Mental Status Exam

Utility of MSE

img_2202The Mental Status Exam (MSE) provides a cross-sectional snapshot of a client’s mental state at a particular point in time (Morrison, 2014; Robinson, 2002). Conducted informally, the MSE is routinely conducted as part of an intake interview (Hays, 2013). This tool provides an organized set of observations made during an interview that pertain to “sensorium, perception, thinking, feeling and behavior” (Robinson, 2002, p6).  Since the MSE is designed to provide accurate snapshot of an individual’s mental state at one point in time, its diagnostic utility is limited (Hays, 2013; Morrison, 2014; Robison, 2002). Nonetheless, this tool can help describe abnormalities in an individual’s mental state and present it in an organize manner (Robinson, 2002). It can shed light on “red flags” that require further assessment (Morrison, 2014). As a key component of the intake interview, the MSE, is used frequently during admission to a facility or program. It is also useful when a client first enters therapy to provide an overview of a client’s current condition. When taken alongside collateral information and other assessments this tool can also can aid in treatment planning. In this respect, the MSE is also useful to determine an individual’s response to treatment. Finally, MSE’s are used to monitor a client’s well being in response to serious diagnoses such as schizophrenia (American Psychiatric Association, 2013).

It is a cross-sectional assessment tool.

It is not a substitute for diagnosis.

A primary goal is to note abnormalities that require further analysis.

Provides set of standardized observations to guide evaluation.

Information Gathered in a MSE

As stated earlier, the MSE is designed to gather information on: (1) sensorium and cognitive functioning, (2) perception, (3) thinking, (4) feeling, and (5) behavior (Robinson, 2002). This information is divided and organized into the following areas (Hays, 2013; Morrison, 2014; Robison, 2002):

Appearance

Information gathered regarding an individual’s appearance can include observed physical traits; grooming habits, and attire.   Additionally, it often reveals demographic information on an individual’s age, gender, and cultural background.   How does the patient look?   My textbooks describe three areas of observation to note here, (Hays, 2013; Morrison, 2014).

  1. GENERAL APPEARANCE:  “information concerning general appearance should be evidence [available to] the unpracticed eye, (Morrison, 2014, p. 119).”
  2. LEVEL OF ATTENTION: How alert is the patient?  Are they hypervigilant?  Are they drowsy & inattentive?
  3. LEVEL OF ACTIVITY:  The patient’s level of activity can be an indicator of diagnosis.  Observations can include level of motor activity, tarditive diskinesia, purposefulness of movement, tremor, etc.
  4. BEHAVIOR:  Is the client pleasant, cooperative, agitated?  Is their behavior appropriate given the current situation?   Observe mannerisms, expression, eye contact, ability to follow commands.
  5. ATTITUDE:  Cooperative, hostile, open, secretive, etc…

Mood & Affect

Morrison, (2014), describes “mood as how we feel, and affect as how we appear to feel” (p122). Observations on affect can include variations in quality, range, appropriateness and degree of reactivity (Robinson, 2002). Notable factors regarding a client’s mood can include reports of feeling states that predominate most often. Finally, the level of congruency between affect and mood is also notable symptom.

  1. MOOD:  “The client’s self-reported feeling, (Hays, 2013, p. 124).”   Assessed via inquiry: how are you feeling?
  2. AFFECT:  “External expression of emotional state, (Hays, 2013, p. 124).”
  3. QUALITIES OF MOOD & AFFECT:
    1. TYPE:  exactly what is the client feeling: Sad, Happy, etc??
    2. LABILITY:  How uncontrollable are their emotional displays??
    3. APPROPRIATENESS:  Is there a congruency between thoughts and emotions???

Speech & Language

Speech reflects an individual’s verbal expression and can vary greatly in fluency, quality, rate and flow (Morrison, 2014; Robinson, 2002). Language refers to the communication of ideas and can be described in terms of the meaning it contains and quality of articulation (Morrison, 2014; Robinson, 2002).

  1. QUALITIES OF SPEECH:
    1. FLUENCY: initiation & flow of speech (Hays, 2014, p. 124).”
    2. REPETITION:  repeating words or phrases (Hays, 2014, p. 124).”
    3. COMPREHENSION: Understanding of spoken/written commands (Hays, 3014, p. 124).”
    4. PROSODY:  Attention to tone, rate, rhythm, (Hays, 2014, p. 124).”
    5. QUANTITY, RATE, VOLUME, FLUENCY, & RHYTHM.
  2. DIAGNOSTIC EXAMPLES FROM MORRISON (2013).
    1. CIRCUMSTANTIAL SPEECH:  indicates nonlinear thought pattern.
    2. DERAILMENT:  speech incoherent where ideas are loosely associated or unrelated.
    3. NEOLOGISM, ECHOLALIA, & INCOHERENCE.

Sensorium & Cognition

Sensorium refers to the brains ability to intake and process information from the senses.  Sensorium also refers to an individual’s level of consciousness overall.  In contrast, cognition refers to the processes of logic, reason, memory, abstract reasoning and intellect (Hays, 2013). Robinson, (2002) adds that cognitive function assessments also assess for level of alertness and orientation in addition the one’s degree of attention and concentration. While these factors frequently reflect one’s level of education d native intelligence, they can also indicate the presence of a functional deficit (Morrison, 2014).

  1. LEVEL OF CONSCIOUSNESS:  LOC refers to the level of wakefulness.  Is the patient conscious, if not can you arouse them?  Are they able to maintain focus on the conversation?
  2. ORIENTATION: Is the client oriented to time, place and person?
  3. ATTENTION & CONCENTRATION:  Is inquired & observed.  How distractable are they?  Assessments involve evaluating how well clients attend and concentrate during an assigned task.
  4. MEMORY: How effective is the client’s ability to recall short term and long term information?
  5. INTELLIGENCE:  Intelligence is the ability to acquire and apply knowledge.  It includes both observed and inquired information.
  6. ABSTRACT THINKING: this refers to an ability to grasp facts that are not concrete and removed from the “here and now”.

Thought & Perception

An assessment of thought and perception is garnered through inquiry via the intake interview.  Perception is a reflection of how the brain interprets sensory input (Robinson, 2002). Hallucinations and illusions are just two examples of perceptive symptoms. In contrast, thought content and process assess what garners the focus of an individual’s mind (Robinson, 2002). For example, thought content focuses on what an individual is thinking about, and can include symptoms of obsession, phobia, and delusion (Hays, 2013; Morrison, 2014; Robison, 2002). In contrast, thought process refers to the clarity and organization of our thinking (Robinson, 2002).

  1. THOUGHT CONTENT:  Thought content refers to what the client is actually thinking about. Examples include the following:
    1. SUICIDAL &/OR HOMICIDAL IDEATION
    2. DELUSIONS:  (i.e. paranoia, etc).
  2. THOUGHT PROCESS: Thought process refers to the clients manner of thinking…observations include “clarity of communication, association, & connectedness between topics (Hays, 2014, p. 124).”    Examples include the following:
    1. highly irrelevant comments (loose associations or derailment)
    2. frequent changes of topic (flight of ideas or tangential thinking)
    3. excessive vagueness (circumstantial thinking)
    4. nonsense words (or word salad)
    5. pressured or halted speech (thought racing or blocking)
  3. PERCEPTION: An assessment of perception examines abnormalities in how a person interprets sensory information, (Hays, 2014).  Disorders of perception can include the following:
    1. DEPERSONALIZATION/DISSOCIATION: altered bodily experience (Robinson, 2002).
    2. HALLUCINATION:  Perception of sensory input when no stimuli present (Robinson, 2002).
    3. ILLUSION:  Misperception of stimuli, (Robinson, 2002).

Insight & Judgment

Insight refers not only to an awareness of reality, but also to the degree of self-knowledge we possess regarding how we influence our world (Hays, 2013; Robinson, 2002). Judgment is defined in one’s decision-making abilities and how this is reflected in our actions (Morrison, 2014).

  1. INSIGHT:  An assessment of insight can include the clients level of acknowledgement regarding issues they currently struggle with and willingness to comply with treatment
  2. JUDGMENT: Assessing a client’s problem solving ability can include utilizing a hypothetical scenarios and asking what they might do.

ABC STAMP LICKER

Robinson (2002) provides the following as a way of remembering the main areas to assess during a mental status exam, “ABC STAMP LICKER”

Appearance
Behaviour
Cooperation

Speech
Thought content & form
Affect
Mood
Perceptions

LOC / Orientation
Insight & Judgement
Cognitive function & Sensorium
Knowledge
Ends (suicide/homicide)
Reliability

For more information read THIS or THIS, or THIS

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Hays, D.G. (2013). Assessment in counseling a guide to the use of psychological assessment procedures (5th Ed.). Belmont, CA: Brooks/Cole, Sengage Learning.
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental leather clinicians, 2nd ed. New York: The Guildford Press.
Robinson, D (2002). Mental Status Exam Explained, 2nd ed. Rapid Psychler.

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