Mental Status Examination

The mental status examination (MSE) is the detailed account of the present state of mind of a patient and is based upon a series of observations and interview conducted in a standardized format.

MSE is the cornerstone of the psychiatric assessment. While the patient tells his story, the clinician concerns himself with both what the patient says and how s/he says it, and asks himself whether and how the patient by his nature and behavior differs from other people in his environment.

The MSE summarizes the impressions gained by the doctor into the mental functioning of the patient before and also throughout the interview.

Therefore, MSE should be carried out on every patient, and all relevant findings should be documented appropriately. Box X-1 lists down the components of MSE.

1. General Appearance, Attitude, and Behavior (GAAB)

Many times, various important findings can be found in the GAAB (like catatonic symptoms—staring, smiling to self, hallucinatory behavior). Broadly one should note and describe the following things:

• Physical health condition
• Attire, manner of dress worn, hygiene, signs of self-neglect, grooming, odor
• Facial expression—verbal and nonverbal cues
• Any signs of physical illness, drug withdrawal, tremors, scar marks, self-harm scars/cut marks
• Eye-to-eye contact—initiated or not, able to maintain during interview or not
• Attitude toward examiner—cooperative, indifferent, disinterested, etc.
• Motor movements such as dyskinesias, akathisia, stereotype movements (repetitive non-goal directed movements, e.g., rocking to and fro in a chair), mannerisms (idiosyncratic goal-directed movements, e.g., style of walking, frequently raising the eyebrows), echopraxia, and catatonic signs
• Gait and posture maintained during the interview
• Rapport—defined as the instantaneous reciprocal emotional resonance between the patient and the interviewer, whether it was established or not, needs to be mentioned

2. Psychomotor Activity (PMA)

This refers to how the psychic component affect the motor activity. It is usually a goal-directed response involving both motor and psychological components. It is usually described as normal/average, increase, and decreased.

PMA is usually increased in cases of agitation, mania, or hypomania and decreased in cases of depression.

Generalized slowing or bradykinesia due to any medical/neurological/drug-related side effects can also be seen and documented. Thus, mere giving specific attention to PMA can also provide hints to adverse reactions or side effects of medications such as extrapyramidal symptoms.

3. Speech

Speech is described under various subheadings. The rate of speech is described as slowed/rapid. The tone of speech is labeled as “normal” with normal tonal inflections or “monotonous” in the absence of tonal inflections.

Additionally, the amount and volume of speech should be noted. If the rate of speech is more than 150 words per minute, then it is denoted as “pressure of speech” (often occurs in mania and agitated psychosis).

One should also note if the speech was spontaneous or not. Further, the relevance and coherence (i.e., understandability) should be examined and documented.

An important aspect of the interpretation of speech is that the examiner should always compare the patient’s current speech with premorbid level by taking the help of patient’s family members/caregivers and interpret accordingly.

4. Mood and Affect

The mood of the individual is defined as the person’s internal and sustained emotional state while affect is an immediate external expression of mood.

The predominant mood should be noted. The affect is described in terms of quality, quantity, range, appropriateness, and congruence.

Quality of mood and affect are described as happy, cheerful, angry, dysphoric, euthymic, euphoric, etc.

The quantity of affect is a measure of its intensity. The range can be restricted, normal, labile, blunted, or flat.

Appropriateness refers to how the affect correlates to the setting. A patient laughing at a funeral service is an example of inappropriateness of the affect.

Affect can be congruent or incongruent with the described mood and thought content, for example, a patient reporting sadness with smiling is an example of incongruent affect.

5. Thought

Form of thought refers to the disturbance in the arrangement of thoughts or the logical connections between ideas. Disorders of the form of thought Opens in new window are usually recognized from speech and writing.

Disorders of the form of thought are known as formal thought disorder. Common abnormal thought processes are flight of ideas, tangentiality, circumstantiality, perseveration, thought block, neologism, and poverty of speech.

Content of thought is essentially what thoughts are occurring to the patient. Disorders of the content of thought include an abnormality in content or material of thought.

It is explored from the spontaneous expression of the patient as well as responses of the patient to the various questions asked. Some common thought content abnormalities include:

• depressive cognitions (hopelessness, worthlessness),
• self-harm/suicidal thoughts or plans, and
• delusions.

Delusion Opens in new window is a false, unshakable belief that is out of keeping with the patient’s social and cultural background.

Possession of thought: Normally a person feels his/her thoughts are under his control, but sometimes a person loses control of his sense of possession of thinking.

Disorders of possession can be obsessions (recurrent, irrational, intrusive, egodystonic thoughts which the patient is unable to control).

Another type of thought possession is thought alienation which includes:

• thought insertion (thoughts are being inserted by someone from outside),
• thought withdrawal (thoughts are being taken out by someone), and



• thought broadcasting (thoughts are being escaped to the surrounding or being diffused to others due to some mechanism and other persons can hear the thoughts). In thought alienation, the patient has an experience that others are participating in his/her thinking.

6. Perceptual Disturbances

Perceptual disturbances Opens in new window include hallucinations and illusions, depersonalization, and derealization. Hallucination Opens in new window is a perception without external stimuli whereas the illusion Opens in new window is a misinterpretation of a real external stimulus.

While describing a hallucination, the presenter should take into account the type of hallucination one is experiencing, how frequently it occurs and when it occurs (e.g., auditory hallucination occurring while falling asleep is a hypnogogic hallucination and may be normal).

Types of the auditory hallucinations Opens in new window, for example, command hallucinations, third person hallucinations, etc. should be noted. Depersonalization is a felling of unfamiliarity with the self and derealization is feeling that one’s environment is changed.

7. Cognitive Functions

The elements of cognitive functioning that should be assessed are orientation, attention and concentration, memory Opens in new window (both short-term Opens in new window and long-term Opens in new window), intelligence Opens in new window, and abstract reasoning.

A major point to note is that the interviewer should describe in detail the exact procedure of how the cognitive tests will be carried out before asking questions to test cognitive functions.

This is necessary as patients often feel that they are being subjected to silly questions that are unrelated to their problems. So it is of utmost importance to explain to them that it is part of their evaluation process.

• Orientation: The person’s orientation to time, place, and person is assessed by direct questioning about the same (i.e., by asking the time, date, day, month, year, season, and the time spent in hospital, the present location/area, his own name, and whether he can identify people around him). disorientation in time usually precedes disorientation in place and person. First, ask orientation to time, then place and then person, finally check if he can name himself/herself.

• Attention and concentration: Attention is the patient’s ability to attend to a specific stimulus without being distracted by extraneous, internal, or environmental stimuli, and concentration is the sustained attention or the ability to maintain attention to a specific stimulus over an extended period.
  
  A basic and simple test of attention and concentration is asking the patient to repeat the days of the week backward and note how long it takes. Similarly, attention can also be tested by asking the patient to repeat digit forwards and backward, and concentration can be tested by asking serial subtraction of 7 from 100 or 3 from 40 and noting the time taken and mistakes done.
• Memory: Memory in clinical practice is usually assessed as immediate registration and recall, which is short-term memory (within minutes); and recent memory is assessed by asking about the things/events occurred within last few days and remote memory assessed by asking facts that had occurred years before.
  
  — Registration of the patient is tested by asking the patient to repeat three words (e.g., “school, sky, horse”) after the interviewer. The recall is tested by asking the patient to recollect the three words given 3 minutes earlier. Digit forwards and backwards and backward also tests the immediate registration and recall.
  — Recent memory is the patient’s capacity to remember current, day-to-day events (e.g., the current date, the doctor’s name, breakfast, or asking how the patient came to the hospital).
  — Remote memory is the recall of facts or events that occurred years earlier (e.g., names of old school/college, birth dates, and anniversary dates).

• Intelligence: Intelligence   Opens in new window is defined as the ability to think logically, act rationally, and deal effectively with others. It is assessed under the following headings:
  
  — General fund of knowledge: General fund of knowledge should be asked keeping in mind the patient’s socio-economic and educational background as well as his experiences and interests (e.g., the current and the past prime ministers, sarpanch/head of the village, the capital of India, naming any five rivers of the country, naming any five cities of the country, and how to prepare a cup of tea, etc.).
  
  
  — Calculations: The test is done by asking the patient to answer verbally (simple calculations), and by writing/calculating on paper (complex calculations). It should start with addition and then moving to substraction, multiplication, and division and sequentially verbal simple and complex and then written simple and complex.
  
  — Comprehension: Comprehension is the ability to understand and get meaning from spoken and written language. It is assessed by asking the patient to follow a command with a motor response, for example, “Squeeze my fingers.”
• Abstract thinking: Abstract reasoning is the ability to conceptualize or break the whole into its parts and to construct the whole from its parts. It is assessed by asking the similarities and differences between different objects such as apple and banana/car and airplane.

Cultural and educational factors and limitations should be kept in mind when assessing the ability to abstract. Proverb interpretation is another method of testing abstraction.

The patient is asked to tell the meaning of common proverbs in the local language. Based on the answers given, the response could be concrete, semi-abstract, or abstract.

For example, when asked “A stitch on time saves nine,” if the patient replies as:

• √ Stitches can save nine persons—it is concrete thinking.
• √ Appropriate action done at the appropriate time can save us from many untoward events—it is abstract thinking.

8. Insight

Insight Opens in new window refers to the patient’s understanding of whether he/she has an illness, the nature of the illness (i.e., physical or psychological), and if he/she requires any treatment or not.

Depending on the assessment, the insight is divided into six grades. Insight is generally absent in acute psychosis.

Box X-2 lists the various grades of insight and how to ask questions for assessing insight.

9. Judgment

Judgment is the ability of the person to take correct decisions and act effectively on them. It has two parts: social judgment and test judgment.

• The social judgment includes how the patient behaves during the interview, that is, if he/she has basic knowledge of the socially appropriate responses in social situations or not.
• The test judgment is assessed by asking the person how s/he would react if placed in a hypothetical/realistic situation like “What you would do if your house gets on fire?” or “What would you do if you find the tap is overflowing the bucket?” It is usually described as normal or impaired.

Ending the Psychiatric Interview

After a detailed history and mental state examination, the interviewer should not end the interview abruptly. The patient should be asked, “Is there any issues left which the patient wants to discuss?” The patient should be given a chance to ask questions. The patient should be informed about the summary of the diagnosis and treatment options available.