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The Elements and Import of the Mental Status Examination

 

Stephen Deutsch, MD

April 2, 2007

 

Associate Chief of Staff, Mental Health Service Line, Department of Veteran Affairs Medical Center; Professor of Psychiatry, Georgetown University School of Medicine

This interview was conducted on January 29, 2006 by Peter Cook.

 

Introduction

Over 2 decades of teaching medical students and residents, Dr. Stephen Deutsch has born witness to an enormous amount of anxiety associated with learning to conduct the Mental Status Examination (MSE).

“Many mistakenly believe that performing a competent MSE requires some sort of innate—and uncommon—aptitude,” he says. “However, the MSE is a clinical skill. As a skill, it requires struggle to acquire and practice to maintain, but very rarely have I met a student who could not be instructed in how to perform the MSE.” Not only does Dr. Deutsch believe that competence at administering the MSE is within the grasp of almost all medical students, he emphasizes the importance of this skill for all practitioners, within and without the psychiatric discipline. “The MSE is too often overlooked these days, and is as essential to good clinical practice as auscultation, palpation, and percussion.”

The Importance of the MSE

“As a student at the Bellevue Psychiatric Hospital in New York City, I was very privileged to be exposed to clinicians who were extremely skilled at performing the MSE and equally thoughtful at interpreting the results,” Dr. Deutsch says. “A skillful examiner can identify not only generalized but localized areas of dysfunction in the brain, and, prior to CT and MRI scans, psychiatrists and neurologists were able to obtain information as rich—and sometimes richer—than what we get today with all of our technology.”

The MSE serves a broader function than just identifying neuropsychiatric disorders, Dr. Deutsch explains. “The MSE can alert a clinician to systemic abnormality. Not infrequently on the consultation-liaison service, it’s the psychiatrist—who generally has more experience with the MSE—who will appreciate a subtle but important change on the MSE not caught by other staff members.” Distinctive changes can arise from metabolic disturbances, electrolytic disturbances, occult infections, and malignancy that present atypically (eg, without a fever). “Unrecognized medical and surgical illnesses can, and frequently are, uncovered as a result of subtle fluctuations of the mental state,” Dr. Deutsch says.

The MSE is also particularly helpful in the assessment of delirium, dementia, and delirium superimposed on dementia. “A skilled clinician who has performed a careful and thorough baseline MSE can recognize subtle alterations in a patient that take place over a span of hours or days, garnering vital information suggesting unrecognized systemic disturbance.”

Conducting the MSE

The routine MSE can be performed in 15–30 minutes, and probes cognition, emotions, behavior, and motor activity; in fact, the examination takes longer to teach and describe than it does to perform. Dr. Deutsch believes that the exam (or at least an abbreviated version thereof) should be administered as an adjunct to a physical exam, thus providing a cross-sectional supplement to a patient’s longitudinal history.

To be of use in diagnosis, the clinician needs to perform the MSE in a consistent manner over time and demonstrate a high degree of inter-rater reliability. “The first MSE with a particular patient serves as the reference point against which all subsequent exams—by the same clinician or others—will be compared,” Dr. Deutsch says. “An examiner needs to train herself so that her examinations are consistent over time and as objective as possible.” Skillful examiners, he adds, will come to the same conclusions when examining the same patient independently at a particular point in time.

Dr. Deutsch also notes the importance of empathy. “This isn’t synonymous with liking the patient—though, of course, we usually do,” he says. “Rather, it reflects our appreciation that another person is suffering and experiencing difficulty, and needs the full benefit of our care and expertise.”

Conclusion

Dr. Deutsch believes that a medical student’s central goals during his or her clinical rotation in psychiatry are to become competent at performing the MSE and obtaining a good longitudinal history. “With practice and dedication, clinicians can become extremely reliable. A thorough MSE is usually conducted in <30 minutes, and is critical in terms of formulating a differential diagnosis, selecting appropriate treatment, and evaluating the longitudinal course of illness.”

Basic Elements of the Mental Status Examination

Appearance and Behavior

Does the patient appear to be well-nourished and well-developed; is he overweight or too thin? Is the patient well-groomed, well-dressed and attentive to personal hygiene? Is the patient accompanied or unaccompanied during the evaluation? Is he sitting, standing or lying down? Is the patient restrained? Is the patient diaphoretic, hypervigilant, able to maintain eye-contact and tolerate the interview situation? Does the patient show an increased or decreased level of psychomotor activity?

Levels of Alertness, Awareness and Consciousness

Is the patient alert and awake during the interview? Is the patient sleepy, drowsy or inattentive? Does the patient show a decreased level of consciousness; is he arousable? Does the patient demonstrate mannerisms and posturing?

Orientation to Time, Place, Person and Situational Context

Disorientation to time is often a sensitive indicator of gross cerebral dysfunction. The affectual display of patients undergoing a psychiatric evaluation usually conveys an understanding of the purpose of the evaluation and possible consequences of a “poor” evaluation; thus, it is always informative when the patient’s attitude and facial expression do not convey an appreciation of the situational context of the psychiatric examination.

Mood

“How do you feel;” this is patient’s subjective self-report and is best presented as direct quotes in the patient’s own words (eg, “I feel angry.”).

Affect

Does the patient display the normally expected range of facial expressiveness; is there a narrowing or constriction of affect; is there a “flattening” of affect? Does the facial expressivity show lability; is the lability marked? Are the facial expressivity and affectual displays appropriate with respect to: prevailing mood, ideational content, and situational context?

Speech

Think about music and describe the musical qualities of speech (ie, rate, rhythm, loudness and tonality). Also, note unusual pauses or latencies, articulation problems, and stuttering and stammering.

Form of Thought

Listen effectively and empathically! Given the amount of verbal production, is there a paucity of informational content conveyed? Does the examiner experience impaired “understandability?” Is the patient able to respond to questions in a logical, relevant coherent and goal-directed manner? Does the patient give too much, unimportant detail (ie, circumstantial); does the patient skip from topic to topic without elaborating fully on any one of them (ie, tangential); does the patient repeat words, phrases and thoughts and have
difficulty switching topics (ie, perseverative)? Does the patient use words idiosyncratically; does he use words in a way that doesn’t adequately serve the purpose of social communication? Does the patient use words that rhyme (ie, clang associations); does the patient create new words (ie, neologisms)? 

Content of Thought

Does the patient have overvalued ideas; does the patient express firmly held, fixed false beliefs that cannot be explained by the patient’s culture or religion? Does the patient have any unusual sensory experiences or perceptions; if so, in which sensory modality? Inquire about active suicidal or homicidal ideation, intent and plan; the latter must be thorough and detailed.

Abstraction

Evaluate with similarities and proverbs given in an ascending order of difficulty.

Cognition

One must assess the patient in the various domains of cognition. These include: attention and working memory (have the patient spell words backward and repeat learned number sequences both forward and backward), registration and short-term memory (ask the patient to repeat a list of three items presented earlier in the interview), long-term memory (ask for the names of the current and preceding Presidents), calculations (serial subtraction),  and visuospatial ability (ask the patient to draw a geometric figure from a sample and later from memory).

 

Reporting and Analyzing Results

While performing the clinical examination of the mental state, it is important to note how anxious the patient appears to be during the examination and how mentally effortful specific items on the examination are for the patient to perform. The results of the mental status examination should be presented in an organized format with subheadings and the entries should be single word descriptors, adjectives or brief phrases. The mental status examination is reviewed like a battery of laboratory tests and detailed narrative is rarely indicated (however, there are exceptions; for example, it is best to give direct quotations for mood, which is patient subjective self-report, and interpretations of proverbs).

Disclosure: Dr. Deutsch reports no affiliation with or financial interest in any organization that may pose a conflict of interest.