Mental Status Exam

by Helen Farrell, MD

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    00:01 Let's now look a little bit more closely at the components of that ever important mental status exam.

    00:07 The mental status exam, remember, it can change every hour, even every minute.

    00:14 In my clinical practice, when I've gone to meet with patients in the Intensive Care Unit, that mental status exam is ever changing moment by moment.

    00:22 Same thing on an in-patient psychiatry unit. Things change very quickly and in an out-patient encounter, your patient might look one way one week, and then the next week or month have a completely different presentation.

    00:35 So, it's very important to include this in all of your encounters.

    00:39 The mental status examination in psychiatry is critical. It's our tool to diagnosing our patients.

    00:46 Consider it similar to the physical exam that's done in internal medicine and remember, I can't over emphasize this point enough. In every single encounter with the patient in every mental status examination that you do, you must evaluate for safety.

    01:04 That includes suicidal and homicidal thoughts, and exploring whether there's any intent or plan to carry out such thoughts. Remember, the mental status exam needs to be recorded at every single encounter with your patients. There are a lot of elements as you'll see here to doing the mental status exam. Let's go through each one in a bit of detail, okay? So, starting with appearance and behavior. Think of it like you're encountering someone on the street.

    01:34 What do you notice about them? What's important to you? Alright, so you're gonna notice their physical appearance, right? What their clothing is, how they're dressed, their hygiene, posture, and their grooming.

    01:46 You're gonna also be able to see their behaviour, their mannerisms, any tics, what kind of eye contact they make? And you're gonna notice if they have any kind of psychomotor agitation like they're moving too much and they're restless or maybe they seem very slowed down and they're barely moving at all which we call psychomotor retardation. You also want to account for their attitude in this part of the examination. So you wanna note are they being cooperative with you, forthcoming, sharing information? Or do they seem guarded, restricted, like they're holding back? Are they engaged and excited or do they seem apathetic and like they don't wanna be there? Next, also you want to comment in enough detail so that, and this is very important, so comment in enough detail so that anyone else on the treatment team whether it's a colleague, or a peer, your supervisor. You wanna be able to make sure they can picture your patient without actually seeing them based on your description of them. Next, let's consider the speech.

    02:52 So, what kind of elements do you think are involved in noting somebody's speech style? Alright, so we'll start with their rate. Is it slow, average, rapid, or pressured? As a pearl of information, we often see pressured speech in manic patients and this is fast, uninterruptible speech. The volume can be described as soft, average, or loud.

    03:17 And you want to also note their articulation. Is it well articulated? Does your patient have a lisp or a stutter? Are they mumbling? These can be very important clues.

    03:28 And also the tone. Are they angry? Are they pleading? Do they sound content? Again, all very important clues to what could be some kind of psychopathology that's going on.

    03:40 Next to consider their mood and affect, alright? So, patient's mood is actually the emotion that the patient tells you that they're experiencing and they can convey this to you verbally or non-verbally. The affect is really the assessment of how to the mood appears to be coming out on the exam and you want to note the kind of range and emotional expression that you see your patient having. So, here's a little quiz. What would you call the depth and range of feelings that are shown? The parameters that could include a flat or lack of affect, a blunted or shallow affect, constricted, limited, full, average, or intense? These are all described as the quality of one's affect.

    04:26 How about what describes how quickly a person appears to shift emotional states meaning the parameters including sluggishness, supple, or labile? That's going to be the motility of their affect. And finally, what describes whether the affect is congruent with the subject of conversation? Parameters here are whether or not the patient appears appropriate or inappropriate given the context and content of what you're talking about. That's the appropriateness to the content.

    04:57 Moving along, think about your patient's thought process.

    05:02 This is where your listening skills are going to be extremely important.

    05:08 Nobody's going to tell you how they're thinking. You're going to discern this through your conversation with them. So, the thought process describes how your patient uses language and puts ideas together, okay? It describes whether the patient's thoughts are logical, meaningful, and whether or not they're actually goal directed.

    05:29 The thought process does not actually comment on what the patient thinks. We'll get to that later.

    05:36 It only describes how the patient expresses his or her thoughts.

    05:43 And this is really important when considering different types of psychopathology such as manic or psychotic thought processes. There are certain disorders that can affect the thought process. As I just mentioned, mania and psychosis.

    06:02 When you're describing somebody's thought process, there are a lot of different ways in which you can describe it. So, here is a list of a few different ways to describe somebody's thought process, okay? So, if you find somebody is not making logical connections from one thought to another, what would you call that? That's a loosening of associations.

    06:24 When somebody has a fast stream of very tangential thoughts, what do you call that? That's a flight of ideas. Sometimes patients will make up words, okay? And when you find that happening, again requiring very attentive listening skills, but when you find your patient is making up words, you would describe that in your mental status exam as neologisms.

    06:51 And when word connections are due to phonetics rather than actual meaning, that is called a clanging association. So, an example of that would be a patient rhyming words together where it doesn't make any sense, or maybe using alliteration and starting of every word with let's say a ka sound but where they string together without making any sense. That's called clanging. And what's it called when there's an abrupt cessation of communication before an idea is actually completed? That's thought blocking, very important to note and often a key signal that there's some sort of a psychotic process happening.

    07:39 When there's a point of conversation that's never reached due to lack of a goal-directed association between ideas. Do you know what you would call that? Right, tangentiality.

    07:52 And similarly but a little bit different, there can also be a form of thought disorder where a patient will have a point of conversation that is reached but after taking a very long road to get there and that's called circumstantiality.

    08:09 The thought content is another very important piece to the mental status exam.

    08:15 There are different things to keep in mind and different types of ideas that are expressed by the patient. So, when a patient uses too few verses, too many expressed ideas, this is poverty of thought versus an overabundance of thought.

    08:35 So, to explain that again, poverty of thought versus overabundance is when a patient either says too little or too much, basically. There can be fixed, false beliefs that are not shared by the person's culture and can't be explained by reasoning.

    08:50 So, what is that called? That's a delusion. And if you ask the patient if they feel like harming themselves or others, you're of course screening their thought content very appropriately for suicidal and homicidal thoughts and you always wanna take that one step further asking the patient if they have a plan that's formulated and whether or not they have intent to carry through with that plan and that's you identifying the plan and going a little bit further in your risk assessment.

    09:20 There are also some ideas that can be expressed by the patient that are persistent, irrational fears. Those are known as phobias. What is it called when somebody has a repetitive, intrusive thought that they can't get out of their head? That's an obsession.

    09:36 And what is it called when a patient is displaying repetitive behaviors, things that they feel are out of their control, maybe something like turning on and off light switches, counting things, washing their hands repeatedly? That's of course a compulsion.

    09:52 Perceptions are another key component to the mental status exam.

    09:57 One perceptual abnormality is known as a hallucination. This is of course a sensory experience that's not based in reality. It can be visual, seeing things, or auditory, such as hearing things.

    10:14 Patient may feel things that aren't really there which is called a tactile hallucination.

    10:19 They can have olfactory hallucination which is of course smelling something that's not really there.

    10:24 Something that's often seen in seizure disorder. And they can also have gustatory hallucinations.

    10:30 Another perceptual disturbance is called an illusion. This is an inaccurate perception of existing sensory stimuli. And it's important to note that the type of hallucination is very important so you always want to dig a lot deeper with patients.

    10:48 So, in my practice, if I'm encountering an individual who tells me, 'Doctor, I'm hearing things, I hear voices.? I'm going to take it a little further than that and I'm going to ask them, "Well who's talking to you? Do you recognize the voice? Is it one or more? Describe the voice that you?re hearing and what exactly are the voices saying?" Because you want to differentiate if the patient is experiencing a command hallucination or command auditory hallucination versus a running commentary hallucination, versus something that's persecutory. So, you always want to ask questions a little bit further and very importantly when somebody is having a hallucination especially hearing a voice, always ask if that is a voice telling them to harm themselves or someone else.

    11:34 The cognition is another critical component to the mental status exam.

    11:39 So, when you think of cognition there are certain things that you're going to ask about in every encounter. Consciousness is one, how would you go about assessing a patient's consciousness? Well, you're going to ask them about their level of awareness.

    11:53 You want to know if they are oriented to the date, the time, Are they alert' Are they drowsy? Are they stuporous? Are they communicating with you? And asking about orientation you gonna wanna know about person, place, time, and maybe even, do they understand the situation that they're in? You want to assess their calculation, okay? This can be a really good test of what's called executive functioning.

    12:18 Do you have any ideas about how you would go about assessing this executive function? Well, numbers are a really good way. So, you can ask the patient to subtract, you may ask them to do serial sevens backwards, you want to also assess their memory and how would you ask about memory? Well, you're going to ask them to recall words immediately after you say them and then again after 5 minutes.

    12:41 The three word test is a really good rule of thumb to do here.

    12:45 And you want to assess the recent memory, events that happened within the past few days.

    12:51 And also their recent past, so, asking about events that happened over the last few months.

    12:57 How would you test their remote memory? Here you may ask about events from childhood and what's been happening a little bit more distant in that patient's life.

    13:06 In assessing the fund of knowledge, this is information processing that you're gathering from the patient. So, you're going to ask them about knowledge, about culture, and education and starting with making sure you have a really good foundation on that highest level of education that your patient has had and this way as you ask questions they'll be appropriate to them.

    13:30 How would you test attention and concentration? Well, you might do something like ask your patient to spell world backwards, or maybe give you the days the week backwards, or days of the month backward. It's a really great test of how they're able to focus.

    13:48 You may want to assess their reading and writing skills. You can do this by asking them to write simple sentences or you may write out a sentence and ask them to follow a command such as close your eyes, show it to the patient, and ask them to complete what you've just instructed them to do. How would you test for abstract concepts? Well, here you could give the patient two objects and ask them to tell you their similarities.

    14:13 For example, an apple and an orange. A patient that's able to say, 'Well, they're both fruit.' Is showing a good ability to abstractly think as oppose to saying, 'They're both circular.' Which would be very concrete thinking. You might also give your patient a proverb to interpret something like 'Don't cry over spilled milk' 'The tongue is the enemy of the neck' 'A rolling stone gathers no moss.' And you also would like to complete in every encounter a mini mental status exam, okay? And this is a brief test that assess the patient's gross cognitive functioning, scored out of 30 points and you're going to hope that your patient who is doing well and has a good cognition is going to score about above a 26 to 30.

    14:59 Insight and judgement is also very important so let's explore these a little bit more.

    15:03 What is the insight? So, insight is the patient's level of awareness and understanding of his or her problem. Problems with insight include complete denial of illness or blaming it on someone else. The judgement is the patient's ability to understand the outcome of his or her own actions and uses awareness in decision making, a very important point. Insight can actually affect the understanding of problems and therefore affect a patient's adherence to treatment recommendations.

    About the Lecture

    The lecture Mental Status Exam by Helen Farrell, MD is from the course Psychiatric Assessment. It contains the following chapters:

    • Components of the Mental Status Examination
    • Appearance/behavior
    • Speech
    • Mood/affect
    • Thought process
    • Thought content
    • Perceptions
    • Cognition
    • Insight/judgement

    Included Quiz Questions

    1. Gait
    2. Speech
    3. Thought process
    4. Perception
    5. Mood/Affect
    1. Rapid, uninterruptible and pressured
    2. Rapid, uninterruptible, discontinuous
    3. Slow, continuous and pressured
    4. Slow, uninterruptible and continuous
    5. Rapid, interruptible and continuous
    1. Motility
    2. Appropriateness to content
    3. Quality
    4. Intensity
    5. Congruency
    1. Failing to reach the point of conversation due to lack of goal-directed associations between ideas
    2. Fast stream of thoughts with lack of goal-directed associations between ideas
    3. Lack of connection from one thought to another
    4. Never reaching the point of conversation due to abrupt cessation of communication
    5. Multiple tangential thoughts taking a circuitous path before reaching the point of conversation
    1. Delusions
    2. Overabundance of thought
    3. Illusion
    4. Hallucination
    5. Poverty of thought
    1. Compulsion
    2. Phobia to germs
    3. Obsession
    4. Delusion
    5. Intrusion
    1. History of tonic-clonic seizures
    2. Characteristics of the voice (e.g. who is talking, how many voices are heard)
    3. Commands given by the voice (e.g. auto-aggression and/or hetero-aggression)
    4. Hallucination is experienced in the first or third person
    5. Content of the conversation with the voice
    1. Asking the patient to explain the similarities between objects
    2. Asking the patient to read simple sentences in abstracts
    3. Asking the patient to calculate-executive functioning
    4. Asking the patient to recall words at 0 and 5 minutes
    5. Asking the patient to spell a word backward

    Author of lecture Mental Status Exam

     Helen Farrell, MD

    Helen Farrell, MD

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    I recommend anyone who's interested in psychiatry to watch it.
    By Abdulaziz H. on 08. August 2018 for Mental Status Exam

    Very helpful work from Dr.Farrell, Thank you very much.

    Very clear discussion
    By Peter R. on 07. July 2017 for Mental Status Exam

    The MSE is clearly explained in this video. Thank you very much!