Tips for performing a good Mental Status Examination
Mental status examination is an important skill to be learnt by a resident and is akin to physical examination in medicine. MSE includes cognitive functions, intelligence, thought, mood, perception, insight and judgement. Though examination of patient is an objective phenomena, symptoms are mind are mostly subjective experiences, hence it is difficult to differentiate between signs and symptoms MSE. Secondly, the identification and categorization of mental symptoms depends on the discipline of descriptive psychopathology, or phenomenology. Phenomenology is referred to the method of evaluating patients experience embracing a broader individualized and subjective experience, with less categorical approach to mental assessment. Psychopathology tends to follow the introduction of operationalized diagnostic techniques, where the interview tends to address the criteria and objectively categorizes the patient’s symptoms.
When we present a case we divide the information into history and MSE. However both history and MSE are not mutually exclusive and occur simultaneously during the interview process. Present Status Examination takes one month duration from the day of interview while a routine MSE for case presentation is of past one week duration.
As with the history, categorizing and recording mental state has a fairly standard structure, covering the domains of appearance and behavior, speech, mood and affect, thought content and perception, concluding with cognition and insight. The exact ordering of these is, however, determined largely by convention.
General Appearance and Behavior
The MSE process starts right from the time the patient walks into the room and even before the interview has actually begun. General appearance and behavior should include the observation of the patient during the process of interview and ward behaviors if the patient is hospitalized. It refers not only to matters of dress and grooming, but would cover physical characteristics worthy of note, such as posture, build, age appropriateness of appearance.
Whether the patient is well kempt or poorly kempt. This depends on whether that patient has dressed and groomed appropriate to his or her age and maintains cleanliness. If a patient follows the fashion of some identifiable subculture, example tribal background, it is appropriate to record this, even though it is not in itself indicative of clinical abnormality.
- Poorly kempt –when not bathed and hair not combed, wearing unkempt clothes
- Excessively loud clothes or overdressing, like excessive makeup, excessive use of ornaments.
It is traditional to comment on patients’ eye contact, whether the patient makes eye contact with the examiner and whether the eye contact is sustained.
- Ill sustaining eye contact is usually seen in patients with inattention in children with ADHD, distractibility seen in patients with mania,
- While avoidance of eye contact, hyper vigilance can be seen in patients with anxiety or psychosis, when the patient is hostile.
A useful additional consideration is the patient’s manner towards the interviewer:
- What was the patients approach to the examiner?
- Were they cooperative, forthcoming, engaged?
- Did they observe the politeness and social behavior being appropriate?
- Did the patient greet the doctor while entering or leaving the interview room?
Rapport is an important element in the engagement of patient. Establishing rapport is an important step towards successful evaluation of phenomenology of the patients.
- Rapport is established when: during the course of interview if the patient is able to respond to most questions in an expected and appropriate way, is willing to discuss about his personal information
- In case the patient is uncooperative and unwilling to talk to the examiner, rapport is not established.
- Kirby’s examination method should be used for the assessment of MSE if the patient is uncooperative.
- There should be continuous effort from the examiner to establish rapport on subsequent interview and subsequent interactions
Behavior during the interview:
The major abnormalities of movement and behavior are those associated with schizophrenia and affective disorder.
Acutely psychotic patients may act in response to delusions (searching for knives in cupboards, etc.), respond to abnormal perceptions (‘behaving as if hallucinated’), or display inappropriate social behavior (e.g. make sexual advances). They may be readily distractible by incidental noises, or suspicious or bewildered and unforthcoming.
Any automatic motor behaviors should be noted, such as restlessness, fidgetiness and nervousness, as well as involuntary movements such as dyskinesia should be described and documented. Any loss of expected motor activity in relation to, for example, facial expression, expressive posture and gesture, can be recorded here or above, as noted.
Stereotypies: purposeless motor acts which are carried out repetitively and with a high degree of uniformity, e.g. rocking, rubbing hands and tapping objects,
Mannerisms: goal directed acts like dressing or grooming which are executed in idiosyncratic ways or when they are repetitive, e.g. keeping one arm tucked under armpit or repeatedly touching nose.
Catatonia is characterized primarily by disturbance in volition and psychomotor disturbances. Catatonia can be seen in organic, psychotic, neurotic conditions. Various manifestations of catatonia include
- Negativism: patients do the reverse of whatever is asked of them; e.g. hold their breath when asked to breathe deeply, resist attempts to get them to stand up, then refuse to lie down. Gegenhalten (opposition): ‘springy’ resistance to passive movement which increases with the force exerted
- Positivism: includes echopraxia; mitgehen and mitmachen (passive movement over complied with, limbs elevate themselves at the slightest touch like an angle poise lamp); and automatic obedience. In the above state the patient offers excessive cooperation, which can be seen in schizophrenia.
- Catatonic stupor: the patient sits or lies motionless, mute, often in a contorted posture; Waxy flexibility and gegenhalten may be evident. Although unresponsive, the patient is aware of his surroundings.
- Catatonic excitement: aimless over activity, destructiveness and violence, often associated with manneristic and stereotyped actions
- Catatonic impulsiveness: sudden, incomprehensible and often violent acts for which the patient is unable to give any more than a facile explanation. May interrupt stupor with catatonic impulsive behavior.
- Catatonic speech disorders; Mutism: it is the total inability to speak, usually the patient appears to make no attempt to speak or make sounds.
- Catatonia patients should be given clear instructions before examining
Any goal directed activity in the recent past and during the course of interview evaluated in psychomotor activity of the patient.
- It is described as either increased or decreased psychomotor activity, depending on the observation.
- Psychomotor activity will be judged while including the speech output and overall movement of the patient.
- It is usually increased in affective disorders like mania and reduced in patients with endogenous or retarded depression.
Speech: Speech consists of words, which articulate vocal sounds that symbolize and communicate ideas. During the interview, the patient’s speech is evaluated for tempo, volume and prosody of speech.
Tempo is the speed of speech which is determined by the individuals thinking process. It can be either increased or decreased depending on the thinking process, usually seen in mood disorders.
Volume is evaluated looking at the Speech output. If it is less than 10 – 15 words per minute is said to be low or reduced and is reduced in retarded depression. Spontaneous speech output of more than 150 words per minutes is said to be pressure of speech, which is usually seen in patients in mania with flight of ideas.
Prosody of the speech is the intonations used while speaking. It can be reduced in patients with schizophrenia. Tone of speech reflects the intensity of sound, which is reduced in depressive patients.
Thought is a subjective process and the primary means open to us to make inferences regarding its form is via speech. As a result, the separation demanded by the traditional MSE into ‘speech’ and ‘thought’ is somewhat artificial.
Form of thought:
Form of thought is the structure and organization of thinking. It is assessed during the interview process and by recording verbatim the patient’s speech sample. Various definitions of normal thinking and disorders of thinking have been described, details of which will be discussed subsequent topics. Important clinical considerations before judging the form of thought includes
- Language of patient- the examiner should be aware of the primary language that the patient speaks
- Intelligence – patients intellectual level has significant impact on his thinking process, hence patients intelligence should be evaluated during history and examination
- Comprehension – Patient’s comprehension of the questions or tasks should be evaluated, as patients with sensory aphasia presents with irrelevant speech
- Attention – Attention towards the questions asked and continuity in thinking is essential for maintaining the flow in the thought. In patients with delirium or mania due to distractibility, irrelevant speech can be present.
Speech Sample from the patient verbatim is essential for evaluation of form and stream of thought.
- Topics given for collecting the speech sample should be neutral to the psychopathology and should be able to elicit abstract concepts.
- Examples include – festivals, current politics, population of our country etc. speech sample is essential when there is incoherent or irrelevant speech during the interview.
- In the thought sample, we need to look at the goal directedness, semantics and the syntax.
- Presence of perseveration of ideas and absence of abstract concepts related to the topic needs to be considered.
If there is impairment in the structure of thinking in the form of loss of goal directedness due to any of the following causes like derailment or tangentiality, presence of neologisms, incoherence, poverty of content, absence of abstract meaning can be judge as presence formal thought disorder.
Stream of thought:
Stream of thinking is related to the flow of thought process which is the determining tendency of thinking. This is significantly influenced by the emotional state of the individual.
In patients with mania or hypomania, there is increase in the flow of thinking which results in excessive thinking.
Flight of ideas – When the flow is significantly increased like in mania, there is loss of direction in thinking resulting in irrelevant and incoherent speech. It is usually associated with pressure of speech and distractibility. There can be chance association between the thoughts and is usually related to internal and external cues.
Prolixity: When there is increase speech, but the individual reaches goal, then it is called as prolixity, which is usually seen in hypomania. In prolixity the person has increase speech output associated with lively embellishment and is able to reach the goal.
Circumstantiality: here the thinking proceeds slowly with many unnecessary trivial details with tedious elaboration but finally the point or goal is reached.
Retardation of thinking: here the train of thought is slow down and the number of ideas and images which present themselves are decreased.
- It is seen in usually seen in patients with retarded depression.
- In these patients there is minimal responses to questions and it is associated with psychomotor retardation.
Thought block is the sudden arrest of train of thought, leaving a blank and the some patients may become acutely aware of the same. It is usually seen in patients with schizophrenia.
Perseveration is the persistence of the mental operations beyond the point of relevance and thus prevent progressive thinking. It can be of three types – compulsive, inability to switch and ideational perseveration. It can be either verbal or ideational. It is usually seen in organic disorders of brain like dementia – frontotemporal dementia and in chronic schizophrenia.
Normally the subject experiences his thinking as being his own although this sense of personal possession is never in the foreground of his consciousness. There is also a feeling of control over his thinking. It can be affected when there is loss of sense of control over this thinking.
Thought alienation phenomenon is present when the individual feels that he has lost control over his thinking and an outside agency is trying to control or participating in his thinking. Commonest symptom experienced by the patient include thought broadcast. In thought broadcast, the patient knows that as he is thinking everyone else is thinking in unison with him. Patient reports that others are getting to know what he is thinking simultaneously as he is thinking and some time he feels this thoughts are getting diffused from his mind. Thought insertion is said to occur when the patient thinks that thoughts are being inserted in to his mind against his will and he recognizes it to be foreign and coming from without. In thought deprivation the patient finds that as he is thinking his thought suddenly disappear and he is acutely aware of the same.
Evaluation of content of thought is necessary to understand the patients concerns and ideas. Disorders of content relate to the ‘what’, as opposed to the ‘how’, of thinking – to the ideas and beliefs one holds. It is also appropriate to record here any abnormal ideas and beliefs the prototypical abnormality being delusions, others include overvalued ideas, obsession and compulsions, depressive ideas about future, self and environment, ideas of reference. All patients attending a psychiatrist should be evaluated for suicidality.
Delusions: It can be defined as false, unshakable beliefs, out of keeping with the individual’s educational, social and cultural background, which are held with utter conviction and are arising out of morbid thinking (illogical or unreasonable thinking).
While describing any delusions, initially patients report of his belief should be recorded verbatim, followed by making a judgement on the below aspects of the delusion.
- Falsely held with high degree of conviction
- Beliefs are not amenable for logical reasoning
- Belief is not held by the family and not considered normal by the society where patient belongs
- Primary or secondary delusion. Secondary delusions are usually secondary to other morbid phenomenon like disturbed mood state or perceptual abnormalities or personality disorders
- Content of belief may be of persecutory, referential, jealousy, love, grandiose, ill health, guilt, nihilistic delusion or delusions of poverty
- Single or multiple beliefs. If there are multiple beliefs then are they logically built or connected, which is called systematization
- Bizarre delusions – Beliefs which are implausible and completely impossible
- Elaboration of the belief with acting out behavior and disturbed affect
- Whether the beliefs are congruent to the underlying mood state or not
Primary delusions were distinguished from ‘secondary’ delusions, where the abnormal belief seems to be based on, grow understandably out of or represent an elaboration of some other element of psychopathology – as in depressed patients who develop beliefs that they have sinned greatly, lost everything, died already, etc. – though this term is less often used nowadays. Where a delusion seems obviously secondary to another psychotic symptom – e.g. a patient with auditory hallucinations who believes he or she has a radio transmitter in their head – the term delusional explanation or secondary delusion is preferred.
Delusions of reference must be distinguished from simple ideas of reference, which are an exaggerated form of self-consciousness, usually driven by social anxiety, comprising an uncomfortable feeling taking notice of them. Almost everyone has experienced this symptom at some time (e.g. on entering a room and noticing that conversation seems to stop) though insight into the lack of reality is retained. Simple ideas of reference can, however, become pervasive and socially incapacitating in some conditions, such as anxiety and depressive states.
Obsessional thoughts and compulsions: ‘an obsession occurs when someone cannot get rid of a content of consciousness, although when it occurs he realizes it is senseless or at least what it is dominating and persisting without cause’ as per Schneider. Obsessions have three characteristics:
- They are recognized by the patient as their own thoughts and are considered ‘non alien’
- Their content is acknowledged as absurd or irrational and there is an attempt to resist them, but at time obsessions may lack insight
- Obsessions are typically repetitive, intrusive and leads to significant anxiety and distress.
- Compulsions are repetitive behaviors in response to obsessions
- Obsessions can be an idea, doubts, images, impulses with varying themes. Most common themes of obsessions include contamination, doubts, aggressive, sexual and others.
Overvalued ideas are beliefs which, because of the excess of emotional tone invested in them, come to dominate to an abnormal degree. They do not have obsessional characteristics (i.e. they are not recognized as absurd or resisted) but rather are qualitatively akin to ‘preoccupations’ that any of us can, from time to time, develop. Examples include querulous paranoid states, morbid jealousy and hypochondriasis. Another example of an overvalued idea, which also illustrates Jasper’s argument that not all fixed, incorrigible beliefs are delusions, is the core belief of anorexia nervosa.
Mental status assessment is incomplete without evaluating the suicidality in all patients with mental illness. While assessing suicidal ideas and behavior, it is necessary to be sensitive and ask appropriate questions to elicit risk of suicidality. Presence of thoughts of helplessness, worthlessness and hopelessness may be the beginning of suicidal behavior. The flow chart below describes how hopelessness and wish to die progresses to suicidal attempt.
Assessment of mood is the one of important part of mental status examination and the difficult one too. ‘Affect’ refers to that short-term component of emotionality which is responsive to circumstance and environment, and comprises a multitude of generally short-lasting feeling states, such as fear, anxiety, contentment, anger, jealousy, etc. (i.e. emotional ‘waves’). ‘Mood ’ on the other hand, refers to one’s longer-term emotional predisposition.
Subjective mood state should be explored and described in the history but it is important to summarize the key findings at this point in the MSE.
- Patient’s impression of severity of mood disturbance described by the presence of persistence and pervasiveness
- Presence of quality of mood change which may be described as lack of vitality and presence of diurnal fluctuations in mood Patients describe their mood as a peculiarly painful quality.
- Presence of anhedonia (inability to experience pleasure)
- Reactivity – presence or absence of reactivity (the patient can temporarily cheer up in the right circumstances).
The objective expression of mood should also be noted and can be considered along two axes breadth and depth.
- ‘Breadth’ affect refers to the variability of emotion exhibited within the interview seen in facial expression, interactive posture, gesture, intonation, flow of speech, etc. Assessment is on the basis of observation.
- ‘Depth’, on the other hand, is the one point in the MSE where empathy must be used to gauge the impact of the patient’s presentation. The classic objectively observed affective abnormality in schizophrenia is flattening of affect in which both the range and depth of emotion are restricted with loss of subtlety and nuance in moment to moment emotional interaction.
- Because of such variability and context, assessment of ‘flattening’ should never be a ‘spot’ diagnosis but should come from observation of the patient’s interaction throughout the interview.
- Blunting of affect refers to coarsening of emotions and an insensitivity to social context – what Kraepelin referred to as a ‘loss of the delicacy of emotion’
- Flattening of affect is complete absence of emotional responses
- Inappropriate or incongruous affect is the appearance of sudden emotional states which are out of keeping with events or the thought process.
- In mania, mood is characteristically one of increased vitality, gaiety and pleasure, with an infectious quality, rather than simple happiness.
- Alternatively (and perhaps increasingly) irritability and excessive response to frustration may predominate.
- Euphoria – a heightened sense of happiness – is distinct from the typical mood change.
- Ecstasy is a state of intense tranquil euphoria which usually has a religious coloring, often attracting descriptions like ‘exalted’ and ‘transfigured’ Patients may become so absorbed in their inner state as to be unresponsive to the external world, and objectively appear to be in a state of so called euphoric (or manic) stupor .
- Facile euphoria is said to be characteristic of the frontal lobe syndrome and Korsakoff’s syndrome.
- Perplexity is seen par excellence in puerperal psychosis, but can be present in any acute psychotic state, including organic ones. It is characterized by fearful affect with confusion, also called as bewildered affect.
Other qualities of mood include
- Lability of mood , where the emotional state shifts from cheerfulness to tears to irritability and back again over brief periods is common in mania, may be found in dementias or other organic states and is also a rare symptom of acute schizophrenia.
- The so called omega sign , in which the inner third of the eyebrows are depressed, the outer third elevated and vertical ridging is evident over the glabellar eminence, is said to be characteristic of major depression though is more likely to be a general expression of extreme worry.
Range of mood is described as the entire range from being sad to happy to anger to fear.
- Patient may have restricted range in mood disorders, example in patients with depression, mood is predominantly restricted to depressed side, while in mania it is in the euphoric or elated state
- Range of mood can be constricted in patients with schizophrenia with blunting or flat affect.
The most important type of misperception in clinical practice is hallucinations, which are most simply defined as ‘percepts without objects’ (i.e. they represent perceptual deceptions). While hallucinatory experiences may occur in any sensory modality, in clinical practice hallucinations of hearing (auditory hallucinations) are the most frequent and important. While describing a hallucination some of the following aspects should be considered
- Clear description of the sensory phenomenon, with respect to the modality (auditory, visual, tactile, olfactory, taste and somatosensory)
- Establishing absence of any source of stimulus or if there is source it needs to be described (functional hallucination)
- Describe the qualities of the sensory phenomenon with the content and clarity
- Whether the patient experiences these phenomenon in his mind (subjective space) or in the objective space outside his mind.
- Whether the patient is able to control this sensory phenomenon
- Changes in the patients beliefs secondary to the hallucinations
- Presence of acting out behavior and emotional response to the sensory phenomenon
They may be elementary (or rudimentary), comprising tapping, banging, music or preverbal whispers, mutterings and mumblings where individual words cannot be made out (but onto which the patient may still graft content). They may comprise a single voice heard only sporadically, through conversations involving several parties to thousands of voices babbling constantly (mass hallucinations). The voice(s) may be recognizable as family, friends, neighbors – even the patient’s own voice – or may be total strangers. They may arise from locations outside the normal perceptual sphere, e.g. ‘from America’ (extracampine hallucinations).
Visual hallucinations can be formless (shapeless images, lights, shadows) or formed objects (fiery crosses, faces, people). Visual hallucinations are perhaps most commonly described in delirium, where they may take all these forms. Visual hallucinations are less common in schizophrenia than auditory hallucinations, but the view that they are so uncommon that their presence should point to an organic disorder.
Somatic hallucinations can be classified on the basis of the specific sensation they replicate – e.g. haptic (touch, tickling, pricking) ; Thermic (heat and cold); hygric (wetness); kinaesthetic (movement and joint position). Like somatic hallucinations, olfactory and gustatory hallucinations may be simple or elaborated in delusional ways. While olfactory hallucinations are not an uncommon symptom of psychosis, their occurrence in organic brain disorders (especially temporal lobe epilepsy) must be borne in mind.
Pseudo hallucinations: Traditional phenomenology distinguishes between ‘true’ hallucinations and ‘pseudo hallucinations’ (where the perception is located to inner subjective space, ‘the mind’s eye’, or heard ‘inside the head’). These are sensory deceptions where the patient has sensory phenomenon similar to hallucinations, but occurring in the subjective space and lacks the veridicality as that of true percept or hallucination. It can be seen in patients with schizophrenia and mood disorders.
Insight is the awareness of the patient about his symptoms and the illness he is suffering. Usually it is evaluated by checking for
- Awareness: in to the symptoms and the illness the patient is suffering
- Attribution: what is the attributing cause for the symptoms or illness
- Acceptance: whether the patient is willing to take treatment
Insight can be graded from 1 to 6.
- Complete denial of illness
- Slight awareness of being sick and needing help, but denying it at the same time
- Awareness of being sick but blaming it on others, on external factors, or on organic factors
- Awareness that illness is caused by something unknown in the patient
- Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are caused by the patient’s own particular irrational feelings or disturbances without applying this knowledge to future experiences
- True emotional insight: emotional awareness of the motives and feelings within the patient and the important persons in his or her life, which can lead to basic changes in behavior
Judgement is a complex mental process whereby a person forms an opinion, makes a decision, or plans an action or response after first analyzing the issues and comparing with the acceptable social behavior. It reflects an individual’s higher thinking ability. Various aspects of judgement include
Personal Judgement: is assessed by asking the individual how to solve a situation or by asking his future plans.
Social Judgement: it is the behavior of the patients towards other people including family and the doctor during the interview.
Test Judgement: Here certain questions are asked to evaluate the patients reasoning.
Ex: what will the patient do when his house catches fire?
– Dr Girish Babu N
– Dr Rishikesh V Behere