Mental status examination

Mental status examination or MSE is the process whereby a clinician (usually a psychiatrist or psychologist) working in the field of mental health systematically examines someone's mind. Each area of function is considered separately under categories. This is akin to the physical examination performed by physicians. However, much of the material for the MSE is gathered during psychiatric history taking.

The result of this examination is then combined with the psychiatric history to produce a psychiatric formulation which describes the person being examined.

Main categories

These vary around the world but there is broad commonality. Some schemes look at ego psychology and defence mechanisms while others are less broad.

Appearance

This category covers the physical aspects of the person. This includes their physical appearance such as age, height and weight, how they are dressed and groomed, and the dominant attitude presented in the interview. Some include factors like the degree of poise or comfort in the interview, and the degree of anxiety and how it is expressed in this category

Behaviour

This looks at the way the person moves and the positions in which they hold their body. Abnormal movements such as tics or chorea as well the degree of movement is noted.

Speech

It is customary to separate speech from thought in the MSE, although this is rather artificial. In general, aspects of the speech that will not be part of the section on thought are covered here. This includes the volume, rate and flow of speech itself as distinct from thought. Mannerisms, accent, stress or lack of it, hesitations, and stuttering are all covered here. Descriptions might use words like: garrulous, monotonous, laboured, loud, or emotional.

Mood and affect

Affect is the outward show of emotions and mood is the general pervasive emotional state. A person's affect may vary through depression, elation, anger and normality but if the overall sense from examination is of depression then that is used to describe the mood. The range of the affect describes whether the person shows a full or even expanded range or if their affect is blunted or restricted. Cultural considerations are important in this and many other aspects of the MSE. Appropriateness of the affect is also important. Is the emotion shown consistent with the topic being discussed? A patient with an inappropriate affect may cry talking about a parking ticket and show little or no emotion when discussing the recent death of a loved one.

Perceptions

This covers the area of the senses and describes any distortions such as illusions or hallucinations. The nature of the experience is described in detail. Auditory hallucinations are common in schizophrenia while visual disturbances are more common in organic problems. Depersonalization, where the person feels unreal, and derealization, where the person feels their surroundings are unreal, are also described here.

Thought

This is divided into form, the way a person thinks, and content, what they think.

Form

This looks at features like the rate of thoughts and how they flow and are connected. Formal thought disorder comprises processes such as pressure of thought (excessively rapid), disconnected thoughts, and circumstantial thoughts (over inclusive and slow to get to the point).

Content

Thought content includes those things discussed in the interview and the beliefs a person has. They may have thoughts that preoccupy them such as compulsions, ruminations, phobias or concerns about physical symptoms. They may have overvalued ideas or delusions.

Cognition

This looks at a number of areas such as the level of abstract thought (which declines or is absent in a number of conditions such as dementia and schizophrenia), the level of general education and intelligence, and the degree of concentration which is often tested by digit span recall or an ability to serially subtract seven starting at 100.

Consciousness

The level of conscious state is assessed whether it is steady or fluctuating, clouded or clear.

Orientation

This frequently looks at whether the person knows the time (including the date), place (where they are), and person (who they are).

Memory

Memory is tested by looking for immediate recall, short-term memory (an ability to remember several things after five minutes) and long-term memory (an ability to remember distant events such as the years of World War II.

Judgement

This looks at how the person makes judgements about events. Is it logical or idiosyncratic? Is it reasoned?

Insight

This describes how much understanding the person has of the situation.

Controversy

The article so far has described how a clinician usually goes about the task of performing a MSE. There is controversy both within the profession about this and also controversy from without.

Within the profession

There are many gaps in the traditional MSE that have been pointed out. The areas of impulse control, ego psychology and defence mechanisms are among them. Cultural concerns and knowledge of the facts can skew the assessment. A clinician who does not know that the person they are examining is who they claim to be may interpret information given as a delusion. The examination is inherently flawed because it relies on interpretation. One attempt to avoid this is with standard testing of personality such as the MMPI or projection such as the Rorscharch test.

Outside the profession

The MSE is one of the more subjective parts of the work of psychiatrists and psychologists. It thus attracts significant criticism from antipsychiatry and related groups.