Day # 5: Intro to the Mental Status Exam

Welcome back. Today we are going to take a quick one day break from our current theme of psychotic disorders. We will be discussing the Mental Status Exam (MSE). It is essential that we cover this topic early on, because every theme from here on out will include one day that will discuss the relevant features of the mental status exam that are specific to that theme (psychotic disorders, mood disorders, anxiety disorders, etc...). Next week we will get back on track and discuss relevant MSE topics specific for psychotic disorders.


Today's Content Level: Beginner


Intro to Mental Status Exam


•When you think about a physical examination you probably picture a physician with a stethoscope listening to a patients heart and lung sounds, testing movement, and trying to elicit a tendon reflex.


•Each speciality within the medical field has their own aspects of the physical exam that they focus on.


•In addition to the traditional medical exam, for us practicing in behavioral health, the mental status exam (MSE) is the psychiatric/psychological equivalent of the physical examination.


•It is a "moment in time" snapshot of the current mental state of the patient and attempts to do this systematically by observing and commenting on the following components.


Elements of the Mental Status Exam


Appearance: General description of how the patient looks during the interview. Write with the goal of later being able to reconjure the person's most salient features during that exam. Consider gender, appeared age, notable weight (obese, cachexia), appropriate or inappropriate dress, grooming, notable smell, unusual skin markings or accessories, etc...


Behavior: Typically includes a general statement regarding if the patient appears in acute distress. It then goes on to describe the patients approach/attitude to the interview (cooperative, agitated, disinterested, etc..). Include relevant motor activity such as slowed (bradykinisea), agitated, or notable postures, gait, and movements such as tremors or involuntary movements.


Speech/Language: Elements considered include fluency (command of spoken language, stuttering, word finding difficulties), amount (normal, increased, decreased), rate (slowed or pressured), prosody (intonation, tone, rhythm), volume, or unusual language (made up words or words used incorrectly).


Mood: Often includes the interviewee's own words: "How would you describe your mood today?" The purpose being to capture an immediate subjective state of the interviewee. Terms such as "sad", "angry", "guilty", or "anxious" are common descriptions of mood.


Affect: Affect is different from mood in that it is the clinicians observation of the emotional state. Elements are often described with the following: quality, range, stability, appropriateness, and congruence. These elements will be explored in detail when we discuss relevant pointers in the mental status exam for each theme (psychosis, mood disorders, anxiety disorders, etc...). Some examples include constricted, blunted, flat, guarded, appropriateness to situation, dysphoric, euthymic, euphoric, irritable, labile, etc...


*A number of authors have recommended combining the two elements (mood and affect) into a new label termed "emotional expression".


Thought process: This is the flow and form of thought (see below to compare with thought content). A normal thought process is linear, logical, and goal-directed. Deviations from this normal thought process are often seen in various behavioral health disorders. Again, this will be expanded upon during further themes, but examples include disorganized, inhibition, thought blocking, tangentiality, circumferential, perseverations, etc... See next weeks lessons on pertinent features in psychotic disorders.


Thought content: This is essentially what thoughts are occurring to the patient as inferred by what the patient spontaneously expresses as well as responses to specific questions. Types of content typically documented are relevant information to include suicidal or violent or homicidal ideations/plans/intent, paranoia, obsessions, compulsions, and delusions.


Perceptual Disturbances: These include hallucinations (visual, auditory, somatic, etc...), illusions (altered perception of something that is actually present), depersonalization (thoughts and feelings seem unreal or not belonging to oneself, loss of identity, out of body experiences) and derealization (things or people do not seem real, related to the environment as opposed to the self).


Cognition: For many patients this is a general sense of cognitive function obtained through conversation, however in certain patients (altered mental status, severe depression, neurocognitive disorders) a more formal assessment should be performed and assess alertness, orientation concentration, memory, calculation, fund of knowledge, intelligence, abstract reasoning, insight, and judgement. This will be covered extensively during the neurocognitive theme. In the meantime feel free to see the Mini Mental Status Exam (MMSE) or the Montreal Cognitive Assessment (MoCA) for a more in depth cognitive assessment.


Insight: The patients understanding of how they are feeling, presenting, and functioning as well as the potential causes of his or her psychiatric presentation.

Do they attribute their symptoms to a mental disorder or are they unconvinced of a problem? Rated as intact, fair, limited, or impaired and provide rational for doing so.


Judgement: This refers to the person's capacity to make good decisions and act on them. This may or may not correlate to the level of insight. During the assessment consider proposing a real-life challenge to the interviewee such as a work/home based scenario and assess planning, self-awareness, safety, and consideration of consequences. Is the patient doing things that are dangerous or going to get them in trouble? Are they able to effectively participate in his or her own care? Rated as intact, fair, limited, or impaired and provide rational for doing so.


Conclusion


Congratulations! You have finished your first week of Bullet Psych material. Todays lesson was not a comprehensive review of the mental status exam, but rather an introduction. Your knowledge of the MSE will expand greatly if you continue to read our daily articles as we will dedicate one day during each theme to cover relevant MSE topics.


Take a two day break from Bullet Psych material. Use this time to rest and recover, dig deeper into a clinical question posed by one of your patients, or explore our recommended resources. We will see you back in a few days. We will, as always, start the week with a "week in review"to remind you of past lessons and then the next lesson will be focused on the mental status exam in psychotic spectrum disorders.


Resources for today include Kaplan and Sadocks Synopsis of Psychiatry and Pocket Psychiatry.












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