Mental status examination

Mental status examination, or MSE, is a medical process where a clinician working in the field of mental health (usually a psychotherapist, social worker, psychiatrist, psychiatric nurse or psychologist) systematically examines a patient's mind. Each area of function is considered separately under categories in a way similar to a physical examination performed by physicians. However, much of the material for the MSE is gathered during psychiatric history taking. The result of this examination is combined with the psychiatric history to produce a "psychiatric formulation" of the person being examined.

Neurologist, emergency physicians, and other physicians perform mental status examinations from different perspectives. In general, the neurological exam seeks evidence of localizable brain anomaly; the emergency physician may wish to quickly discover the effects of head trauma or intoxication (poisoning).

Main categories
These vary around the world but there is broad commonality. Some schemes look at ego psychology and defence mechanisms while others are less broad.

Appearance
This category covers the physical aspects of the person. This includes his/her physical appearance such as age, height and weight, how he/she is dressed and groomed, and the dominant attitude presented in the interview. Some include factors like the degree of poise or comfort in the interview, and the degree of anxiety and how it is expressed in this category.

Behaviour
This looks at the way the person moves and the positions in which he/she holds his/her body. Abnormal movements such as tics or chorea as well the degree of movement is noted.

Speech
It is customary to separate speech from thought in the MSE, although this is rather artificial. In general, aspects of the speech that will not be part of the section on thought are covered here. This includes the volume, rate and flow of speech itself as distinct from thought. Mannerisms, accent, stress or lack of it, hesitations, and stuttering are all covered here. Descriptions might use words like: garrulous, monotonous, laboured, loud, or emotional.

Mood and affect
Affect is the outward show of emotions and mood is the general pervasive emotional state as reported by the patient. A person's affect may vary through depression, elation, anger and normality but if the overall sense from examination is of depression then that is used to describe the mood. The range of the affect describes whether the person shows a full or even expanded range or if his/her affect is blunted or restricted. Cultural considerations are important in this and many other aspects of the MSE. Appropriateness of the affect is also important. Is the emotion shown consistent with the topic being discussed? A patient with an inappropriate affect may cry talking about a parking ticket and show little or no emotion when discussing the recent death of a loved one.

Thought
This is divided into form, the way a person thinks, and content, what he/she thinks.

Process/Form
This looks at features like the rate of thoughts and how they flow and are connected. Formal thought disorder comprises processes such as pressure of thought (excessively rapid), flight of ideas, thought block, disconnected thoughts (loosening of association and derailment and Knight's move), tangentiality and circumstantial thoughts (over inclusive and slow to get to the point).

Content
Thought content includes those things discussed in the interview and the beliefs a person has. He/she may have thoughts that preoccupy him/her such as ideas of reference, obsessions, ruminations or phobias. He/She may have overvalued ideas, first rank symptoms (delusions of control, thought alienation comprising of thought insertion, withdrawal and broadcast, delusional perception, somatic passivity)  or delusions (paranoid, persecutory, religious, erotomania i.e. delusion of love, grandiose, reference, somatic - concerns about physical symptoms). Other types of delusions such as nihilistic delusions, bizarre delusions , morbid jealousy should also be explored. A depressed person may have a delusion of hopelessness, helplessness and worthlessness. These should be taken into account.

Perceptions
This covers the area of the senses and describes any distortions such as illusions, delusions or hallucinations. The nature of the experience is described in detail. Auditory hallucinations are common in schizophrenia while visual disturbances are more common in organic problems. In addition, there are gustatory, olfactory, tactile, somatic and kinaesthetic hallucinations, the account of which should be taken. Some of the Schneiderian first rank symptoms are also hallucinatory in nature such as thought echo, gedankenlautwerden, thought insertion, thought withdrawal and somatic passivity. Depersonalization, where the person feels unreal, and derealization, where the person feels his/her surroundings are unreal, are also described here.

It is also important to ascertain whether hallucinations are in second person or third person and if in second person whether they command the subject to do anything especially suicidal or homicidal acts. Hallucinations can be in the form of a running commentary, whether in second person or third person. Hallucinations may be of a female voice or a male voice and may be known to the person or a totally unknown voice.

Sometimes hallucinations are not in the form of well-formed voices or objects, and the subject might hear bells ringing or knocking at the door or a banging sound in his ears or see vague things like halos or colours which are difficult to describe. These are termed as elementary hallucinations.

Another category of hallucinations is extracampine hallucinations in which the person does see things or hear voices outside his sensory field like hearing voice of a friend sitting 5 miles away or seeing things behind the head or inside the body.

It is worthy to ask whether about functional and reflex hallucinations. It should be acknowledged how a person copes with these hallucinations and whether they are pleasant, unpleasant or terrifying for him.

It is also important to explore and comment on hallucinatory behaviour for example if the person is looking back again and again or gesturing or self talking.

Sometimes a person may see very small people around him, a phenomenon called Lilliputian hallucinations or a trail of objects moving around termed as Palinopsia.

Cognition
This looks at a number of areas such as the level of abstract thought (which declines or is absent in a number of conditions such as dementia and schizophrenia), the level of general education and intelligence, and the degree of concentration which is often tested by digit span recall or an ability to serially subtract seven starting at 100. Folstein's mini mental state examination is often used to more formally assess cognition.

Consciousness
The level of conscious state is assessed whether it is steady or fluctuating, clouded or clear.

Orientation
This frequently looks at whether the person knows the time (including the date), place (where he/she are), person (who he/she is), and situation (that he/she is in).

Memory
Memory is tested by looking for immediate recall, short-term memory (an ability to remember several things after five minutes) and long-term memory (an ability to remember distant events such as the years of World War II).

Judgment
This looks at how the person makes judgments about events. Is it logical or idiosyncratic? Is it reasoned?

Insight
This describes how much understanding or awareness the person has of his/her own psychological functioning or disturbance.

Controversy
The article so far has described how a clinician usually goes about the task of performing a MSE. There is controversy both within the profession about this and also controversy from without.

Within the profession
There are many gaps in the traditional MSE that have been pointed out. The areas of impulse control, ego psychology and defence mechanisms are among them. Cultural concerns and knowledge of the facts can skew the assessment. A clinician who does not know that the person he/she is examining is who he/she claims to be may interpret information given as a delusion. The examination is inherently flawed because it relies on the clinician's inferences about what he/she observes. Any individual's observations and inferences, including those of the clinician, are based upon one's cultural background, education, expectations, belief system, etc. One attempt to reduce the impact of these inherent distortions is to use so-called "objective" testing of personality such as the MMPI or "projective" techniques such as the Rorschach inkblot test. These methods, however, have their own issues with reliability, validity, cultural influences, and possible conscious or unconscious distortion. Integration and/or comparison of clinical observations, such those in an MSE, with objective and projective test data may provide the clinician with an improved basis for clinical inferences about a patient.

Outside the profession
The MSE is one of the more subjective parts of the work of psychiatrists and psychologists. It thus attracts significant criticism from antipsychiatry and related groups.

Resources and documentation

 * MSE Rapid Record Form