Mental Status Examination
Essential Concepts Mnemonic for Elements of the Mental Status Examination:
All Borderline Subjects Are Tough, Troubled Characters
Appearance
Behavior
Speech
Affect
Thought process
Thought content
Cognitive examination
Nothing in the psychiatric assessment is as misunderstood as the mental status examination (MSE). Two misconceptions are ubiquitous. The first is that the MSE takes place at the particular point in the interview when you test orientation and recall. In fact, the MSE occurs throughout the entire interview, during which you are constantly evaluating affect, concentration, memory, and insight. The second myth is that the MSE is identical to the Folstein Mini-Mental State Examination (MMSE). In fact, the Folstein MMSE is a specific screen for dementia. Increasingly, its use in the routine psychiatric interview is being questioned, but we’ll talk more about that later.
The MSE is your evaluation of your patient’s current state of cognitive and emotional functioning. Although most of the initial interview is specifically focused on your patient’s past, doing an excellent MSE requires that you attend at the same time to his present. Here your “third ear” comes into play. How is your patient presenting himself? What is his TP like? How is he emoting? It will take you years to hone your powers of observation, and this is certainly the most interesting part of the diagnostic interview.
An MSE accomplishes two purposes. First, it helps make a diagnosis, especially in those cases in which historical data are unreliable or equivocal. A patient could send you an e-mail listing all of his depressive symptoms, but it requires
direct observation—an MSE—to assess the degree of his anguish and his need for treatment. Second, the MSE allows you to create a vivid patient description for your records. Using this, you can more easily track your patient’s progress from visit to visit, and you can give clinicians to whom you refer a more accurate sense of his condition.
direct observation—an MSE—to assess the degree of his anguish and his need for treatment. Second, the MSE allows you to create a vivid patient description for your records. Using this, you can more easily track your patient’s progress from visit to visit, and you can give clinicians to whom you refer a more accurate sense of his condition.
ELEMENTS OF THE MENTAL STATUS EXAMINATION
The MSE has roughly seven components. This mnemonic will help you to remember them:
All Borderline Subjects Are Tough, Troubled Characters:
Appearance
Behavior
Speech
Affect
Thought process
Thought content
Cognitive examination
Appearance
How does your patient’s appearance help you in your evaluation? At the extremes, a specific diagnosis might immediately suggest itself. For example, a disheveled man wearing bizarrely mismatched layers of clothes is schizophrenic until proven otherwise. Likewise, a flamboyant and seductively dressed woman with bright makeup who bounces into your office with energy to spare strongly suggests mania.
In usual clinical practice, however, these pathognomonic presentations are rare, and appearance provides more subtle, but no less useful, information. Qualities to note include
Self-esteem: Does the patient care about his appearance? Compare the following two patient descriptions:
The patient was a mildly overweight man with unruly black curly hair, dressed in ill-fitting baggy jeans and a T-shirt so tight that his stomach was visibly bulging above his belt.
The patient was a slim man who appeared younger than his 47 years, with fashionably cut short brown hair, an ironed button-down shirt, new jeans, and polished penny loafers.
Both patients were diagnosed with depression, but they presented very differently and required different treatment plans.
Personal statement: Does the appearance say something specific about your patient’s interests, activities, or attitudes?
The patient came into the office dressed in a pressed electrician’s uniform, with his name stitched over his breast pocket. She wore a T-shirt with the slogan, “Every day I’m forced to add one more name to the list of people who piss me off.”
Memorable aspects: Describe whatever particularly strikes you about your patient. For example, if he is particularly attractive, note it, since degree of attractiveness is usually relevant to self-image. However, I have yet to see any report describe a patient as “unattractive,” and I wouldn’t recommend it, because it implies that you disliked him. Instead, describe the unattractive aspects.
This was a man of normal build who had a round, acnecovered face and was essentially bald, with the exception of small amounts of oily black hair on either side.
Sometimes, a particular feature jumps out at you:
She had short curly brown hair, and her left eye was congenitally deviated toward the left, giving her a somewhat unsettling appearance.
TIPThe more vivid the notation, the better. I find it helpful to actually jot down a few descriptors at the beginning of the interview, during the free speech period.
Comment on height and build; hair color, style, and quality, including facial hair, if any; facial features, including eyes; clothes; movements; and any other prominent features of appearance, like tattoos or scars.
Table 21.1 (included in Appendix A as a pocket card) may appear to restate the obvious, but it’s useful to me when I lack the right descriptive words.
Behavior and Attitude
How did your patient behave toward you when you first met her? Was she friendly and cooperative, or did she seem indifferent and apathetic? Did she sit right down and face you, or
was she agitated, pacing around the room and talking rapidly without really attending to your questions? The context of the interview may also be important to making sense of the behavior. Was it a scheduled evaluation interview or did it take place in an emergency room?
was she agitated, pacing around the room and talking rapidly without really attending to your questions? The context of the interview may also be important to making sense of the behavior. Was it a scheduled evaluation interview or did it take place in an emergency room?
TABLE 21.1. Appearance terms | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Descriptors of attitude are similar to descriptors of affect (Table 21.2), but the emphasis is on words that describe a relationship toward someone. Often, a sentence of description is important. Here are some examples:
He presented himself as someone who was very anxious to tell his story and to gain relief from his symptoms. He had an attitude of submissive respect, saying things like, “Do you think you can help me, doctor? What do you think I have?” She presented as indifferent and apathetic. Her general attitude was that this was just the latest in a long string of unhelpful interviews.
TABLE 21.2. Affect terms | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Often, your patient’s attitude toward you will change over the course of the interview.
He was initially reluctant to answer questions and seemed irritable. Over the course of the interview, he became more self-revealing and tearful.
Speech
Description of speech has great overlap with description of TP, because we can only know our patients’ thoughts through speech. Qualities of speech to consider include
Rate: Does he speak rapidly or slowly? Rapid or “pressured” speech is usually a buzzword for manic speech, but you need to be careful not to overpathologize. Rapid speech can signal anxiety or even be the normal speech pattern. We all know people who speak very rapidly but are not manic.
Volume: Patients who speak loudly may be manic, irritable, or anxious. Very low volume may signal depression or shyness. Again, loud or quiet speech may also be a nonpathologic variant of normal.
Latency of response: Normally, when you are asked a question, you’ll think for a fraction of a second before responding. This is the normal latency of response. Manic patients may respond so quickly that they seem to jump
onto the last few words of your questions. Depressed or psychotic patients may show an increased latency of response, waiting several seconds before answering simple questions.
General quality: Does your patient speak thoughtfully and in an articulate manner, or does she ramble in a vague and disconnected way, making her hard to follow? The terms in Table 21.3 are discussed in more detail in Chapter 27, in the section on disorders of TP.
Affect and Mood
Traditional teaching distinguishes mood from affect, with mood defined as a patient’s subjective report of how he feels, and affect defined as your own impression of his emotional state. Although many clinicians do not make this distinction in clinical work, you should become familiar with it, because it is widely used.
Like observation of appearance and behavior, accurate observation of affect is a skill that takes years to master. Although the overall emotional flavor is usually obvious, the gradations and subtleties are not, and assessing degree of affect can be vitally important for such things as determining imminence of SI or predicting the likelihood of aggressive acting out.
Often, you won’t have to explicitly ask your patient how he’s been feeling, because he’ll report it spontaneously. However, what do you do when your patient is vague about his emotions or is reluctant to reveal himself?
TABLE 21.3. Speech terms | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
The obvious (and easiest) approach is to come right out and ask.
How do you feel right now? How has your mood been over the past few days?
If the patient answers with a vague term, follow up with questions aimed at giving a more refined name to the affect, a name on which you both can agree but which you have not “fed” the patient.
CLINICAL VIGNETTE
Interviewer: How have you been feeling over the past few days?
Patient: Not so great.
Interviewer: Hmmm. Not so great. Can you give that feeling a name?
Patient: Just… really lousy.
Interviewer: I mean an emotion word, like sad, nervous, angry, and so on.
Patient: Sad, I guess.
One particularly difficult situation is when your patient says he feels “up and down” or that he has “mood swings.” Suddenly you are faced with a huge diagnostic differential. Does the patient have bipolar disorder? Cyclothymia? Does he have depression with mood reactivity? Does he have a personality disorder? An anxiety disorder? A substance abuse disorder? All of these are compatible with an up-and-down mood.
Your questioning strategy should be based on trying to locate an enduring, persistent mood beneath the variations. Or, if there is true mood instability, you should determine whether the lows meet criteria for major depression and the highs satisfy criteria for mania. I’ll have more to say about these issues in Chapters 23 and 24, but here’s an example of a strategy that usually works well:
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
