The Elements and Import of the Mental Status Examination
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.
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
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.”
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
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.
“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.”).
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
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
Evaluate with similarities and proverbs given in an ascending order of difficulty.
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