The Mental Status Examination

This is the primary type of examination used in psychiatry. Though psychiatrists do not use
many of the more intrusive physical examination techniques (such palpation, auscultation, etc.),
psychiatrists are expected to be expert observers, both of significant positive and negative
findings on examinations. This observation should take place throughout the patient encounter;
it is not limited to any one point. However, the observations are then recorded into a specific
structured format that is labeled the Mental Status Examination (MSE). When properly done, the
MSE should give a detailed "snapshot" of the patient as he presented during the interview.
Often beginners become confused about the difference between this and other parts of the
history. A simple way to keep it apart is to remember that this is, as the title says, an examination,
therefore it should be limited to what is observed. The rest should go in the history. As an
example, if a patient reports that they have been hearing voices throughout the day, but deny
hearing them during the interview and do not seem to be responding to internal stimuli, one
would not report the hallucinations as part of the MSE, but rather include it earlier in the history.
Conversely, if the patient denies any history of hallucination, but seems to be responding to
internal stimuli throughout the examination, one would report the phenomenon on the MSE.
The MSE can be divided into the following major categories: (1) General Appearance, (2)
Emotions, (3) Thoughts, (4) Cognition, (5) Judgment and Insight. These are described in more
detail in the following sections.

General Description

As implied, this is a general description of the patient’s appearance. Being detailed and accurate
is important, and such observations can be of great use to the next examiner. Imagine, for
example, if a patient presents looking disheveled, poorly groomed with poor hygiene to an
emergency department, but a note from only a month ago reports the same patient to have been
well dressed and groomed. Something is going on!

Some of the areas that might be commented on, particularly if they have significant negative or
positive findings include:

Appearance
One should describe the prominent physical features of an individual. At least one writer on the
subject has suggested this should be detailed enough "such that a portrait of the person could be
painted that highlights his or her unique aspects” but that is probably asking a lot. Some aspects
of appearance once might note include a description of a patient’s facial features, general
grooming, hair color texture or styling, and grooming, skin texture, scar formation, tattoos, body
shape, height and weight, cleanliness and neatness, posture and bearing, clothing (type,
appropriateness) or jewelry.

Motor Behavior
The examination should incorporate any observation of movement or behavior.
Some aspects of motor behavior that might be commented on include gait, freedom of
movement, firmness and strength of handshake, any involuntary or abnormal movements,
tremors, tics, mannerisms, lip smacking or akathisias
Speech
This in not an evaluation of language or thought (save that for later), but a
behavioral/mechanical evaluation of speech. Items that might be commented on include the rate
of speech, the spontaneity of verbalizations, the range of voice intonation patterns, the volume of
speech, and any defects with verbalizations (stammering or stuttering).

Attitudes
One should comment on how the patient related to the examiner. This usually includes a
discussion of the patient’s degree of cooperativeness with the examiner. When appropriate, a
recording of the evaluator’s attitude toward the patient might be appropriate, as we believe such
reactions (“countertransference”) may be useful information. Such discussions should be done
with the understanding that the patient has a legal right to read the record, and any strong
emotions or reactions should be recorded in a diplomatic manner.

Emotions
For the sake of consistency, the observation of a patient’s emotions is divided into a discussion of
mood and affect.
Mood is usually defined as the sustained feeling tone that prevails over time for a patient.
At times, the patient will be able to describe their mood. Otherwise, evaluator must inquire about
a patient’s mood, or infer it from the rest of the interview. Qualities of mood that may be
commented on include the depth of the mood, the length of time that it prevails, and the degree
of fluctuation. Common words used to describe a mood include the following: Anxious,
panicky, terrified, sad, depressed, angry, enraged, euphoric, and guilty. Once should be as
specific as possible in describing a mood, and vague terms such as “upset” or “agitated” should
be avoided.
Affect is usually defined as the behavioral/observable manifestation of mood. Some
aspects of a mood that we might comment on include the following: the appropriateness of the
affect to the described mood (does the person look the way they say they feel?); the intensity of
the affect during the examination (is their too much--heightened or dramatic--or too little blunted or
flat); the mobility of the affect (does the affect change at an appropriate rate, or does there seem to
be too much variation–a labile affect-- or too little--constricted or fixed; the range of the affect (is
there an expected range of affect–usually interview will have light and heavier moments–or does
the affect seem restricted to a limited range; and the reactivity of the patient (is the response to
external factors, and topics as would be expected for the situation. Alternatively, is there too
little change--nonreactive or nonresponsive?).

Thought
Usually, a description of a patient’s thoughts during the interview is subdivided into (at
least) 2 categories: a description of the patient’s thought process, and the content of their thoughts.
Thought process describes the manner of organization and formulation of thought.
Coherent thought is clear, easy to follow, and logical. A disorder of thinking tends to impair this
coherence, and any disorder of thinking that affects language, communication or the content of
thought is termed a formal thought disorder.
Some aspects of thought process that are usually commented on include the stream of
thought and the goal directedness of a thought. A discussion of the stream of thought might
include a discussion of the quantity of thought: does there seem to be a paucity of thoughts, or
conversely, a flooding of thoughts? Also, it might include a discussion of the rate of thought: do the
thoughts seem to be racing? Retarded?
 Most commonly, examiners comment on the goal directedness or continuity of thoughts.
In normal thought, a speaker presents a series an ideas or propositions that form a logical
progression from an initial point, to the conclusion, or goal of the thought. Disorders of
continuity tend to distract from this goal or series, and the relatedness of a series of thoughts
become less clear. As the thought disorder gets more serious, the logical connectedness of
different thoughts becomes weaker. Some examples of disorders of thought process include:
Circumstantial thought: a lack of goal directedness, incorporating tedious and unnecessary
details, with difficulty in arriving at an end point; Tangential thought: a digression from the
subject, introducing thoughts that seem unrelated, oblique, and irrelevant; Thought blocking: a
sudden cessation in the middle of a sentence at which point a patient cannot recover what has
been said; and Loose associations: a jumping from one topic to another with no apparent
connection between the topics. In the other direction, a perseveration refers the patient's
repeating the same response to a variety of questions and topics, with an inability to change his
or her responses or to change the topic.
Other less common abnormalities of thought process include the following: Neologisms:
words that patients make up and are often a condensation of several words that are unintelligible
to another person. Word salad: incomprehensible mixing of meaningless words and phrases.
Clang associations: the connections between thoughts become tenuous, and the patient uses
rhyming and punning.
Disturbances of thought content include such abnormalities as Perceptual Disturbances
and Delusions.
The most common perceptual disturbances are Hallucinations, which are perceptual
experiences that have no external stimuli. Hallucinations can be auditory (i.e., hearing noises or
voices that nobody else hears); visual (i.e., seeing objects that are not present); tactile (i.e., feeling
sensations when there is no stimulus for them); gustatory (i.e., tasting sensations when there is
no stimulus for them); or olfactory (i.e., smelling odors that are not present). They are not
necessarily pathonogmonic of any specific disorder. For example hypnagogic (i.e., the drowsy
state preceding sleep) and hypnopompic (i.e., the semiconscious state preceding awakening)
hallucinations are experiences associated with normal sleep and with narcolepsy.
Another disorder of perception is an Illusion, which is a false impression that results from
a real stimulus. Other examples of abnormal perceptions include Depersonalization, which is a
patients' feelings that he is not himself, that he is strange, or that there is something different
about himself that he cannot account for, and Derealization, which expresses a patients' feeling
that the environment is somehow different or strange but she cannot account for these changes.
Delusions can be defined as false fixed beliefs that have no rational basis in reality, being
deemed unacceptable by the patient's culture. Primary delusions are unrelated to other
disorders. Examples include thought insertion, thought broadcasting, and beliefs about world
destruction. Secondary delusions are based on other psychological experiences. These include
delusions derived from hallucinations, other delusions, and morbid affective states.
Types of delusions include those of persecution, of jealousy, of guilt, of love, of poverty,
and of nihilism. The most common are persecutory delusions, in which one believes,
erroneously, that another person or group of persons it trying to do harm to oneself. Note that
this is often referred to as a paranoid delusion, but that is a misuse of the word paranoid, which is
a more generic in meaning and does not imply a specific type of delusion. Other abnormal
thoughts sometimes found as part of a delusion include ideas of reference and ideas of influence.
Ideas of reference are erroneous beliefs that an unrelated event in fact pertains to an individual.
Thus, if a patient observes a car on a street make a sudden turn, and assumes that it is because
the driver is following the patient, that would be an idea of reference. Such ideas can become
even more improbable, such as a belief that something an announcer is saying on the television is
actually a coded message intended for the patient. Ideas of influence are similar in that the
patient may believe that somehow they caused an unrelated event to happen (for example,
believing that through one’s will one was able to cause an accident, even though one was not
directly involved in any way).
 In addition to describing the type of delusion a patient has, one wants to comment on
other aspects of the delusion, such as the quality of the delusion, or the degrees of organization
of the delusion.
There are other types of abnormal thoughts. Examples include obsessions and
compulsions, which, though irrational, are not as severe a disorder as hallucinations or
delusions. Obsessions are repetitive, unwelcome, irrational thoughts that impose themselves on
the patient's consciousness over which he or she has no apparent control. They are accompanied
by feelings of anxious dread and are thought to be ego alien (coming from “outside” one’s normal
self or desires), unacceptable, and undesirable. They are often resisted by the patient.
Compulsions are repetitive stereotyped behaviors that the patient feels impelled to perform
ritualistically, even though he or she recognizes the irrationality and absurdity of the behaviors.
Although no pleasure is derived from performing the act, there is a temporary sense of relief of
tension when it is completed. These are usually associated with obsessions.
Some other specific thoughts to ask about, which may be of great practical concern,
suicidal and homicidal. These should be inquired about on any examination, as patients with
such thoughts commonly present to medical settings, but often do not spontaneously reveal
these thoughts.
The Cognitive Exam

Cognition refers to the ability to use the higher cortical functions: thinking, logic,
reasoning, and to communicate these thoughts to others. Unlike the rest of the mental status
examination, examinations of cognition often involve the administering of specific tests of
cognitive abilities. However, much can also be deduced from the whole of the examination. The
cognitive examination is usually divided into the following domains:

1. Consciousness
2. Orientation
3. Attention and Concentration
4. Memory
5. Visuospatial ability
6. Abstractions and conceptualization.

Consciousness should be assessed early on. Consciousness may range from normal
alertness to stupor and coma. Obviously, this affects the rest of the examination and should be
noted early on.

Orientation refers to the ability to understand one’s situation in space and time.
Generally, orientation to place and time is tested. Place may include asking about the building
and floor a person is in, as well as the city and state. Orientation to time is tested by asking a
person to give the day and date. Though an ill person who has spent a good deal of time
convalescing may not be clear on the exact date, a cognitively intact person generally can give an
approximate date, and it would be unusual for a cognitively intact person to not know the month
or year, or what part of the month they are in. Orientation to person generally remains intact
except in the most severe of cognitive disorders. In fact, a patient who presents disoriented to
person, but otherwise cognitively intact almost assuredly is almost never displaying a cognitive
disorder, but is most likely suffering from some other problem (for example a dissociative
disorder, or perhaps malingering).
 Attention and Concentration. Attention refers to the ability to focus and direct one’s
cognitive in a physiologically aroused state. Concentration refers to the ability to maintain
attention for a period. They need not go together: one can imagine a person who is attentive,
but cannot concentrate on any one thing: for example a patient with early Alzheimer’s disease
who is easily distracted. The patient’s attention and concentration during the interview should
be noted. Most screening tests for dementia include a test of these items. For example, on the
Folstein Mini-Mental Status Examination (below), a patient is asked to do serial seven’s
(described below). Though this does involve some mathematical skill (about a 3 rd grade level),
the ability to sustain the task over time implies a reasonable degree of attention and
concentration.
An example of a specific attentional task is the digit span, in which a patient is asked to
repeat increasing lengths of numbers forwards, and then backwards. A normal person should be
able to recite about 7 numbers forwards. A person usually can recite a reverse series that is 2 less
than their forward series (thus, 5 for most people). It is important to recite the numbers in a
relatively monotone way, put an equal interval between the numbers to avoid potential cues.
A simple test of concentration is to ask a person to count backwards starting at 65 and
stopping at 49. The instructions should be given only once, with no cuing during the task.
Another example is the serial sevens task, in when a patient is asked to start at 100 and subtract
7, then keep subtracting 7 from each answer. Usually a person is asked to perform 5
subtractions, and each correct interval of 7 scores 1 point.

Memory. Though variously defined, for the purposes here, memory will refer to the
process of learning involving the registering of information, the storage of that information, and the ability
to retrieve the information later. Thus, there are separate component of memory, and the
boundaries between them are somewhat controversial. A simple approach to testing will be used
here, and memory will be divided into registration, short-term memory, and long-term
memory.
Registration refers to the ability to repeat information immediately. It is usually limited
in capacity to about seven bits of information. Registration is usually tested by asking a patient
to repeat a series of items (for example, three unrelated words). If the patient cannot do on the
first try, the words should be repeated until the patient can do it, and the number of tries should
be recorded (more than 2 trials for 3 words would be abnormal). Registration should always be
ascertained before testing other parts of memory: an inattentive patient who cannot register
properly may appear to have a deficit of short or long-term memory, when in fact the memory
items were never incorporated properly for information storage.
Short-term memory refers to the storage of information beyond the immediate
(registration) period, but prior to the consolidation of memory into long-term memory.
Practically speaking, it lasts from a few seconds to a few minutes, and may or may not be
temporary (depending on the purpose of the memory). It is limited in capacity, though the
specific limits are very individual. Short-term memory can be tested by asking a patient to recall
3 or 4 words after a five-minute delay. After the initial test, a patient can be cued, or given
multiple changes, which subsequent performance being recorded (although if the patient were
being scored, these correct answers would not add to the score). Other typical tests of short-
term memory include reading a paragraph to a patient and asking them to recall as much
information from the story as possible in 5 minutes.
Long-term memory is usually divided into procedural and declarative memory.
Procedural memory refers to the ability to remember a specific set of skills. As one thinks of any
task one has learned–say, driving a car–it is clear that there is a point at which one no longer has
to think about the specific steps in the task—it has become unconscious and automatic.
Procedural memory is generally not assessed during a standard mental status examination, but
can be specifically tested when indicated. For example, a person may be asked to act out a
specific task (“show me how you brush your teeth”).
 Declarative memory refers to the retention of data or facts, which can be verbal or
nonverbal (i.e., sounds, images). In contrast to short-term memory, it is not temporary (though it
can decay over time), and it has no known limit.
Long-term (declarative) memory is usually tested by asking a patient to recall past details.
These details may be personal (wedding dates, graduations, past medical history–all of which
would have to then be independently confirmed), or historical (important historical dates that a
patient would reasonably be expected to know, based on their own upbringing and culture).
Typically, a patient is asked to name past presidents, but some patients (ex. recent immigrants)
may now know politics. One can usually assess appropriate questions after learning of a
patient’s background. Some events are fairly universal: Pearl Harbor, for example, at least for
people living in the US who are old enough to have been old enough in 1941. Similarly, one can
expect, at least in this general area, that asking when the Red Sox won the World Series will be
pretty reliable, at least for a while.

Constructional Ability refers to the ability to recognize the relationship of different

objects in the world. Though occasionally neglected during cognitive testing, it is of great
practical significance, particularly if a person wishes to drive, or live alone. Constructional tasks
require reasonable vision, motor coordination, strength, praxis and tactile sensation, and in cases
in which patient’s appear to have a deficit in this ability, these other domains should be tested as
well. Usually, constructional ability is tested by having a person copy a design, such as a
transparent cube, or a clock. The Folstein Mini Mental Status examination includes a
constructional task in which a person is asked to draw intersecting pentagrams: a patient is
expected both to draw the correct number of sides on both polygons as well as the two
intersection points.

Abstraction and Conceptualization refer to higher intellectual functions. Abstraction involves

the ability to understand the meanings of words beyond the literal interpretation.
Conceptualization involves a number of intellectual functions, including the ability to be self-
aware: of one’s existence, one’s thoughts, and one’s behaviors. Deficits in these areas may be
inferred during an examination, especially from overly concrete answers to questions (example:
doctor: “what brought you to the hospital” patient: “an ambulance.”). These abilities can be
tested through such tasks as asking a patient to identify similarities between objects (example:
“how are an apple and an orange both alike.” One would expect an abstract answer such as
“fruit”, as opposed to a concrete answer such as that they are both round). Often, patients are
asked to interpret proverbs as a test of abstract reasoning. Examples of proverbs typically used
including “The grass is greener on the other side” and “Don’t count your chicken’s before they
hatch.” Harder ones include “People who live in glass houses shouldn’t throw stones” and “A
rolling stone gathers no moss.” In each case, it should first be explained what a proverb is (“a
saying that has a broader meaning”) and an example might be given. A number of things can
impair proverb interpretations besides deficits in abstract functioning: lower education (usually
at least 8 years of education is expected for proverb interpretations), or a lack of cultural
applicability, and these should be investigated as possibilities in a person who is having trouble
with proverbs.

Standardized tests. There are a number of tests designed to examine various domains of
cognitive ability. An example of a commonly used one is the Folstein Mini-Mental Status exam,
and this is shown below.
 Figure 8-1. The Mini-Mental State
Examination (MMSE)
Figure 8-2. Normative Data for MMSE.
Maximum Score
ORIENTATION
5 ( ) What is the (year) (season) (date) (month)?
Age
5 ( ) Where are we (state) (country) (town or city) (hospital) (floor)?

REGISTRATION
3
Education (
18-24 )25-29Name 3 common objects (e.g. “apple”, “table”, “penny”).
30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 >84
Take 1 second to say each. Then ask the patient to repeat all 3 after
you have said them. Give 1 point for each correct answer.
Then repeat them until they lean all 3. Count trials and record.
4th grade 22 25 25 23 23 23 23 22 23 22 22 21 20 19
Trials:
ATTENTION AND CALCULATION
5 ( ) Ask patient to count back by sevens, starting at 100. Alternately, spell
8th grade 27 27 “world”
26 backwards.
26 27 The 26 score
27is the26number
26 of numbers
26 25or words25 in25 23
the correct order.
(93___86___79___72___65___)
(D____L___R____O___W____)
High 29 29 29 28 28 28 28 28 28 28 27 27 25 26
School RECALL
3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct
answer. (Note: Recall cannot be tested if all 3 objects were not
remembered during registration.
College 29 29 LANGUAGE
29 29 29 29 29 29 29 29 28 28 27 27
2 ( ) Name a “pencil” and “watch”
These
1 numbers can be used the
to compare a patient's
ifs, ands,performance on the MMSE against
( ) Repeat following: “No or buts.”
norms
3
for their age and education.
Follow a 3-stage command:
( )
“Take a paper in your right hand,
Fold it in half, and
Put it on the floor.”
1 ( ) Read and obey the following
Close our eyes.
1 ( ) Write a sentence.
1 ( )

Copy the following design.

Total Score ________ compare this score against norms for education and age.
Insight And Judgment.

Insight and Judgment refer to complex tasks that require a good deal of cognitive functioning
(including conceptual thinking and abstract ability), though intact cognitive functioning alone is
not adequate for good judgment and insight. One could spend a good deal of time debating
what these terms really mean. For the purposes here, suffice it to say that these concepts are
much more approachable when seen in specific circumstances. Thus, rather than discussion
these are overarching functions (“Judgment and insight: intact”), it is more useful to discuss
them as they relate to a particular activity or question. In context, one can specifically discuss a
patient’s insight into a particular problem, or their ability to use judgment to arrive at a
particular decision. For example, a patient’s ability to make a particular medical decision
requires both insight into their specific malady, as well as the judgment to weigh alternatives in
the service of arriving at an appropriate decision.

Insight (in the medical context) refers to the capacity of the patient to understand that he or she
has a problem or illness and to be able to review its probable causes and arrive at tenable
solutions. Self-observation alone is insufficient for insight. In assessing a patient’s insight into
their medical situation, the examiner should determine whether patients recognizes that they are
ill, whether they understand that the problems they have are not normal, and whether they
understand that treatment might be helpful. In some situations, it may also be important
determine whether a patient realizes how their behaviors affect other people.

Judgment (in the medical context) refers to the patient's capacity to make appropriate decisions
and appropriately act on them in social situations. The assessment of this function is best made
in the course of obtaining the patient's history, and formal testing is rarely helpful. An example
of testing would be to ask the patient, "What would you do if you saw smoke in a theater?
Clearly, a meaningful judgment first requires appropriate insight into one’s situation. There is
no necessary correlation between intelligence and judgment.

Figure 8-3. The Mental Status Exam

 Cooperative
Appearance: Attitude Normal
Uncooperative, Hostile, Guarded, Suspicious
Abnormal
calm, comfortable, euthymic, friendly, pleasant,
Mood Euthymic
unremarkable

angry, bellicose, belligerent, confrontational,

Angry
frustrated, hostile, impatient, irascible, irate,
irritable, oppositional, outraged, sullen

cheerful, ecstatic, elated, euphoric, giddy, happy,

Euphoric
jovial

apathetic, bland, dull, flat

Apathetic
despondent, distraught, dysphoric, grieving,
Dysphoric
hopeless, lugubrious, overwhelmed, remorseful,
sad

anxious, apprehensive, fearful, frightened, high-

Apprehensive
stung, nervous, overwhelmed, panicked, tense,
terrified, worried.

appropriate, congruent
Affect Appropriaten normal
ess inappropriate incongruent
abnormal
normal
Intensity normal
blunted, exaggerated, flat, heightened, overly
abnormal
dramatic

mobile
Variability/ normal
Mobility constricted, fixed, immobile, labile.
abnormal
full
Range normal
restricted range
abnormal
reactive, responsive
Reactivity normal
nonreactive, nonresponsive
abnormal
Fluency, repetition, Comment specifically
Speech
comprehension, naming,
writing, reading, prosody,
quality of speech.

circumstantiality, flight of ideas, loose

Thought Process Disorders of
associations, tangentiality, word salad
Connectedness
clanging, echolalia, neologisms, perseveration,
Other
thought blocking

delusions, homicidal ideation, magical thinking,

Content thoughts
obsessions, overvalued ideas, paranoia, phobia,
poverty of speech, preoccupations, ruminations,
suicidal ideation, suspiciousness.

autoscopy, déjà vu, depersonalization,

perceptions
derealization, hallucinations, illusion, jamais vu.

Cognition See description in text

Judgment
and Insight

Reliability