MENTAL STATUS EXAMINATION

Introduction

• Known as Mental status examination in USA • Mental state examination in the rest of the

world • Abbreviated as “ MSE “ • Should not be confused with the Mini-Mental

State Examination (MMSE), which is a brief neuro -psychological screening test for dementia.

• General physical examination (GPE) is a must in every patient

• Physical disease causing psychiatric symptoms or accidentally co-existent or caused by psychiatric condition or treatment can be detected by GPE

• MSE is a part of Case History

“MSE” at a glance • An important part of the clinical assessment

process in psychiatric practice • Also considered as a part of the

comprehensive physical examination performed by physicians and nurses

• 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 judgement

• Minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

• Data is collected through a combination of direct and indirect means, (unstructured observation, focused questions, psychological tests, etc)

• Core skill of psychiatrists, psychologists, physician assistants, nurse practitioners and other qualified mental health personnel.

• Key part of the initial psychiatric assessment in an out-patient or psychiatric hospital setting .

• 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.

• Information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.

• A standardized format in which the clinician records the psychiatric signs and symptoms present at the time of the interview

The Theory • Derives from an approach to psychiatry known as

descriptive psychopathology or descriptive phenomenology

• Which developed from the work of the philosopher and psychiatrist Karl

• Jaspers Jaspers' perspective 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)

• In practice, MSE is a blend of empathic, descriptive set of objective descriptions of a psychiatric patient and empirical clinical observation

The purpose • To obtain a comprehensive cross-sectional

description of the patient's mental state • To get information on the patient's insight,

judgment, and capacity for abstract reasoning • 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

• To make an accurate diagnosis and formulation, which are required for coherent treatment planning

• To inform decisions about treatment strategy and the choice of an appropriate treatment setting

Major Domains • MSE should describe all areas/domains of

mental functioning such as; General appearance and Behavior,

Speech, Mood and Affect, Thought process, Perceptions, Cognition (Higher Mental functions), Insight, Judgment

• Emphasis shall be given to some areas according to clinical impressions arise from the history (mood and affect in depression, cognitive functions in delirium and dementia)

1.General appearance and Behavior

• A rich deal of information can be elicited • Important to remember patient’s socio-

cultural background and personality • More emphasis in the examination of an

un co-operative patient

1.1. General Appearance • Physique and body habitus (build) • Physical appearance (height, weight and

appearance) • Looks comfortable/uncomfortable • Physical health • Grooming, hygiene, self care• Dressing (adequate/appropriate/peculiarities) • Facies (non-verbal expression of mood) • Effeminate / masculine

1.2. Attitude towards Examiner

• Co-operation/guardedness/evasiveness/ hostility/combativeness/haughtiness

• Attentiveness • Appears interested/disinterested/apathetic • Ingratiating behavior • Perplexity

1.3. Comprehension

• Intact/impaired (partially/fully) 1.4. Gait and Posture

• Normal/abnormal (way of sitting, standing, walking, lying )

1.5. Motor activity

• Increased/decreased • Excitement/stupor • Abnormal involuntary movements (AIMs)

such as tics, tremors, akathisia • Restlessness/ill at ease

• Catatonic signs (mannerisms, steriotypies , posturing, waxy flexibility, negativism, ambitendency , automatic obedience, stupor, echopraxia , psychological pillow, forced grasping,

• Conversion and dissociative signs ( pseudo seizures , possession states)

• Social withdrawal, Autism • Compulsive acts, rituals or habits (nail biting,

etc) • Reaction time

1.6. Social manner and non-verbal behavior

• Increased/decreased/inappropriate behavior • Eye contact (gaze aversion, staring vacantly,

staring at the examiner, hesitant eye contact, normal eye contact )

1.7. Rapport • Whether a working and empathetic

relationship can be established with the patient

1.8. Hallucinatory behavior

• Smiling /crying without reason • Muttering or talking to self (non-social

speech) • Odd gesturing in response to auditory or

visual hallucinations

2 . Speech

2.1. Rate and quantity • Speech Present or absent ( mutism ) • If present, whether spontaneous • Productivity increased/decreased • Rate is rapid/slow/appropriate • Pressure of speech/poverty of speech

2.2.Volume and tone

• Increased/ decreased/appropriate • Low/high/normal pitch

2.3. Flow and rhythm

• Smooth/hesitant • Blocking (sudden) • Dysprosody ,

suffering/stammering/cluttering, any accent

• Circumstantiality, tangentiality • Verbigeration , steriotypies (verbal)• Flight of ideas, clang associations

Mood and Affect :

3.1 Mood • Is the pervasive feeling tone which is

sustained (last for some length of time) and colors the total experience of the person

• Described as general warmth/ euphoria/ elation/ exaltation and/ or ecstasy in mania, anxious/ restless in anxiety and depression, sad/ irritable/angry and/or despaired in depression, shallow/blunted/indifferent/restricted/inappropriate and or labile in schizophrenia

• Anhedonia may occur on both schizophrenia and depression

• Quality of mood - assessed subjectively – how do you feel? , and objectively – by examination

• Stability of mood – over a period of time • Reactivity of mood – variation in mood with

stimuli • Persistence of mood – length of time the

mood lasts

3.2. Affect• Is the outward objective expression of the

immediate, cross sectional experience of emotion at a given time

• Quality of affect • Range of affect - of emotional changes

displayed over time • Depth / intensity of affect – normal /

increased / blunted• Appropriateness of affect – in relation to

thought and surrounding environment

4. Thought • Normal thinking is – goal directed flow of

ideas, symbols and associations initiated by a problem/task, characterized by rational connections between successive ideas/thoughts, leading towards a reality oriented conclusion

• Thought process considered not normal when – not goal-directed/ not logical/ does not lead to realistic solution to the problem at hand

• In traditional clinical examination, thought is assessed – by the content of speech- under 4 headings- stream, form, content, and possession of thought

• Due to widespread disagreement regarding the sub-division now assessed under 2 headings – stream and form , content

4.1. Stream and form

• “Stream of thought” overlaps with examination of “speech”

• Spontaneity• Productivity• Flight of ideas• Prolixity• Poverty of content of speech• Thought block

• “Continuity of Thought” is assessed as follows: Whether the thought processes are relevant to the questions asked

• Any loosening of associations • Tangentiality • Circumstantiality • Illogical thinking • Perseveration • Verbigeration

4.2. Content • Preoccupations • Obsessions – recurrent/irrational/intrusive/ego-

dystonic /ego-alien ideas • Content of phobias – irrational fears • Delusion (false/unshakable beliefs ) or over-valued

ideas; ideas of persecution, reference, grandeur, love, jealousy(infidelity), guilt, nihilism, poverty, somatic( hypochondriacal )symptoms, hopelessness, worthlessness, suicidal ideation

• Schneiderian first rank symptoms(SFRS) - delusions of control, thought insertion, thought withdrawal, thought broadcasting

• Presence of neologisms

5. Perception

• Is the process of being aware of a sensory experience and being able to recognize it by comparing it with previous experience

5.1. Hallucinations • Is a perception experienced in the absence of an

external stimulus. • Can be auditory, visual, olfactory, gustatory, tactile

domains • Auditory hallucinations are common types in non-

organic psychiatric disorders • Clarify - Elementary(only sounds are heard) /

complex(voices heard) • Experienced like a true perception and seems to

come from an external objective space(from outside the ears in case of auditory hallucination)

• Pseudo hallucination - does not appear to be a true perception or comes from a subjective internal space(inside the person’s own head in the case of auditory hallucination)

• What was heard/how many voices were heard/in which part of the day/male or female voices/how interpreted

• Whether these are second person or third person hallucinations (the voices were addressing the patient/discussing him in third person)

• Command(imperative)Hallucinations – give commands to the person

• Occurred during wakefulness • Were they hypnagogic (while going to

sleep) and/or hypnopompic (while getting up from sleep)

5.2. Illusions and misinterpretations

• Visual / auditory / or in other sensory fields • Occur in clear circumstances or not • Any steps taken to check the reality of

distorted perceptions

5.3. De personalization / de realization

• Are abnormalities in the perception of a person’s reality

• Described as “ as if ” phenomena

5.4. Somatic passivity phenomenon

• Is the presence of strange sensations described by the patient as being imposed on the body by “some external agency”, with the patient being a passive recipient

• One of the Schneider’s first rank symptoms(SFRS)

5.5. Others

• Autoscopy • Abnormal vestibular sensations • Sense of presence

6. Cognition (Neuropsychiatric) Assessment

• Assessment Higher mental functions • An important part of MSE • Disturbance of cognitive functions points

to the presence of an organic psychiatric disorder

• Folstein’s mini mental state examination (MMSE) is used for a systematic clinical examination of higher mental functions

6.1. Consciousness • The intensity of stimulation needed to arouse the

patient should be indicated to demonstrate the level of alertness

• By calling a patient’s name in a normal voice/ in a loud voice, light touch on the arm, vigorous shaking of the arm or painful stimulus

• Grade the level consciousness ; conscious/ confusion/ somnolence/ clouding/delirium/stupor/coma

• Disturbance in the level of consciousness be rated on Glasgow Coma Scale, where numeric value is given to the best response in 3 categories – eye opening, verbal, motor

6.2. Orientation • Whether well oriented to time – ask the time,

date, day, month, year, season, the time spent in hospital

• Place – ask the present location, building, city, country

• Person – ask his own name, whether identifies people around him and their role in that setting

• Disorientation in time precedes disorientation in place and person

6.3. Attention • Check, attention easily aroused and

sustained • Ask to repeat digits forwards and backwards

(digit span test, digit forward and backward test)

• One at a time ( may be able to repeat 5 digits forward and 3 digits backward)

• Start with 2 digit numbers increasing gradually up to 8 digits or till failure occurs on 3 consecutive occasions

6.4. Concentration

• Can the patient concentrate / easily distractible

• Ask to subtract serial sevens from hundred (100-7 test), or serial threes from fifty (50-3 test), or to count backwards from 20, or enumerate the names of the months(or days of the week) in the reverse order

• Note the answers and time taken to perform the tests

6.5. Memory

a). Immediate Retention and Recall (IR and R)

• Use Digit Span Test to assess the immediate memory; digit forward and digit backward subtests (also used for testing Attention)

b). Recent memory • Ask how did the patient come to the room/hospital;

what he ate for dinner the day before or for breakfast the same morning

• Give an address to be memorized and ask to recall 15 minutes later or at the end of the interview

c). Remote memory • Ask for the date and place of marriage, name and

birthdays of children, any relevant questions from the person’s past

• Note any amnesia( anterograde / retrograde), or confabulation

6.6. Intelligence • Is the ability to think logically, act rationally,

and deal effectively with environment • Keep in mind, patient’s educational and

social background, experiences and interests • Can ask about the current and past prime

ministers, presidents of India, the capital of India, and the same of various states

• Test for reading and writing • Simple tests of calculation

6.7. Abstract thinking

Characterized by the ability to : a).Assume a mental set voluntarily b).Shift voluntarily from one aspect of situation

to another c).Keep in mind simultaneously the various

aspects of a situation d).Grasp the essentials of a “whole” (situation

or concept) e).To break a “ Whole” into its parts

f).Abstract Thinking Tests assesses Patient’s concept formation

1.Proverb Testing – the meaning of simple proverbs , usually 3

2. Similarities(and differences) between familiar objects, such as table/chair, banana/orange, dog/lion, eye/ear

3. Answers may be overly concrete or abstract 4. Appropriateness of answers is judged 5. Concretization of responses or inappropriate answers

may occur in schizophrenia

7. Insight • Is the degree of awareness and understanding

that the patient has, regarding his illness • Ask the patient’s attitude towards his present

state ; whether there is illness or not; • If yes , What kind of illness(physical

psychiatric or both) • Any treatment needed ; hope for recovery • Cause of the illness

• Depending on response , insight is rated on a 6 point scale:

1. Complete denial of illness2. Slight awareness of being sick and needing help, but

denying it at the same time 3. Awareness of being sick, but it is attributed to external or

physical factors 4. Awareness of being sick, due to something unknown in

self 5. Intellectual Insight : awareness of being ill and that the

symptoms/failures in social adjustment are due to own particular irrational feelings/thoughts; yet does not apply this knowledge to the current/future experience

6. True Emotional Insight ; It is different from intellectual insight in that the awareness leads to significant basic changes in the future behavior

8.Judgement • Is the ability to assess a situation correctly

and act appropriately within that situation • Both social and test judgement are assessed 1. Social judgement • Observed during hospital stay and the

interview session • Includes an evaluation of personal judgement

2. Test judgement • Assessed by asking, what would he do in

certain test situations – a house on fire , a man lying on the road , a sealed , stamped, addressed envelope lying on a street

• Judgement is rated as Good/Intact/Normal or Poor/Impaired/Abnormal

Investigations

• After the detailed history and examination, investigations - laboratory tests, diagnostic standardized interviews, family interviews, and/or psychological tests - are carried out based on the diagnostic and aetiological possibilities.