Mental status examination
Encyclopedia
The mental status examination in the USA or mental state examination in the rest of the world, abbreviated MSE, is an important part of the clinical assessment
process in psychiatric practice. It is a structured way of observing and describing a patient
's current state of mind
, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.
The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history
, allows the clinician to make an accurate diagnosis
and formulation, which are required for coherent treatment planning.
The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests
.
The MSE is not to be confused with the mini-mental state examination
(MMSE), which is a brief neuro-psychological screening test for dementia
.
known as descriptive psychopathology or descriptive phenomenology
which developed from the work of the philosopher and psychiatrist Karl Jaspers
. From Jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives.
In practice, the MSE is a blend of empathic descriptive phenomenology and empirical
clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective
descriptions of a psychiatric patient (a synonym for signs
and symptom
s), is incompatible with the original meaning which was concerned with comprehending a patient's subjective
experience.
setting.
It is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting.
It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination
performed by physician
s and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example by paramedics or emergency department
staff.
The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.
, while unkempt, dirty clothes might suggest schizophrenia
or depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture, body modification
s, or clothing not typical of the patient's gender, might give clues to personality
. Observations of physical appearance might include the physical features of alcoholism
or drug abuse
, such as signs of malnutrition
, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal hygiene
due to extreme self-neglect, or alcohol intoxication.Gelder, Mayou & Geddes (2005) tells us to look out for weight loss. This could signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety.
, refers to the patient's approach to the interview process and the interaction with the examiner. The patient's attitude may be described for example as cooperative, uncooperative, hostile, guarded, suspicious or regressed
. The most subjective element of the mental status examination, attitude depends on the interview situation, the skill and behaviour of the clinician, and the pre-existing relationship between the clinician and the patient. However, attitude is important for the clinician's evaluation of the quality of information obtained during the assessment.
and gait
. Abnormal movements, for example choreiform
, athetoid or choreoathetoid
movements may indicate a neurological
disorder. A tremor
or dystonia
may indicate a neurological condition or the side effects of antipsychotic
medication. The patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette's syndrome. There are a range of abnormalities of movement which are typical of catatonia
, such as echopraxia
, catalepsy
, waxy flexibility
and paratonia
(or gegenhalten). Stereotypies (repetitive purposeless movements such a rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism
. More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation
or hyperactivity) which might reflect mania
or delirium
. An inability to sit still might represent akathisia
, a side effect of antipsychotic medication. Similarly a global decrease in arousal and movement (described as psychomotor retardation
, akinesia or stupor
) might indicate depression or a medical condition such as Parkinson's disease
, dementia
or delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient's emotional state). Lack of eye contact may suggest autism.
and affect
in the MSE is subject to some disagreement. For example Trzepacz and Baker (1993) describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims (1995) refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation.
Mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may be suffering from anhedonia
.
Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. For example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. The intensity of the affect may be described as normal, blunted, exaggerated, flat, heightened or overly dramatic. A flat or blunted affect
is associated with schizophrenia, depression or post-traumatic stress disorder
; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorder
s. Mobility refers to the extent to which affect changes during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one's disability may be described as showing belle indifférence, a feature of conversion disorder
, which is historically termed "hysteria
" in older texts.
This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought form and thought content (see below).
When observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic
features such as the loudness, rhythm, prosody
, intonation
, pitch, phonation
, articulation
, quantity, rate, spontaneity and latency of speech.
A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests form part of the mini-mental state examination
. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see below).
Language assessment will allow the recognition of medical conditions presenting with aphonia
or dysarthria
, neurological conditions such as stroke
or dementia
presenting with aphasia
, and specific language disorders such as stuttering
, cluttering
or mutism. People with autism or Asperger syndrome
may have abnormalities in paralinguistic and pragmatic
aspects of their speech. Echolalia
(repetition of another person's words) and palilalia
(repetition of the subject's own words) can be heard with patients with autism
, schizophrenia or Alzheimer's disease
. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them.
Speech assessment also contributes to assessment of mood, for example people with mania or anxiety
may have rapid, loud and pressured speech; on the other hand depressed
patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.
Thought
process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. Regarding the tempo of thought, some people may experience flight of ideas, when their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a chain of poetic associations in the patient's speech. Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and thought perseveration
refers to a pattern where a person keeps returning to the same limited set of ideas. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight's move thinking. Thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic.
Flight of ideas is typical of mania. Conversely, patients with depression may have retarded or inhibited thinking. Poverty of thought is one of the negative symptoms of schizophrenia, and might also be a feature of severe depression or dementia
. A patient with dementia might also experience thought perseveration. Formal thought disorder is a common feature of schizophrenia. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders.
A delusion can be defined as "a false, unshakeable idea or belief which is out of keeping with the patient's educational, cultural and social background ... held with extraordinary conviction and subjective certainty", and is a core feature of psychotic disorders. The patient's delusions may be described as persecutory or paranoid delusions
, delusions of reference, grandiose delusions
, erotomanic delusions, delusional jealousy
or delusional misidentification
. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychoses
, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal
, thought insertion
, thought broadcasting
, and somatic passivity. Schneiderian first rank symptoms
are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses
.
An overvalued idea is a false belief that is held with conviction but not with delusional intensity. Hypochondriasis is an overvalued idea that one is suffering from an illness, dysmorphophobia is an overvalued idea that a part of one's body is abnormal, and people with anorexia nervosa
may have an overvalued idea of being overweight.
An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In obsessive-compulsive disorder
, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes).
A phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview.
Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include thoughts of suicide
, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortion
s of anxiety and depression.
The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life.
in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucination
s and illusion
s. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as "voices in my head") and is regarded as akin to fantasy.
Other sensory abnormalities include a distortion of the patient's sense of time, for example déjà vu
, or a distortion of the sense of self (depersonalization
) or sense of reality (derealization
).
Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations.
Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the patient) and hearing one's thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the Schneiderian first rank symptoms
indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression
or schizophrenia. Visual hallucinations are generally suggestive of organic conditions such as epilepsy
, drug intoxication
or drug withdrawal. Many of the visual effects of hallucinogenic drugs are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations are suggestive of dissociative disorders
. Déjà vu, derealization and depersonalization are associated with temporal lobe epilepsy
and dissociative disorders.
, orientation
, attention
, memory
, visuospatial functioning, language
functions and executive functions
. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation.
Alertness is a global observation of level of consciousness i.e. awareness of, and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporose. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by the serial sevens
test (or alternatively by spelling a five-letter word backwards), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. Executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter F, in one minute"). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE.
Mild impairment of attention and concentration may occur in any mental illness
where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain
functioning such as delirium, dementia or intoxication. Specific language abnormalities may be associated with pathology in Wernicke's area
or Broca's area
of the brain. In Korsakoff's syndrome
there is dramatic memory impairment with relative preservation of other cognitive functions.
Visuospatial or constructional abnormalities here may be associated with parietal lobe
pathology, and abnormalities in executive functioning tests may indicate frontal lobe
pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing.
The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-stone").
The posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles.
The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed.
A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again.
Pathology in the basal ganglia
may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements.
A lesion in the posterior fossa
can be detected by asking the patient to roll his or her eyes upwards (Perinaud's sign).
Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries
, tumors
or other brain disorders.
can be said to have three components: recognition that one has a mental illness, compliance
with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively.
Impaired insight is characteristic of psychosis
and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent
to treatment.
, self-awareness and planning ability.
Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe
of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others.
context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations - without understanding may seem similar though they have different roots. Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder.
Psychiatric assessment
A psychiatric assessment, or psychological screening, is a process of way of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for...
process in psychiatric practice. It is a structured way of observing and describing a patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
's current state of mind
Mind
The concept of mind is understood in many different ways by many different traditions, ranging from panpsychism and animism to traditional and organized religious views, as well as secular and materialist philosophies. Most agree that minds are constituted by conscious experience and intelligent...
, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.
The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history
Psychiatric history
A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient...
, allows the clinician to make an accurate diagnosis
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
and formulation, which are required for coherent treatment planning.
The data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests
Psychological testing
Psychological testing is a field characterized by the use of samples of behavior in order to assess psychological construct, such as cognitive and emotional functioning, about a given individual. The technical term for the science behind psychological testing is psychometrics...
.
The MSE is not to be confused with the mini-mental state examination
Mini-mental state examination
The mini–mental state examination or Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is commonly used in medicine to screen for dementia...
(MMSE), which is a brief neuro-psychological screening test for dementia
Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
.
Theoretical foundations
The MSE derives from an approach to psychiatryPsychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
known as descriptive psychopathology or descriptive phenomenology
Phenomenology (psychology)
Phenomenology is an approach to psychological subject matter that has its roots in the philosophical work of Edmund Husserl. Early phenomenologists such as Husserl, Jean-Paul Sartre, and Maurice Merleau-Ponty conducted their own psychological investigations in the early 20th century...
which developed from the work of the philosopher and psychiatrist Karl Jaspers
Karl Jaspers
Karl Theodor Jaspers was a German psychiatrist and philosopher who had a strong influence on modern theology, psychiatry and philosophy. After being trained in and practicing psychiatry, Jaspers turned to philosophical inquiry and attempted to discover an innovative philosophical system...
. From Jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives.
In practice, the MSE is a blend of empathic descriptive phenomenology and empirical
Empiricism
Empiricism is a theory of knowledge that asserts that knowledge comes only or primarily via sensory experience. One of several views of epistemology, the study of human knowledge, along with rationalism, idealism and historicism, empiricism emphasizes the role of experience and evidence,...
clinical observation. It has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective
Objectivity (philosophy)
Objectivity is a central philosophical concept which has been variously defined by sources. A proposition is generally considered to be objectively true when its truth conditions are met and are "mind-independent"—that is, not met by the judgment of a conscious entity or subject.- Objectivism...
descriptions of a psychiatric patient (a synonym for signs
Medical sign
A medical sign is an objective indication of some medical fact or characteristic that may be detected by a physician during a physical examination of a patient....
and symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s), is incompatible with the original meaning which was concerned with comprehending a patient's subjective
Subjectivity
Subjectivity refers to the subject and his or her perspective, feelings, beliefs, and desires. In philosophy, the term is usually contrasted with objectivity.-Qualia:...
experience.
Application
The mental status examination is a core skill of psychiatrists, psychologists,Occupational therapist, physician assistants, nurse practitioners and other qualified mental health personnel. It is a key part of the initial psychiatric assessment in an out-patient or psychiatric hospitalPsychiatric hospital
Psychiatric hospitals, also known as mental hospitals, are hospitals specializing in the treatment of serious mental disorders. Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients...
setting.
It is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting.
It is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. The MSE can also be considered part of the comprehensive physical examination
Physical examination
Physical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
performed by physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. Information is usually recorded as free-form text using the standard headings, but brief MSE checklists are available for use in emergency situations, for example by paramedics or emergency department
Emergency department
An emergency department , also known as accident & emergency , emergency room , emergency ward , or casualty department is a medical treatment facility specialising in acute care of patients who present without prior appointment, either by their own means or by ambulance...
staff.
The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan.
Appearance
Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. Colorful or bizarre clothing might suggest maniaMania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...
, while unkempt, dirty clothes might suggest schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
or depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture, body modification
Body modification
Body modification is the deliberate altering of the human body for any non-medical reason, such as aesthetics, sexual enhancement, a rite of passage, religious reasons, to display group membership or affiliation, to create body art, shock value, or self expression...
s, or clothing not typical of the patient's gender, might give clues to personality
Personality psychology
Personality psychology is a branch of psychology that studies personality and individual differences. Its areas of focus include:* Constructing a coherent picture of the individual and his or her major psychological processes...
. Observations of physical appearance might include the physical features of alcoholism
Alcoholism
Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker's health, personal relationships, and social standing...
or drug abuse
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
, such as signs of malnutrition
Malnutrition
Malnutrition is the condition that results from taking an unbalanced diet in which certain nutrients are lacking, in excess , or in the wrong proportions....
, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal hygiene
Hygiene
Hygiene refers to the set of practices perceived by a community to be associated with the preservation of health and healthy living. While in modern medical sciences there is a set of standards of hygiene recommended for different situations, what is considered hygienic or not can vary between...
due to extreme self-neglect, or alcohol intoxication.Gelder, Mayou & Geddes (2005) tells us to look out for weight loss. This could signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety.
Attitude
Attitude, also known as rapportRapport
Rapport is a term used to describe, in common terms, the relationship of two or more people who are in sync or on the same wavelength because they feel similar and/or relate well to each other....
, refers to the patient's approach to the interview process and the interaction with the examiner. The patient's attitude may be described for example as cooperative, uncooperative, hostile, guarded, suspicious or regressed
Regression (psychology)
Regression, according to psychoanalyst Sigmund Freud, is a defense mechanism leading to the temporary or long-term reversion of the ego to an earlier stage of development rather than handling unacceptable impulses in a more adult way...
. The most subjective element of the mental status examination, attitude depends on the interview situation, the skill and behaviour of the clinician, and the pre-existing relationship between the clinician and the patient. However, attitude is important for the clinician's evaluation of the quality of information obtained during the assessment.
Behavior
Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contactEye contact
Eye contact is a meeting of the eyes between two individuals.In human beings, eye contact is a form of nonverbal communication and is thought to have a large influence on social behavior. Coined in the early to mid-1960s, the term has come in the West to often define the act as a meaningful and...
and gait
Gait (human)
Human gait is the way locomotion is achieved using human limbs. Different gaits are characterized by differences in limb movement patterns, overall velocity, forces, kinetic and potential energy cycles, and changes in the contact with the surface .- Foot strike :One variable in different gaits is...
. Abnormal movements, for example choreiform
Chorea (disease)
Choreia is an abnormal involuntary movement disorder, one of a group of neurological disorders called dyskinesias. The term choreia is derived from the Greek word χορεία , see choreia , as the quick movements of the feet or hands are vaguely comparable to dancing or piano playing.The term...
, athetoid or choreoathetoid
Choreoathetosis
Choreoathetosis is the occurrence of involuntary movements in a combination of chorea and athetosis ....
movements may indicate a neurological
Neurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...
disorder. A tremor
Tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...
or dystonia
Dystonia
Dystonia is a neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. The disorder may be hereditary or caused by other factors such as birth-related or other physical trauma, infection, poisoning or reaction to...
may indicate a neurological condition or the side effects of antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
medication. The patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette's syndrome. There are a range of abnormalities of movement which are typical of catatonia
Catatonia
Catatonia is a state of neurogenic motor immobility, and behavioral abnormality manifested by stupor. It was first described in 1874: Die Katatonie oder das Spannungsirresein ....
, such as echopraxia
Echopraxia
Echopraxia is the involuntary repetition or imitation of the observed movements of another. It is closely related to echolalia, the involuntary repetition of another's speech. The etymology of the term is from Ancient Greek: "ἠχώ from ἠχή " and "πρᾶξις "...
, catalepsy
Catalepsy
Catalepsy is also a term used by hypnotists to refer to the state of making a hypnotised subject's arm, leg or back rigid. "Arm catalepsy" is often a pre-hypnotic test performed prior to an induction into a full trance.-Causes:...
, waxy flexibility
Waxy flexibility
Waxy flexibility is a psychomotor symptom of catatonic schizophrenia which leads to a decreased response to stimuli and a tendency to remain in an immobile posture....
and paratonia
Paratonia
Paratonia or gegenhalten is classified as a form of hypertonia with an involuntary variable resistance during passive movement . Paratonia develops during a period of dementia and the degree of effect is dependent upon the disease's progress...
(or gegenhalten). Stereotypies (repetitive purposeless movements such a rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism
Autism
Autism is a disorder of neural development characterized by impaired social interaction and communication, and by restricted and repetitive behavior. These signs all begin before a child is three years old. Autism affects information processing in the brain by altering how nerve cells and their...
. More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation
Psychomotor agitation
Psychomotor agitation is a series of unintentional and purposeless motions that stem from mental tension and anxiety of an individual. This includes pacing around a room, wringing one's hands, pulling off clothing and putting it back on and other similar actions...
or hyperactivity) which might reflect mania
Mania
Mania, the presence of which is a criterion for certain psychiatric diagnoses, is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. In a sense, it is the opposite of depression...
or delirium
Delirium
Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior...
. An inability to sit still might represent akathisia
Akathisia
Akathisia, or acathisia, is a syndrome characterized by unpleasant sensations of inner restlessness that manifests itself with an inability to sit still or remain motionless...
, a side effect of antipsychotic medication. Similarly a global decrease in arousal and movement (described as psychomotor retardation
Psychomotor retardation
Psychomotor retardation involves a slowing-down of thought and a reduction of physical movements in an individual. Psychomotor retardation can cause a visible slowing of physical and emotional reactions, including speech and affect...
, akinesia or stupor
Stupor
Stupor is the lack of critical cognitive function and level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain. This is often mistaken for delirium and treated with Haldol and or other anti-psychotic drugs...
) might indicate depression or a medical condition such as Parkinson's disease
Parkinson's disease
Parkinson's disease is a degenerative disorder of the central nervous system...
, dementia
Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
or delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient's emotional state). Lack of eye contact may suggest autism.
Mood and affect
The distinction between moodMood (psychology)
A mood is a relatively long lasting emotional state. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event....
and affect
Affect (psychology)
Affect refers to the experience of feeling or emotion. Affect is a key part of the process of an organism's interaction with stimuli. The word also refers sometimes to affect display, which is "a facial, vocal, or gestural behavior that serves as an indicator of affect" .The affective domain...
in the MSE is subject to some disagreement. For example Trzepacz and Baker (1993) describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims (1995) refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation.
Mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable to describe their subjective mood state. An individual who is unable to experience any pleasure may be suffering from anhedonia
Anhedonia
In psychology and psychiatry, anhedonia is defined as the inability to experience pleasure from activities usually found enjoyable, e.g. hobbies, exercise, social interaction or sexual activity....
.
Blunted affect
Blunted affect is the scientific term describing a lack of emotional reactivity on the part of an individual. It is manifest as a failure to express feelings either verbally or non-verbally, even when talking about issues that would normally be expected to engage the emotions...
is associated with schizophrenia, depression or post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorder
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
s. Mobility refers to the extent to which affect changes during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile. The person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. The affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland lack of concern for one's disability may be described as showing belle indifférence, a feature of conversion disorder
Conversion disorder
Conversion disorder is a condition in which patients present with neurological symptoms such as numbness, blindness, paralysis, or fits without a neurological cause. It is thought that these problems arise in response to difficulties in the patient's life, and conversion is considered a psychiatric...
, which is historically termed "hysteria
Hysteria
Hysteria, in its colloquial use, describes unmanageable emotional excesses. People who are "hysterical" often lose self-control due to an overwhelming fear that may be caused by multiple events in one's past that involved some sort of severe conflict; the fear can be centered on a body part, or,...
" in older texts.
Speech
The patient's speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions.This heading is concerned with the production of speech rather than the content of speech, which is addressed under thought form and thought content (see below).
When observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic
Paralanguage
Paralanguage refers to the non-verbal elements of communication used to modify meaning and convey emotion. Paralanguage may be expressed consciously or unconsciously, and it includes the pitch, volume, and, in some cases, intonation of speech. Sometimes the definition is restricted to...
features such as the loudness, rhythm, prosody
Prosody (linguistics)
In linguistics, prosody is the rhythm, stress, and intonation of speech. Prosody may reflect various features of the speaker or the utterance: the emotional state of the speaker; the form of the utterance ; the presence of irony or sarcasm; emphasis, contrast, and focus; or other elements of...
, intonation
Intonation (linguistics)
In linguistics, intonation is variation of pitch while speaking which is not used to distinguish words. It contrasts with tone, in which pitch variation does distinguish words. Intonation, rhythm, and stress are the three main elements of linguistic prosody...
, pitch, phonation
Phonation
Phonation has slightly different meanings depending on the subfield of phonetics. Among some phoneticians, phonation is the process by which the vocal folds produce certain sounds through quasi-periodic vibration. This is the definition used among those who study laryngeal anatomy and physiology...
, articulation
Manner of articulation
In linguistics, manner of articulation describes how the tongue, lips, jaw, and other speech organs are involved in making a sound. Often the concept is only used for the production of consonants, even though the movement of the articulars will also greatly alter the resonant properties of the...
, quantity, rate, spontaneity and latency of speech.
A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests form part of the mini-mental state examination
Mini-mental state examination
The mini–mental state examination or Folstein test is a brief 30-point questionnaire test that is used to screen for cognitive impairment. It is commonly used in medicine to screen for dementia...
. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see below).
Language assessment will allow the recognition of medical conditions presenting with aphonia
Aphonia
Aphonia is the inability to speak. It is considered more severe than dysphonia. A primary cause of aphonia is bilateral disruption of the recurrent laryngeal nerve, which supplies nearly all the muscles in the larynx...
or dysarthria
Dysarthria
Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes...
, neurological conditions such as stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
or dementia
Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
presenting with aphasia
Aphasia
Aphasia is an impairment of language ability. This class of language disorder ranges from having difficulty remembering words to being completely unable to speak, read, or write....
, and specific language disorders such as stuttering
Stuttering
Stuttering , also known as stammering , is a speech disorder in which the flow of speech is disrupted by involuntary repetitions and prolongations of sounds, syllables, words or phrases, and involuntary silent pauses or blocks in which the stutterer is unable to produce sounds...
, cluttering
Cluttering
Cluttering is a speech disorder and a communication disorder characterized by speech that is difficult for listeners to understand due to rapid speaking rate, erratic rhythm, poor syntax or grammar, and words or groups of words unrelated to the sentence...
or mutism. People with autism or Asperger syndrome
Asperger syndrome
Asperger's syndrome that is characterized by significant difficulties in social interaction, alongside restricted and repetitive patterns of behavior and interests. It differs from other autism spectrum disorders by its relative preservation of linguistic and cognitive development...
may have abnormalities in paralinguistic and pragmatic
Pragmatics
Pragmatics is a subfield of linguistics which studies the ways in which context contributes to meaning. Pragmatics encompasses speech act theory, conversational implicature, talk in interaction and other approaches to language behavior in philosophy, sociology, and linguistics. It studies how the...
aspects of their speech. Echolalia
Echolalia
Echolalia is the automatic repetition of vocalizations made by another person. It is closely related to echopraxia, the automatic repetition of movements made by another person....
(repetition of another person's words) and palilalia
Palilalia
Palilalia is the repetition or echoing of one's own spoken words. It can be a complex tic, like echolalia and coprolalia and may sound like stuttering; all can be symptoms of Tourette syndrome, obsessive–compulsive disorder, or autism...
(repetition of the subject's own words) can be heard with patients with autism
Autism
Autism is a disorder of neural development characterized by impaired social interaction and communication, and by restricted and repetitive behavior. These signs all begin before a child is three years old. Autism affects information processing in the brain by altering how nerve cells and their...
, schizophrenia or Alzheimer's disease
Alzheimer's disease
Alzheimer's disease also known in medical literature as Alzheimer disease is the most common form of dementia. There is no cure for the disease, which worsens as it progresses, and eventually leads to death...
. A person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them.
Speech assessment also contributes to assessment of mood, for example people with mania or anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
may have rapid, loud and pressured speech; on the other hand depressed
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.
Thought process
Thought
"Thought" generally refers to any mental or intellectual activity involving an individual's subjective consciousness. It can refer either to the act of thinking or the resulting ideas or arrangements of ideas. Similar concepts include cognition, sentience, consciousness, and imagination...
process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. Regarding the tempo of thought, some people may experience flight of ideas, when their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a chain of poetic associations in the patient's speech. Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and thought perseveration
Perseveration
Perseveration is the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus, usually caused by brain injury or other organic disorder. If an issue has been fully explored and discussed to a point of resolution, it is not uncommon for...
refers to a pattern where a person keeps returning to the same limited set of ideas. A pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight's move thinking. Thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic.
Flight of ideas is typical of mania. Conversely, patients with depression may have retarded or inhibited thinking. Poverty of thought is one of the negative symptoms of schizophrenia, and might also be a feature of severe depression or dementia
Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
. A patient with dementia might also experience thought perseveration. Formal thought disorder is a common feature of schizophrenia. Circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders.
Thought content
A description of thought content would describe a patient's delusions, overvalued ideas, obsessions, phobias and preoccupations. Abnormalities of thought content are established by exploring individual's thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts.A delusion can be defined as "a false, unshakeable idea or belief which is out of keeping with the patient's educational, cultural and social background ... held with extraordinary conviction and subjective certainty", and is a core feature of psychotic disorders. The patient's delusions may be described as persecutory or paranoid delusions
Paranoia
Paranoia [] is a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself...
, delusions of reference, grandiose delusions
Grandiose delusions
Grandiose delusion or delusions of grandeur is principally a subtype of delusional disorder that can occur as a wide range of mental illness, including in two thirds of those in manic state of bipolar disorder, half those with schizophrenia and a substantial portion of those with substance abuse...
, erotomanic delusions, delusional jealousy
Delusional jealousy
Morbid jealousy is a psychiatric disorder in which a person holds a strong delusional belief that that their spouse or sexual partner is being unfaithful without having any, very little, or insignificant proof to back up their claim.-Definition:This disorder occurs when a person typically makes...
or delusional misidentification
Delusional misidentification syndrome
Delusional misidentification syndrome is an umbrella term, introduced by Christodoulou for a group of delusional disorders that occur in the context of mental or neurological illness. They all involve a belief that the identity of a person, object or place has somehow changed or has been altered...
. Delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychoses
Psychotic depression
Psychotic major depression is a type of depression that can include symptoms and treatments that are different from those of non-psychotic major depressive disorder . PMD is estimated to affect about 0.4% of the population .PMD is sometimes "mistaken" for NPMD, schizoaffective disorder,...
, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of thought withdrawal
Thought withdrawal
In psychiatry, thought withdrawal is the delusion that thoughts have been 'taken out' of the patient's mind. It often accompanies thought blocking. The patient may experience a break in the flow of their thoughts believing that the missing thoughts have been withdrawn from their mind by some...
, thought insertion
Thought insertion
Thought insertion is the idea that another thinks through the mind of the patient. The patient may sometimes be unable to distinguish between their own thoughts and those inserted into their minds. A patient who is diagnosed with this disorder is found to be convinced of their beliefs and...
, thought broadcasting
Thought broadcasting
Thought broadcasting is a positive symptom of schizophrenia in the diagnostic process undertaken by mental health professionals. Thought broadcasting has been suggested as one of the so-called "first rank symptoms" believed to distinguish schizophrenia from other psychotic disorders.During thought...
, and somatic passivity. Schneiderian first rank symptoms
Kurt Schneider
Kurt Schneider was a German psychiatrist known largely for his writing on the diagnosis and understanding of schizophrenia.-Biography:...
are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses
Psychotic depression
Psychotic major depression is a type of depression that can include symptoms and treatments that are different from those of non-psychotic major depressive disorder . PMD is estimated to affect about 0.4% of the population .PMD is sometimes "mistaken" for NPMD, schizoaffective disorder,...
.
An overvalued idea is a false belief that is held with conviction but not with delusional intensity. Hypochondriasis is an overvalued idea that one is suffering from an illness, dysmorphophobia is an overvalued idea that a part of one's body is abnormal, and people with anorexia nervosa
Anorexia nervosa
Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
may have an overvalued idea of being overweight.
An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In obsessive-compulsive disorder
Obsessive-compulsive disorder
Obsessive–compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry, by repetitive behaviors aimed at reducing the associated anxiety, or by a combination of such obsessions and compulsions...
, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes).
A phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview.
Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include thoughts of suicide
Suicidal ideation
Suicidal ideation is a common medical term for thoughts about suicide, which may be as detailed as a formulated plan, without the suicidal act itself. Although most people who undergo suicidal ideation do not commit suicide, some go on to make suicide attempts...
, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortion
Cognitive distortion
Cognitive distortions are exaggerated and irrational thoughts identified in cognitive therapy and its variants, which in theory perpetuate certain psychological disorders. The theory of cognitive distortions was first proposed by Aaron T. Beck. Eliminating these distortions and negative thoughts is...
s of anxiety and depression.
The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life.
Perceptions
A perceptionPerception
Perception is the process of attaining awareness or understanding of the environment by organizing and interpreting sensory information. All perception involves signals in the nervous system, which in turn result from physical stimulation of the sense organs...
in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucination
Pseudohallucination
A pseudohallucination is an involuntary sensory experience vivid enough to be regarded as a hallucination, but recognised by the patient not to be the result of external stimuli. In other words, it is a hallucination that is recognized as a hallucination, as opposed to a "normal" hallucination...
s and illusion
Illusion
An illusion is a distortion of the senses, revealing how the brain normally organizes and interprets sensory stimulation. While illusions distort reality, they are generally shared by most people....
s. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as "voices in my head") and is regarded as akin to fantasy.
Other sensory abnormalities include a distortion of the patient's sense of time, for example déjà vu
Déjà vu
Déjà vu is the experience of feeling sure that one has already witnessed or experienced a current situation, even though the exact circumstances of the prior encounter are uncertain and were perhaps imagined...
, or a distortion of the sense of self (depersonalization
Depersonalization
Depersonalization is an anomaly of the mechanism by which an individual has self-awareness. It is a feeling of watching oneself act, while having no control over a situation. Sufferers feel they have changed, and the world has become less real, vague, dreamlike, or lacking in significance...
) or sense of reality (derealization
Derealization
Derealization is an alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional coloring and depth. It is a dissociative symptom of many conditions, such as psychiatric and...
).
Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations.
Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the patient) and hearing one's thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the Schneiderian first rank symptoms
Kurt Schneider
Kurt Schneider was a German psychiatrist known largely for his writing on the diagnosis and understanding of schizophrenia.-Biography:...
indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression
Psychotic depression
Psychotic major depression is a type of depression that can include symptoms and treatments that are different from those of non-psychotic major depressive disorder . PMD is estimated to affect about 0.4% of the population .PMD is sometimes "mistaken" for NPMD, schizoaffective disorder,...
or schizophrenia. Visual hallucinations are generally suggestive of organic conditions such as epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
, drug intoxication
Drug overdose
The term drug overdose describes the ingestion or application of a drug or other substance in quantities greater than are recommended or generally practiced...
or drug withdrawal. Many of the visual effects of hallucinogenic drugs are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations are suggestive of dissociative disorders
Dissociative disorders
Dissociative disorders are defined as conditions that involve disruptions or breakdowns of memory, awareness, identity and/or perception. See also dissociation. People with dissociative disorders are able to escape from reality involuntarily...
. Déjà vu, derealization and depersonalization are associated with temporal lobe epilepsy
Temporal lobe epilepsy
Temporal lobe epilepsy a.k.a. Psychomotor epilepsy, is a form of focal epilepsy, a chronic neurological condition characterized by recurrent seizures. Over 40 types of epilepsies are known. They fall into two main categories: partial-onset epilepsies and generalized-onset epilepsies...
and dissociative disorders.
Cognition
This section of the MSE covers the patient's level of alertnessAlertness
Alertness is the state of paying close and continuous attention, being watchful and prompt to meet danger or emergency, or being quick to perceive and act. It is related to psychology as well as to physiology...
, orientation
Orientation (mental)
Orientation is a function of the mind involving awareness of three dimensions: time, place and person. Problems with orientation lead to disorientation, and can be due to various conditions, from delirium to intoxication...
, attention
Attention
Attention is the cognitive process of paying attention to one aspect of the environment while ignoring others. Attention is one of the most intensely studied topics within psychology and cognitive neuroscience....
, memory
Memory
In psychology, memory is an organism's ability to store, retain, and recall information and experiences. Traditional studies of memory began in the fields of philosophy, including techniques of artificially enhancing memory....
, visuospatial functioning, language
Language
Language may refer either to the specifically human capacity for acquiring and using complex systems of communication, or to a specific instance of such a system of complex communication...
functions and executive functions
Executive functions
The executive system is a theorized cognitive system in psychology that controls and manages other cognitive processes. It is responsible for processes that are sometimes referred to as the executive function, executive functions, supervisory attentional system, or cognitive control...
. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation.
Alertness is a global observation of level of consciousness i.e. awareness of, and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporose. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by the serial sevens
Serial sevens
Serial sevens, counting down from one hundred by sevens, is a clinical test used to test mental function; for example, to help assess mental status after possible head injury or in suspected cases of dementia. It forms part of the Mini mental state examination...
test (or alternatively by spelling a five-letter word backwards), and by testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. Executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter F, in one minute"). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE.
Mild impairment of attention and concentration may occur in any mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain
Human brain
The human brain has the same general structure as the brains of other mammals, but is over three times larger than the brain of a typical mammal with an equivalent body size. Estimates for the number of neurons in the human brain range from 80 to 120 billion...
functioning such as delirium, dementia or intoxication. Specific language abnormalities may be associated with pathology in Wernicke's area
Wernicke's area
Wernicke's area is one of the two parts of the cerebral cortex linked since the late nineteenth century to speech . It is involved in the understanding of written and spoken language...
or Broca's area
Broca's area
Broca's area is a region of the hominid brain with functions linked to speech production.The production of language has been linked to the Broca’s area since Pierre Paul Broca reported impairments in two patients. They had lost the ability to speak after injury to the posterior inferior frontal...
of the brain. In Korsakoff's syndrome
Korsakoff's syndrome
Korsakoff's syndrome is a neurological disorder caused by the lack of thiamine in the brain. Its onset is linked to chronic alcohol abuse and/or severe malnutrition...
there is dramatic memory impairment with relative preservation of other cognitive functions.
Visuospatial or constructional abnormalities here may be associated with parietal lobe
Parietal lobe
The parietal lobe is a part of the Brain positioned above the occipital lobe and behind the frontal lobe.The parietal lobe integrates sensory information from different modalities, particularly determining spatial sense and navigation. For example, it comprises somatosensory cortex and the...
pathology, and abnormalities in executive functioning tests may indicate frontal lobe
Frontal lobe
The frontal lobe is an area in the brain of humans and other mammals, located at the front of each cerebral hemisphere and positioned anterior to the parietal lobe and superior and anterior to the temporal lobes...
pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing.
The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-stone").
The posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles.
The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed.
A cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again.
Pathology in the basal ganglia
Basal ganglia
The basal ganglia are a group of nuclei of varied origin in the brains of vertebrates that act as a cohesive functional unit. They are situated at the base of the forebrain and are strongly connected with the cerebral cortex, thalamus and other brain areas...
may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements.
A lesion in the posterior fossa
Posterior fossa
Posterior fossa may refer to:* Posterior cranial fossa* Posterior intercondyloid fossa...
can be detected by asking the patient to roll his or her eyes upwards (Perinaud's sign).
Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries
Traumatic brain injury
Traumatic brain injury , also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism , or other features...
, tumors
Brain tumor
A brain tumor is an intracranial solid neoplasm, a tumor within the brain or the central spinal canal.Brain tumors include all tumors inside the cranium or in the central spinal canal...
or other brain disorders.
Insight
The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context, insightInsight
Insight is the understanding of a specific cause and effect in a specific context. Insight can be used with several related meanings:*a piece of information...
can be said to have three components: recognition that one has a mental illness, compliance
Compliance (medicine)
In medicine, compliance describes the degree to which a patient correctly follows medical advice...
with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively.
Impaired insight is characteristic of psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent
Consent
Consent refers to the provision of approval or agreement, particularly and especially after thoughtful consideration.- Types of consent :*Implied consent is a controversial form of consent which is not expressly granted by a person, but rather inferred from a person's actions and the facts and...
to treatment.
Judgment
Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. Traditionally, the MSE included the use of standard hypothetical questions such as "what would you do if you found a stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual's executive system capacity in terms of impulsiveness, social cognitionSocial cognition
Social cognition is the encoding, storage, retrieval, and processing, in the brain, of information relating to conspecifics, or members of the same species. At one time social cognition referred specifically to an approach to social psychology in which these processes were studied according to the...
, self-awareness and planning ability.
Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the frontal lobe
Frontal lobe disorder
Frontal lobe disorder is an impairment of the frontal lobe that occurs as a result of a number of diseases as well as head trauma. The frontal lobe of the brain plays a key role in higher mental functions such as motivation, planning, social behaviour, and speech production...
of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others.
Cultural considerations
There are potential problems when the MSE is applied in a cross-culturalCross-cultural psychiatry
Cross-cultural psychiatry or transcultural psychiatry is a branch of psychiatry concerned with the cultural and ethnic context of mental disorders and psychiatric services...
context, when the clinician and patient are from different cultural backgrounds. For example, the patient's culture might have different norms for appearance, behavior and display of emotions. Culturally normative spiritual and religious beliefs need to be distinguished from delusions and hallucinations - without understanding may seem similar though they have different roots. Cognitive assessment must also take the patient's language and educational background into account. Clinician's racial bias is another potential confounder.
Children
There are particular challenges in carrying out an MSE with young children, and others with limited language such as people with intellectual impairment. The examiner would explore and clarify the individual's use of words to describe mood, thought content or perceptions, as words may be used idiosyncratically with a different meaning from that assumed by the examiner. In this group, tools such as play materials, puppets, art materials or diagrams (for instance with multiple choices of facial expressions depicting emotions) may be used to facilitate recall and explanation of experiences.See also
- Diagnostic classification and rating scales used in psychiatryDiagnostic classification and rating scales used in psychiatryThe following diagnostic systems and rating scales are used in psychiatry and clinical psychology.-Diagnostic Criteria:*Diagnostic and Statistical Manual of Mental Disorders *ICD-10 Chapter V: Mental and behavioural disorders...
- Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental DisordersThe Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
- DSM-IV CodesDSM-IV CodesDiagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as DSM-IV-TR, is a manual published by the American Psychiatric Association that includes all currently recognized mental health disorders...
- Glossary of psychiatryGlossary of psychiatryIn this glossary of psychiatric terms, mostly Greek, secondly French and German and some English terms, as used in psychiatric literature, were defined...
- ICD-10 Chapter V: Mental and behavioural disordersICD-10 Chapter V: Mental and behavioural disorders- Organic, including symptomatic, mental disorders :* Dementia in Alzheimer's disease* Vascular dementia** Multi-infarct dementia* Dementia in other diseases classified elsewhere** Dementia in Pick's disease...
- NormocephalicNormocephalicNormocephalic is a medical term referring to a person whose head and all major organs of the head are in a normal condition and without significant abnormalities.See Physical examination....