What does a mental status exam assess what is its outcome?

Summary

The mental status examination (MSE) is an important diagnostic tool in both neurological and psychiatric practice. MSE is used to describe a patient's mental state and behaviors, both quantitatively and qualitatively, at a specific point in time. The main components of an MSE are appearance and behavior, mood and affect, speech, thought process and content, perceptual disturbances, sensorium and cognition, and insight and judgment. The clinician conducting an MSE collects data by observing the interviewed individual's behavior and asking specific questions. The findings of the MSE summarize the results of a psychiatric examination on a comprehensive, cross-sectional level. When integrated with the interviewee's biographical information and psychiatric history, MSE findings form the basis for diagnostic and therapeutic decisions. A thorough MSE also provides essential information for establishing a diagnosis according to DSM-5 criteria.

When conducting the MSE or interpreting MSE findings, it is important to consider the cultural background of both the clinician conducting the MSE and the interviewee because behavioral patterns vary significantly across cultures (e.g., nodding your head as a sign of approval in some countries might signify disagreement in others). Other factors that should be taken into account when conducting an MSE include the religious, educational, and social backgrounds of the interviewed individuals. Similarly, the clinician should be aware of any potential language barriers. The MSE is not to be confused with the Mini-Mental State Examination (MMSE), which is a screening tool for dementia but can also be used as part of the MSE to assess sensorium and cognition.

General structure

Appearance and behavior

Behavior

Abnormal motor activity

• Abnormal movements: See “Examination of the motor system” and “Muscle appearance” in neurological examination.
• Gait: See gait assessment in neurological examination for more information.
• Apraxia: difficulty performing targeted, voluntary movements despite an intact motor function and the willingness to perform the movement

Sensorium and cognition

Orientation to person, place, and time

Level of consciousness

• Level of consciousness is a person's level of arousability and response to external stimuli (e.g., verbal, painful stimuli).
• It is typically assessed by evaluating the patient's response to external stimuli and can be described using the following:
  • Alertness (consciousness)
    • A state of awareness of oneself and the surrounding environment
    • Considered a normal finding
  • Somnolence
    • A state of drowsiness from which a patient can be easily aroused
    • The patient responds normally except for a slight delay when addressed.
  • Lethargy
    • A state of impaired consciousness and drowsiness from which the patient can be awoken if exposed to moderate stimuli [3]
    • The patient has decreased interest in the surrounding environment and tends to fall back asleep after being aroused.
  • Obtundation
    • A state of impaired consciousness characterized by increased sleepiness and a slow response to external stimuli
    • Similar to lethargy, the patient has a decreased interest in the surrounding environment and experiences drowsiness between the sleeping episodes.
  • Stupor
    • A state of insensitivity bordering on unconsciousness; from which the patient is not easily awoken, except if exposed to strong external stimuli,; (e.g., sternal rub) and into which the patient returns in the absence of further stimulation
    • Communication is not possible and a painful stimulus provokes a withdrawal response.
  • Coma
    • A state of complete unarousable unresponsiveness regardless of the stimulus, typically lasting for 2–4 weeks [4]
    • A comatose state is characterized by closed eyes and decreased/absent reflex responses and motor activity, but preserved circulatory function and breathing drive.
  • Delirium
    • A transient loss of consciousness, cognitive function, and psychomotor behavior that is usually the result of an underlying medical condition (e.g., acute kidney injury)
    • See delirium for more information.
• A quantitative assessment of consciousness is more likely to be used in clinical settings because it provides a more objective assessment of the patient's level of consciousness.
• Glasgow Coma Scale (GCS): A common neurological scoring scale used for the evaluation of consciousness in acute settings (especially after head injury) and sometimes for monitoring patients in the ICU.
  • Patient's verbal, motor, and eye-opening responses are scored on a scale of 1–6 points; 1 point denotes a complete lack of response and 6 points denotes normal findings.
  • See “Diagnostics” in traumatic brain injury for more information.

Cognition

Cognition is the mental process of gaining knowledge and understanding via thinking, experiencing, and sensing, and includes many aspects listed below. The assessment of cognitive function during an MSE is usually performed using screening tools such as the MMSE and/or the Saint Louis University Mental Status Examination (SLUMS). (See “Cognitive assessment” in major neurocognitive disorder for more information.)

• Attention (cognition) and concentration
  • The ability of an individual to focus and sustain their thoughts on a specific task/topic
  • Can be assessed by asking the patient to spell a word backward or count in twos
• Memory (cognition)
  • The process of recalling information
  • Classified according to the length of time a particular piece of information can be recalled.
    • Sensory (immediate) memory (registration)
      • The shortest type of information storage
      • Can be assessed by asking the patient to repeat a set of numbers or words in the original order
    • Short-term memory
      • Information is stored for a few minutes in order to be processed and used while performing a task
      • Can be assessed by asking the patients to look at a set of numbers/words/images for a couple of seconds, and then asking them to recall the items 5 minutes later
    • Long-term memory
      • Information is stored for days to years
      • Can be assessed by asking the patient about an objectively verifiable personal or historical fact (e.g., date of marriage, a former president's name)
  • Amnesia: loss of memory
    • Retrograde amnesia: inability to recall memories and/or information acquired prior to the incident
    • Anterograde amnesia: inability to recall memories and/or information acquired after the incident
    • Global amnesia: inability to recall memories and/or information acquired prior to and after the incident
  • Confabulation: filling in lapses of memory with fabricated events, without the intention of deceiving the interviewer
• Calculation
  • The ability to perform simple calculations, according to the patient's level of education
  • Can be assessed by asking the patient to continuously subtract 7 starting from 100
  • Acalculia: inability to perform simple calculations (usually a sign of parietal lobe lesions)
• Language: see “Language” section below.
• Fund of knowledge
  • The amount of general information an individual stores in their long-term memory
  • Can increase with education; decreases in a number of conditions (e.g., dementia)
  • Can be assessed by asking the patient to name the last five presidents or the state capital
• Abstract reasoning
  • The ability to analyze information, detect patterns and connections between different pieces of data, and apply that knowledge to practice
  • Can be assessed by asking the patient to find the similarities between objects (e.g., the similarities between a triangle and a square)
• Executive function
  • A set of cognitive functions that allows an individual to plan, evaluate, and execute new and complex tasks
  • Can be assessed by using neuropsychological tests, such as the Wisconsin Card Sorting Test or the clock drawing test [5]

Language

Mood and affect

Speech

• Speech is the spontaneous production of the spoken language (i.e., the act of speaking ) and is characterized by the following:
  • Rate: rapid, normal, slow, or pressured
  • Volume: loud, normal, soft, or whispered
  • Quantity: logorrheic, talkative, responsive, or reserved
  • Articulation and fluency: incomprehensible, accented, stuttered, lisping, mumbled, slurred, clear, or articulated
  • Speech latency: increased, decreased, or no latency
• Because speech impairment is characteristic of a large number of conditions, it is an important diagnostic tool.
  • Individuals with depression may have soft, almost incomprehensible speech with increased latency.
  • Individuals in a manic state are often logorrheic and speak loudly and extremely fast.
  • Individuals with schizophrenia usually have disorganized, incomprehensible speech.
• Some of the speech abnormalities that can be observed during an MSE include:
  • Mutism: an inability to speak that is caused by a structural or motor dysfunction of the vocal apparatus or that is the result of an individual's unwillingness to speak despite having an intact vocal apparatus (e.g., akinetic mutism)
  • Dysarthria: the impaired articulation of words resulting from motor dysfunction of the vocal apparatus
  • Echolalia: the involuntary repetition of another person's speech
  • Palilalia: the involuntary repetition of words or phrases with increasing rapidity
  • Alogia/poverty of speech: impaired thinking that manifests with reduced speech output (e.g., always replying to questions with one-word answers)
  • Pressured speech: accelerated thoughts that are expressed as rapid, loud, and voluminous speech often in the absence of social stimulation
  • Neologisms: the creation and use of new words that are only understood by the speaker (e.g., Pepsidiction =Pepsi + addiction, Spritependency =Sprite + dependency)
  • Word salad: incoherent thinking expressed as a sequence of words without a logical connection
    • Characteristic of schizophrenia and dementia
    • Example: “They’re destroying too many cattle and oil just to make soap. If we need soap when you can jump into a pool of water, and then when you go to buy your gasoline, my folks always thought they should get pop but the best thing to get is motor oil and money.” [6]

Thought process

Thought content

Delusions

• Delusions are fixed, false beliefs (unrelated to one's religious beliefs or culture) that are maintained despite being contradicted by reality or rational arguments.
• All delusions can be classified as either:
  • Bizarre delusions: delusions that cannot be true or are inconsistent with the patient's social and cultural norms (e.g., a patient insisting that they can fly)
  • Nonbizarre delusions: delusions that could be true or are consistent with the patient's social and cultural norms (e.g., a patient insisting that they have won the lottery when this is not the case)
• Based on their mood congruence, delusions can be classified as either:
  • Mood congruent delusions: the content of delusions is consistent with the patient's current mood (e.g., a manic patient insisting they have special powers)
  • Mood incongruent delusions: the content of delusions is not consistent with the patient's current mood (e.g., a patient having a manic episode insisting that they are being chased by a murderer)

To remember the different types of delusions (Grandiosity, Erotomanic, Ideas of reference, Paranoid, Persecutory, Somatic, Jealousy), think: “Grand, Erotic Ideas can cause Paranoia, Persecution and So much (so-ma-tic) Jealousy.”

Suicidal and homicidal ideation

• Suicidal ideation: any type of thoughts that an individual has regarding ending their own life (see suicide for more details)
• Homicidal ideation: thoughts regarding ending someone else's life
• Assessment
  • Ask the patient if they sometimes feel that life is not worth living and if they have ever felt the desire to harm other people.
  • Can range from a brief consideration of the act to concrete planning of the time, place, and/or method of suicide/homicide.
    • Assess the threat (organized plan, access to weapons).
    • Admit the patient involuntarily if they refuse medical care.
    • In homicidal threats, inform the authorities and the threatened individual.

Perceptual disturbances

Perceptual disturbances are characterized by disruption in perception, which may be caused by physical and/or mental disorders.

Hallucinations

• Hallucinations are a type of perceptual abnormality in which sensory experiences occur in the absence of external stimuli.
• Can be assessed by asking the patient if they ever hear, see, feel, smell, or taste things that other individuals do not.
• Some of the most common causes of hallucinations include:
  • Substance abuse
  • Delirium or dementia
  • Epilepsy
  • Fever (especially in children and the elderly)
  • Narcolepsy
  • Schizophrenia
  • Sensory impairment (e.g., deafness, blindness)

Illusions

• Perceptual disturbancescharacterized by inaccurate perception (distortion) of real sensory input (e.g., perceiving a stationary object as being in motion)
• Assess by asking the patient whether they sometimes misinterpret real things around them, such as shadows or faint noises
• Similar to hallucinations, illusions can be categorized according to the misinterpreted sensory input as visual, auditory, tactile, olfactory, and gustatory.
• Although illusions are characteristic of some mental disorders (e.g., schizophrenia), most illusions are physiological in nature and generated by each individual's perceptive assumptions based on their psychological profile (e.g., influenced by darkness, fatigue, or under the influence of drugs or alcohol).

Hemineglect (also known as unilateral neglect or spatial neglect)

• Hemineglect is the impaired ability to perceive and respond to different types of stimuli coming from one side of the body usually due to a brain unilateral injury (most commonly strokes).
• Typically associated with right hemisphere damage resulting in neglect (esp. visual) of the left side [15]
• The lesion is usually contralateral to the side where the perception is absent
• Can be tested by asking to copy a figure, draw the face of a clock, cancel symbols on a paper, etc. An individual with hemineglect is only able to copy the part of the image or cancel symbols on the perceived side.
• Common types:
  • Motor neglect
  • Sensory or perceptual neglect

Insight and judgment

What is the outcome of a mental status exam?

What are 4 things that the Mental Status test evaluate?

How do you assess patients Mental Status?