Information: Who is the President? Vice-President? County in which you reside? State Capital? How many weeks are there in a year? What direction are you traveling when going from San Francisco to Boston? Insight: Awareness of how one s own personality traits and behaviors contribute to symptoms and problems. To understand cause and meaning of a situation. Judgement: Ability to access situation correctly, choose among different options, and act appropriately within that situation Evaluate: Issues regarded in an upcoming decision, or way past decisions handled.

MSE AREA

ASSESSMENT TOOLS

CLINICAL PRESENTATION

Appearance: how the client looks; the overall image projected by the client

observation of: hygiene; clothing; general observation of how the client looks; cosmetics/make-up; odors; hair grooming/style/adornment

bizarre make-up or clothing may alert you to the possibility of a manic illness; grooming may be a good indication of the person s ability to function independent ly; depression and psychosis may prevent normally well-groomed individuals from attending to personal hygiene; manner of dress can provide clues to a client s sel f image; any change in appearance should be explored with the client and family, documenting when the change occurred and under what circumstances; clothes are costumes-what people wear is what they choose to communicate; facial expression often mirrors the client s mental state

Affect: observable expression of emotion; affect is to mood what weather is to climate ; th e more immediate emotional tone

observation of the client during the interview to determine the client s feelings state; observation of the client s nonverbal expression of feelings; includes rang e, appropriateness, stability and intensity

increase reactivity is common among histrionic individuals; blunted and flat aff ect are often seen in schizophrenia; blunted affect may be seen with clients on anti-psychotic medications; depressed clients may be unable to control sudden te arful outbursts; manic individuals may experience uncontrollable bouts of rage o r laughter; people with borderline personality disorder may display labile affec t

Mood: a pervasive and subjectively experienced feeling state; colors the person s world view; mood is a more long-termed sustained emotion

client s description of his/her own feeling state over the past few weeks or longe r; how would you describe your general mood recently? ; ask about usual mood level and how it has varied with life s events; how do you feel? ; note the duration of the mood states; can the moods be attributed to events or circumstances in the clie nt s life

Memory: the client s ability to recall

Immediate: digit span-ask client to repeat a series of random numbers, first forward and th en backward Recent: Say 3 emotionally neutral object words; ask the client to repeat the wor ds; tell the client you will ask again for these words to be repeated; later in the interview, ask the client to repeat the name of the three objects Remote: ask about the names and dates from the client s earlier life; ask the clie nt to name the US Presidents beginning with the current one and going backwards

if a client can register the three words but not recall them this may indicate d ementia; if the client can recall with cueing (e.g. I ll give you a hint...the firs t word is a color), then this may indicate dementia; sensing their failing memor ies, some clients may conceal it with confabulation, denial, and circumstantiali ty; when concentration is impaired the client may be unable to attend to tasks a nd will appear to have a memory deficit when none exists; clients who recognize their memory impairment may react to your questions with anxiety, depression or hostility

Attention: the ability to sustain a focus on one task or activity

count by threes-1,4,7 (1-40)

count backwards from 21-1

spell world or state forward and backward

Concentration: the ability to focus and maintain attention to outside stimuli as well as to mental operations such as puzzle solving and calculations

serial 7's (or 3's)- ask client to subtract 7's (or 3's) in succession, starting from 100; count backward from 20

lack of concentration is another indicator of thought people with thought disord ers cannot perform calculations in the serial 7 test; the norm serial 7 test is to reach 1 in 60 seconds anxiety, dementia, and psychosis are in concentration

Eye Contact

observation during interview

eye contact often decreases with psychosis or dementia may not focus on

Motor Activity: the way the client moves

observe the clients physical activity during the interview

gives further indications of the client s ability to maintain normal control; post ure and body movements can be related to attitude, mannerisms particular to spec ific psychiatric disorders, mediation side effects, or physical disorders; rigid posture and gait may indicate a client s anxiety or vigilance; seriously depresse d clients may demonstrate slumped posture and slow gait; physical handicaps ofte n are almost always of great emotional significance to the client and should be noted; constant restlessness (psychomotor agitation) and pacing may signal anxie ty, agitated depression, or mania; slow movements and little reactivity (psychom otor retardation) may indicate depression, drug reactions, and catatonia;

Speech: speech is a hybrid of what one may observe and the thought processes of the client

observation of client; the way the client speaks; the quality (relevance, approp riateness to topic, coherence, clarity, and voice volume) and quantity (amount a nd rate of speech, and any sense of pressure) of the client s speech

provides information about the thought processes; pressured speech is often pres ent in the manic phase of bipolar disorder; rapid speech is found in a variety o f conditions, most commonly in acute anxiety states; slowed speech is common amo ng depressed people; absence of speech occurs in some severely psychotic people; some psychotic clients inappropriately loud; extremely shy clients may whisper; garbled is found in some alcoholic clients; note any speech impediments speech abnormalities

Delusions: a false belief firmly held despite incontrovertible and obvious proof or evidence to the contrary; the belief is not one ordinarily accepted by other members of the client s culture or subculture

do you feel you have special knowledge or powers? ; do you think anyone wants to hur t you or has spread lies about you? ; have you felt that your thoughts were influen ced or controlled by some outside force? ; do you feel that you can control the tho ughts of others? ; has anything unusual happened to your body? ; do you have any parti cular worries about your body? ; have had any unusual spiritual experiences? ; has any thing unusual happened your home lately

Delusions are hallmarks of psychotic illness, although in all psychotic individu als; ask questions in a naturalistic manner to avoid evoking paranoia or minimiz ation

Intellect: the client s basic knowledge and awareness of social events

observation of client s general fund of knowledge; affected by the client s culture, education, performance anxiety, willingness to cooperate and psychopathology; e valuating the client s fund of information involves questioning the client s general knowledge and awareness of current events, geared to the client s background; obs ervation of clients diction and vocabulary

may be helpful in determining the level/type of treatment for the client

Judgment: the ability to make and carry out plans and to discriminate accurately and behave appropriately in social situations

observation during the interview; ask what the client would do in a social situa tion that requires judgment; what would you do if you smelled smoke in a crowded theater? ; what would you do if you found a stamped, addressed envelope lying on th e street? ; what would you do if you were given a $1000? ; what should you do if you a re stopped for speeding? ; what should you do if you lose a library book? ; why are cr iminals put in prison?

Note the client s response to family situations, jobs, school, use of money, and i nterpersonal conflicts. Note whether decisions and actions are based on reality or are based on impulse, wish fulfillment, or disordered thought content; what v alues seem to underlie the clients decisions and behaviors; allow for cultural v ariations; how do these compare to the norm for others in the same age bracket;

Hallucinations: perceptions the client believes to be real despite evidence to t he contrary; the client perceives something that does not exist; may involve any of the five senses

do you ever hear voices or see things other people do not hear or see? ; does your m ind ever play tricks on you? ; the circumstances in which the hallucinations occur , with an eye possible precipitating factors; content of the hallucination; whet her hallucinations related; be alert to hallucinatory experiences interview

visual hallucinations alone may suggest in schizophrenia auditory hallucinations induced psychosis, tactile hallucinations hallucinations may be associated use; clients may be hallucinating when they stare at nothing, are listening to voice s; some if the voices come from hallucinations may be induced by such

Insight into Problems: client s awareness and understanding of their illness

what are your reasons for seeking help? ; do you feel you have emotional/substance a buse problems right now? ; how serious are these problems? ; do you feel you need help in understanding and learning to cope with these problems?

Assesses the client s ability to identify the existence of a problem (does not ref er to etiology or psychodynamics aspects of the illness) and to have an understa nding of its nature; this is an important factor in assessing the clients potent ial for compliance with treatment; insight into illness is particularly impaired in psychotic illnesses and later stage dementias.

Orientation: awareness of time, place, person, situation

what is today s date? ; what is the day of the week? ; what is the name of this place? ; t is your full name? ; do you know who I am? ; Why are you here?

Determines the presence of confusion or clouding of consciousness; is an importa nt information for determining whether a client has organic mental impairment; o rientation to self is usually retained with early stages of confusion or disorie ntation; with increasing impairment, the client tend to have more difficulty wit h these questions; disturbances in orientation may be an indicator of substance misuse or toxicity medication, especially antidepressants

Thought Content: ideas the client communicates; clients ideas about themselves and the world

always ask for clarification when you do not understand something the client sai d; begin with general questions and move to specific ones; have you had any unusu al or troublesome experiences? ; have you had thoughts you feel other people would not understand? ; have you had any strange or disturbing thoughts?

Depersonalization and derealization are common in anxiety well as in borderline personality disorder; morbid preoccupations often found in depressed people

Suicidal Ideation: desire to harm oneself or end one s life

actively raise questions related to suicidal thoughts; assess thoughts, plans, p otential for action, deterrents to action, and the client s feelings about these s uicidal ideas

Do you ever feel that life is not worth living? ; have you ever had thoughts of harm ing yourself? ; have you ever wanted to kill yourself? ; do you wish that you were dea d, even if you would not do harm to yourself? ; have you ever tried to kill or harm yourself? ; has anyone in your family or a close friend tried to harm themselves? ; a re you having feelings or thoughts now about harming yourself? ; do you have a plan for harming yourself? ; note whether the client makes reference to future events

someone who hears voices commanding or suggesting that they kill themselves is a t extreme high risk for suicide

assess specificity, lethality and availability of means; the person with very sp ecific plan, for a highly lethal not easily reversed plan, who also ready access to the means to themselves is at high risk.

Can the person guarantee that they will contact you or some other person if they feel like acting on their suicidal or self harm ideas?; be specific in contract ing with the client; does the client need supervision of family/friends?; does t he client need screening for hospitalization

Some studies suggest that contracting for no self harm with clients has little i f any efficacy

individuals lacking resources/a significant support system as well as individual s facing seemingly dire circumstances have an increased risk for acting on their ideations

Homicidal Ideation: desire to do serious harm to or to take the life of another person

actively raise questions related to homicidal thoughts; assess thoughts, plans, potential for action, deterrents to action, and the client s feelings about these homicidal ideas

Is there anyone that you are angry with? ; have you ever had thoughts of harming oth ers? ; have you ever wanted to kill another person? ; do you wish someone else were de ad, even if you would not directly cause them harm? ; have you ever tried to kill o r harm another? ; has anyone in your family or a close friend tried to harm another ? ; are you having feelings or thoughts now about harming another? ; do you have a pla n for harming another?

someone who hears voices commanding or suggesting that they harm or kill another is at extreme high risk for homicide

assess specificity, lethality and availability of means; the person very specifi c plan, for a highly not easily reversed plan, ready access to the another is at high

individuals lacking resources/a significant support system as well as individual s facing seeming dire circumstances have an increased risk for acting on their i deations

Thought Process: the way the client puts ideas together; the association between ideas and to the form and flow of thoughts in conversation

inferred from client s speech and behavior; evaluate rate and flow of ideas and as sociation of ideas (the relationship between ideas)

racing thoughts often seen in clients with anxiety, mania or schizophrenia; depr ession may cause clients to have slowed or retarded thoughts; obsessional or sch izophrenic clients be circumstantial; Blocking is seen in the client with severe anxiety and schizophrenia; loose associations are often seen in clients in psyc hotic states; flight of ideas is common in clients who are manic; clanging is so metimes present in mania; punning is seen in mania; neologisms are seen in schiz ophrenia, word salad is characteristic of schizophrenia; echolalia is observed i n mania Interview Behavior: the client s response to you the interviewer

in what ways does the client engage or distance you; does the client become more or less comfortable as the interview proceeds; does the client show an ability to form an alliance and work with you provides an indication of the client s motivation for treatment; clients may adopt surface attitudes to compensate for deeper problems ( a frightened person acts angry or hostile); attitudes provide important clues as to how people defend the mselves against unpleasant feelings; paranoid individuals are typically suspicio us, evasive, and arrogant; a manic person may be inpatient and uncooperative; sc hizophrenics may be reserved, remote, and seemingly unfeeling; a depressed perso n appear apathetic, hopeless, and helpless; people with dementia demonstrate dis tractibility and apparent indifference to their

Other

assess for self mutilation and risk taking behaviors

assess for potential for violence

ask questions related to self mutilation to include type of frequency, any medic al attention needed as a result

this is difficult to assess with any degree of accuracy; based on known history for violent behavior, others about the person s behavior previous upon the words a nd behavior of the person anger, swearing, threats, agitation); substance for vi olent behavior as does irrational dementia or psychosis

individuals lacking resources/a significant individuals facing seemingly increased risk for acting on their ideations

note any repetitive such as hand

Specific mannerisms depression or anxiety; people taking anti-psychotic medications should be observ ed for involuntary movements of the tongue, mouth or extremities.