The mental status examination (MSE) begins when we first encounter and observe a patient. How the patient interacts with us and the environment may reveal underlying psychiatric disturbances or clues signifying the patient’s emotional and mental state.
“The psychiatric interview begins with observation, but the interviewer needs to recall that first impressions work both ways. At the same time that the clinician is silently creating and discarding potential diagnoses, the patient is likely formulating questions of her own. Does the interviewer seem pleasant? Respectful? Trustworthy? Knowledgeable? It would be difficult to overstate the importance of nonverbal communication to the psychiatric interview.”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
The MSE has multiple components, which we will discuss further below:
- Appearance, behavior, and motor activity
- Speech
- Mood and affect
- Thought process and thought content
- Perceptual disturbances
- Cognition
- Insight and judgment
Appearance, behavior, and motor activity
“Regarding general appearance and behavior, the interviewer notes the patient’s level of consciousness, behavior, dress, grooming, and attitude toward the examiner. A well-considered assessment of appearance can, therefore, contribute heavily to the development of a differential diagnosis. For example, a disheveled, distracted, hypoactive elderly hospitalized patient presents a differential diagnosis that centers on delirium even before the interviewer or patient says a word. Level of cooperation can contribute directly to an understanding of the patient and inform aspects of the interview that require motivation (e.g., the history, cognitive testing).”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
- Dress
- Grooming
- Eye contact (e.g., good, fleeting, sporadic, evasive, avoidant, none)
- Cooperation
- Approachability
- Mannerisms
- Posture
- Movement/gait
- Facial expressions
- Restlessness (i.e., akathisia)
- Psychomotor agitation (excessive motor activity may include pacing, wringing of hands, inability to sit still, etc.)
- Bradykinesia (generalized slowing of physical and emotional reactions)
- Tics/tremors
- Disheveled appearance may suggest schizophrenia
- Provocative dress may suggest bipolar disorder
- Unkempt appearance may suggest depression or psychosis
- Poor eye contact may occur with psychotic disorders
- Paranoid, psychotic patients may be guarded
- Irritability may occur in patients with anxiety
- Abnormal motor activity occurs in parkinsonism, schizophrenia, severe major depressive disorder, PTSD, anxiety, drug overdose or withdrawal, medication side effects (e.g., antipsychotics), etc.
- Tendency toward exaggerated movements occurs in the manic phase of bipolar disorder and with anxiety
Speech
“Speech patterns are a window into the patient’s thought process. For example, rate, volume, and organization of speech should be observed throughout the interview. Pressured, tangential speech is often found in mania. Slow speech with impoverished content is often found in depression, schizophrenia, and delirium. Guarded, withholding speech can accompany paranoia… Based on patterns of communication, diagnoses can often be tentatively made within moments of meeting a patient.”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
- Quantity
- Rate
- Volume
- Fluency/rhythm
- Coherence
Abnormal speech patterns occur in a number of conditions: schizophrenia; substance abuse; depression; bipolar disorder; anxiety; medical conditions affecting speech, such as cerebrovascular accident, Bell palsy, poorly fitting dentures, laryngeal disorders, multiple sclerosis, amyotrophic lateral sclerosis, etc.
Mood and affect
“Mood refers to the patient’s predominant emotional state during the interview, whereas affect is the expression of those feelings. The interviewer infers mood from the patient’s posture and appearance as well as the patient’s own account of his or her mood. Affect is described in multiple ways, including range (e.g., labile or constricted), appropriateness to the situation, congruency with the thought content, and intensity (e.g., blunted).”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
- Intensity
- Congruency with thought content
Thought process and thought content
“The evaluation of thought content focuses on unusual, preoccupying, or dangerous ideas. Delusions are common in psychosis, for example, whereas ruminations of guilt are common in depression. Both delusions and ruminations can be “fixed and false,” but the two symptoms are associated with different diagnoses and treatments. Suicidality and homicidality are integral to the evaluation of thought content. For both, the interviewer assesses for ideation, intent, and plan, as well as access to weapons. Interviewers will sometimes shy away from such exploration, perhaps fearing that introduction of the topic will cause the patient to become offended or impulsive or that the mere presence of suicidal or homicidal ideation will inevitably lead to psychiatric admission. Such concerns are generally unwarranted. Passive suicidal and homicidal thoughts are common, and discussion can often lead to a deepening of the alliance.”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
- Process: form/flow of thought, logic, coherence
- Content: delusions, ruminations, obsessions, SI/HI
- A delusion is a fixed false belief that cannot be corrected by reasoning, persuasion, or logical argument
Abnormalities in thought process and/or thought content occur in a number of conditions:
- Process: anxiety, depression, schizophrenia, dementia, delirium, substance use disorders, etc.
- Content: obsessions, phobias, delusions (e.g., schizophrenia, alcohol or drug intoxication), suicidal or homicidal thoughts
Perceptual disturbances
Perceptions refer to any perceptual abnormalities, including hallucinations, illusions, derealization, and depersonalization.
“Hallucinations have the clarity and impact of true perceptions but without the pertinent sensory input. For example, a person who “hears voices” is hearing a voice coming from outside her head that generally consists of meaningful sentences or phrases. Hallucinations that occur just prior to falling sleep and just prior to waking are termed hypnagogic and hypnopompic, respectively, and are considered normal. Talking to oneself is not considered an auditory hallucination (even if so labeled by the patient), nor is misinterpretation of actual voices from the hallway (those are often misperceptions and/or reflections of paranoia). Auditory hallucinations have long been associated with schizophrenia, but they are also present in psychoses related to mania, depression, delirium, substance abuse, and dementia. Hallucinations can occur in any of the five senses, although nonauditory hallucinations tend to be symptoms of neuropsychiatric and/or systemic medical disease.”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
- Hallucinations (any of all 5 senses)
- Responsiveness to internal stimuli
- Illusions (misperceptions of actual sensory inputs; e.g., a delirious patient might misinterpret the shadows on a television screen as crawling bugs)
- Depersonalization (a sense of being detached from one’s own thoughts, body, or actions)
- Derealization (a sense of being detached from one’s own surroundings)
Perceptual disturbances occur in a range of conditions: schizophrenia, severe unipolar depression, bipolar disorder, dementia, delirium, acute intoxication and withdrawal, etc.
Cognition
“Assessment of cognition can be an uncomfortable part of the MSE… Straightforward is good. Explain that a cognitive assessment is part of the interview, ask a few questions, do a Montreal Cognitive Assessment and/or a clock drawing test, and make the preliminary assessment. For patients with no risk factors or signs of cognitive decline, a cognitive screen can be done quickly, and experience with normal cognitive examinations is helpful when faced with abnormal examinations. For patients with apparent neuropsychiatric dysfunction, a working knowledge of typical symptom clusters and disorders can help make sense of the functional decline.”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
- Level/stability of consciousness
- Orientation
- Attention (the ability to sustain interest in a stimulus)
- Concentration (the ability to maintain mental effort)
- Memory
Insight and judgment
“Insight and judgment are often linked within the MSE because both are part of interrelated skills and behaviors that include such executive functions as reasoning, impulsivity, initiation, organization, and self-monitoring. Various types of executive dysfunction underlie or accompany most psychiatric disorders. Insight refers to how well the patient understands his or her own current psychiatric situation; it does not refer to insightful perspectives on politics, sports, or the interviewer. Judgment is often extrapolated from recent behavior or assessed by asking such questions as “If you were in a movie theater and smelled smoke, what would you do?” The assessments of insight and judgment depend heavily on context, and the structured calm of the interview setting can lead many patients to appear healthier than their recent history might suggest.”
Barnhill JW. The Psychiatric Interview and Mental Status Examination. In: Roberts et al. The American Psychiatric Association Publishing Textbook of Psychiatry. 7th ed. 2019
- Awareness and understanding of situation/illness
- Recognition of consequences of action
Blog post based on Med-Peds Forum talk by Matt Lorenz, MP Core Faculty