The Mental Status Examination

This is the primary type of examination used in psychiatry. Though psychiatrists do not use many of the more intrusive physical examination techniques (such palpation, auscultation, etc.), psychiatrists are expected to be expert observers, both of significant positive and negative findings on examinations. This observation should take place throughout the patient encounter; it is not limited to any one point. However, the observations are then recorded into a specific structured format that is labeled the Mental Status Examination (MSE). When properly done, the MSE should give a detailed "snapshot" of the patient as he presented during the interview.

Often beginners become confused about the difference between this and other parts of the history. A simple way to keep it apart is to remember that this is, as the title says, an examination, therefore it should be limited to what is observed. The rest should go in the history. As an example, if a patient reports that they have been hearing voices throughout the day, but deny hearing them during the interview and do not seem to be responding to internal stimuli, one would not report the hallucinations as part of the MSE, but rather include it earlier in the history. Conversely, if the patient denies any history of hallucination, but seems to be responding to internal stimuli throughout the examination, one would report the phenomenon on the MSE.

The MSE can be divided into the following major categories: (1) General Appearance, (2) Emotions, (3) Thoughts, (4) Cognition, (5) Judgment and Insight. These are described in more detail in the following sections.

General Description

As implied, this is a general description of the patient’s appearance. Being detailed and accurate is important, and such observations can be of great use to the next examiner. Imagine, for example, if a patient presents looking disheveled, poorly groomed with poor hygiene to an emergency department, but a note from only a month ago reports the same patient to have been well dressed and groomed. Something is going on!

Some of the areas that might be commented on, particularly if they have significant negative or positive findings include:

Appearance

One should describe the prominent physical features of an individual. At least one writer on the subject has suggested this should be detailed enough "such that a portrait of the person could be painted that highlights his or her unique aspects” but that is probably asking a lot. Some aspects of appearance once might note include a description of a patient’s facial features, general grooming, hair color texture or styling, and grooming, skin texture, scar formation, tattoos, body shape, height and weight, cleanliness and neatness, posture and bearing, clothing (type, appropriateness) or jewelry.

Motor Behavior

The examination should incorporate any observation of movement or behavior.

Some aspects of motor behavior that might be commented on include gait, freedom of movement, firmness and strength of handshake, any involuntary or abnormal movements, tremors, tics, mannerisms, lip smacking or akathisias

Speech

This in not an evaluation of language or thought (save that for later), but a behavioral/mechanical evaluation of speech. Items that might be commented on include the rate of speech, the spontaneity of verbalizations, the range of voice intonation patterns, the volume of speech, and any defects with verbalizations (stammering or stuttering).

Attitudes

One should comment on how the patient related to the examiner. This usually includes a discussion of the patient’s degree of cooperativeness with the examiner. When appropriate, a recording of the evaluator’s attitude toward the patient might be appropriate, as we believe such reactions (“countertransference”) may be useful information. Such discussions should be done with the understanding that the patient has a legal right to read the record, and any strong emotions or reactions should be recorded in a diplomatic manner.

Emotions

For the sake of consistency, the observation of a patient’s emotions is divided into a discussion of mood and affect.

Mood is usually defined as the sustained feeling tone that prevails over time for a patient. At times, the patient will be able to describe their mood. Otherwise, evaluator must inquire about a patient’s mood, or infer it from the rest of the interview. Qualities of mood that may be commented on include the depth of the mood, the length of time that it prevails, and the degree of fluctuation. Common words used to describe a mood include the following: Anxious, panicky, terrified, sad, depressed, angry, enraged, euphoric, and guilty. Once should be as specific as possible in describing a mood, and vague terms such as “upset” or “agitated” should be avoided.

Affect is usually defined as the behavioral/observable manifestation of mood. Some aspects of a mood that we might comment on include the following: the appropriateness of the affect to the described mood (does the person look the way they say they feel?); the intensity of the affect during the examination (is their too much–heightened or dramatic–or too little blunted or flat); the mobility of the affect (does the affect change at an appropriate rate, or does there seem to be too much variation–a labile affect— or too little–constricted or fixed; the range of the affect (is there an expected range of affect–usually interview will have light and heavier moments–or does the affect seem restricted to a limited range; and the reactivity of the patient (is the response to external factors, and topics as would be expected for the situation. Alternatively, is there too little change–nonreactive or nonresponsive?).

Thought

Usually, a description of a patient’s thoughts during the interview is subdivided into (at least) 2 categories: a description of the patient’s thought process, and the content of their thoughts.

Thought process describes the manner of organization and formulation of thought. Coherent thought is clear, easy to follow, and logical. A disorder of thinking tends to impair this coherence, and any disorder of thinking that affects language, communication or the content of thought is termed a formal thought disorder.

Some aspects of thought process that are usually commented on include the stream of thought and the goal directedness of a thought. A discussion of the stream of thought might include a discussion of the quantity of thought: does there seem to be a paucity of thoughts, or conversely, a flooding of thoughts? Also, it might include a discussion of the rate of thought: do the thoughts seem to be racing? Retarded?

Most commonly, examiners comment on the goal directedness or continuity of thoughts. In normal thought, a speaker presents a series an ideas or propositions that form a logical progression from an initial point, to the conclusion, or goal of the thought. Disorders of continuity tend to distract from this goal or series, and the relatedness of a series of thoughts become less clear. As the thought disorder gets more serious, the logical connectedness of different thoughts becomes weaker. Some examples of disorders of thought process include: Circumstantial thought: a lack of goal directedness, incorporating tedious and unnecessary details, with difficulty in arriving at an end point; Tangential thought: a digression from the subject, introducing thoughts that seem unrelated, oblique, and irrelevant; Thought blocking: a sudden cessation in the middle of a sentence at which point a patient cannot recover what has been said; and Loose associations: a jumping from one topic to another with no apparent connection between the topics. In the other direction, a perseveration refers the patient's repeating the same response to a variety of questions and topics, with an inability to change his or her responses or to change the topic.

Other less common abnormalities of thought process include the following: Neologisms: words that patients make up and are often a condensation of several words that are unintelligible to another person. Word salad: incomprehensible mixing of meaningless words and phrases. Clang associations: the connections between thoughts become tenuous, and the patient uses rhyming and punning.

Disturbances of thought content include such abnormalities as Perceptual Disturbances and Delusions.

The most common perceptual disturbances are Hallucinations, which are perceptual experiences that have no external stimuli. Hallucinations can be auditory (i.e., hearing noises or voices that nobody else hears); visual (i.e., seeing objects that are not present); tactile (i.e., feeling sensations when there is no stimulus for them); gustatory (i.e., tasting sensations when there is no stimulus for them); or olfactory (i.e., smelling odors that are not present). They are not necessarily pathonogmonic of any specific disorder. For example hypnagogic (i.e., the drowsy state preceding sleep) and hypnopompic (i.e., the semiconscious state preceding awakening) hallucinations are experiences associated with normal sleep and with narcolepsy.

Another disorder of perception is an Illusion, which is a false impression that results from a real stimulus. Other examples of abnormal perceptions include Depersonalization, which is a patients' feelings that he is not himself, that he is strange, or that there is something different about himself that he cannot account for, and Derealization, which expresses a patients' feeling that the environment is somehow different or strange but she cannot account for these changes.

Delusions can be defined as false fixed beliefs that have no rational basis in reality, being deemed unacceptable by the patient's culture. Primary delusions are unrelated to other disorders. Examples include thought insertion, thought broadcasting, and beliefs about world destruction. Secondary delusions are based on other psychological experiences. These include delusions derived from hallucinations, other delusions, and morbid affective states.

Types of delusions include those of persecution, of jealousy, of guilt, of love, of poverty, and of nihilism. The most common are persecutory delusions, in which one believes, erroneously, that another person or group of persons it trying to do harm to oneself. Note that this is often referred to as a paranoid delusion, but that is a misuse of the word paranoid, which is a more generic in meaning and does not imply a specific type of delusion. Other abnormal thoughts sometimes found as part of a delusion include ideas of reference and ideas of influence. Ideas of reference are erroneous beliefs that an unrelated event in fact pertains to an individual. Thus, if a patient observes a car on a street make a sudden turn, and assumes that it is because the driver is following the patient, that would be an idea of reference. Such ideas can become even more improbable, such as a belief that something an announcer is saying on the television is actually a coded message intended for the patient. Ideas of influence are similar in that the patient may believe that somehow they caused an unrelated event to happen (for example, believing that through one’s will one was able to cause an accident, even though one was not directly involved in any way).

In addition to describing the type of delusion a patient has, one wants to comment on other aspects of the delusion, such as the quality of the delusion, or the degrees of organization of the delusion.

There are other types of abnormal thoughts. Examples include obsessions and compulsions, which, though irrational, are not as severe a disorder as hallucinations or delusions. Obsessions are repetitive, unwelcome, irrational thoughts that impose themselves on the patient's consciousness over which he or she has no apparent control. They are accompanied by feelings of anxious dread and are thought to be ego alien (coming from “outside” one’s normal self or desires), unacceptable, and undesirable. They are often resisted by the patient. Compulsions are repetitive stereotyped behaviors that the patient feels impelled to perform ritualistically, even though he or she recognizes the irrationality and absurdity of the behaviors. Although no pleasure is derived from performing the act, there is a temporary sense of relief of tension when it is completed. These are usually associated with obsessions.

Some other specific thoughts to ask about, which may be of great practical concern, suicidal and homicidal. These should be inquired about on any examination, as patients with such thoughts commonly present to medical settings, but often do not spontaneously reveal these thoughts.

The Cognitive Exam

Cognition refers to the ability to use the higher cortical functions: thinking, logic, reasoning, and to communicate these thoughts to others. Unlike the rest of the mental status examination, examinations of cognition often involve the administering of specific tests of cognitive abilities. However, much can also be deduced from the whole of the examination. The cognitive examination is usually divided into the following domains:

1. Consciousness

2. Orientation

3. Attention and Concentration

4. Memory

5. Visuospatial ability

6. Abstractions and conceptualization.

Consciousness should be assessed early on. Consciousness may range from normal alertness to stupor and coma. Obviously, this affects the rest of the examination and should be noted early on.

Orientation refers to the ability to understand one’s situation in space and time. Generally, orientation to place and time is tested. Place may include asking about the building and floor a person is in, as well as the city and state. Orientation to time is tested by asking a person to give the day and date. Though an ill person who has spent a good deal of time convalescing may not be clear on the exact date, a cognitively intact person generally can give an approximate date, and it would be unusual for a cognitively intact person to not know the month or year, or what part of the month they are in. Orientation to person generally remains intact except in the most severe of cognitive disorders. In fact, a patient who presents disoriented to person, but otherwise cognitively intact almost assuredly is almost never displaying a cognitive disorder, but is most likely suffering from some other problem (for example a dissociative disorder, or perhaps malingering).

Attention and Concentration. Attention refers to the ability to focus and direct one’s cognitive in a physiologically aroused state. Concentration refers to the ability to maintain attention for a period. They need not go together: one can imagine a person who is attentive, but cannot concentrate on any one thing: for example a patient with early Alzheimer’s disease who is easily distracted. The patient’s attention and concentration during the interview should be noted. Most screening tests for dementia include a test of these items. For example, on the Folstein Mini-Mental Status Examination (below), a patient is asked to do serial seven’s (described below). Though this does involve some mathematical skill (about a 3rd grade level), the ability to sustain the task over time implies a reasonable degree of attention and concentration.

An example of a specific attentional task is the digit span, in which a patient is asked to repeat increasing lengths of numbers forwards, and then backwards. A normal person should be able to recite about 7 numbers forwards. A person usually can recite a reverse series that is 2 less than their forward series (thus, 5 for most people). It is important to recite the numbers in a relatively monotone way, put an equal interval between the numbers to avoid potential cues.

A simple test of concentration is to ask a person to count backwards starting at 65 and stopping at 49. The instructions should be given only once, with no cuing during the task. Another example is the serial sevens task, in when a patient is asked to start at 100 and subtract 7, then keep subtracting 7 from each answer. Usually a person is asked to perform 5 subtractions, and each correct interval of 7 scores 1 point.

Memory. Though variously defined, for the purposes here, memory will refer to the process of learning involving the registering of information, the storage of that information, and the ability to retrieve the information later. Thus, there are separate component of memory, and the boundaries between them are somewhat controversial. A simple approach to testing will be used here, and memory will be divided into registration, short-term memory, and long-term memory.

Registration refers to the ability to repeat information immediately. It is usually limited in capacity to about seven bits of information. Registration is usually tested by asking a patient to repeat a series of items (for example, three unrelated words). If the patient cannot do on the first try, the words should be repeated until the patient can do it, and the number of tries should be recorded (more than 2 trials for 3 words would be abnormal). Registration should always be ascertained before testing other parts of memory: an inattentive patient who cannot register properly may appear to have a deficit of short or long-term memory, when in fact the memory items were never incorporated properly for information storage.

Short-term memory refers to the storage of information beyond the immediate (registration) period, but prior to the consolidation of memory into long-term memory. Practically speaking, it lasts from a few seconds to a few minutes, and may or may not be temporary (depending on the purpose of the memory). It is limited in capacity, though the specific limits are very individual. Short-term memory can be tested by asking a patient to recall 3 or 4 words after a five-minute delay. After the initial test, a patient can be cued, or given multiple changes, which subsequent performance being recorded (although if the patient were being scored, these correct answers would not add to the score). Other typical tests of short-term memory include reading a paragraph to a patient and asking them to recall as much information from the story as possible in 5 minutes.

Long-term memory is usually divided into procedural and declarative memory. Procedural memory refers to the ability to remember a specific set of skills. As one thinks of any task one has learned–say, driving a car–it is clear that there is a point at which one no longer has to think about the specific steps in the task—it has become unconscious and automatic. Procedural memory is generally not assessed during a standard mental status examination, but can be specifically tested when indicated. For example, a person may be asked to act out a specific task (“show me how you brush your teeth”).

Declarative memory refers to the retention of data or facts, which can be verbal or nonverbal (i.e., sounds, images). In contrast to short-term memory, it is not temporary (though it can decay over time), and it has no known limit.

Long-term (declarative) memory is usually tested by asking a patient to recall past details. These details may be personal (wedding dates, graduations, past medical history–all of which would have to then be independently confirmed), or historical (important historical dates that a patient would reasonably be expected to know, based on their own upbringing and culture). Typically, a patient is asked to name past presidents, but some patients (ex. recent immigrants) may now know politics. One can usually assess appropriate questions after learning of a patient’s background. Some events are fairly universal: Pearl Harbor, for example, at least for people living in the US who are old enough to have been old enough in 1941. Similarly, one can expect, at least in this general area, that asking when the Red Sox won the World Series will be pretty reliable, at least for a while.

Constructional Ability refers to the ability to recognize the relationship of different objects in the world. Though occasionally neglected during cognitive testing, it is of great practical significance, particularly if a person wishes to drive, or live alone. Constructional tasks require reasonable vision, motor coordination, strength, praxis and tactile sensation, and in cases in which patient’s appear to have a deficit in this ability, these other domains should be tested as well. Usually, constructional ability is tested by having a person copy a design, such as a transparent cube, or a clock. The Folstein Mini Mental Status examination includes a constructional task in which a person is asked to draw intersecting pentagrams: a patient is expected both to draw the correct number of sides on both polygons as well as the two intersection points.

Abstraction and Conceptualization refer to higher intellectual functions. Abstraction involves the ability to understand the meanings of words beyond the literal interpretation. Conceptualization involves a number of intellectual functions, including the ability to be self-aware: of one’s existence, one’s thoughts, and one’s behaviors. Deficits in these areas may be inferred during an examination, especially from overly concrete answers to questions (example: doctor: “what brought you to the hospital” patient: “an ambulance.”). These abilities can be tested through such tasks as asking a patient to identify similarities between objects (example: “how are an apple and an orange both alike.” One would expect an abstract answer such as “fruit”, as opposed to a concrete answer such as that they are both round). Often, patients are asked to interpret proverbs as a test of abstract reasoning. Examples of proverbs typically used including “The grass is greener on the other side” and “Don’t count your chicken’s before they hatch.” Harder ones include “People who live in glass houses shouldn’t throw stones” and “A rolling stone gathers no moss.” In each case, it should first be explained what a proverb is (“a saying that has a broader meaning”) and an example might be given. A number of things can impair proverb interpretations besides deficits in abstract functioning: lower education (usually at least 8 years of education is expected for proverb interpretations), or a lack of cultural applicability, and these should be investigated as possibilities in a person who is having trouble with proverbs.

Standardized tests. There are a number of tests designed to examine various domains of cognitive ability. An example of a commonly used one is the Folstein Mini-Mental Status exam, and this is shown below.

SEQ CHAPTER h r 1

Insight And Judgment.

Insight and Judgment refer to complex tasks that require a good deal of cognitive functioning (including conceptual thinking and abstract ability), though intact cognitive functioning alone is not adequate for good judgment and insight. One could spend a good deal of time debating what these terms really mean. For the purposes here, suffice it to say that these concepts are much more approachable when seen in specific circumstances. Thus, rather than discussion these are overarching functions (“Judgment and insight: intact”), it is more useful to discuss them as they relate to a particular activity or question. In context, one can specifically discuss a patient’s insight into a particular problem, or their ability to use judgment to arrive at a particular decision. For example, a patient’s ability to make a particular medical decision requires both insight into their specific malady, as well as the judgment to weigh alternatives in the service of arriving at an appropriate decision.

Insight (in the medical context) refers to the capacity of the patient to understand that he or she has a problem or illness and to be able to review its probable causes and arrive at tenable solutions. Self-observation alone is insufficient for insight. In assessing a patient’s insight into their medical situation, the examiner should determine whether patients recognizes that they are ill, whether they understand that the problems they have are not normal, and whether they understand that treatment might be helpful. In some situations, it may also be important determine whether a patient realizes how their behaviors affect other people.

Judgment (in the medical context) refers to the patient's capacity to make appropriate decisions and appropriately act on them in social situations. The assessment of this function is best made in the course of obtaining the patient's history, and formal testing is rarely helpful. An example of testing would be to ask the patient, "What would you do if you saw smoke in a theater? Clearly, a meaningful judgment first requires appropriate insight into one’s situation. There is no necessary correlation between intelligence and judgment.

Reliability

Upon completion of an interview, the psychiatrist assesses the reliability of the information that has been obtained. Factors affecting reliability include the patient's intellectual endowment, his or her (perceived) honesty and motivations, the presence of psychosis or organic defects and the patient's tendency to magnify or understate his or her problems. In cases in which there is a strong reason to question a patient’s reliability (ex. significant dementia), the assessment of reliability should be discussed early in the examination, rather than waiting to the end to reveal that much of the information reported already is unreliable!

Figure 8-1. The Mini-Mental State

Examination (MMSE)

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compare this score against norms for education and age.�

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Figure 8-2. Normative Data for MMSE.

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29

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28

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These numbers can be used to compare a patient's performance on the MMSE against norms for their age and education.

Source: Crum RM, Anthony JC, Bassett SS and Folstein MF (1993) Population-based norms for the mini-mental state examination by age and educational level, JAMA, 18: 2386-2391.

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