[HD 202] E01-T06-Mental Status Exam in Practice

Mental Status Examination (MSE)

• A detailed investigation and account of a patient's behaviors and responses reflecting their current mental state.
• Based on examiner observation and interaction in the present, focusing on higher cortical functioning within a neurological context.
• Consists of objective data observed and elicited during the interaction.
• Does NOT mix findings with subjective history or reports from other informants.

Key Points in Conducting and Documenting

• Clinicians can elicit findings in any sequence, noting many items simply through conversation.
• Maintain a conversational flow while eliciting MSE findings.
• Documentation and reporting follows a prescribed format.
• State pertinent negatives or normal findings.
• If an item can't be assessed, note and explain why, distinguishing this from a negative finding.
• Note uncooperative patients and explain; not being able to elicit an answer doesn't imply a 'no.'
• A good MSE can be obtained from uncooperative patients by observing and listening.
• It's unacceptable to report "no MSE was performed."
• Clinicians aren't limited to formal terms but should add relevant, helpful explanations.
• Avoid assumptions; document only what's explicitly elicited, and avoid assuming the patient "feels normal" without asking.
• Additional preparation includes: Informing the patient about the questions, obtaining consent, ensuring visual/hearing aids are in place, comfortable seating.
• The environment should be quiet, private, and conducive.

Outline of Documenting and Reporting the MSE: General Survey

• Covers appearance and behavior.

Appearance and Behavior

• Assesses apparent physical features (wounds, medical devices, dysmorphologies), manner of dressing (appropriate), and personal hygiene (kempt/unkempt).
• Psychomotor symptoms include restlessness, retardation, agitation, tics, compulsions, involuntary movements, catatonia.
• Notable behaviors include clinging, seeking assurance, shying away, fidgeting, and mannerisms.

Eye Contact

• Evaluated as good/fair/poor, shifting, or fixed.

Speech

• Assesses production (unresponsive, gestures, hypo/normo/hyperproductive, pressured, incoherent).
• Tone and rate is slow/normal/fast, monotonous, dramatic, irritable, anxious, or dysphoric.
• Volume includes soft/normal/loud, child-like, highfaluting, or overly formal.
• Additional speech qualities include fluency (command of language, stuttering, word-finding difficulties, paraphasic errors.)
• Also amount is normal, increased, or decreased.

Attitude Toward the Interviewer

• Can be cooperative, hostile, evasive, dismissive, overly familiar, or condescending.

Mood and Affect

• Mood is the patient's internal, sustained emotional state, best described in their own words (euthymic, elevated, depressed, anxious, labile).
• Affect is the patient's emotional expression as perceived by the clinician (quantity, intensity, and congruence with mood.)
• Affect is rated as full (100%), constricted, blunted, or flat.

Thought Process

• Examines the flow of thoughts, reflected through speech and manner of answering,
• Assesses how thoughts are formulated, organized, and expressed.
• A normal thought process is linear, organized, and goal-directed.

Common Findings in Thought Process

• Circumspect: Answers are partially connected to the question, common in mania and hyperactivity.
• Tangential: Answers are totally disconnected from the question, common in psychosis.
• Flight of ideas: Many connected ideas occur rapidly, common in mania and hyperactivity.
• Looseness of associations: Ideas are no longer connected logically.
• Thought blocking: An otherwise cooperative patient doesn't answer or stops mid-conversation, common in trauma.
• Other qualities: Preservation, neologisms (new, nonsensical words, common in aphasia or schizophrenia), and word salad (incomprehensible speech, with severe loosening of associations.)

Thought Content

• Focuses on the patient's thoughts and beliefs like delusions, preoccupations, obsessions, and ideations.

Delusions

• Fixed, false beliefs not amenable to logical explanation, either bizarre (impossible) or non-bizarre (possible but untrue).
• They should be elicited through conversation.

Types of Non-Bizarre Delusions

• Erotomanic: Convinced that someone, usually a celebrity, is in love with them.
• Persecutory: Believing someone is plotting to harm them.
• Referential: Believing everything is about them.
• Grandiose: Believing they have superpowers.

Preoccupations

• Predominant themes like religion, sex, family, safety, or health.

Obsessions

• Repetitive, intrusive thoughts, often with unreasonable or taboo content.
• May or may not be coupled with compulsions.

Ideations

• Themes of plans with detrimental effects, like suicide, homicide, escape, assault, or revenge.
• Suicide inquiry should include presence of a plan, motivation, intensity, perceived control, and feelings about recent attempts.

Perceptual Disturbances: Hallucinations

• False perceptual experiences arising without stimuli.
• Details noted include sensory modality (auditory is common in psychiatric disorders; visual in organic brain disorders, tactile in substance abuse), and content (command, commentary, derogatory.)
• Note the patient's reaction like ignoring, conversing, or becoming anxious.
• Differentiate hallucinations from "voices in the mind."
• Hallucinatory gestures are actions that indirectly point to hallucinations such as talking alone.

Sensorium

• Refers to the wakefulness of the patient (awake, drowsy...).

Cognition

• Refers to the mental processes screened through orientation, memory, and concentration.

Orientation

• Assesses awareness of current time, place, and person.

Memory

• Includes immediate, recent, and remote recall.

Concentration

• Usually screened using serial 7's or alternative methods for those with lower education.

Other High Cognitive Skills

• Assess judgment and abstract thinking through situations or common proverbs.

Insight

• Refers to the patient's awareness of having a mental disorder and needing help.
• Levels range from total denial (Level 1) to true emotional insight.

Additional Cognitive Examinations

• Such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) have cutoff scores indicating cognitive problems.
• The MMSE screens for cognitive problems like dementia
• It does NOT summarize the mental state examination (MSE)

Live Demo of the MSE: Interviewer Conduct

• Conducted systematically using language adapted to the patient's comfort.
• Maintained a neutral tone, objectivity, and respect for the patient's decisions.

Reporting of Findings in Demo

• Noted patient's well-kempt appearance, inconsistent eye contact, hyperproductive speech, restlessness.
• Observed to be overly familiar but cooperative and with an expansive mood and full affect.
• Demonstrated circumstantial speech with grandiose tendencies, but denied self-harm.
• Noted to be preoccupied.
• Revealed impaired immediate memory, abstract thinking, and judgment.
• Displayed little to no insight into their condition.