2 - The Mental Status Examination | Manual of Psychiatric Therapeutics: Practical Psychopharmacology and Psychiatry (Little, Browns Paperback Book Series)

Editors: Shader, Richard I.

Title: Manual of Psychiatric Therapeutics, 3rd Edition

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The Mental Status Examination

Richard I. Shader

A mental status examination (MSE), sometimes called the mental status schedule or the psychiatric examination, is an integral part of a comprehensive medical examination. Adolph Meyer championed the use of the MSE in the United States during the first third of the last century. This chapter reviews the MSE as it is conducted in adults and older adolescents. Assessing younger children requires modifications of the MSE that are beyond the scope of this chapter, although some ways to adapt the MSE to children and youths are discussed in Chapter 21. In any initial clinical interview, the clinician usually has several goals, including understanding why the patient is seeking help (or why someone else has asked the physician to see and evaluate the patient), creating rapport and laying the groundwork for working together (i.e., establishing a therapeutic relationship), and developing a diagnosis and treatment plan and presenting these conclusions to the patient. Whenever a clinician suspects some alteration in a patient's level of consciousness; the individual's awareness of his or her environment; his or her orientation to time, place, or person; or some other aspect of cognitive or emotional functioning, an MSE, which is a cross-sectional picture of a patient's functioning, should be included in the initial interview and should be administered again if the patient's condition changes. Moreover, a complete evaluation includes taking a pertinent personal and family history, with special emphasis on recent and relevant life changes and on stresses, assets and adaptive strengths, and social networks and support systems. When something has changed, developing a clear picture of what has changed is important. This means asking about its onset and duration, any precipitants, the context in which the shift occurred, and what might be reinforcing or maintaining any new symptoms or findings. In other words, what has happened, why did it happen, why now, and why to this particular patient?

Just as clinicians may omit selected parts of a physical examination, they may infer some aspects of mental and cognitive performance. However, omissions may lead to clinician errors. For example, one physician omitted testing for orientation because the patient had correctly said, I'm glad to see you, Dr. Smith, I know you are busy today. This patient had a mild delirium and said to the nurse after Dr. Smith left the room, They picked a good one to play his part he really looks like a doctor. This anecdote also highlights the importance of interviewing other informants. When parts of the MSE are omitted, this fact should be recorded.

Optimal circumstances for conducting an MSE include comfortable, well-lit, but not overly bright, surroundings that enable open discussion. The clinician needs to be comfortable and familiar enough with the task to encourage trust and confidence in the doctor patient relationship. Obviously, the context in which the clinician is called on to see the patient may be far from ideal. Having privacy and establishing rapport may be difficult in a busy emergency department or on an open ward, even when curtains are available and closed. Nevertheless, the clinician must try to demonstrate concern, compassion, empathy, and sensitivity. Eye contact and an optimal distance between the patient and interviewer are important. Note-taking may be necessary to ensure accurate recording of findings, but the clinician's style of note-taking should not be obtrusive it should be done in a way that does not interfere with the flow of the interaction. The clinician must also be free to observe and to record the nonverbal responses and behaviors of the patient (e.g., blushing, tearfulness). Making notes on a prepared document or checklist is sometimes helpful.

The clinician must be sensitive to the patient's feelings and reactions; this is best accomplished by having opportunities to practice conducting MSEs. Tolerating silence also needs to be mastered, as does the art of encouraging responses to both direct and open-ended questioning. Taking a detailed sexual history or asking about homicidal or suicidal thoughts (see Chapter 17) may feel awkward during an initial visit, but tactful

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inquiry, particularly about suicide, may be central to what needs to be understood about the patient at the time of the assessment (e.g., in the depressed patient). Going into the vicissitudes and techniques of interviewing is beyond the scope of this chapter. However, a rapid-fire style or an abruptly given series of questions may discourage spontaneous responses from the patient and thus should be avoided. These issues are raised to heighten students' awareness of the importance of developing interview skills.

In the sections that follow, elements of the MSE, along with possible facilitating questions, are reviewed. These are meant to be illustrative only, and they are not exhaustive in scope. The order of the elements of the MSE given below does not imply a sequence that must be followed. The interviewing clinician should adopt a sequence that encourages the flow of information and that is responsive to the patient's affect and condition. Appendix III contains a prototypical outline for the MSE.

I. Demography, Appearance, Behavior, and Attitude

Even though a receptionist, triage nurse, or referring physician may already have recorded pertinent information about the patient, redocumenting the patient's name, age, gender, education, and marital status and collecting data about children, siblings, and parents can have value. Data on race and religion may also be helpful. Is English the patient's primary language? If not, this should be recorded. Discrepancies from any previously recorded data should be explored. The clinician should also ascertain whether the patient can read and write and can hear adequately. Does the patient require eyeglasses or a hearing aid? This should be recorded.

A. Appearance and Level of Consciousness

What is the patient's physical build (e.g., short, thin)? Does the patient have any obvious physical limitations, disabilities, or abnormalities? Does he or she have any visible scars, asymmetries, or disfigurements? Are the patient's grooming, personal hygiene, and style of dress appropriate? Depression, for example, may reveal itself in lack of self-care. What is the patient's level of alertness and/or consciousness? Scales that delineate levels from alert to comatose are useful for standardization. Does the patient seem drowsy? Has anyone noted that the patient becomes less alert or cooperative when the room is dark or when evening begins (sometimes called sundowning)?

B. Motor Status and Behavior

Posture (e.g., slumping in the chair, waxy flexibility) and gait (e.g., ataxic, broad-based, festinating) should be described. Noting the patient's facial expression (e.g., tension, fearfulness, gaze aversion, tearfulness) is important. Is the facial expression consistent with the patient's affect? Are the pupils constricted or dilated? Difficulty sitting still (e.g., hyperactivity, agitation, akathisia), mannerisms or rituals, repetitive or involuntary movements (e.g., chorea, tremor, tics, tardive dyskinesia), nail biting, arms hugging the body, and echopraxia are also important to note and describe. Is any overt evidence of impaired coordination or any observable nystagmus present? This section of the MSE must be complemented by a thorough neurologic examination to clarify any suspicious findings and to provide a documented baseline.

C. Interpersonal Behavior and Attitude

The style of the interaction with the clinician (e.g., cooperativeness, indifference, guardedness, suspiciousness, embarrassment, assaultiveness, seductiveness) should also be recorded.

II. The Chief Complaint

The clinician should record verbatim the patient's explanation of why he or she is seeing the doctor or why he or she is in the clinic or hospital. Early questions such as How can I help you? , What has been troubling you? , or What led you to come in for help? may be useful. For example, one patient responded to the question What brought you into the emergency department? with My own two feet, stupid! Such a response may tell the clinician a lot about what to expect in the forthcoming discussion; in this situation, the patient was being sarcastically angry rather than showing concrete thinking. A medical student and a resident had asked him this question before he was seen by the attending. This

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example also illustrates the idea that the interviewer should phrase questions with care. For the elderly or with very young patients, having an informant may be essential. Some approaches to the MSE are exemplified in section V. As a general rule, a separate inquiry and recording of the chief complaint has value. Providing time for patients to offer their chief complaints and any other concerns before responding in a way that narrows the scope of inquiry is important. If only one complaint is given (e.g., I'm having nervous attacks. ), saying something like, That must be upsetting to you and in a few moments I'm going to ask more about them, but before I do, has anything else been bothering you? or Are there any other concerns you'd like to bring up? , may be useful

III. Characteristics of Speech (Talk)

This descriptive dimension combines elements that are also listed in sections I.B and V. It is listed separately here to emphasize the importance of speech as a window to the individual's overall thought processes and emotional state. The following are some key elements of speech that should be assessed.

A. Descriptors

Volume, tone, and quality. Is speech loud or soft? Does the patient sigh at key points?
Articulation and enunciation. Abnormalities are numerous, and they include stuttering; stammering; slurring; staccato speech (as in multiple sclerosis); cerebellar or explosive speech (loud and sudden with slurring); clipped speech; lisping; and other forms of dysfluency, dysarthria, or dysphemia. Describing accents that may reflect regional or national differences is also important. Is English this person's primary language? Enunciation can be tested by the use of selected phrases (e.g., Methodist Episcopal, liquid linoleum ).
Rate and coherence. Is speech coherent or incoherent? Is the patient overly talkative (as in mania), or is the rate of speech retarded (as in some depressions)? Speech can be characterized by its tempo (i.e., the rate of patterned rhythmic speech), its coherence or logical connectedness, and its continuity (i.e., uninterrupted connectedness).
Initiation. Does the patient have a problem initiating a stream of speech (as in Parkinson disease), or is a long latency to speech onset present?

B. Patterns and Styles

Loose associations. This term describes a pattern of disconnected speech (and thought) in which sentences or a string of ideas seem either unrelated or only loosely connected. The apparent lack of continuity may worsen as the patient, who is usually suffering from schizophrenia, continues to talk.
Word salad. This term is used to describe incoherent speech in which the associative continuity within the stream of spoken words is lost or inapparent. Neologisms (self-invented words) are often heard in word salad. This pattern, although not frequent, is found more often in schizophrenia than in other psychiatric disorders. It is replicated in Wernicke aphasia. Word salad differs from verbigeration (oral stereotypy), which refers to the repetition of meaningless phrases.
Blocking. In blocking, the flow of speech stops suddenly without apparent connection to either the thought content of the moment or the interchange between the patient and the listener.
Circumstantiality. Although the patient exhibiting circumstantiality eventually gets to the point, excessive, unnecessary, or irrelevant detail is included, and the message lacks incisiveness. Circumstantiality may be used to mask memory impairment in dementia (see Chapter 5).
Tangentiality. This term is used to describe responses that are off the mark but that are usually related to the question in some way and are oblique to the central idea. Tangential responses are more coherent than the repeated derailments seen in loose associations. Sometimes, tangential responses feel as if they are an evasive tactic.
Perseveration. This consists of the involuntary repetition of words or phrases. It may interfere with the patient's efforts to answer or make a
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point. The term palilalia is sometimes used to describe this pattern of perseveration; palilalia is not uncommon in Tourette disorder (see Chapter 7). Palilalia is not the same as echolalia, in which the repetition is an involuntary parrot-like restating of words or phrases just heard from another speaker; echolalia is found more commonly in patients with schizophrenia.
Flight of ideas. This increased rate or pressure of speech, often with frequent or abrupt changes in topic, may result in fragmentation of speech. The patient may seem distracted but he or she is not easily interrupted; he or she may also produce clang associations (i.e., sound determines the connection to subsequent words), rhyming, or punning. The original goal of a particular thought is usually lost during the process.
Mutism. The patient with mutism seems to be engaged with the questioner, but no response is forthcoming. In some instances, the mutism is voluntary, perhaps stemming from terror; more often, it is the result of stubbornness or negativism, hence the use of the term elective mutism.

IV. Cognitive Status

A. Attention and Concentration

Is the patient connecting with the interviewer (i.e., paying adequate attention)? How distracted or preoccupied does the patient seem to be? Many approaches can be used to establish impairments in attention and concentration. When one is selecting tests, choosing those that give additional information relevant to other sections of the MSE is also possible. For example, asking the patient to spell the name of the city in which he or she lives tests orientation, as well as attention, spelling, and memory. Then asking the patient to spell the city name backwards tests concentration and elements of memory. When a word other than the city is used, choosing a five-letter word is reasonable for testing purposes. Patients can also be asked to listen to and then repeat sequences of numbers. The ability to retain and repeat seven digits forward (the length of a standard telephone number) is common; achieving six digits is probably modal; and being able to repeat no more than five digits suggests impairment of attention. The advantage of using numbers is the ability to standardize performance. With the city task, the length of the word becomes a factor in the test. Patients can be asked to name in sequence the days of the week or the months of the year and then to reverse the direction (i.e., say them backward).

Another commonly used method is to have patients subtract 7 from 100 and then to subtract 7 from each subsequent answer, continuing the task serially hence the name serial 7s. With older patients, performing the first two subtractions for them may make the task less anxiety provoking. Serial 3s are sometimes used to make the task simpler. Assessing arithmetic ability while one is testing attention and concentration can also be useful. The patient can be asked to multiply 3 by 7, to add 3 and 7, to divide 21 by 7, and so forth. Obviously, this area of testing can be made into a task with graded degrees of difficulty. If a patient fails on the more standard tasks, the interviewer should simplify the tasks to distinguish impairments in attention from defects in memory, spelling, or calculation.

B. Orientation

The goal is to establish whether the patient is oriented to time, place, person, and self (in this context, person refers to others). Disorientation to self is rare, except in psychotic states where the patient identifies himself or herself as royalty, a deity, or someone else (e.g., schizophrenia, bipolar disorder). Some patients may both give their correct name and also say that they are a deity, a form of double orientation for self. Beginning this section by asking if the patient remembers the interviewer's name may be helpful for the interviewer. When the patient does not remember the interviewer's name, one should restate the name and should then ask the patient to repeat it. Again, this procedure tests a number of dimensions. The patient can then be asked to give his or her full name, followed by Do you have a nickname? or What do you prefer to be called? Next, the interviewer may ask,

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Do you know where you are? Here, determining various spatial levels (e.g., in a hospital, in which city, in which state, in which country) is possible. Another question should be Have you been keeping track of time? The patient may have been asleep or unconscious and may not know the hour; the examiner then shifts to the day of the week, date, month, season, or year (e.g., Do you know today's date? or Today is what day of the week? ). When the patient gives an incorrect response, the interviewer should supply the correct one and should then repeat the question later. This process adds data to the testing of registration, recall, and retention.

C. Memory

Scientific understanding of memory processes continues to increase. Many current models exist, each with its own definitions and terms (e.g., fluid, logical). When significant memory impairment is suspected, referral to a neuropsychologist should be considered to obtain more objective and more sophisticated answers. Getting to that point is the goal of memory assessment in the MSE. Perhaps the most appropriate initial step is reflection on what the patient has revealed through his or her responses to earlier questions and the way the history was given. Next, one can probe for memory problems through questions such as How far did you go in school? Direct questioning, as in the following, is mandatory: Have you noticed any problems with your memory [or with remembering things]? For the MSE, the effort is to establish whether information gets in (registration), whether it can be repeated (very short term or immediate recall), and whether it can be restated after a specific amount of time (delayed recall). The delay interval for the MSE is usually 5 minutes, and more complete testing also elicits recall after 30 minutes. The usual test consists of naming three to five unrelated words (e.g., vine, table, purple, fence, mirror) to the patient and then going through the process just described.

More remote memory (i.e., a period of a week or a month ago, or longer) should also be assessed. Here the point is to determine something that both the interviewer and the patient know happened. For instance, asking the patient what he or she ate or was served for breakfast is of little value unless the answer can be verified.

Remembering that motivation influences performance in many elements of the MSE is important. Lack of motivation may particularly obfuscate memory assessment in depressed elderly persons.

Testing visual memory separately has value. Can the patient copy simple figures or shapes, such as a triangle touching a circle or three parallel swerving or sine wave-like lines, and later (e.g., after 5 minutes) reproduce them? This is usually a good point in the examination to see whether the patient can draw a clock and insert the hands at a specified time (e.g., 8:20 or 2:45); this form of testing may also reveal apraxias or visual field problems.

D. Language and Communication Ability

By this point in the assessment, the clinician should have already learned a great deal about the patient's use of language; vocabulary, which is usually highly correlated with intelligence; and ability to communicate. Testing a few additional areas may help to complete this assessment. Can the patient name selected objects that the interviewer presents (e.g., a key, a spoon, a wooden pencil, a plastic pen, a notepad)? Reasoning and categorization ability can also be assessed through this task. Objects that are used can be chosen so that they can be sorted (e.g., pen and pencil = writing instruments; pen, pencil, and notepad = written communication devices; key and spoon = metal objects). When this has been done, the patient can then be asked, What do these things have in common? The patient can also be asked to tell a story that incorporates the objects or to describe a picture on the wall or what can be seen from the window. This activity can also be helpful for checking the patient's ability to spell (e.g., ask the patient to spell notepad ). From the tasks and activities evaluated so far and from the subsequent assessment of judgment and ability to think abstractly, making a reasonable estimate of the patient's functional intelligence should be possible.

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E. Judgment and Abstraction

The goal of this section is to assess a patient's ability to cope with everyday matters, to make generalizations, and to form opinions. When possible, questions should be free of cultural bias. Unfortunately, sociocultural background, education, and prior exposure to the ideas influence much of what is tested in this area. In listening to the patient's responses, one is looking for patterns (e.g., consistently concrete, literal, personalized, or bizarre responses). Some impressions of the patient's mental assets and abilities may have already been gleaned from earlier responses (e.g., from object naming and sorting [see section IV.D]). Formally developed tests are also available. Some potential probes are discussed in the following.

Reasoning. One may test reasoning skills by asking What would you do if you found a stamped and addressed envelope on the street? or What would you do if you were the first person to notice a fire in this building?
Similarities and differences. Another check involves queries like How are a dwarf and a child different from one another? or In what way are an orange and an apple alike? (both are fruit or food), A horse and an airplane? (both are forms of transportation), A radio and a newspaper? (both are forms of communication), and A fly and a tree? (both are alive).
Proverb interpretation. The interviewer asks the patient to restate the meaning of common sayings. This is usually begun by asking, Do you know this saying? If the patient does not know the proverb, trying several more is useful. In addition to disorders such as schizophrenia, many factors, including the patient's general level of intelligence and sociocultural background, can influence his or her interpretation of the proverb. Table 2.1 contains a sampling of common proverbs.

Answers to these proverbs are then categorized as concrete, subjective, personalized, bizarre, or well conceptualized. The author also uses the proverb The tongue is the enemy of the neck, as it tends to be less familiar to patients; it may elicit bizarre or highly idiosyncratic responses from psychotic patients.

V. Content of Thought

The previously elicited chief complaint (see section II) may guide this area of inquiry. The goal here is to see what is on the patient's mind. For example, is anything preoccupying, troubling, or frightening the patient?

A. Delusions

In response to general and open-ended questions about life, family, work, play, and relationships, the patient may reveal delusions, which are false beliefs that are not corrected by an appeal to reason or by contradictory evidence. Delusions are inconsistent with the facts, if they are all known. The clinician should not challenge the patient's beliefs but rather should explore them so that they can be differentiated from superstitions or ideas supported

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by a subculture and that are consistent with the patient's social and educational background. When delusional material does not emerge spontaneously and some form of distorted thinking can be reasonably suspected, selective probes, such as the following, may be used:

TABLE 2.1. SOME PROVERBS THAT APPEAR TO BE RELATIVELY FREE OF BIAS

The bigger they are, the harder they fall.
What goes around comes around.
Don't judge a book by its cover.
Two wrongs don't make a right.
Don't count your chickens before they are hatched.
You don't realize what water is worth until the well has run dry.
A stitch in time saves nine.
A bird in the hand is worth two in the bush.
People who live in glass houses shouldn't throw stones.
The grass is always greener on the other side of the street.

Do you have the sense that people like you?
Do you ever feel singled out?
Do you ever feel that anyone has it in for you or that you are being watched?
Do you have experiences that you don't think you could easily explain to others?
Do you ever feel someone else is controlling your mind or your thoughts?
Do you feel that you are in special touch with heaven or God?
Do you feel that you have special powers or that you are destined for a special role or job?

Kendler et al. proposed a useful way to describe delusions in terms of delusional involvement (cognitive and emotional) and content (disorganization, bizarreness, encapsulation). To what degree does the patient challenge the false belief by wondering if it is his or her imagination? To what degree does the delusion preoccupy the patient? Is it encapsulated, or does it spill into the patient's other thoughts and alter activities? How much does the content depart from customary consensual reality? Is the delusion logical, consistent, and systematized?

B. Hallucinations

A patient may spontaneously mention false sensory experiences, or the clinician may infer them from the patient's responses to cues that are not seen or heard by others. Hallucinations may be auditory, visual, tactile, gustatory, or olfactory. The presence of the latter four should raise suspicion of a toxic state, a mental disorder due to an altered metabolic state (e.g., anticholinergic overactivity or exposure to organic solvents), or a degenerative neurologic disease or space-occupying lesion (e.g., partial complex seizures) that is present in the brain. The location of auditory hallucinations in space may be important. In toxic metabolic states, the patient usually describes the auditory hallucinations as coming from a location that is within reason (e.g., from inside a closet). In schizophrenia, the location tends to be more unusual (e.g., from radar or from the patient's shoulder). Knowing when, where, and under what circumstances hallucinations occur (e.g., only with the use of alcohol or drugs) is also useful. Do they occur only when the patient is just waking or falling asleep? Only when the patient is feeling lonely or is actually alone? Are they consistent (congruent) with the patient's mood (e.g., when feeling depressed, the patient hears a voice saying he or she has sinned and deserves punishment)? This same question also applies to delusions. Some general probes include the following:

Are you sensitive to sound or noise? To light?
Do you daydream?
Do your daydreams ever seem real?
Do you have a strong imagination?
Have you ever felt as if you were outside your own body and could watch yourself?
Do you ever hear a voice speaking to you when no one is actually there?
Do you ever experience odors or smells that you don't think others notice?
Have you ever seen things crawling on your skin or on the floor or walls when others claim not to see them?
If these questions don't seem to apply to what you have experienced, can you tell me what would be a better way of describing your experience?
Do such experiences seem natural to you? Are they frightening? Are they ever comforting or reassuring?

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C. Other Forms of Disordered Thought

Many types of thought content (and related feelings) may trouble and preoccupy people, including suicidal and homicidal thoughts, sexual impulses, ruminations, obsessions, illness fears, depersonalization, and so on. To the extent that they are consistent with specific disorders, these types are discussed in the subsequent chapters dealing with those symptoms, problems, or disorders.

VI. Affect and Mood

A. Affect

Affect refers to the patient's observable feeling tone that accompanies behavior, communication (i.e., both during silence and when thoughts are being expressed), or reactions to life events. A patient's affect influences others. In that sense, affect is in the eye of the beholder. Not all clinicians watch and listen carefully enough to be attuned to shifts in or subtle expressions of affect. Numerous words have been used to characterize affect, including anxious, blunted, bright, broad, constricted, expansive, flat, full range, inappropriate, labile, sad, and sluggish. Affect can be harmonious (congruent or consonant) with behavior and ideation (e.g., a manic patient expresses grandiose ideas and appears expansive and too upbeat), inappropriate to the thought content (e.g., the person laughs nervously during the communication of a sad story), or isolated (e.g., the patient does not show sadness while telling a sad story).

B. Mood

Mood refers to what the patient describes about his or her own feeling state. Mood may be communicated spontaneously (e.g., I feel great today, Doctor ), or the clinician may have to ask questions (e.g., How are your spirits today, Mr. Smith? ). Mood tends to be more sustained than affect (i.e., prevailing mood). Again, noticing and documenting congruence or its absence among behavior, ideation, and stated mood is important. As with affect, numerous words with subtle shifts in emphasis can describe the mood (e.g., blue, depressed, despondent, low, sad). Other common descriptors include angry, anxious, bland, fearful, flat, irritable, nervous, and restless. Mood is said to be subjective, whereas affect, because it is observed, is considered more objective. This distinction may have limited value. Elderly persons and some adolescents may deny low moods, believing they have to bear up.

VII. Insight

Understanding whether the patient has insight is a central element of the MSE. For a clinician to establish an alliance with a patient who denies or who does not recognize something is wrong is difficult. The patient who can reasonably reflect on his or her illness and life situation is a better partner at all steps of the diagnostic, treatment, and rehabilitation process. Simple probes are as follows: What view do you have about your troubles? How do you understand what is going on with you? Lack of insight is common in schizophrenia. As suggested in Chapter 1, this alteration may be self-protective.

ADDITIONAL READING

Andreasen NC. Thought, language, and communication disorders. I. Clinical assessment, definition of terms, and evaluation of reliability. Arch Gen Psychiatry 1979;36:1315 1321.

Apell KE, Strecker EA. Practical examination of personality and behavior disorders. New York: Macmillan, 1936.

Kendler KS, Glazer WM, Morgenstern H. Dimensions of delusional experience. Am J Psychiatry 1983;140:466 469.

Small SM. Outline for psychiatric examination. East Hanover, NJ: Sandoz Pharmaceuticals Corporation, 1984.

Wells FL, Ruesch J. Mental examiners' handbook. New York: Psychological Corp., 1945.