Mental Status Exam (MSE)

The Mental Status Exam (MSE) is a systematic way of describing a patient's mental state at the time you were doing a psychiatric assessment.

Mnemonic

The mnemonic ASEPTIC can be used to remember the components of the Mental Status Examination.[1]

  • A - Appearance/Behaviour
  • S - Speech
  • E - Emotion (Mood and Affect)
  • P - Perception (Auditory/Visual Hallucinations)
  • T - Thought Content (Suicidal/Homicidal Ideation) and Process
  • I - Insight and Judgement
  • C - Cognition
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Why write down a mental status exam over and over again?

Often times, the MSE can seem redundant. As a single data point in time, the MSE can sometimes be of limited clinical utility. However, with repeated MSEs, you can begin to develop a picture of how a patient's mental status is changing over time. It is especially helpful when other clinicians read your MSE of a patient in the past and compare to the current presentation. The Mental Status Exam is a “snapshot” of a patient, that describes their behaviours and thoughts at the time you interviewed them. Think about how a psychotic individual's MSE might change over the course of a few hours, or how a manic patient might similarly fluctuate.

  • Appearance: Gait, posture, clothes, grooming
  • Behaviours: mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions
  • Attitude: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive
  • Level of Consciousness: Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating
  • Orientation: “What is your full name?” “Where are we at (floor, building, city, county, and state)?” “What is the full date today (date, month, year, day of the week, and season of the year)?”
  • Rapport
  • Quantity descriptors: talkative, spontaneous, expansive, paucity, poverty.
  • Rate: fast, slow, normal, pressured
  • Volume (tone): loud, soft, monotone, weak, strong
  • Fluency and Rhythm: slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic
  • Response latency

Affect vs. Mood

Affect is momentary (like the weather), while, mood is a prolonged emotion (like the climate). Hence, “mood is climate, and affect is the weather.”[2]
  • Mood (how the patient tells you they're feeling): “How are you feeling?”
  • Affect (what you observe): appropriateness to situation, consistency with mood, congruency with thought content
    • Fluctuations: labile, even, expansive
    • Range: broad, restricted
    • Intensity: blunted, flat, normal, hyper-energized
    • Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable
  • Congruency: congruent or not congruent mood?
  • Auditory Hallucinations
  • Visual Hallucinations
  • Homicide
  • Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?)
    • Delusions are fixed, false beliefs
    • These are unshakable beliefs that are held despite evidence against it, and despite the fact that there is no logical support for it
    • Is there a delusional belief system that supports the delusion?
  • If not a delusion, then could it be an overvalued idea?
    • An unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. - the person is able to acknowledge the possibility that the belief is false)
  • Ideas of Reference (IOR) - everything one perceives in the world relates to one's own destiny (e.g. - thinking the newspaper or TV is sending messages or hints)
  • First Rank Symptoms: auditory hallucinations, thought withdrawal, insertion and interruption, thought broadcasting, somatic hallucinations, delusional perception, and feelings or actions experienced as made or influenced by external agents
  • What is actually being said? Does the content contain delusions?
  • Are the thoughts ego-dystonic or ego-syntonic?
  • What is the logic, relevance, organization, flow and coherence of thought in response to general questioning during the interview?
  • Descriptors: linear, goal-directed, circumstantial, tangential, loose associations, clang associations, incoherent, evasive, racing, blocking, perseveration, neologisms.
  • Cognitive testing
  • Ask about education level
  • What is the patient's understanding of the world around them and their illness?
  • Are they able to do reality-testing? (i.e. - are they able to see the situation as it really is?)
  • Are they help-seeking? Help-rejecting?

Anosognosia

Anosognosia is the clinical term for the lack of ability to perceive the realities of one's own diagnosis.
  • What have the patient's actions been? Have they done anything to put themselves or other people at harm?
  • Are they behaving in a way that is motivated by perceptual disturbances or paranoia?
  • What is your confidence in the patient's decision making?
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