Mental Status Examination
The mental status examination (MSE) is the psychiatristís equivalent of the physical examination
Goal of MSE: to record a clinical description of a patient at a particular point in time, such that another clinician would be able to see the patient at another time and, based on the MSE, be able to say whether the patient had changed
Two categories of the MSE (described more fully below):
- Core Section - focuses on describing a patientís appearance, emotions and thinking
- Cognitive Section - provides a more formal assessment of a patientís individual neuropsychological abilities
Core Mental Status Examination - (mostly observational)
Perception - presence or absence of hallucinations, which are possible in any of the five senses; specific questioning is often required (positive for visual and auditory hallucinations)
- Appearance - a brief description of the patient, noting the nature of their dress, the quality of their hygiene and any identifying physical characteristics (well dressed, disheveled)
- ttitude - an assessment of the level of cooperation with the interview and MSE; the degree of eye contact is also included here (controlling, intense eye contact, uncooperative)
- Motor Behavior - the level of activation of the patient, along with specific descriptions of any abnormalities present (comfortable, agitated)
- Verbal Output (or Speech) - a description of the rate, volume and rhythm of a patientís speech; be careful of overlap with Thought Process (odd rhythm, volume varies, rate ok)
- Mood - the patientís statement about his current emotional state, can use a quote (concerned, anxious, worried, "Iíd sell my soul for a beer")
- Affect - the clinicianís impression of the patientís emotional state, based on the patientís tone of voice, behavior and facial expressions (worried, angery, wide range of emotions ranging from stunned to expansive, spooky, odd)
- Thought Content - presence or absence of suicidal and homicidal thoughts or plans, as well as the presence or absence of delusions, overvalued ideas and obsessions; specific questioning is often required (delusional, homicidal)
- Thought Process - a description of the level of organization and logic in a patientís thoughts (logical, organized)
- Circumstantial: when a patient wanders from the topic but returns to the topic
- Tangential: when a patient wanders from the topic and never returns to the topic
- Flight of Ideas: when a patient wanders from the topic and does so in a way that the listener can see the relation of one idea to the next even as the patient wanders
- Looseness of Associations: when a patient wanders from the topic in an illogical, unconnected manner, such that the listener cannot see any logical relation of one idea to the next
The Cognitive Mental Status Examination:
- Attention - the level of alertness, as well as the degree of distractibility
- Orientation - whether a patient knows his name, where he is, and date (in reverse order of sensitivity to disturbance)
- Concentration - the ability to do a specific task which requires concentration: serial subtraction, digit span, or spelling a word backwards, for example
- Memory - several levels can be tested: immediate (digit span, 3 or 4 word recall), short-term (3 or 4 word recall after 5 minutes) and long-term (names of Presidents or the Great Lakes)
- Language - not to be confused with speech or verbal output; typical aspects that are tested include repetition, comprehension (usually a three-step command), naming and reading and writing
- Construction - the ability to reproduce a drawing or to make a drawing on command ("draw the face of a clock and set the hands at 10 past 11")
- Abstraction - the ability to understand and communicate concepts; tested by asking patients to interpret common
- Proverbs (what does "the grass is greener on the other side" mean?) or to express the similarity between two words (How are an apple and orange similar? "fruit" is the only acceptable answer, if patient answers "round" this is concrete understanding rather than abstract understanding)
- Insight and Judgment - not very amenable to simple testing; rather, these are clinical estimates of a patientís ability to make reasoned decisions based on an understanding of his/her circumstances, especially including decisions regarding the treatment of his/her illness
: provides a single score that gives an estimate of a patientís cognitive capacity; easy to administer and score (even an attending can do it), but provides only a rather crude measure of a patientís cognitive ability
Halstead-Reitan Battery: an elaborate and complex series of tests which requires extensive training to administer and is used to identify patients with brain damage
Luria-Nebraska Neuropsychological Battery: also fairly extensive and requires training to use; distinguishes between brain-damaged patients and normals and may also identify psychiatric patients
- Stanford-Binet: age-graded and highly verbal; designed primarily for children; yields only a global score, without subscales
- Weschsler Adult Intelligence Scale-Revised (WAIS-R): the standard for clinical assessment of adult intelligence, with multiple subtest scales and both verbal and nonverbal scores as well as a full-scale score; the IQ test
Higher Cognitive Function
Wisconsin Card Sort: tests abstract ability, conceptual shifting and "learning to learn"; is sensitive to lesions in or dysfunction of frontal lobes; patients are expected to organize cards with different shapes and symbols
Trail-Making: part of the Halstead-Reitan Battery; a measure of visual searching, visual sequencing and the ability to make conceptual shifts
Bender-Gestalt Test: (construction) a series of paper and pencil drawings that are reproduced by the patient; sensitive to neurologic lesions in any quadrant, especially in the non-dominant hemisphere
Peabody Picture Vocabulary: (language) matching spoken words to pictures in a graded format of increasing difficulty; a test of spoken language comprehension and of intellectual function.
: the most commonly used standardized test of emotional status and personality traits for both psychiatric and neurologic patients, it consists of 566 statements which require a true or false answer, the answers are scored using templates (often computerized). This test has been extensively researched and normed to a variety of clinical population; it also has three validity subscales, which can be very useful
- Minnesota Multiphasic Personality Inventory (MMPI)
- Rorschach: widely used and extensively researched with a fairly clear role in assessment; requires training to interpret properly; consists of ten inkblots that are ambiguous stimuli that provoke associations that are carefully recorded by the examiner and then scored and interpreted.
- Thematic Apperception Test (TAT): uses pictures that are ambiguous in detail and show ambiguous situations to elicit fantasy-based stories by the patient; the goal is to gain an understanding of underlying personality dynamics.
The Mini-Mental State Examination (MMSE) - only measures cognitive function!!!
- Orientation - 10 points
- What is the date (date, month, year), day of the week, season? (5 points)
- Where are we (state, county, city, building, name of unit/clinic)? (5 points)
- Registration - Language - 3 points
- Name three items. Ask patient to repeat the three items. One point for each correct answer. Then repeat the three items until he can state all three. (If patient canít complete, recall cannot be retested)
- Attention and Calculation - Attention and concentration - 5 points
- Serial 7ís. Ask the patient to start at 100 and subtract 7. One point for each correct answer; stop after 5 answers. Alternate: ask patient to spell the word "world"; then ask the patient to spell it backwards; one point for each correct on reverse spelling. Alternate: add up penny+quarter+dime
- Recall - Memory - 3 points
- Ask patient to state the three items given above. One point for each correct
- Language - Language and construction - 9 points
- Name a pencil and watch (or clock). One point each.
- Repeat the following: "no ifs and or buts." One point.
- Follow a three-step command: "Take this piece of paper, fold it in half and give it back to me." Three points.
- Read and obey the following: "Close your eyes." One point.
- Write a sentence. One point.
- Copy a design (intersecting pentagons). One point (all 10 angles) must be present and two must intersect to score the point).
- Total Score - 30 points possible
- A total <20 indicates dementia, delirium or serious mental illness. *** score doesnít identify etiology!!!
- missing Abstraction
Summary of the Mental Status Exam
General: patientís appearance (physical characteristics and hygiene), attitude (eye contact and ability to cooperate), and motor behavior (level of activity)
Thought Process: description of the level of logic in patientís thoughts
Thought Content: homicidal, suicidal, or delusional thoughts
- Circumstantial - patient wanders but returns to topic
- Tangential - patient wanders from topic never to return
- Flight of Ideas-patient wanders from one idea to the next in a way that the listener can see a relationship between topics
- Looseness of Association - patient wanders in an illogical way (no apparent relationship between topics)
Speech: a description of rate, volume, and rhythm of patientís speech
Orientation: patient knows self, surroundings, and date
Mood: (ideally a quote from the patient), patient describes their current emotional state
Affect: observerís impression of the patientís emotional state based on observation of the patient
- homocidal or suicidal ideation (HI/SI), delusions = patient might have homicidal thoughts, no suicidal or delusional thoughts
Insight and Judgement: clinical estimates of patientís ability to make reasoned decisions based on an understanding of their circumstances, especially regarding treatment of their illness
Perception: presence or absence of hallucinations
- " Mood is the color, Affect is the brightness" meaning that a patient can be sad with a flat affect
- AH/VH = auditory or visual hallucinations