Mental status examination
The mental status examination is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.
The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning.
The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests.
The MSE is not to be confused with the mini–mental state examination, which is a brief neuropsychological screening test for dementia.
Theoretical foundations
The MSE derives from an approach to psychiatry known as descriptive psychopathology or descriptive phenomenology, which developed from the work of the philosopher and psychiatrist Karl Jaspers. From Jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description, as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives.In practice, the MSE is a blend of empathic descriptive phenomenology and empirical clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient, is incompatible with the original meaning which was concerned with comprehending a patient's subjective experience.
Application
The mental status examination is a core skill of qualified health personnel. It is a key part of the initial psychiatric assessment in an outpatient or psychiatric hospital setting.It is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting.
It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example, by paramedics or emergency department staff.
The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.
Domains
The mnemonic ASEPTIC can be used to remember the domains of the MSE:- A - Appearance/Behavior
- S - Speech
- E - Emotion
- P - Perception
- T - Thought Content and Process
- I - Insight and Judgement
- C - Cognition
Appearance
Attitude
Attitude, also known as rapport or cooperation, refers to the patient's approach to the interview process and the quality of information obtained during the assessment. Observations of attitude include whether the patient is cooperative, hostile, open or secretive.Behavior
Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait. Abnormal movements, for example choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder. A tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medication. The patient may have tics which may be a symptom of Tourette's syndrome. There are a range of abnormalities of movement which are typical of catatonia, such as echopraxia, catalepsy, waxy flexibility and paratonia. Stereotypies or mannerisms may be a feature of chronic schizophrenia or autism.More global behavioural abnormalities may be noted, such as an increase in arousal and movement which might reflect mania or delirium. An inability to sit still might represent akathisia, a side effect of antipsychotic medication. Similarly, a global decrease in arousal and movement might indicate depression or a medical condition such as Parkinson's disease, dementia or delirium. The examiner would also comment on eye movements, and the quality of eye contact. Lack of eye contact may suggest depression or autism.
Mood and affect
The distinction between mood and affect in the MSE is subject to some disagreement. For example, Trzepacz and Baker describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation.Mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may have anhedonia.
Image:SelbstPortrait VG2.jpg|thumb|Vincent van Gogh's 1889 Self Portrait suggests the artist's mood and affect in the time leading up to his suicide.
Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior, and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. The intensity of the affect may be described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders. Mobility refers to the extent to which affect changes during the interview: the affect may be described as fixed, mobile, immobile, constricted/restricted or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one's disability may be described as showing la belle indifférence, a feature of conversion disorder, which is historically termed "hysteria" in older texts.
Speech
Speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions.This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought process and thought content.
When observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech. Many acoustic features have been shown to be significantly altered in mental health disorders.
A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests also form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition.
Language assessment will allow the recognition of medical conditions presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism spectrum disorders may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia and palilalia can be heard with patients with autism, schizophrenia or Alzheimer's disease. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them.
Speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.