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August 15, 2013
Doc Los Baños Mental Status
"It  is  not  how  much  we  have,  but  how  much  we  enjoy  that  makes  happiness."    
-­‐  Charles  Sprugeon   Exam
 
OUTLINE PAGE
ATTITUDE TOWARD THE EXAMINER
I. Mental Status Exam (MSE) 1 • Can be described as follows:
II. Outline for MSE 1 o cooperative o seductive o hostile
A. General Description 1 o friendly o defensive o playful
B. Mood and Affect 1 o attentive o contemptuous o ingratiating
C. Perceptions 2 o interested o perplexed o evasive
D. Thought Content and Mental trends 2 o frank o apathetic o guarded
E. Sensorium and Cognition 3
• Any number of other adjectives can be used.
F. Impulsivity 4
• Record the level of rapport established.
G. Judgment and Insight 5
III. Reliability 5
IV. Psychiatric Report 5 SPEECH CHARACTERISTICS
• Physical characteristics of speech
MENTAL STATUS EXAMINATION o QUANTITY
o RATE OF PRODUCTION
• Part of the clinical assessment which describes the sum
total of the examiner's observations and impressions o QUALITY
• Examples: Talkative, garrulous, voluble, taciturn, unspon-
of the psychiatric patient at the time of the interview.
• DESCRIPTION of the patient's APPEARANCE, SPEECH, taneous, or normally responsive to cues from the
ACTIONS, and thoughts during the interview. (Appearance interviewer
Behavior Communication) • Patient’s speech can be:
• More dynamic than any other examination o Rapid or slow o Dramatic o Slurred
o Can change from day to day or hour to hour o Pressured o Monotonous o Staccato
NOTE: Even when a patient is mute, is incoherent, or refuses o Hesitant o Loud, whispered o Mumbled
to answer questions, the clinician can obtain a wealth of o Emotional
information through careful observation. • Includes Speech Impairment (e.g. Stuttering)
• DYSPOSODY
o Any unusual rhythms or accent that should be noted.
OUTLINE FOR THE MSE
1. APPEARANCE
OVERT BEHAVIOR AND PSYCHOMOTOR ACTIVITY
2. OVERT BEHAVIOR
3. ATTITUDE • Describe both QUANTITATIVE and QUALITATIVE aspects
of the patient's motor behavior.
4. SPEECH
5. MOOD & AFFECT • Include:
o Mannerisms o Echopraxia o Rigidity
6. THINKING
o Form o Tics o Hyperactivity o Agility
o Gestures o Agitation o Stereotyped
o Content
7. PERCEPTIONS
o Twitches o Combativeness Behavior
o Gait o Flexibility
8. SENSORIUM
o Alertness • Describe restlessness, wringing of hands, pacing, and
other physical manifestations.
o Orientation (person, place, time)
o Concentration • Note psychomotor retardation or generalized slowing
of body movements and describe any aimless,
o Memory (immediate, recent, long term)
o Calculations purposeless activity.
o Fund of knowledge
o Abstract reasoning MOOD AND AFFECT
9. INSIGHT MOOD
10. JUDGMENT • Pervasive and sustained emotion that colors the person's
perception of the world.
GENERAL DESCRIPTION • Should include depth, intensity, duration, and fluctuations
APPEARANCE • Commonly adjectives used:
o Depressed o Expansive o Futile
• Describes patient's appearance & overall physical impression.
(Examples: body type, posture, poise, clothes, o Despairing o Euphoric o Self-
o Irritable o Empty contemptuous
grooming, hair, and nails)
• Common terms used: o Anxious o Guilty o Frightened
o Angry o Hopeless o Perplexed
o Healthy o Old looking o Childlike
o Sickly o Young looking o Bizarre* • Can be labile, fluctuating or alternating rapidly
between extremes
o Ill at ease o Disheveled o Anxious**
o Poised o e.g., laughing loudly and expansively one moment,
* tearful and despairing the next
If the patient appears bizarre, the clinician may ask:
o “Has anyone ever commented on how you look?”
o “How would you describe how you look?” AFFECT
o “Can you help me understand some of the choices you • Patient's present emotional responsiveness
make in how you look?” • Inferred from the patient's facial expression, including the
**
Signs of anxiety: moist hands, perspiring forehead, tense amount and the range of expressive behavior.
posture, wide eyes. • May or may not be congruent with mood

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page  1  of  6  

 
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• Can be described as: ILLUSION
• range of affect can be variation in • Distortion of the senses; stimuli must be present.
NORMAL
facial expression, tone of voice, use • Examples
of hands and body movement o A patient sees the rope as a snake.
• Range and intensity of expression o Déjà vu - A false sense of visual familiarity in a situation
CONSTRICTED
are reduced o Jamais vu - strange feeling that one does not recognize
• Emotional expression further a familiar situation
BLUNTED
depressed o Hypersensitivity to light, sound and smell
• No signs of affective expression
should be present
FLAT THOUGHT CONTENT AND MENTAL TRENDS
§ patient's voice - monotonous
§ face – immobile THOUGHT PROCESS THOUGHT CONTENT
• Note the patient's difficulty in initiating, sustaining, or • Way in which a person puts • WHAT a person is
terminating an emotional response. together ideas & actually thinking about:
associations ideas, beliefs,
• The form in which a person preoccupations,
APPROPRIATENESS AFFECT
thinks obsessions
• In the context of the subject the patient is discussing • Can be logical and coherent
• Example: or completely illogical and
Delusional patients even incomprehensible
Appropriate Affect:
(who are describing a à
Anger or Fear
delusion of persecution)
THOUGHT PROCESS (FORM OF THINKING)
• Either an overabundance or a poverty of ideas
• INAPPROPRIATE AFFECT
• A patient may exhibit slow or hesitant thinking
o Affect is incongruent with what the patient is saying.
• Can be vague or empty
o Quality of response found in some schizophrenia
patients
o Example: flattened affect when speaking about FORMAL THOUGHT DISORDERS
murderous impulses. 1. CIRCUMSTANTIALITY
o Overinclusion of trivial or irrelevant details that impede
the sense of getting to the point
PERCEPTIONS
o Indicates the loss of capacity for goal-directed thinking
PERCEPTUAL DISTURBANCES
o e.g. When asked about a bruise on her arm, the
• Can be experienced in reference to the self or the patient recounts everything else that happened that
environment same day before explaining how she was injured.
• Sensory system is involved.
HALLUCINATIONS 2. CLANG ASSOCIATIONS
• Sensory experience in which a person can see, hear, o Thoughts are associated by the sound of words rather
smell, taste, or feel something that is not there than by their meaning
• Can also occur in particular times of stress o e.g., through rhyming or assonance - “He went in
• Types: entry in trying tieing sighing dying ding-dong dangles
§ Auditory* § Gustatory dashing dancing ding-a-ling!”
§ Visual § Olfactory*
§ Tactile § Command 3. DERAILMENT / LOOSENESS OF ASSOCIATION
• Note content and the time of occurrence. o A breakdown in both the logical connection between
• Questions used to elicit the experience of hallucinations: ideas and the overall sense of goal-directedness; no
o Have you ever heard voices or other sounds that no one connection at all
else could hear or when no one else was around? o The words make sentences, but the sentences do not
make sense.
Notes from lecture: o e.g. “…So after the storm we found the canoe a bit
*Auditory hallucinations is commonly associated with down the river, and then, uh…my mother came to see
psychiatric condition while olfactory hallucination is more of me today.”
neurologic.
4. FLIGHT OF IDEAS
**Hypnagogic and hypnopompic hallucinations are normal o A succession of multiple associations so that thoughts
but must not occur for too long. (Ito yung kapag seem to move abruptly from idea to idea
naaalimpungatan ka) o Often (but not invariably) expressed through rapid,
pressured speech
Hypnagogic o e.g. A man starts talking about his business, but
• Occurring as a person falls asleep quickly shifts to discussing the economy, the
hallucinations
government, and other countries.
• Occurring as a person awakens (or
Hypnopompic
in between sleep and full
hallucinations 5. NEOLOGISM
wakefulness)
o Invention of new words or phrases or the use of
Depersonalization • Extreme feelings of detachment conventional words in idiosyncratic ways
and Derealization from the self or the environment o New words created by the patient ( may be by
combining or condensing other words)
• Feeling of bugs crawling on or under
o E.g. “the only problem i have is my frustionating!”
Formication the skin
• Seen in cocainism

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page2  of  5    

 
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6. PERSEVERATION o THEMES OF DELUSIONS:
o Repetition of out of context of words, phrases, or ideas a. PERSECUTORY OR PARANOID
o e.g. Asked for the day, the patient says it’s Sunday. § Involve the theme of being followed, harassed,
Subsequent questions about month, year, and place cheated, poisoned or drugged, conspired against, spied
are all met with the same reply. on, attacked, or obstructed in the pursuit of goals.
o Another example is iba na yung topic bumabalik parin § E.g. They will all kill me.
ang px sa isang topic.
b. GRANDIOSE
7. TANGENTIALITY § Individual exaggerates his or her sense of self-
o In response to a question, the patient gives a reply importance and is convinced that he or she has special
that is appropriate to the general topic without actually powers, talents, or abilities
answering the question § E.g. “I am the President of the world.”
o The patient loses the thread of the conversation,
pursues divergent thoughts stimulated by various c. JEALOUS
external or internal irrelevant stimuli, and never § Falsely believes that his or her spouse or lover is
returns to the original point having an affair
o e.g.
§ Doctor: Have you had any trouble sleeping lately? d. SOMATIC
§ Patient: I usually sleep in my bed, but now I'm § E.g. A patient after medical tests confirm otherwise;
sleeping on the sofa. still insists, “I have cancer in my stomach”

8. THOUGHT BLOCKING e. GUILTY

o A sudden disruption of thought or a break in the flow § False feeling of remorse or guilt of delusional intensity
of ideas
o patient may indicate an inability to recall what was f. NIHILISTIC
being said or intended to be said § Centers on the nonexistence of self or parts of self,
o e.g. In the middle of talking about his childhood, the others, or the world
patient abruptly pauses, after which he can’t § E.g. A patient states, “i am dead.” Doctor: “if your
remember what he was saying. dead, how can you talk?”, patient: “i don’t know but
i’m dead.”
9. WORD SALAD
o Incoherent or incomprehensible connections of g. EROTIC
thoughts § One believes that another person, usually someone of
o e.g. “It was shockingly not of the best quality I have higher status, is in love with him or her
known all such evildoers coming out of doors with the
best of intentions!” § IDEAS OF REFERENCE - person's belief that the television
or radio is speaking to or about him or her
10. PUNNING - association by double meaning § IDEAS OF INFLUENCE- are beliefs about another person
11. RACING THOUGHTS or force controlling some aspect of one's behavior
§ CAPGRAS SYNDROME – belief that people have been
THOUGHT CONTENT taken away and been replaced by duplicates
• Disturbances include:
o Delusion SENSORIUM AND COGNITION
o Preoccupations - may involve the patient's illness • Assess brain function, including intelligence, capacity for
o Obsessions - ideas that are intrusive and repetitive abstract thought, and level of insight and judgment
o Compulsions – actions; things you do over and over,
in a repetitive manner; things you must do in a CONSCIOUSNESS
particular way or order; and if you do not do them that • Disturbances usually indicate organic brain impairment
way, must you repeat them • CLOUDING OR OBTUNDING OF CONSCIOUSNESS
o Phobias - Overall reduced awareness of the environment.
o Plans, intentions, recurrent ideas about suicide or o Patient may be unable to sustain attention to
homicide environmental stimuli or to maintain goal-directed
o Hypochondriacal symptoms thinking or behavior
o Specific antisocial urges o Frequently not a fixed mental state
o Typically exhibits fluctuations in the level of awareness
• DELUSIONS of the surrounding environment
o Fixed, false beliefs out of keeping with the patient's o Patient who has an altered state of consciousness often
cultural background (cannot be altered by reasoning shows some impairment of orientation as well (although
with the px). the reverse is not necessarily true)
o May be mood concruent or incongruent:
MOOD CONGRUENT MOOD INCONGRUENT Some terms used to describe Level of Consciousness:
§ thoughts that are in § Elated patient thinks
Alert responds fully and appropriately to stimuli
keeping with a depressed he has a brain tumor
Lethargy drowsy, responds to questions then fall asleep
or elated mood § Can be bizarre and
Clouding
§ Depressed patient thinks may involve beliefs
he is dying about external control Somnolence
§ Elated patient thinks she Stupor arouses from sleep only after painful stimuli
is the Virgin Mary Coma unaroused with eyes closed
 
Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page3  of  5    
 
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o Digit-span measures
QUESTIONS USED TO TEST COGNITIVE FUNCTIONS IN THE Immediate o asking patients to repeat six digits
SENSORIUM SECTION OF THE MENTAL STATUS EXAMINATION retention forward and then backward (unimpaired
1. Alertness (Observation) and recall memory can usually repeat six digits
What is your name? backward)
Who am I? • Often recent or short-term memory is impaired first
2. Orientation
What place is this? Where is it located? • Efforts made to cope with the impairment or to conceal it:
What city are we in? o Denial
Serial 7’s. Starting at 100, count backward o Confabulation - unconsciously making up false answers
by 7 (or 3). when memory is impaired
3. Concentra- Say the letters of the alphabet backward o Circumstantiality
tion starting with Z. • Reactions to the loss of memory can give important clues to
Name the months of the year backward underlying disorders and coping mechanisms
starting with December.
4. Memory CONCENTRATION AND ATTENTION
Repeat these numbers after me: 1, 4, 9, • Some reasons for impaired concentration:
Immediate
2, 5. o Cognitive disorder
What did you have for breakfast? o Anxiety
What were you doing before we started o Depression
talking this morning? o Internal stimuli, such as auditory hallucinations
Recent I want you to remember these three
things: a yellow pencil, a cocker spaniel, • CONCENTRATION
and Cincinnati. After a few minutes I'll ask o Subtracting serial 7s from 100; if the patient could not
you to repeat them. subtract 7s, could 3s be subtracted
What was your address when you were in o Assess whether anxiety, some disturbance of mood or
the third grade? consciousness, or a learning deficit (dyscalculia) is
Long term Who was your teacher? responsible for the difficulty
What did you do during the summer
between high school and college? • ATTENTION
If you buy something that costs P3.75 and o Assessed by calculations or by asking the patient to spell
you pay with a P5 bill, how much change the word world (or others) backward or name five things
5. Calculations should you get? that start with a particular letter
What is the cost of three oranges if a
dozen oranges cost P4.00? READING AND WRITING
What is the distance between New York
• Ask the patient to read a sentence and write a simple but
6. Fund of and Los Angeles?
complete sentence
knowledge What body of water lies between South
America and Africa?
VISUOSPATIAL ABILITY
Which one does not belong in this group: a
7. Abstract pair of scissors, a canary, and a spider? • Asked to copy a figure, such as a clock face or interlocking
reasoning Why? pentagons
How are an apple and an orange alike?
ABSTRACT THOUGHT
ORIENTATION AND MEMORY • Abstract thinking is the ability to deal with concepts
• Disorders are traditionally separated accdg to: (usually o Patient explain similarities or meanings of simple
appears in this order) proverbs
o Patient can give the approximate date and
TIME time of day • E.g. When asked to explain the proverb “People in glass
o know how long he or she has been there houses should not throw stones” a schizophrenic patient
replied, “That's easy, you can break the glass.”
o Patients should be able to state the name and
PLACE the location of the hospital correctly and to
o ANSWERS CAN BE:
behave as though they know where they are
§ CONCRETE (giving specific examples to illustrate the
o Patients should know the names of the people
meaning)
PERSON around them and whether they understand
§ OVERLY ABSTRACT (giving too generalized an
their roles in relationship to them
explanation)
• As the patient improves, the impairment clears in the
o Note the appropriateness of answers and the manner in
reverse order
which they are given
• Memory functions are divided into four areas:
Remote o asking patients for information about their
INFORMATION AND INTELLIGENCE
memory childhood that can be verified later
o (past few months) • INTELLIGENCE
Recent past o Related to vocabulary and general fund of knowledge
o asking patients to recall important news
memory
events from the past few months
o (past few days) • Patient's educational level (both formal and self-
Recent o asking patients about their appetite and education) and socioeconomic status must be taken into
memory then about what they had for breakfast or account.
for dinner the previous evening

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page4  of  5    

 
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IMPULSIVITY • Addresses critical questions in the report
• Capability to control sexual, aggressive, and other impulses o E.g. Are future diagnostic studies needed and, if so,
• Assessment of impulse control is critical in ascertaining the which ones?
patient's awareness of socially appropriate behavior • Includes a diagnosis made according to the revised fourth
• Measure of the patient's potential danger to self and others edition of the Diagnostic and Statistical Manual of
• Estimated from information in the patient's recent history Mental Disorders (DSM-IV-TR)- uses a multiaxial
and from behavior observed during the interview classification scheme consisting of five axes, each of which
should be covered
• Prognosis is also discussed, with both good and bad
JUDGEMENT AND INSIGHT
prognostic factors listed
JUDGMENT
• Treatment plan is discussed, and makes firm
• Assess many aspects of the patient's capability for social recommendations about, management issues.
judgment.
*********************END********************
• SOCIAL JUDGEMENT SOURCES
o Can the patient understand the likely outcome of his J Kaplan and upper batch trances J
behavior

• TEST JUDGEMENT  
o Imagining situation (e.g., smelling smoke in a crowded
movie theater)
o Situations should be pertinent to patient’s case
o Ask about situations that are significant to the patient

INSIGHT
• Patient's degree of awareness and understanding about
being ill
• Patients may exhibit complete denial of their illness or may
show some awareness that they are ill but place the blame
on others, on external factors, or even on organic factors
• They may acknowledge that they have an illness but ascribe
it to something unknown or mysterious in themselves

• INTELLECTUAL INSIGHT
o Patients can admit that they are ill and acknowledge that
their failures to adapt are partly because of their own
irrational feelings or disturbances without applying this
knowledge to future experiences
o Major limitation - inability to apply their knowledge to
alter future experiences

• TRUE EMOTIONAL INSIGHT

o Awareness of the motives and deep feelings within the
patient and the important persons in his or her life,
which can lead to basic changes in behavior or
personality

• SIX LEVELS OF INSIGHT:

o Complete denial of illness
o Slight awareness of being sick and needing help, but
denying it at the same time
o Awareness of being sick but blaming it on others, on
external factors, or on organic factors
o Awareness that illness is caused by something unknown
in the patient
o Intellectual insight
o True emotional insight

RELIABILITY
• Includes an estimate of the psychiatrist's impression of the
patient's truthfulness or veracity
• May estimate the patient's reliability to be good

PSYCHIATRIC REPORT
• Written document that details the findings obtained from the
psychiatric history and mental status examination
• Final summary of both positive and negative findings and an
interpretation of the data

Transcribers:  Noe,  Gisela,  Jess  J                                                                                                                                                                                                                                          Page5  of  5