MENTAL STATUS

EXAMINATION (MSE)
Julie Ann Kristy L. Torres, MD, FPCP, FPNA
Brokenshire College – School of Medicine
  The psychiatric equivalent of the physical examination in
Medicine.
 Explores all the areas of mental functioning and denotes evidence
of signs and symptoms of mental illnesses.
Mental Status  Most of the information does not require direct questioning and
Examination the information gathered from observation may five the clinician a
different dataset than patient responses.
 Gives the clinician a snapshot of the patient’s mental status at the
time of the interview and is useful for subsequent visits to
compare and monitor changes over time.
  General description of how the patient looks and acts during the
interview
 Attire and whether it is appropriate for the context
 Distinguishing features
Appearance  Grooming and hygiene
and Behavior  Description of patient’s behavior
 Patient’s approach to the interview
  Facial expression
 (may or may not be related to attitude toward interviewer); smiling,
blank, scowling, smirking, blushing,
 May vary depending on context of the interview, so may want to add
Appearance contextualization: Scowling while describing how family insisted he
get help; Blushing when discussing behaviors during her manic
and Behavior episode; Smirking when answering questions about having suicidal
thoughts:

 Eye contact:
 intermittent, irregular, staring at interviewer, staring through
interviewer, shifty, avoidant, wearing sunglasses, scanning
  Attitude toward interviewer
 appropriate, cooperative, compliant
Appearance  defensive, aggressive, manipulative, demanding, hostile,
threatening
and Behavior  passive/submissive, disinterested, aloof, withdrawn, evasive,
 seductive, provocative, condescending, arrogant, patronizing
 suspicious, frightened, puzzled
  Descriptions:
 Normal
 Bradykinesia or slow
 Hyperkinesia or agitated
Motor Activity  May give clues to the diagnosis as well as confounding
neurological or medical issues
 Neurologic disorder
 Effect of drugs
  Psychomotor level
 Movements-(Is patient agitated?--work on a more specific
description): tapping foot, shifting in chair, rocking, squirming, hand
gesturing, hand wringing, drumming fingers, unable to sit/has to
stand, pacing around the room, chewing, nail biting
 Involuntary movements or mannerisms-aimless/purposeless,
grimacing, tics, twitches, picking, blinking, lip smacking, hand
Motor Activity tremor, stereotyping (an isolated, purposeless movement
performed repetitively), echopraxia (repetitive imitation of
movements of another person), asterixis
 Calm-sitting quietly, any spontaneous movements? no spontaneous
movements?, slowed movements, catatonic,
paraplegic/hemiplegic/quadriplegic
 Posture-relaxed, rigid, tense, hunched over, stooped, bizarre,
slouched, relaxed, stiff, erect
  Diagnostic Considerations of Behavior
 Major depression-psychomotor retardation or agitation, withdrawn
 Manic-demanding, provocative, seductive, restless, distractible
 OCD-repetitive behavior
 Generalized Anxiety Disorder-muscle tension, fidgety, sweaty palms
 Anti-Social Personality-calm, glib, manipulative, demanding
Appearance  Schizotypal Personality-odd, eccentric, peculiar behavior
 Schizophrenia negative symptoms-disinterested, withdrawn,
and Behavior  Psychotic-scanning the room (paranoid?), unidentifiable
distractions/responding to internal stimuli (hallucinations?)
 Psychotropic medication side effects: -tremor (Ex. Lithium,
Depakote, Parkinsonism from dopamine blocking medication) -
rhythmic athetoid and/or choreiform movements (Tardive
Dyskinesia) -restlessness/akathisia (Ex. from dopamine blocking
medication) -muscle spasms/abrupt stiffness (dystonia from
dopamine blocking medication)
  Description of the following:
 Fluency
 Amount – normal, increased or decreased
 Rate – slow or rapid/pressured
 Tone – irritable, anxious, dysphoric, loud, quiet, timid, angry
Speech  Volume

 Take note of the following:

 Stuttering
 Word finding difficulties or anomic aphasia
 Paraphrasic errors
  Various qualities of speech to describe include:
 Clarity - clear, slurred, coherent, accent present, mumbles, stutters,
stammers, garbled
 Rate - slow, relaxed/conversational, rapid, pressured
 Quantity - talkative, verbose, increased, pressured, minimal,
Speech decreased, mute
 Tone - monotonous, flat, increased/decreased inflection, sullen,
irritated, animated, excited, expressive, emphatic
 Flow - spontaneous, hesitations, pauses, word finding difficulties,
delayed response, latency, deliberate, methodical, fluent, non-
fluent
 Volume - whispered, soft/quiet, low, conversational, loud/yelling
  Other descriptive terms for Speech
 Dysarthric - slow and slurred speech
 Pressured speech - increased in quantity, accelerated, and difficult-
to-impossible to interrupt. A person with pressured speech will
verbally run you over in a very one sided conversation. Usually the
speech is also loud and emphatic. Frequently the person talks
Speech without any social stimulation and may continue to talk even though
no one is listening;
 Fluency - ability to produce sentences of normal length, rhythm,
and prosody; For clinical purposes a patient is either fluent or non-
fluent;
 Prosody - reflection of emotion in speech typically created by the
combination of rate, volume, and tone
  Diagnostic Considerations of Speech 
 Mania - classically pressured speech; or not quite pressured but rapid
and increased quantity

Speech  Anxiety disorder - increased quantity, rapid speech

 Depression - decreased quantity, soft, monotone or decreased
prosody/inflection
 Schizophrenia - decreased quantity; monotone or decreased
prosody/inflection, non-spontaneous, increased latency
  Defined as the patient’s internal and sustained emotional state.
 It is subjective, hence best to use patient’s own words in
describing mood.

Mood  Examples:
 Angry
 Anxious
 Guilty
 Sad
  Types of mood include:
 Dysphoric - an unpleasant mood, such as sadness, anxiety, or
irritability
 Elevated - an exaggerated feeling of well being, or euphoria or
elation. A person with elevated mood may describe feeling "high",
"ecstatic", "on top of the world", or "up in the clouds"
 Euthymic - mood in the "normal" range, which implies the absence
Mood of depressed or elevated mood
 Expansive - lack of restraint in expressing one's feelings, frequently
with an over-valuation of one's significance or importance
 Irritable - easily annoyed and provoked to anger
 Good/happy; sad/depressed; angry/hostile;
anxious/apprehensive/nervous
 Alexithymia - patient incapable of describing mood
  The expression of mood or what the patient’s mood appears to be
to the clinician.
 Take note of the following:
Affect 

Quality – dysphoric, happy, euthymic, irritable, angry, agitated, flat
Quantity – measure of intensity
 Range – restricted, normal, labile
 Appropriateness – how it correlates to the setting
 Congruence
  Typically it is useful to describe 4 components of affect:
 1) State:
 your assessment of the pts current emotional state (dysphoric,
euthymic, euphoric, irritable, anxious, etc.) Guarded-very similar to
restricted (below), but you feel the other person is attempting to hide
their emotions from you
 2) Range: describes the variance of the state within the interview
 Full-range of emotional expression is what is typically seen in a
Affect "normal" person. Note, what is considered the normal range of the
expression of affect may vary considerably, both within and among
different cultures.
 Restricted or Constricted-mild reduction in the range and intensity of
emotional expression
 Blunted-significant reduction in the intensity of emotional expressions
 Flat-absence or near absence of any sign of affective expression
 Labile-abnormal or more extreme variability in affect with repeated,
rapid, and abrupt shifts in affective expression
  Typically it is useful to describe 4 components of affect:
 3) Appropriateness:
 Is the affect appropriate to the thought content and contextual
elements? Tearful when discussing something sad or upsetting;
laughing at something funny

Affect  Inappropriate - discordance between affective expression and the

content of speech or ideation; laughing when discussing death, being
overly familiar/excessively jocular/flirtatious with the interviewer, etc.
 4) Congruence:
 is the affect congruent with stated mood?
 Mood is “good" or "fine” despite ongoing tearfulness throughout
interview
  Diagnostic Considerations of Mood & Affect:
 Mania - classic presentation is an elevated/expansive mood and a
labile range of affect
 Borderline Personality - DSM5 criteria-chronic feelings of emptiness;
Affect affective instability with dysphoria, irritability, anxiety (labile range
of affect?); intense anger;
 Delirium - may see a labile range of affect (hyperactive delirium);
may also see a blunted range of affect (hypoactive delirium)
 Major depression - may see restricted, constricted, or guarded affect
 Schizophrenia-classically a blunted or flat affect is observed
  The thoughts occurring to the patient
 Inferred by what the patient spontaneously expresses as well as
responses to specific questions aimed at eliciting particular
pathology
 Take note of the following:
 Perseveration or rumination

Thought 

Obsessions – repetitive and unwelcome thoughts
Compulsions – repetitive, ritualized behavior
Content  Delusions – false, fixed ideas that are not shared by others;
grandiose, erotomanic, jealous, somatic, persecutory, ideas of
reference
 Paranoia
 Suicidality
 Homicidality
  Suicidal ideation:
 Thoughts of death - thinks about what it would like to be dead, the
Thought implications, funeral plans.
 Passive ideation - wishes he could go to sleep and not awaken;
Content wishes he were dead or that God would call him home
 Active ideation - wants to die, preferably today with or without a
specific plan (the details would be in the HPI)
  Delusions are subdivided according to their content. Some
delusion categories include:
 persecutory/paranoid - most common delusion in which the central
theme is that one (or someone to whom one is close) is being
attacked, harassed, cheated, persecuted, or conspired against.
Thought  Referential - a delusion in which events, objects, or other persons in
one's immediate environment are seen as having a particular and
Content unusual significance. (Cubs lost, that's the signal for me to evacuate
because the alien invasion is beginning!). These delusions are
usually of a negative or pejorative nature but also may be grandiose
in content. A delusion of reference differs from an idea of reference,
in which the false belief is not as firmly held nor as fully organized
into a true belief that random events are of some special
significance.
  Delusions are subdivided according to their content. Some
delusion categories include:
 Grandiose - a delusion of inflated worth, power, knowledge, identity,
or special relationship to a deity or famous person, patient believes
Thought they have some great, unrecognized talent, insight, they have made
some great discovery (eureka, cold fusion! unlimited energy source),
Content or have a special relationship to a famous person
 Jealousy - a delusion that one's sexual partner is unfaithful
 Erotomanic - a delusion that another person, usually of higher
status, is in love with the individual
 Somatic - involves bodily functions or sensations
  Delusions are subdivided according to their content. Some
delusion categories include:
 bizarre-a delusion that involves a phenomenon that the person's
culture would regard as physically impossible.
 Thought withdrawal-belief that other people are taking away one's
Thought thoughts

Content
 Thought insertion-a delusion that certain of one's thoughts are not
one's own, but rather are inserted into one's mind
 Thought broadcasting-a delusion that one's thoughts are being
broadcast out loud so that they can be perceived by others.
 Delusion of control-a delusion in which feelings, impulses, thoughts,
or actions are experienced as being under the control of some
external force rather than being under one's own control
  Obsessions & Compulsions
 Obsessions - persistent ideas, thoughts, impulses, or images that
are experienced as intrusive and inappropriate and cause marked
anxiety and distress; the individual feels they "just have to" think
these thoughts. Most common obsessions are about:
contamination, self-doubt, orderliness, sexual imagery,
Thought aggressive/horrific impulses,
 Compulsions - repetitive behaviors (hand washing, ordering,
Content checking) or mental acts (praying, counting, repeating words
silently) that the individual feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly. The
behaviors or mental acts are aimed at preventing or reducing
anxiety or distress, or preventing some dreaded event or situation;
however, these behaviors or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent or
are clearly excessive.
  Feelings of derealization & depersonalization
 Derealization - the experience of feeling detached from, and as if
one is an outside observer of, one's surroundings (individuals or
objects are experiences as unreal, dreamlike, foggy, lifeless, or
Thought visually distorted).
 Depersonalization - the experience of feeling detached as if one is
Content an outside observer of one's mental processes, body, or action
(feeling like one is in a dream; a sense of unreality of self, perceptual
alterations; emotional and/or physical numbing; temporal
distortions; sense of unreality) Derealization and depersonalization
typically occur together and may be different aspects of the same
phenomenon.
  Diagnostic Considerations of Thought Content
 Alcohol withdrawal-hallucinosis
 Cocaine intoxication-formication delusion, insects are crawling on or
under the skin
 Schizophrenia, Schizophreniform disorder, Schizoaffective disorder,
Brief Psychotic disorder, Mood disorder with psychosis, Dementia,
Delirium- delusions, hallucinations

Thought  Delusional disorder-delusions

 Obsessive Compulsive Disorder-obsessions and compulsions
Content  Obsessive Compulsive Personality-preoccupation with rules, order,
organization such that the point of the activity is lost
 Post Traumatic Stress Disorder-recurrent and distressing
thoughts/memories (flashbacks) of the event; derealization,
depersonalization
 Paranoid Personality-suspicion others want to harm him;
preoccupied about other's loyalty
 Schizotypal Personality-odd beliefs, suspiciousness or paranoid
ideas
  Does not describe what the person is thinking but rather how the
thoughts are formulated, organized and expressed
Thought  Normal thought process but delusional thought
 Normal though content but impaired thought process
Process
 Normal thought process is typically linear, organized, goal
directed.
  Flight of ideas – rapidly moves from one thought to another but
all ideas are logically connected
 Circumstantiality – overinclusion of details that is not directly
relevant to the subject or an answer to the question eventually
return to address the subject

Thought  Tangentiality – does not return to the original point or question

Process  Perseveration – tendency to focus on a specific idea or content

without the ability to move on to other topics
 Thought blocking – disordered thought process in which the
patient appears to be unable to complete a thought
  Neologisms – new word or condensed combination of several
words that is not a true word and is not readily understandable
 Word salad – confused, repetitious language with no apparent
meaning or relationship attached to it
 Clang association – thoughts are associated by the sound of
words rather than by their meaning

Thought  Derailment – breakdown in both logical connection between

ideas and the overall sense of goal directedness; sentences do not
Process make sense
 Looseness of associations – connection between ideas is not
obvious, unclear or nonsensical
  Diagnostic Considerations of Thought Process
 Schizophrenia - may see derailment, looseness of association,
Thought fragmentation, word salad, incoherence (if severe)

Process  Mania/hypomania - racing thoughts, flight-of-ideas

 Delirium - any disorder in thought process
 Dementia- errors in word choice and grammar
  Hallucinations – perceptions in the absence of stimuli to account
for them; Auditory – most commonly encountered in psychiatry
 Visual – common in schizophrenia
 Tactile
 Olfactory
 Gustatory / taste

Perceptual  Include description of what the patient is experiencing, when it

occurs, how often it occurs and whether or not it is uncomfortable
Disturbances (ego dystonic)
 For auditory
 Commands
 Words
 Conversations
 Voice recognition
  Illusions – wrong perception or interpretation of the senses
 Depersonalization – feeling that one is not oneself or that
something has changed
 Derealization – feeling that one’s environment has changed in
some strange way that is difficult to describe

Perceptual
Disturbances
  Take note of the following:
 Level of functioning
 Education
Performance at work
Cognition

 Handling daily chores
 Self-care activities
 Financial handling
 Medication management
  Assess the following:
 Alertness
 Orientation
 Concentration
Memory – short and long term
Cognition

 Calculation
 Fund of knowledge
 Abstract reasoning
 Insight
 judgment
  Oriented x 4
 person-need to ask if patient knows the people around them; only in
the most severe instances will the patient not know who they are
 place-in addition to knowing where they are, does the patient
Cognition behave as though he knows where he is
 time-can patient give the approximate date and time of day; does
the patient behave as though he is oriented to the present?
 situation-does the patient behave as if he is oriented to place and
time; oriented to purpose of the interview; also deals with the
patient's level of insight
  level of consciousness
 sedated, groggy, or drowsiness-sleeplike state from which the
patient cannot be fully aroused by minor stimuli like a spoken
request
 clouding-impaired awareness of the environment
Cognition  stupor-vigorous and repeated stimulation is required to rouse the
patient
 somnolence/lethargy-drowsy, inactive, indifferent patients respond
in delayed or incomplete manner
 coma-neither verbal nor motor responses can be elicited by noxious
stimuli (obviously this will limit any formal questioning in the MSE)
  Concentration & Attention
 serial 7's calculations or spell world/earth forwards and then
backwards

 Memory
 Recent memory-can patient recall recent news events from past few
Cognition months
 Remote memory-can patient recall childhood data, important
events known to have occurred, personal matters; verification by
interviewer needs to be done
 Recall-able to recall the 3 unrelated words 3-5 minutes later; Ex.
apple, honesty, star rather than apple, cider, red
  Abstract thinking
 can patient interpret proverbs, similarities & differences (how are a
bush and a tree alike and different) or is his thinking concrete in
which words and figures of speech are taken literally

 General Fund of Knowledge

Cognition  name 5 past presidents, 5 large cities, 5 sports teams, etc.; need to
take into account the patient's educational level

 Folstein Mini-Mental State exam

 series of questions and simple cognitive tasks that can be done at
the bedside; scored out of 30 (See separate handout) Also
assessment options: SLUMS and MOCA
Folstein Mini-
Mental State
exam
  Diagnostic Considerations of Cognition
 Delirium-disorientation to situation, time and place; rarely to
person; very poor concentration; serial MMSE testing encouraged
 Dementia-memory impairment, poor abstract thinking, apraxia,
agnosia
Cognition  Substance Intoxication-decreased alertness, disoriented, poor
concentration
 Major Depression-poor concentration, indecisive
 Manic/Hypomanic-distractible/poor concentration
 Korsakoff syndrome- anterograde amnesia (poor or variable short
term memory)
Cognition
  Ability to shift back and forth between general concepts and
specific examples
 Take note of:
Abstract  Cultural limitations

Reasoning  Education

 Example:
 Similarities between concepts or objects I.e. apple and pear, bus and
airplane, poem and painting
  Refers to the patient’s understanding of how he or she is feeling,
presenting and functioning as well as the potential causes of his or
her psychiatric presentation
Insight  Take note:
 No insight
 Partial insight
 Full insight
  Anthony S. David defined concept of insight having at least three
distinct dimensions:

1.The recognition that one has a mental illness (awareness).

Insight 2.The ability to re-label unusual mental events (delusions and
hallucinations) as pathological (attribution).

3.The recognition of the need for treatment (action).

  In the routine mental status examination, insight is graded as:

1.Complete denial of illness.

2.Slight awareness of being sick and needing help, but denying it at the
same time.

3.Awareness of being sick but blaming it on others, external events

Insight 4.Awareness that illness is due to something unknown in the patient

5.Intellectual insight - admission that the patient is ill and that

symptoms or failures in social adjustment are due to the patient's own
particular irrational feelings or disturbances without applying this
knowledge to future experiences

6.True emotional insight - emotional awareness of the motives and

feelings within the patient and the important people in his or her life,
which can lead to basic changes in behavior.
  Refers to the person’s capacity to make good decisions and act on
them
 May or may not correlate with level of insight
Judgment  May have insight but lack good judgment

 Issues to consider
 Danger to patient
 Participation in care
A Guide to the MSE
Thank you