Introduction
To see what one is actually seeing – to see wisely, as Sir William Osler advised – is not necessarily as easy as it might seem at first glance. When performing a mental status we are attempting to accurately observe the patient’s appearance, behaviors, and reported symptoms, as we search for both health and pathology. Our picture of the patient would be wondrously accurate, and our resulting interpretations splendidly wise, if we had the recording power of a camera lens and the objectivity of a computer chip. We don’t. We are all too human. This simple fact is both to our benefit and to our detriment when performing a mental status. As humans, we are drawn towards empathy and sensitivity. Such predilections are generally very useful in our interviewing – indeed critical to success – as we have emphasized throughout our book. But sometimes our natural proclivities can lead us astray to the detriment of our patients.
By way of illustration, sensitive clinicians are naturally drawn toward the vantage point of looking with the patient in an empathic sense. It is our nature. But such an alignment can be a trap if the clinician over-utilizes it to the detriment of seeing what is actually before one’s eyes in an objective fashion. Empathic connection can cast a fog over accurate observation. A clinician can begin to see not what is there but what the clinician wishes were there.
In this context, I observed a clinician empathizing with a subtly psychotic patient to the point that the clinician did not recognize that the patient was displaying a loosening of associations and other soft signs of psychosis. In this instance, sole reliance upon empathic listening blocked the clinician from establishing enough distance to observe with an objective compassion. The clinician was drawn into the patient’s worldview, with the result that the patient did not receive the appropriate recommendation for antipsychotic medication.
The Impact Status
Two slightly different approaches are useful when attempting to observe the patient with a sensitive, yet accurate, eye: (1) the impact status and (2) the mental status. The impact status refers to the immediate behavior and affect of the patient at any single moment of the interview. Thus, the impact status represents a quick subjective mental “take” of the patient’s presentation, in which the clinician focuses upon the immediate impact on the patient of both the patient’s inner world and of the behaviors of the clinician.
In contrast, the mental status is a composite of all the observations made during the course of the interview. Metaphorically speaking, if one were to view the patient’s reported history as representing an ongoing video of the patient’s problems and symptom history, then the mental status is an attempt to create – as best we can – an objective snapshot of the patient’s presentation during the interview itself.
In many respects, the impact status was discussed in length in Chapter 8 on nonverbal behavior, but this area is worth a second look. The skilled clinician keenly observes all aspects of the patient’s behavior, including mode of dress, hygiene, motor activity, affect and facial expression, mannerisms, and attitude. It is valuable, during the course of the interview, to periodically note the immediate affect of the patient, while asking oneself whether one’s own behavior may be affecting the patient negatively, as evidenced by a decrease in the blending process. If such negative interactions are recognized early, one can quickly act to alleviate the stress before significant disengagement has occurred. At other times, one may opt to explore with the patient the reasons behind the change in affect. In this fashion, the clinician may uncover projective defenses or parataxic distortion, as described by Harry Stack Sullivan (see Chapter 6, pages 192–193).
The clinician may also uncover significant unconscious material or attitudes betrayed by the patient’s mannerisms. In this regard, it is also useful to consciously make a note of the baseline nonverbal activity of the patient, so that subtle variations can be reflected upon. I am reminded of a young woman who had been in psychotherapy for roughly a year and a half. In one of her sessions she described an upcoming meeting with a supervisor in her graduate program. While she commented, “I guess I better go in and find out what my future is gonna be,” she gave a child-like grin, accompanied by a helpless tone of voice. Apparently, at that moment in time, the thought of meeting her supervisor produced an attitude of child-like subservience.
This impact status observation could be immediately put to use. I asked her what she had been feeling while discussing her upcoming supervision. I also shared some of my observations on her appearance at that time. This led to a rich exploration of her tendency to not take herself seriously. As she became more aware of her facial expressions, she was also able to successfully role-play meeting this supervisor while displaying an adult affect and attitude.
Throughout the book, much has already been discussed with regard to nonverbal behavior, the behavioral indicators of blending, and other aspects key to the concept of the impact status. Consequently, it may be of value to shift our emphasis to the numerous considerations involved in uncovering a sound mental status.
The Mental Status
General Characteristics of the Mental Status: What Is It?
The mental status represents an attempt to objectively describe the behaviors, thoughts, feelings, and perceptions of the patient throughout the course of the interview itself. Although it primarily focuses upon how the patient looked during the interview, when recording the mental status, recent psychiatric symptoms not present during the interview but uncovered as recently being experienced by the patient are also recorded. These observations are usually typed as a separate section in the patient’s electronic health record (EHR). The general topics covered by the mental status are categorized as follows: (1) appearance and behavior, (2) speech characteristics and thought process, (3) thought content, (4) perception, (5) mood and affect, (6) sensorium, cognitive ability, and insight.2 Clinicians may vary on the exact categories that are used, and some clinicians collect all of these observations into a single narrative paragraph (although I find this somewhat confusing). In any case, the clinician attempts to convey the state of the patient during the course of the interview.
When documenting the mental status, checklists are often commonly used as well and can quickly alert the reader of the EHR to the presence of psychopathology. A cautionary note: checklists alone are never adequate for a mental status. A checklist without the accompanying descriptive mental status paints a woefully weak clinical picture of the patient. It also invites a malpractice suit, for a good lawyer will quickly pounce on the clinician’s appearance of being both disinterested and negligent in taking the time to critically hunt for evidence of psychopathology, as evidenced by a lack of a descriptive component to the mental status.
There exist two broad aspects to the mental status. First, there is the type of questioning that is required to be done in any standard initial assessment when undertaking a review and exploration of the patient’s psychiatric symptoms. We are familiar with these types of questions from the previous chapters of this book. Interviewers use such sensitive questioning to explore various diagnostic categories, from mood disorders to anxiety disorders, as well as uncovering troubling pathologic processes such as psychosis and suicidal thought that can occur across many disorders. These questions are not done in an artificial “section” of the interview. As we have seen earlier, this review of psychiatric symptoms is woven gracefully throughout the body of the interview.
Thus, most of the mental status is not done in a specific section of the interview. Nor, if the interviewer skillfully structures the interview following the principles of facilics, will a patient be aware that a mental status is being performed. A good mental status is artfully hidden within the natural flow of an initial interview, and consists both of questions focused upon uncovering psychiatric symptoms and our observations of the patient’s appearance and behaviors as we ask those questions.
On the other hand, there does exist a second, more formal part to the mental status. In this part, the interviewer tests the patient’s cognitive functioning. Here one will see the interviewer devoting a specific section of the interview to questions on orientation, concentration, memory, and intellectual functioning. One can easily recognize when an interviewer is performing a formal cognitive mental status exam, for they will be using specific “cognitive tests” such as digit spans, three-object recall, and constructions. This aspect of the mental status – formal cognitive testing – is more optional in nature and will be expanded depending upon the diagnostic suspicions and age of the patient (suspected delirium, dementia, etc.). Later in our chapter, we will discuss and observe a complete cognitive mental status being performed, known as the Folstein Mini-Mental State Examination.
At this point, I believe it will be useful to turn our attention to our first video module. In it I will further clarify the various aspects of the mental status including the interface between the performance of the mental status and its placement and documentation in the EHR. I’ll also demonstrate several practical techniques for gracefully weaving aspects of the mental status throughout the interview.
Documenting the Mental Status
It is difficult to discuss the performance of the mental status without carefully considering the process of documenting it in the EHR (or in some instances a written record). The recorded document (whether typed or written) frequently reflects the clinician’s activities during the interview itself. For example, if the clinician has a difficult time moving into a relatively pure vantage point of observing the patient, then the mental status frequently reflects this inability with omissions, premature assessment opinions, or misplaced bits of the history of the present illness that “explain the patient’s psychopathology.” In this light, a disorganized or confusing clinical document is usually a reflection of an equally disorganized interview. Thus, one of the most effective ways to explore how to do the mental status is to explore how it is documented, which will be the focus of this chapter.
Subjective opinions, diagnostic formulations, and other conceptual perspectives do not belong in the mental status. The mental status should represent an earnest attempt to describe objectively what is being encountered during the actual clinical interview. It therefore represents a unique and highly valuable aspect of the psychiatric record, because it serves as an area in which a clinician can read about the appearance, behaviors, and level of symptomatology of the patient, as recorded by a fellow mental health professional at a given point in time. The clinician can then compare the patient’s current presentation with the past in an effort to determine evidence of improvement or decline. The use of the mental status in this more disciplined fashion trains clinicians to effectively utilize the vantage point of looking at the patient with as clear an eye as is possible, exactly as Sir William Osler counseled in our opening epigram.
The mental status complements other aspects of the EHR and is relatively distinct from them. By way of example, the History of the Present Illness (HPI) describes the pertinent historical aspects of the patient’s behavior, the patient’s concerns, and the patient’s symptomatology up until the interview itself. The HPI is primarily culled from the patient’s own words, but the clinician frequently also pulls from the patient’s family, previous clinicians, written documents, and other sources of information. The mental status only includes information gathered from the patient, in the same sense that a physical examination only includes the immediate blood pressure reading of the patient, not the history of blood pressure readings taken by previous clinicians.
In a similar vein, the Narrative Summary and Clinical Formulation, a different section of the EHR appearing towards the end of the document, allows the clinician to piece together the patient’s history and immediate presentation into a cohesive whole, utilizing the added perspective of the clinician’s opinions and knowledge base. It is in the Narrative Summary and Clinical Formulation that the clinician shares his or her DSM-5 diagnostic impressions, conceptions of the etiology of the patient’s problems, and possible treatment interventions within the patient’s matrix.
The History of the Present Illness and the mental status should be as objective a relating of the facts associated with the patient’s presentation as possible. They do not include the clinician’s impressions of what those facts may mean. Thus, in the HPI and mental status, a clinician will document the patient’s symptoms, but they will not proffer their DSM-5 diagnostic impressions. A diagnosis is a subjective formulation of what the facts mean. Hence, diagnostic impressions and treatment recommendations belong in the part of the EHR designated Narrative Summary and Clinical Formulation. All of this material – related to how to document the initial assessment – is nicely described, simplified, and illustrated with examples in Appendix III.
On a practical level, one of the reasons why it is important to emphasize these distinctions in this chapter is the fact that clinicians frequently waste an inordinate amount of time repeating themselves in the EHR. If a good description of the patient’s delusions appears in the HPI, then the mental status need only refer to this material rather than repeat it, because the focus should be the current thought content of the patient as illustrated below:
Thought Content
The patient has a history of an extensive delusional system regarding communist infiltration (see HPI). In the interview itself he continues to believe that his place of work is teeming with communists. He even believed that the psychiatric nurse he had just met was also a communist. Upon asking whether his mind might be playing tricks on him, he reported, “I’m not crazy. I know for a fact that the communist invasion has begun, will you help me?” He currently denies the belief of an alien invasion from Jupiter, which he had believed earlier this year, as reported in the HPI.
Note that the clinician does not go into detail about the specifics of the delusional system, because those details had already been related in the HPI. Moreover, the clinician does not discuss his assessment of the patient’s distance from his delusion with a statement such as, “This patient clearly remains very delusional and psychotic,” for such an appraisal is most effectively made in the Narrative Summary and Clinical Formulation, where the clinician provides his or her clinical opinions. Instead, the clinician carefully records the exact words of the patient, which demonstrate the patient’s adamant belief in his delusional system. The focus is once again where it belongs in the mental status, on the actual behaviors and thoughts of the patient during the interview itself.
To become an accurate observer, the clinician must learn how to look, in a relative sense, without the contamination of previous beliefs and theoretical biases. This objective stance is one of the prerequisites of a sound mental status and of the vantage point of looking at the patient. To convey one’s observations accurately, it becomes critical for one to utilize a common language. There is no room for a sloppy use of terminology, because such a practice can clearly confuse other clinicians, potentially biasing them towards faulty observations themselves.
Upon graduation from a psychiatric residency or graduate school in nursing, counseling, clinical psychology, or social work, all mental health professionals will be expected to be able to perform and document a sound mental status. The organization and terms used in the mental status are quite specific and accurately defined. To a trainee, the terms are not necessarily self-evident. But by the time of graduation the mental health professional must feel at home with the terms, be able to utilize them proficiently to describe underlying and subtle psychopathology, and be able to rapidly translate their observations into a sound clinical record. This chapter attempts to provide the tools with which to accomplish these goals, whether one finds oneself working in a community mental health center, an inpatient psychiatric unit, a specialized clinic, a high school or college counseling center, or an emergency department.
Consequently, we shall now examine each of the six components of the mental status as it might appear in a standard EHR. An effort will be made to summarize commonly utilized descriptive terms, clarify confusing terms, point out common mistakes, and provide an example of a well-documented mental status as a model for the reader as he or she begins clinical rotations. As the clinician becomes adept at documenting the mental status, he or she will also be developing improved interviewing skills using the vantage point of looking at the patient with a highly skilled focus and increased awareness.
Components of the Mental Status
1. Appearance and Behavior
In this section the clinician attempts to accurately describe the patient’s outward behavior and presentation. One place to start is with a description of the patient’s clothes and self-care. As Wallace suggests, it is probably best to avoid interpretations when describing the patient’s clothing and presentation. Instead, the clinician records the exact data that ultimately leads to the opinions written in the subsequent Narrative Summary and Clinical Formulation. In this regard, the clinician should describe the patient’s apparel as opposed to relying solely on subjective terms such as “stylish,” because not everyone would agree upon the meaning of the word “stylish.”3
Striking characteristics, whether decorative in nature (as in tattoos) or unwanted (such as scars and deformities), should be noted, as well as any tendencies for the patient to look older or younger than his or her chronological age. Eye contact is usually mentioned. Any peculiar mannerisms are noted, such as twitches or the patient’s apparent responses to hallucinations, which may be evident through tracking movements of the eyes or a shaking of the head as if shutting out an unwanted voice.
The clinician should note the patient’s motor behavior; common descriptive terms include restless, agitated, subdued, shaking, tremulous, rigid, pacing, and withdrawn. Displacement activities, such as picking at a cup or chain smoking, are frequently mentioned. An important and frequently forgotten characteristic is the patient’s apparent attitude toward the interviewer. With these ideas in mind, let us first take a look at a relatively poor description.
Although this selection gives some idea of the patient’s appearance, one does not come away with a feeling for what it would be like to meet this patient. Generalities are used instead of specifics. Let us look at a description of the same patient that captures her presence more precisely.
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