The Mental Status Exam (MSE) Explained

• The Mental Status Exam (MSE) is a standard part of a psychiatric interview.
• It describes clinical observations of a patient's current emotional state and mental functioning, obtained through informal observation and formal questioning.
• MSE data aids diagnosis, treatment planning, and provides a baseline for future reference.
• Medical students should document a descriptive MSE in progress notes and initial evaluations.

Mental Status Exam Sections

• Appearance
• Behavior
• Mood
• Affect
• Speech
• Thought Process
• Thought Content
• Cognition
• Judgment
• Insight

Interview Setting

• Environment context is important, e.g., hospital room, time of day.

Appearance

• Capture appearance in a photo, behavior in a movie.
• Includes gender, apparent age, body type, clothing, grooming/hygiene, hair, facial hair, makeup, nails, ID markings, facial expression and eye contact.
• Grooming/Hygiene: Body odor, clean/soiled clothes, stains, torn clothing.
• Hair: Length, cleanliness, style, presence of lanugo.
• Facial Hair: presence of mustache, beard etc
• Facial Expression: Smiling, blank, scowling, blushing (consider context).
• Eye Contact: Staring, downcast, avoidant (changes during interview).

Diagnostic Considerations of Appearance

• Major depression: poor grooming, poor hygiene.
• Anorexia Nervosa: decreased body weight, baggy clothes, lanugo.
• Substance Use Disorder: poor grooming; IV drug use (needle marks); marijuana (conjunctival injection); alcohol (bruising).
• Mania/Histrionic: excessive makeup, jewelry, bright clothing.
• Trichotillomania: patchy hair loss.
• Dementia: poor grooming, food stains, body odor.

Behavior

• Describes psychomotor level and attitude toward interviewer.
• Psychomotor level: movements (agitation, tics), calmness, posture.
• Movements: Foot tapping, rocking, pacing.
• Involuntary Movements: Grimacing, tics, tremor, echopraxia.
• Posture: Relaxed, rigid, hunched.
• Attitude toward interviewer: cooperative, defensive, seductive, suspicious, frightened.
• Facial expression may or may not be related to attitude toward interviewer.
• Eye contact changes that may or may not be related to attitude toward interviewer.

Diagnostic Considerations of Behavior

• Major depression: Psychomotor retardation or agitation, withdrawn.
• Manic: Demanding, provocative, restless.
• OCD: Repetitive behavior.
• Generalized Anxiety: Fidgety, sweaty palms.
• Anti-Social Personality: Manipulative, demanding.
• Schizotypal Personality: Odd, eccentric.
• Schizophrenia: Disinterested, withdrawn.
• Psychotic: Scanning, responding to internal stimuli.
• Medication Side Effects: Tremor, Tardive Dyskinesia, Akathisia, Dystonia.

Mood

• Pervasive and sustained emotion coloring perception of the world.
• Types: Dysphoric (unpleasant), elevated (euphoria), euthymic (normal), expansive (lack of restraint), irritable.
• Mood is the emotional "climate". -Patient's own description of how they have been feeling recently
• Other descriptive terms: good/happy, sad/depressed, angry/hostile, anxious, alexithymia (inability to describe mood).

Affect

• Observable behaviors expressing a subjectively experienced feeling state or emotion.
• Emotional "weather" experienced during the interview
• Components: State (current emotional state), range (variance of state), appropriateness (to thought content), congruence (with stated mood).
• Range: Full, restricted/constricted, blunted, flat, labile (rapid shifts).
• Appropriateness: Tearful when upset; inappropriate (laughing at death).

Diagnostic Considerations of Mood & Affect

• Mania: Elevated/expansive mood, labile affect.
• Borderline Personality: Affective instability, intense anger.
• Delirium: Labile or blunted affect.
• Major depression: Restricted, constricted, or guarded affect.
• Schizophrenia: Blunted or flat affect.

Speech

• Qualities to describe: clarity, rate, quantity, tone, flow, volume, and other descriptive terms
• Clarity: Clear, slurred, coherent.
• Rate: Slow, rapid, pressured.
• Quantity: Talkative, minimal, mute.
• Tone: Monotonous, animated.
• Flow: Spontaneous, hesitations.
• Volume: Whispered, loud.
• Dysarthric: Slow and slurred speech.
• Pressured speech: Rapid, increased quantity, difficult to interrupt.
• Fluency: Ability to produce sentences of normal length and rhythm.
• Prosody: Reflection of emotion in speech.

Diagnostic Considerations of Speech

• Mania: Pressured or rapid speech.
• Anxiety disorder: Increased quantity, rapid speech.
• Depression: Decreased quantity, soft, monotone.
• Schizophrenia: Decreased quantity, monotone, non-spontaneous, increased latency.

Thought Process

• Describes associations between thoughts.
• Associations: Logical/sequential, circumstantial, tangential, flight-of-ideas, or looseness of associations.
• Logical and sequential/goal-directed: Clear linkage between ideas.
• Circumstantial: Over-inclusive details.
• Tangential: Does not address the point.
• Flight-of-ideas: Rapid speech with abrupt topic changes.
• Looseness of associations: Unclear connections between ideas. -Fragmentation: Disconnected phrases. -Word salad: Intact words, lost sentence structure. -Incoherence: Unintelligible words.
• Rate or Flow
• Describes the rate or flow of ideas.
• Racing thoughts: Fast thoughts that can't be articulated.
• Perseveration: Repetition of verbal responses.
• Thought blocking: Interruption of thought.
• Derailment: Speech stops and shifts topic.

Thought Process Assessment

• Thought process is usually not 100% one way the entire time; may document most prominent features.

Diagnostic Considerations of Thought Process

• Schizophrenia: Derailment, looseness of association, fragmentation, incoherence.
• Mania/hypomania: Racing thoughts, flight-of-ideas.
• Delirium: Any disorder in thought process.
• Dementia: Errors in word choice and grammar.

Thought Content

• Concerns what the patient is thinking about. -Suicidal ideation -Homicidal ideation -Delusions -Hallucinations -Obsessions & Compulsions -Feelings of derealization & depersonalization

Suicidal Ideation

• Thoughts of death, passive (wishes to be dead), or active (wants to die with/without a plan).

Homicidal Ideation

• Thoughts of harming another, active (wants to kill another with/without a plan).

Delusions

• False belief based on incorrect inference about external reality.
• Not an ordinary belief of the person's culture
• Types: Persecutory/paranoid, referential, grandiose, jealousy, erotomanic, somatic, bizarre.
• Persecutory/Paranoid- Central theme is that one is being attacked, harassed, cheated, persecuted, or conspired against.
• Referential- Events, objects, or other persons are seen as having a particular and unusual significance.
• Grandiose- Inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
• Delusion of control: Feelings, impulses, thoughts, or actions are experienced as being under the control of some external force
• Thought Withdrawal: Belief that other people are taking away one's thoughts
• Thought insertion: A delusion that certain of one's thoughts are not one's own but rather are inserted into one's mind
• Thought broadcasting- A delusion that one's thoughts are being broadcast out loud so that they can be perceived by others

Hallucinations

• False perceptions experienced in a clear sensorium.
• Types: Auditory (including command), hypnagogic (falling asleep), hypnopompic (waking up), visual, tactile (Formication), olfactory, gustatory.
• Illusions: Misinterpretation of real stimuli. Includes misperceptions of environmental stimuli
• Hallucinosis: Patient knows that what the patient sees or hears is not real; insight into one's hallucination

Obsessions and Compulsions

• Obsessions: Intrusive, inappropriate thoughts causing anxiety. Most common obsessions are about: contamination, self-doubt, orderliness, sexual imagery, aggressive/horrific impulses,
• Compulsions: Repetitive behaviors or mental acts to reduce anxiety. (hand washing, ordering, checking)
• The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation

Derealization and Depersonalization

• Derealization: Detachment from surroundings (unreal).
• Depersonalization: Detachment from mental processes or body (feeling like one is in a dream)
• Derealization and depersonalization typically occur together and may be different aspects of the same phenomenon.

Diagnostic Considerations of Thought Content

• Alcohol withdrawal: Hallucinosis.
• Cocaine intoxication: Formication delusion.
• Schizophrenia, Mood disorder with psychosis, Dementia, Delirium: Delusions, hallucinations.
• Delusional disorder: Delusions.
• Obsessive Compulsive Disorder: Obsessions and compulsions.
• Obsessive Compulsive Personality: Preoccupation with rules, order, organization such that the point of the activity is lost
• Post Traumatic Stress Disorder: Flashbacks, derealization, depersonalization.
• Paranoid Personality: Suspicion others want to harm.
• Schizotypal Personality: Odd beliefs, suspiciousness.

Cognition

• Assessed during interview or formally (Mini Mental Status Exam).
• Oriented x 4: person, place, time, situation (insight).
• Level of consciousness: -Sedated, groggy, or drowsiness -Clouding: impaired awareness of the environment -Stupor: Vigorous and repeated stimulation is required to rouse the patient -Somnolence/lethargy: Drowsy, inactive, respond in delayed or incomplete manner -Coma: Neither verbal nor motor responses can be elicited by noxious stimuli
• Concentration & Attention: Serial 7's or spell world backwards.
• Memory: Recent, remote, recall (3 words after 3-5 minutes).
• Abstract thinking: Proverbs, similarities & differences.
• General Fund of Knowledge: Name presidents, cities, etc.
• Folstein Mini-Mental State exam: scored out of 30
• Also assessment options: SLUMS and MOCA

Diagnostic Considerations of Cognition

• Delirium: Disorientation, poor concentration, serial MMSE testing.
• Dementia: Memory impairment, poor abstract thinking.
• Substance Intoxication: Decreased alertness, disoriented.
• Major Depression: Poor concentration, indecisive.
• Manic/Hypomanic: Distractible.
• Korsakoff syndrome: Anterograde amnesia.

Judgment

• Current/recent ability to assess a situation correctly and act appropriately within that situation; or current/recent ability to make and carry out plans that are consistent with reality.
• Assessed by patient's recent choices/decisions.
• Poor judgment: suicidal thoughts, psychosis, or other behaviors that are not consistent with reality

Insight

• Understanding of the true cause and meaning of a situation.
• Varies: Complete denial, blame on others, partial awareness, true/full insight (understanding and motivation to change).
• Judgment and Insight are often described as being: good/intact, fair/partial, or poor/impaired.
• Default for Judgment and Insight is that it is good or intact unless there is a reason to say the patient's Judgment and/or Insight is faulty or poor.

The Mental Status Exam (MSE) is a key part of a psychiatric evaluation. It assesses a patient's emotional state and mental function through observation and questioning. MSE data assists in diagnosis, treatment planning and is important for medical students.