Mental Status Exam (MSE)

Primer

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. An observant clinician can do a comprehensive mental status exam that helps guide them towards a diagnosis.

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 and Behaviour

The mental status exam begins before you even begin talking to the patient! Appearance and behaviours can give you a small sense of how the rest of your psychiatric interview will go.
  • Descriptors of appearance include:
    • Movement and Gait
    • Appearance
      • Note the posture, clothes, grooming, and cleanliness
      • Make note of any evidence of self-harm (cuts on wrists/legs), significant weight loss or cachexia (think anorexia), or signs of physical injury (think domestic abuse, or involvement in violent situations)
    • Behaviours
      • Note any mannerisms, gestures, expression, eye contact, ability to follow commands/requests, compulsions
    • Attitude
      • Note if the patient is cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, or defensive
    • Level of Consciousness
      • Is the patient vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating
      • You may need to do further cognitive testing if there is concern (see Cognition section below)
      • You may want to quickly ask about 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
      • Is the rapport good, fair, or bad?
      • Does the patient trust you and do you have a good connection/relationship?

Speech

When assessing speech, consider the presence of word-finding difficulty, echolalia, and signs of aphasia.
  • Speech can be described using the following descriptors:
    • Quantity of speech
      • Talkative, spontaneous, expansive, paucity, poverty of speech (i.e. - very little is said)
    • Rate of speech
      • Fast, slow, normal, pressured
    • Volume (tone) of speech
      • Loud, soft, monotone, weak, strong
    • Fluency and rhythm of speech
      • Slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic
    • Response latency
      • How long does it take the patient to respond?

Emotion

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]
  • Emotion consists of mood and affect.
  • Mood is how the patient subjectively tells you they're feeling
    • Ask the patient: “How are you feeling?” or “How is your mood?”
  • Affect is what you objectively observe
    • Note the appropriateness of the patient's affect to the current situation
    • Other descriptors for affect include:
      • Fluctuations in affect: labile, even, expansive
      • Range of affect: broad, restricted
      • Intensity of affect: blunted, flat, normal, hyper-energized
      • Quality of affect: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable
  • Congruency
    • Is there congruency between mood and affect? (i.e. - they say they are sad, but are laughing)
    • Is there congruency between thought content and affect? (i.e. - they look sad, but say “I feel happy.”)

Perception

When assessing perception, make sure to ask in detail, and not just whether they “hear voices” or “see things.” This is too generic, and patients may either under report hallucinations or falsely endorse hallucinations when they do not have them!
  • Illusions are misperceptions of actual stimuli, and are either a misinterpretation or clear error in perception (e.g. - patient feels as though a clock has eyes, that wind blowing is whispers, or they see figures moving in the dark at night when leaves on a tree are blowing)
    • Illusions are non-pathologic – most individuals can point to a time when they had a misperception or fleeting perception (e.g. - thinking hearing one's name called when no one else is home, or thinking there is someone hiding in the dark at night).
  • Hallucinations are perceptions in the absence of sensory stimuli in any of the five senses (auditory, visual, gustatory, olfactory, and tactile). The two most commonly asked in psychiatry are:
    • Auditory hallucinations
      • Does the patient hear one or several voices?
      • Are the voices male or female?
      • Are the voices or people they know or are they unfamiliar?
      • Are these voices simple statements, or complex sentences?
      • Do the voices engage in a conversation with the patient or comment on the patient’s thoughts?
      • Command auditory hallucinations (i.e. - voices instructing the patient do to things) are frequently considered a concerning feature of psychosis that requires inpatient hospitalization.
      • Auditory hallucinations are the most common type of hallucination in non-organic (i.e. - primary) psychiatric conditions
    • Visual hallucinations
      • Visual hallucinations can be both psychiatric or neurological and it is important to understand what exactly is occurring.
      • Migraines are the most common single cause of visual hallucinations and illusions.
      • Visual phenonemona (e.g. - auras from seizures) can also be reported as visual hallucinations.
      • Individuals with Dementia with Lewy Bodies may experience visual hallucinations are part of their core symptoms.
      • Charles Bonnet Syndrome (CBS) is a common non-psychiatric condition among people with serious vision loss (macular degeneration, glaucoma, and diabetic retinopathy) characterized by temporary visual hallucinations.
      • Individuals with narcolepsy may also experience visual hallucinations
    • One should also ask if if hallucinations are congruent with any underlying delusions. Hallucinations may be mood congruent (e.g. - a depressed patient hearing a voice chiding her for failure and urging her to commit suicide) and mood incongruent (e.g. - a patient with schizophrenia who despite being quite paranoid hears voices that they find calm and soothing).
  • Depersonalization, and derealization may also occur for some patients
    • Ask the patient: “Do you ever feel you are not in your own body, or you are looking from the outside in?”
    • Derealization
      • Perception that one’s surrounding and events are experienced as if the person is detached from them, or that they are distorted, changed, or unreal
    • Depersonalization
      • Perception that one is standing outside oneself as a detached observer to surroundings, experiences, and events that occur

Thought Content

When assessing thought content, consider the totality of your conversation with the patient, what is being said, and just as importantly, what is not said?
  • Thought content may include:
    • Delusions
      • Delusions are fixed, false beliefs. These are unshakable beliefs are held despite evidence against it, and despite the fact that there is no logical support for it.
      • Delusions may have erotomanic, grandiose, jealous, persecutory, and/or somatic themes.
      • Also consider if there an extensive delusional belief system that supports the delusion (e.g. - patient may have a very intricate and detailed explanation of why they believe they are being targeted)
  • If not a delusion, then could it be an overvalued idea?
    • Overvalued ideas are 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)
    • This is the belief that everything one perceives in the world relates to one's own destiny (e.g. - thinking the newspaper or TV is sending messages or hints to them)
  • First rank symptoms:
    • First rank symptoms are a range of schizophrenia symptoms proposed by psychiatrist Kurt Schneider in 1959 (however, the diagnostic specificity and sensitivity of these symptoms is not perfect and cannot be relied on to diagnose schizophrenia alone).[3] First rank symptoms include:
    • Auditory hallucinations
      • Auditory perceptions with no cause. These auditory hallucinations have to be of particular types:
        • Hearing thoughts spoken aloud
        • Hearing voices referring to himself/herself made in the third person, or
        • Auditory hallucinations in the form of a commentary
    • Thought withdrawal (TW), thought insertion (TI) and interruption
      • A patient's thoughts are under control of an outside agency and can be removed, inserted (and felt to be alien to him/her) or interrupted by others (e.g. - “My thoughts are fine except when the Pope stops them.”)
    • Thought broadcasting (TB)
      • The patient is thinking everyone is thinking in unison with him/her (e.g. - “My thoughts filter out of my head and everyone can pick them up if they walk past.”)
    • Somatic hallucinations
      • A hallucination involving the perception of a physical experience with the body
    • Delusional perception
      • A true perception, to which a person attributes a false meaning (e.g. - traffic lights turning red may be interpreted by the patient as meaning that Martians are about to land)
    • Feelings or actions experienced as made or influenced by external agents
      • Where there is certainty that an action of the person or a feeling is caused not by themselves but by some others or other force (“The FBI, NSA, and CIA controlled my arm.”)
  • Are the thoughts ego-dystonic or ego-syntonic?
    • Ego-dystonic thoughts are thoughts that are not in line with who we are and/or what we believe (i.e. - the thoughts of hurting themselves (suicide) or others (homicide) may be very distressing to the patient)
    • Ego-syntonic thoughts
      • Ego-syntonic thoguhts refers to instincts or ideas that are acceptable to the self; that are compatible with one's values and ways of thinking.
  • Don't forget critical safety content such as:

Thought Form/Process

When assessing thought form (also called thought process), ask yourself: what is the logic, relevance, organization, flow, and coherence of thought in response to questions during the interview?
  • Thought process can be described as:
    • Linear and goal-directed
      • The individual's ideas string together in a relatively linear fashion, and obeys the conventions of grammar and syntax.
    • Circumstantial
      • Over-inclusion of trivial or irrelevant details that impede the sense of getting to the point. Patients will often get back to the original point or question you asked, may wander and be over-inclusive.
    • Tangential
      • The patient provides an answer to a question that veers off from the target of the question, but the connection may still be appreciated or inferred by the clinician.
    • Incoherent
      • Coherence is the orderly flow of information when speaking, and how well words, sentences, and overall speech is connected.
      • Incoherence is an overall descriptor. If someone is incoherent, they may be mumbling, have loose associations, be tangential, or otherwise have some kind of thought disorder.
    • Flight of ideas
      • Rapid jumping (“flight”) from topic to topic without completing each train of thought (usually occurs during a manic episode)
    • Thought blocking
      • Loss of the goal of a communication and not being able to return to the topic
    • Perseveration
      • Persistent inappropriate repetition of same thoughts (e.g. - saying “I'm dead. I'm dead. I'm dead.”)
    • Neologisms
      • A word created by the patient that does not have any meaning to others (e.g. - “cranium sock” to mean hat)
    • Loose associations (also called derailment)
      • A breakdown in both the logical connection between ideas/words and the overall sense of goal-directedness. The words make sentences, but the sentences do not make sense!
      • Clang associations is one type of loose association where words that sound alike are lumped together.[4]
    • Word salad
      • A confused or unintelligible mixture of seemingly random words and phrases

Cognition

If you are concerned about cognition, start by asking the patient if they know the date, location of where they are, and their name (often documented as Alert or Oriented (AO) × 3 in charts). This can give the clinician a very rough sense of the person's overall cognition, but is only a start. This is important if you are concerned about delirium or acute confusional states.

Insight

When assessing insight, ask yourself:
  • What is the patient's understanding of the world around them and their illness?
  • Are they able to reality test? (i.e. - are they able to see the situation as it really is?)
  • Are they help-seeking? Help-rejecting?
  • Insight can be described as:
    • Poor (patient may be in complete denial of their symptoms or diagnosis, or there may be some slight awareness)
    • Fair
      • The patient may understand their symptoms or diagnosis intellectual “on paper,” but fail to understand it emotionally, or fully grasp the impact of it on their life
    • Good/Excellent
      • Overall, a good intellectual and emotional understanding of their symptoms or difficulties. Patient is acutely aware of their symptoms or illness, and also of their own limitations and strengths. Their symptoms are likely to be in remission, and they know when to reach out for help and when to rely on themselves.
  • Insight does not mean agreeing with the doctor![5]

Anosognosia

Anosognosia is the clinical term for the lack of ability to perceive the realities of one's own diagnosis. This can occur in conditions including schizophrenia, dementia, and stroke.[6]

Judgment

When considering judgment, ask yourself:
  • What have the patient's recent 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?
  • Judgment can be described as:
    • Impaired (for individuals who are acutely intoxicated)
    • Poor (in the context of acute psychosis in schizophrenia or dementia)
    • Good (patient is aware and makes decisions in a way that does not put them or others in harm)
  • Keep in mind there is no formal way of describing judgment, and even the descriptors may vary among clinicians

Resources

References

1) Mnemonics in a mnutshell: 32 aids to psychiatric diagnosis. Current Psychiatry. 2008 October;7(10):27-33
2) Manjunatha, N., Khess, C. R. J., & Ram, D. (2009). The conceptualization of terms:‘Mood’and ‘affect’in academic trainees of mental health. Indian journal of psychiatry, 51(4), 285.
3) Soares‐Weiser, K., Maayan, N., Bergman, H., Davenport, C., Kirkham, A. J., Grabowski, S., & Adams, C. E. (2015). First rank symptoms for schizophrenia. Cochrane Database of Systematic Reviews, (1).
4) Fountoulakis, K. N. (2010). The emerging modern face of mood disorders: a didactic editorial with a detailed presentation of data and definitions. Annals of general psychiatry, 9(1), 1-22.
5) Psychiatry at the Margins: Insight into “Insight”
6) Acharya AB, Sánchez-Manso JC. Anosognosia. [Updated 2021 Aug 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan