Understanding the Mental Status Exam (MSE)

This is a brief video on the mental status exam. We're going to be talking about all the portions of the mental status exam that you can report in your notes for a psychiatric patient. We're going to be breaking down the parts of the mental status exam into chunks, and then at the end, we'll show them all on the same slide. Let's get started. First thing you want to report is the appearance of the patient. This is essentially the general appearance of a patient, including that patient's apparent age, their height, weight, and their manner of dress and grooming. So some examples of what you might want to put under appearance are whether the patient looks disheveled, if the patient has proper or poor hygiene, if the patient appears older or younger than their stated age, or if they appear their stated age. Next, you want to report the behavior. This is an observation of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal. as well as patient's eye contact and gait. So quite a few things that might go under behavior. Things you might want to include here are whether or not the patient was cooperative with the exam, what kind of eye contact they had, if they looked at you too much, if they looked at you too little, if they looked at you the proper amount, if they were engaged in the conversation, if they were wandering off, if they were really into it, or a normal amount, if they had repetitive movements like constantly tapping their hands, or some other repetitive behavior that might indicate OCD. would also go under the behavior component. Next you want to comment on the patient's motor function. This is essentially a psychiatric disturbance that manifests in a change or deficiency in a patient's motor function. Some things to include here are psychomotor agitation, psychomotor retardation, any tremors, or restlessness. Oftentimes restlessness is indicative of Parkinsonism and it can also be a side effect of some antipsychotics. So that would be important to note. Some patients that are on too many antipsychotics might be moving slowly or talking slowly, and that could be a manifestation of psychomotor retardation. So there are manifestations of a patient's psychiatric condition into their motor movements, and those can be reported here. Lastly, for this section, you want to comment on the patient's speech. And by speech, we mean how they talk rather than exactly what they are saying. So you're concerned with the production of speech rather than the content of their speech. So for instance, you want to talk about how fast they talk. If a patient's talking fast like I am right now, you might want to say rapid speech. If they talk slow, that might be associated with psychomotor retardation. You might say slow speech, psychomotor retardation. So the speed, the rate, the volume, whether or not the volume of speech is consistent. If they talk high all the time, if they talk very softly all the time, if they go high and low, depending on what they're talking about, pressured speech. Can be indicative of mania. Fluent, understandable speech would also be important to note versus impoverished speech. If they don't use many words, if they reply to all your answers with no, I don't know, I'm not sure, you're the psychiatrist, I don't know. That would be impoverished speech. You can comment on their tone, which might give hints as to their mood or affect. And also if there's a delay or latency in their speech. If you ask them a question and it takes them a few seconds to get talking or a few seconds to respond. That might be a latency in speech. Next, you want to report on the patient's mood. This is, in their own words, you can often put it in quotes, a description of the patient's internal emotional state. So you might want to blatantly ask the patient, how do you feel today? Or how would you describe your mood? And they'll say something, and you can put that down in quotes as their mood. Some examples of what the patient might say include happy, sad, okay, good, great, or depressed. And those will often go in quotes. Ask the patient how's their mood, and if they say good, you put it in quotes as good. Next up is the affect, which is the description of a patient's apparent emotion conveyed by their person's nonverbal behavior, and also by using parameters of appropriateness, intensity, range, reactivity, and mobility. So this is using like the context clues of the conversation to make your judgment of what a patient's apparent emotional state is. If they say they feel great, do they actually look like they feel great? If they say they're depressed, do they actually look like they feel depressed? So a patient's affect might be neutral. It could be euthymic. It could be dysphoric. It could be euphoric. So it could be any of these things listed here. You also want to comment on if a patient's... So I'm going to talk about this bullet here. You also want to report on if a patient's affect is congruent with their reported mood. If a patient says they're happy, but they're obviously not happy when they're talking to you, they're looking down at their feet, they're making poor eye contact, and they look depressed, you might want to say their mood is happy and their affect is depressed, non-congruent or... reported mood. That would be appropriate. You also want to report the range of affect. How do they look throughout the conversation? If you're talking to this patient for 30 minutes or so, and they look the same the whole time, and they don't react to anything you're talking about, and they kind of have that same affect the entire time, they might have a blunted affect. And the range of affect can be described on a spectrum, kind of listed over the second bullet here. On one end of the spectrum, a patient might be flat. or have a blunted affect. And in this patient, essentially nothing elicits a reactivity. You can talk about something that's terrifying to them, a previous trauma, or something very exciting, and they would not have a reaction. They have the same face. They have the same nonverbal context clues. On the other hand of the spectrum, a patient might have an expansive affect or a labile affect. And this is a patient who's kind of out of control with their emotions. It's almost like they're not in control of their emotions. they laugh at random times or they're overly happy at one moment and then very very sad at the other and it's almost like exaggerated it's almost comical. and some more normal affects in the middle would be a full effect or maybe even a restricted or constricted effect. it's kind of on the blunted side but more normal than a flat effect so that's a good spectrum to know. one other thing to comment on for affect is this word here, appropriate. or inappropriate. If a patient, for instance, laughs when there's a very sad topic at hand, or laughs when talking about a previous trauma, or is overly excited when talking about trauma, or is overly sad when talking about what should be a joyous occasion, you might describe that patient's affect as inappropriate. It's out of context. It doesn't match what you would expect. It doesn't match what a normal person would do. Next section is describing the patient's thoughts. process. This is a description of the quantity, tempo, and form of thought. So some things to comment on here are if the patient has linear thought, if they think logically, if they're able to go through a conversation and be goal-directed, if they're organized in their thought, if they make logical conclusions from one point to another, that would be a linear, logical, and goal-directed thought. On the other hand, if a patient has flight of ideas, they might rapidly talk about something and immediately be distracted by another idea or immediately be distracted by what they see or what they think of next or another story they come up with there in their head. And those thoughts would be so rapid that the end product is almost incoherent. They talk about a situation that they went home and talked to their mom and then they tell you a story about their mom who met her cousin and then they story about mom's cousin and it kind of goes on and on and on. That might be flight of ideas. Similarly, tangential and circumferential, I think I have definitions for those here. Tangential thought process is a thought process that goes off on a tangent and never returns to the matter at hand. So a patient is distracted and they keep telling stories and going on and on and getting distracted by different things, going on a tangent and never coming back to the question that you asked. On the other hand, circumferential thought process goes off with extraneous details, but does eventually come back to the matter at hand. It does circle back like the circumference of a circle and they do eventually answer your question. So you ask a question about them going home to their mom. They tell you a story about their mom, their mom's cousin, their mom's cousin's cooking habits, and how they like their mom's cousin's cooking food. But then they do answer the question about coming home to the mom, and they do get back to what you were asking. That would be circumferential versus tangential. Thought content, on the other hand, is a description of a patient's delusions, overvalued ideas, obsessions, phobias, and preoccupations. What are they thinking? This is the what they are thinking. So you might want to... Write about comments endorsing or denying suicidal ideation, homicidal ideation, paranoid ideations, ideas of reference. That's when they think that a newscaster or a television reporter is specifically talking to them, or any fixations or preoccupations that they might have. If they fixate on a certain habit, or if they fixate on a certain event in their life, that could be reported in thought contents as well. But the big ones are definitely suicidal ideation, homicidal ideation, and paranoid ideations. Perceptual disturbances is next. This is essentially hallucinations and interpretations of sensory information. So it's a description of any disruption of their sensory information. As we said, auditory hallucinations, visual hallucinations, illusions, whether or not the patient responds to these stimuli. A lot of times you might see patients that are kind of pacing the halls or talking to themselves or looking at their hands responding to internal stimuli. That would be appropriate to report under perceptual disturbances. Next section you might want to comment on is the patient's level of insight. This is a description of patient's understanding of his or her mental status evaluated by exploring their mental explanatory account of the problem and available treatment options. So it's essentially how well do they know what's going on? How well do they understand their mental illness? You can use words like good, fair, poor to describe their insight. If they know they have psychoses and they know that their psychoses might be coming and they know how to cope with them, that would be good insight. If the patient knows that they're in a psych hospital for schizophrenia, but they don't really think they have schizophrenia and they believe their delusions are real, that would be very poor insight. On the other hand is judgment, which is a patient's capacity to make sound, reasoned, and responsible decisions. So essentially, how well do they follow up with their treatments? A patient who has schizophrenia, for instance, and takes their medications, is very compliant with them, takes them at the same time every day as instructed, would have good judgment. A patient who has poor insight is more predisposed to have poor judgment. If they don't think they have a problem, they might be less likely to act upon that problem and cooperate with the plan. If a patient reports that they were forced by their family to come in for their hallucinations or for their drug problem, that would show poor judgment. They themselves didn't bring themselves in. They're relying on their family and they were kind of forced by their family. That's poor judgment. And lastly, there's some other cognitive tests that you can add to the mental status exam. The first one is a test of a patient's memory. A quick way to do this is to report three words to the patient, to give them three words like dog, bicycle, and tree. And then five minutes later, ask the patient to repeat those three words to you. and see if they remember them five minutes later. So a good way to do this is to start with memory, then do the two next sections that I'm going to talk about, and then go back and ask the patient to remember those three words that you brought up to them. And you can report this as the patient remembering one of the three words, two of the three words, or all three of the words after a five-minute time period. You can also test a patient's concentration. A couple ways to do this. One of them is... to do serial sevens, which is when a patient starts with the number 100 and subtracts seven consecutively. So you'd expect the patient to say 100, 93, 86, 79, and kind of keep subtracting seven probably five or six times to see if they're able to concentrate on a task like that. Another would be to spell the word world backwards. Also would require them to concentrate on a task to get through all five letters in the correct order. Lastly, you want to test a patient's orientation to person, place, and time. When you ask a patient about their person, you can ask for their full name and their date of birth. When you ask about the place, you can ask for the state, the town, the current hospital that they're in, the current location, the building and floor, perhaps. If that's relevant, whatever a normal patient would be expected to know would be reasonable to ask. In terms of time, you can ask for the season, the year, the month. Those are usually easier than the day or the date, and that is also whatever would be relevant or whatever would be important for a patient to know. If they've been in the hospital for a very long time, they might lose track of the day or the date, but they could still be oriented to month and season. And after doing concentration and orientation would be a good time to go back and ask the patient about three words that you asked them to remember to finish up that memory portion of the exam. And that's the entire mental status exam. Here's a summary of it all that might be helpful to keep with some examples of what to do when assessing the different sections of the mental status exam. I hope this was helpful, and thank you for listening.

This is essentially the general appearance of a patient, including that patient's apparent age, their height, weight, and their manner of dress and grooming. So some examples of what you might want to put under appearance are whether the patient looks disheveled, if the patient has proper or poor hygiene, if the patient appears older or younger than their stated age, or if they appear their stated age. Next, you want to report the behavior.

This is an observation of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal. as well as patient's eye contact and gait. So quite a few things that might go under behavior.

Things you might want to include here are whether or not the patient was cooperative with the exam, what kind of eye contact they had, if they looked at you too much, if they looked at you too little, if they looked at you the proper amount, if they were engaged in the conversation, if they were wandering off, if they were really into it, or a normal amount, if they had repetitive movements like constantly tapping their hands, or some other repetitive behavior that might indicate OCD. would also go under the behavior component. Next you want to comment on the patient's motor function. This is essentially a psychiatric disturbance that manifests in a change or deficiency in a patient's motor function. Some things to include here are psychomotor agitation, psychomotor retardation, any tremors, or restlessness.

Oftentimes restlessness is indicative of Parkinsonism and it can also be a side effect of some antipsychotics. So that would be important to note. Some patients that are on too many antipsychotics might be moving slowly or talking slowly, and that could be a manifestation of psychomotor retardation.

So there are manifestations of a patient's psychiatric condition into their motor movements, and those can be reported here. Lastly, for this section, you want to comment on the patient's speech. And by speech, we mean how they talk rather than exactly what they are saying. So you're concerned with the production of speech rather than the content of their speech. So for instance, you want to talk about how fast they talk.

If a patient's talking fast like I am right now, you might want to say rapid speech. If they talk slow, that might be associated with psychomotor retardation. You might say slow speech, psychomotor retardation.

So the speed, the rate, the volume, whether or not the volume of speech is consistent. If they talk high all the time, if they talk very softly all the time, if they go high and low, depending on what they're talking about, pressured speech. Can be indicative of mania.

Fluent, understandable speech would also be important to note versus impoverished speech. If they don't use many words, if they reply to all your answers with no, I don't know, I'm not sure, you're the psychiatrist, I don't know. That would be impoverished speech.

You can comment on their tone, which might give hints as to their mood or affect. And also if there's a delay or latency in their speech. If you ask them a question and it takes them a few seconds to get talking or a few seconds to respond. That might be a latency in speech.

Next, you want to report on the patient's mood. This is, in their own words, you can often put it in quotes, a description of the patient's internal emotional state. So you might want to blatantly ask the patient, how do you feel today?

Or how would you describe your mood? And they'll say something, and you can put that down in quotes as their mood. Some examples of what the patient might say include happy, sad, okay, good, great, or depressed.

And those will often go in quotes. Ask the patient how's their mood, and if they say good, you put it in quotes as good. Next up is the affect, which is the description of a patient's apparent emotion conveyed by their person's nonverbal behavior, and also by using parameters of appropriateness, intensity, range, reactivity, and mobility. So this is using like the context clues of the conversation to make your judgment of what a patient's apparent emotional state is.

If they say they feel great, do they actually look like they feel great? If they say they're depressed, do they actually look like they feel depressed? So a patient's affect might be neutral.

It could be euthymic. It could be dysphoric. It could be euphoric. So it could be any of these things listed here. You also want to comment on if a patient's...

So I'm going to talk about this bullet here. You also want to report on if a patient's affect is congruent with their reported mood. If a patient says they're happy, but they're obviously not happy when they're talking to you, they're looking down at their feet, they're making poor eye contact, and they look depressed, you might want to say their mood is happy and their affect is depressed, non-congruent or... reported mood.

That would be appropriate. You also want to report the range of affect. How do they look throughout the conversation? If you're talking to this patient for 30 minutes or so, and they look the same the whole time, and they don't react to anything you're talking about, and they kind of have that same affect the entire time, they might have a blunted affect.

And the range of affect can be described on a spectrum, kind of listed over the second bullet here. On one end of the spectrum, a patient might be flat. or have a blunted affect.

And in this patient, essentially nothing elicits a reactivity. You can talk about something that's terrifying to them, a previous trauma, or something very exciting, and they would not have a reaction. They have the same face. They have the same nonverbal context clues. On the other hand of the spectrum, a patient might have an expansive affect or a labile affect.

And this is a patient who's kind of out of control with their emotions. It's almost like they're not in control of their emotions. they laugh at random times or they're overly happy at one moment and then very very sad at the other and it's almost like exaggerated it's almost comical. and some more normal affects in the middle would be a full effect or maybe even a restricted or constricted effect.

it's kind of on the blunted side but more normal than a flat effect so that's a good spectrum to know. one other thing to comment on for affect is this word here, appropriate. or inappropriate. If a patient, for instance, laughs when there's a very sad topic at hand, or laughs when talking about a previous trauma, or is overly excited when talking about trauma, or is overly sad when talking about what should be a joyous occasion, you might describe that patient's affect as inappropriate.

It's out of context. It doesn't match what you would expect. It doesn't match what a normal person would do. Next section is describing the patient's thoughts.

process. This is a description of the quantity, tempo, and form of thought. So some things to comment on here are if the patient has linear thought, if they think logically, if they're able to go through a conversation and be goal-directed, if they're organized in their thought, if they make logical conclusions from one point to another, that would be a linear, logical, and goal-directed thought.

On the other hand, if a patient has flight of ideas, they might rapidly talk about something and immediately be distracted by another idea or immediately be distracted by what they see or what they think of next or another story they come up with there in their head. And those thoughts would be so rapid that the end product is almost incoherent. They talk about a situation that they went home and talked to their mom and then they tell you a story about their mom who met her cousin and then they story about mom's cousin and it kind of goes on and on and on. That might be flight of ideas. Similarly, tangential and circumferential, I think I have definitions for those here.

Tangential thought process is a thought process that goes off on a tangent and never returns to the matter at hand. So a patient is distracted and they keep telling stories and going on and on and getting distracted by different things, going on a tangent and never coming back to the question that you asked. On the other hand, circumferential thought process goes off with extraneous details, but does eventually come back to the matter at hand. It does circle back like the circumference of a circle and they do eventually answer your question.

So you ask a question about them going home to their mom. They tell you a story about their mom, their mom's cousin, their mom's cousin's cooking habits, and how they like their mom's cousin's cooking food. But then they do answer the question about coming home to the mom, and they do get back to what you were asking. That would be circumferential versus tangential.

Thought content, on the other hand, is a description of a patient's delusions, overvalued ideas, obsessions, phobias, and preoccupations. What are they thinking? This is the what they are thinking.

So you might want to... Write about comments endorsing or denying suicidal ideation, homicidal ideation, paranoid ideations, ideas of reference. That's when they think that a newscaster or a television reporter is specifically talking to them, or any fixations or preoccupations that they might have. If they fixate on a certain habit, or if they fixate on a certain event in their life, that could be reported in thought contents as well. But the big ones are definitely suicidal ideation, homicidal ideation, and paranoid ideations.

Perceptual disturbances is next. This is essentially hallucinations and interpretations of sensory information. So it's a description of any disruption of their sensory information.

As we said, auditory hallucinations, visual hallucinations, illusions, whether or not the patient responds to these stimuli. A lot of times you might see patients that are kind of pacing the halls or talking to themselves or looking at their hands responding to internal stimuli. That would be appropriate to report under perceptual disturbances.

Next section you might want to comment on is the patient's level of insight. This is a description of patient's understanding of his or her mental status evaluated by exploring their mental explanatory account of the problem and available treatment options. So it's essentially how well do they know what's going on? How well do they understand their mental illness? You can use words like good, fair, poor to describe their insight.

If they know they have psychoses and they know that their psychoses might be coming and they know how to cope with them, that would be good insight. If the patient knows that they're in a psych hospital for schizophrenia, but they don't really think they have schizophrenia and they believe their delusions are real, that would be very poor insight. On the other hand is judgment, which is a patient's capacity to make sound, reasoned, and responsible decisions. So essentially, how well do they follow up with their treatments?

A patient who has schizophrenia, for instance, and takes their medications, is very compliant with them, takes them at the same time every day as instructed, would have good judgment. A patient who has poor insight is more predisposed to have poor judgment. If they don't think they have a problem, they might be less likely to act upon that problem and cooperate with the plan.

If a patient reports that they were forced by their family to come in for their hallucinations or for their drug problem, that would show poor judgment. They themselves didn't bring themselves in. They're relying on their family and they were kind of forced by their family.

That's poor judgment. And lastly, there's some other cognitive tests that you can add to the mental status exam. The first one is a test of a patient's memory. A quick way to do this is to report three words to the patient, to give them three words like dog, bicycle, and tree.

And then five minutes later, ask the patient to repeat those three words to you. and see if they remember them five minutes later. So a good way to do this is to start with memory, then do the two next sections that I'm going to talk about, and then go back and ask the patient to remember those three words that you brought up to them.

And you can report this as the patient remembering one of the three words, two of the three words, or all three of the words after a five-minute time period. You can also test a patient's concentration. A couple ways to do this. One of them is...

to do serial sevens, which is when a patient starts with the number 100 and subtracts seven consecutively. So you'd expect the patient to say 100, 93, 86, 79, and kind of keep subtracting seven probably five or six times to see if they're able to concentrate on a task like that. Another would be to spell the word world backwards. Also would require them to concentrate on a task to get through all five letters in the correct order. Lastly, you want to test a patient's orientation to person, place, and time.

When you ask a patient about their person, you can ask for their full name and their date of birth. When you ask about the place, you can ask for the state, the town, the current hospital that they're in, the current location, the building and floor, perhaps. If that's relevant, whatever a normal patient would be expected to know would be reasonable to ask. In terms of time, you can ask for the season, the year, the month. Those are usually easier than the day or the date, and that is also whatever would be relevant or whatever would be important for a patient to know.

If they've been in the hospital for a very long time, they might lose track of the day or the date, but they could still be oriented to month and season. And after doing concentration and orientation would be a good time to go back and ask the patient about three words that you asked them to remember to finish up that memory portion of the exam. And that's the entire mental status exam. Here's a summary of it all that might be helpful to keep with some examples of what to do when assessing the different sections of the mental status exam. I hope this was helpful, and thank you for listening.

Transcript for:Understanding the Mental Status Exam (MSE)

Transcript for:
Understanding the Mental Status Exam (MSE)