Mental status examination
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2]
Overview
Mental status examination, or MSE, is a medical process where a clinician working in the field of mental health (usually a psychotherapist, social worker, psychiatrist, psychiatric nurse or psychologist) systematically examines a patient's mind. Each area of function is considered separately under categories in a way similar to a physical examination performed by physicians. However, much of the material for the mental status examination is gathered during psychiatric history taking. The result of this examination is combined with the psychiatric history to produce a "psychiatric formulation" of the person being examined. The purpose of the mental status examination is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning.
Neurologist, emergency physicians, and other physicians perform mental status examinations from different perspectives. In general, the neurological exam seeks evidence of localizable brain anomaly; the emergency physician may wish to quickly discover the effects of head trauma or intoxication (poisoning).
It is a structured way of observing and describing a patient's current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment.[1] There are some minor variations in the subdivision of the mental status examination and the sequence and names of mental status examination domains. 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 mental status examination is not to be confused with the mini-mental state examination (MMSE), which is a brief neuro-psychological screening test for [[dementia]}[3]
Main categories
These vary around the world but there is broad commonality. Some schemes look at ego psychology and defence mechanisms while others are less broad.
Appearance
This category covers the physical aspects of the person. This includes his/her physical appearance such as age, height and weight, how he/she is dressed and groomed, and the dominant attitude presented in the interview. Some include factors like the degree of poise or comfort in the interview, and the degree of anxiety and how it is expressed in this category.
- Clothing:
- Colorful or bizarre clothing : Mania, schizotypical personality
- Unkempt, dirty clothes : Schizophrenia, depression
- Clothing and accessories of a particular subculture, body modifications
- Clothing not typical of the patient's gender, might give clues to personality
- Hygiene: Odor, which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication.
- Attitude towards interviewer: Cooperative, uncooperative, hostile, guarded, suspicious or regressed. The most subjective element of the mental status examination, attitude depends on the interview situation, the skill and behavior of the clinician, and the pre-existing relationship between the clinician and the patient. However, attitude is important for the clinician's evaluation of the quality of information obtained during the assessment. Attitude, also known as rapport, refers to the patient's approach to the interview process and the interaction with the examiner.
- Age: If apparent age is greater than the chronological age, it may be indicative of chronic illness or chronic poor self care.
- Weight loss: This could signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety.
Behaviour
Abnormalities of behavior, also called abnormalities of activity,[4] include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait.
- Psychomotor agitation: An increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium.
- Psychomotor retardation: A global decrease in arousal and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression or a medical condition such as Parkinson's disease, dementia or delirium.
- Akinesia: Absent physical movement, seen in the catatonic schizophrenia; and extrapyramidal side effect of antipsychotic medications.
- Akathisia: A compulsive feeling to move and inability to sit still because of a subjective feeling of motor restlessness, a side effect of antipsychotic medication. It can be confused with psychomotar agitation.
- Tics: Involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette's syndrome.
- Dystonia: Tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medications.
- Chorea, athetoid or choreoathetoid movements may indicate a neurological disorder.
- Catalepsy or waxy flexibility: It is seen in catatonic schizophrenia, person remains the position they were given.
- Stereotype and Mannerisms: Stereotype is repetitive purposeless movements such a rocking or head banging. Mannerisms are repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait. They may be a feature of chronic schizophrenia or autism.
- Tardive diskinesia: It is extra-pyramidal side effect of anti-psychotics.
- Echopraxia: In spite of instructions, interviewer's actions are repeated by the patient, it is seen in Tourret's syndrome.
- Eye contact:
Mood and affect
The distinction between mood and affect in the MSE is subject to some disagreement. Mood is 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.[10] Cultural considerations are important in this and many other aspects of the mental status examination.
- Affect is "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"[11].
- Affect is described by labeling 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. A person's affect may vary through depression, elation, anger and normality but if the overall sense from examination is of depression then that is used to describe the mood.
- The range of the affect describes whether the person shows a full or even expanded range or if his/her affect is blunted or restricted.
- Appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia.
- The intensity described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorder.
- Mobility refers to the extent to which affect changes during the interview. It can be described as mobile, constricted, fixed, immobile or labile.
- Reactive or non reactive : If Reactive affect is flexibly and appropriate with the flow of conversation, it is termed as reactive. A bland lack of concern for one's disability may be described as showing la belle indifférence,[12] a feature of conversion disorder, which is historically termed "hysteria" in older texts.[13][14][15]
- Mood: Mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoria, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may be suffering from anhedonia.
Thought
Thought is described into two virtues, form and content.
- Process/Form:
The quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. Regarding the tempo of thought, some people may experience flight of ideas, when their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a chain of poetic associations in the patient's speech. Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and thought perseveration refers to a pattern where a person keeps returning to the same limited set of ideas. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight's move thinking. Thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Flight of ideas is typical of mania. Conversely, patients with depression may have retarded or inhibited thinking. Poverty of thought is one of the negative symptoms of schizophrenia, and might also be a feature of severe depression or dementia. A patient with dementia might also experience thought perseveration. Formal thought disorder is a common feature of schizophrenia. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders.[16][17][18] This looks at features like the rate of thoughts and how they flow and are connected. Formal thought disorder comprises processes such as pressure of thought (excessively rapid), flight of ideas, thought block, disconnected thoughts (loosening of association and derailment and Knight's move), tangentiality and circumstantial thoughts (over inclusive and slow to get to the point). A description of thought content would describe a patient's delusions, overvalued ideas, obsessions, phobias and preoccupations. Abnormalities of thought content are established by exploring individual's 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.[19][20][21] A delusion can be defined as "a false, unshakeable idea or belief which is out of keeping with the patient's educational, cultural and social background . They held with extraordinary conviction and subjective certainty",[22] and is a core feature of psychotic disorders. The patient's delusions may be described as persecutory or paranoid delusions, delusions of reference, grandiose delusions, erotomanic delusions, delusional jealousy or delusional misidentification. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychoses, 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 psychoses.
An overvalued idea is a false belief that is held with conviction but not with delusional intensity. Hypochondriasis is an overvalued idea that one is suffering from an illness, dysmorphophobia is an overvalued idea that a part of one's body is abnormal, and people with anorexia nervosa may have an overvalued idea of being overweight.
An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition",[23] but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In 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).
A phobia is "a dread of an object or situation that does not in reality pose any threat",[24] 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 are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include suicidal ideation, 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 distortion of anxiety and depression. 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.[25]
- Content
Thought content includes those things discussed in the interview and the beliefs a person has. He/she may have thoughts that preoccupy him/her such as ideas of reference, obsessions, ruminations or phobias. He/She may have overvalued ideas, first rank symptoms (delusions of control, thought alienation comprising of thought insertion, withdrawal and broadcast, delusional perception, somatic passivity) or delusion (paranoid, persecutory, religious, erotomania i.e. delusion of love, grandiose, delusions of reference, somatic delusion - concerns about physical symptoms). Other types of delusions such as nihilistic delusions, bizarre delusions, morbid jealousy should also be explored. A depressed person may have a delusion of hopelessness, helplessness and worthlessness. These should be taken into account.
Speech
It is customary to separate speech from thought in the mental status examination, although this is rather artificial. In general, aspects of the speech that will not be part of the section on thought are covered here. This includes the volume, rate and flow of speech itself as distinct from thought.
The patient's 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 form and thought content. 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, latency of speech mannerisms, accent, and stuttering are all covered here. Descriptions might use words like: garrulous, monotonous, labored, loud, or emotional.
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 form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under cognition.[26]
Language assessment will allow the recognition of medical conditions presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism or Asperger syndrome may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another person's words) and palilalia (repetition of the subject's own words) can be heard with patients with autism, schizophrenia or Alzheimer's disease. A person with schizophrenia might use 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 anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.[27][28][29]
Perceptions
This covers the area of the senses and describes any distortions such as illusions, delusions or hallucinations. The nature of the experience is described in detail. Auditory hallucinations are common in schizophrenia while visual disturbances are more common in organic problems. In addition, there are gustatory, olfactory, tactile , somatic and kinaesthetic hallucinations, the account of which should be taken. Some of the Schneiderian first rank symptoms are also hallucinatory in nature such as thought echo, gedankenlautwerden, thought insertion, thought withdrawal and somatic passivity. Depersonalization, where the person feels unreal, and derealization, where the person feels his/her surroundings are unreal, are also described here.
It is also important to ascertain whether hallucinations are in second person or third person and if in second person whether they command the subject to do anything especially suicidal or homicidal acts. Hallucinations can be in the form of a running commentary, whether in second person or third person. Hallucinations may be of a female voice or a male voice and may be known to the person or a totally unknown voice.
Sometimes hallucinations are not in the form of well-formed voices or objects, and the subject might hear bells ringing or knocking at the door or a banging sound in his ears or see vague things like halos or colours which are difficult to describe. These are termed as elementary hallucinations.
Another category of hallucinations is extracampine hallucinations in which the person does see things or hear voices outside his sensory field like hearing voice of a friend sitting 5 miles away or seeing things behind the head or inside the body.
It is worthy to ask whether about functional and reflex hallucinations. It should be acknowledged how a person copes with these hallucinations and whether they are pleasant, unpleasant or terrifying for him.
It is also important to explore and comment on hallucinatory behaviour for example if the person is looking back again and again or gesturing or self talking.
Sometimes a person may see very small people around him, a phenomenon called Lilliputian hallucinations or a trail of objects moving around termed as Palinopsia.
Cognition
This looks at a number of areas such as the level of abstract thought (which declines or is absent in a number of conditions such as dementia and schizophrenia), the level of general education and intelligence, and the degree of concentration which is often tested by digit span recall or an ability to serially subtract seven starting at 100. Folstein's mini mental state examination is often used to more formally assess cognition.
Consciousness
The level of conscious state is assessed whether it is steady or fluctuating, clouded or clear.
Orientation
This frequently looks at whether the person knows the time (including the date), place (where he/she are), person (who he/she is), and situation (that he/she is in).
Memory
Memory is tested by looking for immediate recall, short-term memory (an ability to remember several things after five minutes) and long-term memory (an ability to remember distant events such as the years of World War II).
Judgment
This looks at how the person makes judgments about events. Is it logical or idiosyncratic? Is it reasoned?
Insight
This describes how much understanding or awareness the person has of his/her own psychological functioning or disturbance.
Controversy
The article so far has described how a clinician usually goes about the task of performing a mental status examination. There is controversy both within the profession about this and also controversy from without.
Within the profession
There are many gaps in the traditional mental status examination that have been pointed out. The areas of impulse control, ego psychology and defense mechanisms are among them. Cultural concerns and knowledge of the facts can skew the assessment. A clinician who does not know that the person he/she is examining is who he/she claims to be may interpret information given as a delusion. The examination is inherently flawed because it relies on the clinician's inferences about what he/she observes. Any individual's observations and inferences, including those of the clinician, are based upon one's cultural background, education, expectations, belief system, etc. One attempt to reduce the impact of these inherent distortions is to use so-called "objective" testing of personality such as the Minnesota Multiphasic Personality Inventory or "projective" techniques such as the Rorschach inkblot test. These methods, however, have their own issues with reliability, validity, cultural influences, and possible conscious or unconscious distortion. Integration and/or comparison of clinical observations, such those in an mental status examination, with objective and projective test data may provide the clinician with an improved basis for clinical inferences about a patient.
Outside the profession
The mental status examination is one of the more subjective parts of the work of psychiatrists and psychologists. It thus attracts significant criticism from antipsychiatry and related groups.
Theoretical foundations
The mental status examination derives from an approach to psychiatry known as descriptive psychopathology[30] or descriptive phenomenology[31] which developed from the work of the philosopher and psychiatrist Karl Jaspers.[32] From Jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or 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 mental status examination is a blend of empathic descriptive phenomenology and empirical clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient (a synonym for signs and symptoms), is incompatible with the original meaning which was concerned with comprehending a patient's subjective experience.[33][34]
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 out-patient 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.[35] 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.[36] The mental status examination can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings.[37] Information is usually recorded as free-form text using the standard headings,[38] but brief mental status examination checklists are available for use in emergency situations, for example by paramedics or emergency department staff.[39][40] The information obtained in the mental status examination is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.
Resources and documentation
See also
- Mental illness for an introduction into the various disorders
- Thought disorder
References
- ↑ Trzepacz, PT (1993). The Psychiatric Mental Status Examination. Oxford, U.K.: Oxford University Press. p. 202. ISBN 0-19-506251-5. Unknown parameter
|coauthors=ignored (help) - ↑ Trzepacz & Baker (1993) Ch 1
- ↑ http://www.slate.com/id/2130897/
- ↑ Trzepacz & Baker (1993) p 21
- ↑ German: holding against
- ↑ Hamilton (1985) p 92-114
- ↑ Sims (1995) p 274
- ↑ Trzepacz & Baker (1993) p 21-38
- ↑ Sadock, Benjamin J.; Sadock, Virginia A.; Sadock, Benjamin J. (2008). Kaplan Sadock's concise textbook of clinical psychiatr. Philadelphia: Wolters Kluwer/Lippincott Williams Wilkins. ISBN 0-7817-8746-7.
- ↑ Supported for example by "Mental state examination: Mood and affect". Psychskills. Retrieved 2008-06-26.
- ↑ Trzepacz & Baker (1993) p 39
- ↑ French: beautiful indifference "la belle indifference". Retrieved 2008-06-26.
- ↑ Hamilton (1985) Ch 6
- ↑ Sims (1995) Ch 16
- ↑ Trzepacz & Baker (1993) Ch 3
- ↑ Hamilton (1985) Ch 4
- ↑ Sims (1995) Ch 8
- ↑ Trzepacz & Baker (1993) p 83-91
- ↑ Hamilton (1985) p 41-53
- ↑ Trzepacz & Baker p 91-106
- ↑ Sims (1995) p 118-125
- ↑ Sims (1995 p 82)
- ↑ Trzepacz & Baker p 101
- ↑ Trzepacz & Baker p 103
- ↑ Jacobs, Douglas (November 2003). "Assessment and Treatment of Patients With Suicidal Behaviors". American Psychiatric Association Practice Guidelines. PsychiatryOnline. Retrieved 2008-07-30. Unknown parameter
|coauthors=ignored (help) - ↑ See for example "Mental state examination: Cognitive function". Psychskills. Retrieved 2008-06-26.
- ↑ Hamilton (1985) p 56-62
- ↑ Sims (1995) Ch 9
- ↑ Trzepacz & Baker (1993) Ch 4
- ↑ Sims (1995) Ch 1
- ↑ Kräupl Taylor F (1967) The Role of Phenomenology in Psychiatry. The British Journal of Psychiatry 113: 765-770
- ↑ Owen G and Harland R (2007) Editor's Introduction: Theme Issue on Phenomenology and Psychiatry for the 21st Century. Taking Phenomenology Seriously. Schizophrenia Bulletin 33 (1) pp. 105–107 doi:10.1093/schbul/sbl059
- ↑ Berrios GE (1989) What is phenomenology? Journal of the Royal Society of Medicine. 82:425-8
- ↑ Beumont PJ (1992) Phenomenology and the history of psychiatry. Australian and New Zealand Journal of Psychiatry. 26(4):532-45 PMID 1476517
- ↑ Vergare,, Michael (June 2006). "Psychiatric Evaluation of Adults, Second Edition". American Psychiatric Association Practice Guidelines. PsychiatryOnline. Retrieved 2008-07-30. Unknown parameter
|coauthors=ignored (help) - ↑ "History and Mental Status Examination". eMedicine. February 4, 2008. Retrieved 2008-06-26.
- ↑ Trzepacz & Baker (1993) Preface
- ↑ "Mental state examination examples". Monash University learning support. Retrieved 2008-06-27.
- ↑ Kaufman DM, Zun L.A. (1995) A quantifiable, Brief Mental Status Examination for emergency patients. Journal of Emergency Medicine. Jul-Aug;13(4):449-56. PMID 7594361
- ↑ "Brief Mental Status Examination" (PDF). Retrieved 20 August 2013.