MENTAL STATUS EXAMINATION

A systematically conducted mental status examination is an important component of case

taking it is essential to record the observations properly, whenever positive findings are
obtained, they should be described in detail. It is not adequate to say `delusions present’ or
`hallucinations. MSE has to be repeated several times during the course of the illness to know
the evolution of symptoms, effectiveness of treatment etc. The time frame covered by the
MSE is restricted to the hour of observation, but extends longer, while the following account
highlights the major components of MSE, details should be obtained from other sources
cited. The MSE is used to determine whether a patient is experiencing abnormalities in
thinking and reasoning ability, feelings or behavior.

1. GENERAL BEHAVIOUR:

Description as complete, accurate, life like as possible, of the observations of ward

staff and your own; the following points may be considered, though not exclusively.
Enquiry about the ways of spending the day, eating, sleeping, cleanliness in general,
self care, hair and dress. Behaviour towards other patients, doctors and nursing staff
does the patient look ill?

Note whether the patient is fully conscious, stuporose or comatose; is he in touch with
surroundings? Is the patient relaxed or tense and restless / is he slow or hesitant? How
does he respond to various requirements and situations? Are there abnormal responses
to external events? Can his attention be held or diverted? Is the patient Co-operative?
Can adequate rapport be established? Does the patient maintain adequate eye contact?
Does the patient’s behaviour suggest that he is oriented/disoriented? Note the
presence of any tics on mannerisms. Note the presence of any catatonic phenomena.

2. PSYCHOMOTOR ACTIVITY:

Note if the Psychomotor activity is increased, decreased or normal.

3. SPEECH:

Note here the form of utterances rather than the content does the patient speak
spontaneously or only in response to questions?
Is the amount of speech little or excessive? Is it high toned or low toned ? Is the
tempo fast or slow?
Is the reaction time increased or decreased?
Is it relevant?
Is the coherent?
Describe under these headings; relevance, coherence, volume, tone, tempo, reaction
time

4. THOUGHT:
Examine thought processes with respect to-
Form: Presence of formal thought disorder
Stream: Flight of ideas, retardation of thinking, circumstantially, perseveration,
thought blocking
 Possessions: Obsessions and compulsions, thought alienation. With respect to
obsession, elicit their nature-ideas, doubts, imagery, impulses and phobias. Similarly
clarify the nature of compulsive acts checking, counting or washing; Are these
`controlling’ compulsions or yielding compulsions?
Content: Look for the presence of overvalued ideas and delusions before making an
inference, a detailed description of the phenomenon must be given. Note whether the
delusion is single or there are multiple delusions, the type of delusion (grandiose,
persecutory, nihilistic etc.), the exact content of the delusion, whether they are fleeting
or fixed, whether they are well systematized or poorly systematized and whether they
are mood congruent or not; Enquire about worries and preoccupations,
hypochondriacal and somatic symptoms. Depressive ideation, ideas of worthlessness,
guilt, hopelessness and suicidal ideas must be enquired and recorded.

5. MOOD:
This should be assessed by both subjective report and objective evaluation;
assessment should be both longitudinal (mood) and cross-sectional (affect).
Description should be given regarding the following components; the quality of affect
(happiness, sadness, anxiety etc.), the intensity or depth of emotional experience, the
range of affective responses, reactivity (changes in emotion in relation to
environmental factors), diurnal variation, congruity (in relation to thought processes)
and appropriateness (in relation to situations). Note any evidence of lability (rapid and
extreme changes in emotion).

6. PERCEPTION:

Record the presence of illusions and hallucinations. Enquiry should be made into the
following modalities, vision, hearing, smell, taste, pain and deep sensations vestibular
sensations and sense of presence; record also the presence of special varieties of
hallucinations like functional hallucinations, reflex hallucinations, extra-campine
hallucinations, synesthesia and autoscopy. Detailed descriptions of the actual
experience should be obtained, for example, with respect to auditory hallucination
enquiry whether the hallucinations are verbal or nonverbal, continuous or intermittent,
single voice or multiple voices; familiar or unfamiliar voice; first person, second
person or third person; pleasant or unpleasant, if unpleasant, whether commanding,
abusive or threatening; response to hallucinations; whether mood congruent.
Distinguish hallucinations from imagery and pseudo-hallucinations. Other perceptual
disturbances, that must be enquired into include heightened perception, dulled
perception, depersonalization/derealization experiences.

7. COGNITIVE FUNCTIONS:
Insight: test the patient’s level of awareness of his illness; does he think that he is not
ill at all
(absence of insight)? Does he recognize the presence of illness but gives explanation
in physical term (partial insight)? Does he fully realize the emotional nature of his
illness and the cause of his symptoms (insight present)?

CLINICAL ASSESSMENT OF COGNITIVE FUNCTIONS

Clinical assessment includes the areas of

1. Orientation
2. Attention and concentration
3. Memory
4. Intelligence
5. Judgment

ORIENTATION
Three aspects are described to time, place and person the following questions may be
asked in the relevant areas:

Time:
1. Approximately what time of the day is it? (If the patient is unable to reply a
more specific question may be asked)
2. Is it morning, afternoon, evening or night? (In addition further questioning
may be done to assess estimation of time)
3. Approximately how long is it since you had your breakfast/lunch tea/dinner?
(OR) Approximately how long have I been talking to you?
4. What is the day today? (day of week)
5. What is the date (day of the month, month, and year) today?

Place:
1. What place is this? (If the answer is not forthcoming, a specific question is
asked)
2. Is this a school, office, hospital, restaurant etc.,? (If the patient says it is a
hospital details may be asked depending on background)

Person:
a) Orientation to self is tested by asking the identity of the patient.
b) Inquiring about the identity of the patient’s relatives or family members.

ATTENTION AND CONCENTRATION:

Tests used in clinical situation include
1. The digit span test
2. Serial subtraction
3. Days or months forward to backward

1. Digit Span Test

a) Forward:
Patient is given the following instruction: I will be saying some digits, listen to
me
carefully, When I finish saying them you will have to repeat them in the same
order the examiner after instructing the patient.

a) Give an example (for example if I say 3, 7 you repeat 3, 7)

b) Read digits at the rate of one per second to the patient
c) Notes whether the immediate response of the patient is correct or incorrect.
The
 following digits may be used:
5-7-3 4-1-7
5-3-8-7 6-1-5-8
1-6-4-9-5 2-9-7-6-3
3-4-1-7-9-6 6-1-5-8-3-9
7-2-5-9-4-8-3 4-7-1-5-3-8-6
4-7-2-9-1-6-8-5 9-2-5-8-3-1-7-4

The digit span is the highest number of digits repeated correctly.

The same digits should not be presented more than once if the patient cannot repeat a
particular number of digits on one trial, a 2nd trial with the same number of digits is
given and credit is given if the response is correct.

b) Backward

The patient is instructed as follows: I will be saying some digits, listen to me

carefully
and procedure is the same as for digits forward.
- The same digits be repeated not be used as for the forward test
- Digit backward score is the highest number of digits correctly repeated backward
after a maximum of 2 trials.

SERIAL SUBTRACTIONS:

Increasingly difficult tests are presented. The examiner a) instructs the patient, b)
gives an example of how to perform task, c) notes the responses verbatim and d) notes
the time taken in seconds.

Task: Correct response and the limit

20-1 20 to 0 reversed in 15 secs.
40-3 40, 37, 34, 31 etc. in 60 secs.
100-7 100, 93, 86, 79 etc. in 120 secs.

Days or months may be asked for in backward to the patient who is familiar with the
correct order.

MEMORY:

Assessment includes immediate, recent and remote memory

a) Immediate memory – tested by digit span test

b) Recent memory: Tested by:

1) Address Test. An address consisting of about 4-5 facts that is not known to the
patient is slowly read to the patient after instructing him to attend to the examiner.
He is engaged in conversation (to avoid rehearsal) and the response is noted
verbatim. Recall is asked for after 3-5 minutes.

2) Asking the patient to recall events in the last 24 hours e.g., details of the time and
 amount in a meal, visitors to the hospital from an inpatient. Responses given by
the patient should be noted of any cross-checked from reliable source.

c) Remote memory: Information on life events

i) date of birth or age
ii) number of children
iii) names and number of family members
iv) time since marriage of death or any family member
v) Year of completing education
4-5 facts may be asked that are relevant to the patient’s background and answers
should be cross checked.

INTELLIGNECE

This includes the areas of general information, comprehension, arithmetic and

vocabulary.

General information: information relevant to the patients literacy age or occupation

may be asked
e.g., in literate

a) Name of Prime Minister

b) 5 river, cities or states
c) Capitals of countries
d) Current events (major)

For illiterates:

a) Seasons
b) Crops of fruits growing particular seasons
c) Prices of food grains or food items
d) Prices of land

Comprehension: The ability to understand questions asked during an interview is an

index.
Specifically, the following questions of increasing difficulty may be asked.
1. What will you do when you feel cold?
2. What will you do if it rains when you start to work?
3. What will you do when you miss the bus when you are on a journey?
4. What will you do when you find on your way that it will be late by the time
you reach your work spot?
5. Why should we be away from bad company?
Arithmetic: The following questions may be asked with increasing time units
1. How such is 4 rupees and 5 Rupees?
2. I borrowed 6 rupees from a friend and returned 2 rupees, how much do I still
owe to him?
3. If a man buys cloth for 12 rupees and gives a shopkeeper 20 rupees; how
much change would he get back?
4. How many pencils can you buy for 2 rupees if one pencil costs quarter of a
rupee (on 25 paise)?
 5. If 18 boys are divided into groups of 6, how many groups will there be?

Time limits: 1 to 3 15 secs

4 to 5 30 secs

Correct answers: 1)9, 2)4, 3)9, 4)8, 5)3

Abstraction:
Tested by a similarities, differences and proverbs

Similarities: The patient is given the following instructions.

I will be giving you some pair of words. You have to tell me in what way they are
alike, what is common between them, or what is the similarity between them.

Orange - Banana (fruits)

Dog - Lion (animals)
Eye - ear (sense organs)
North - west (directions)
Table - chair (items of furniture)
Correct responses, i.e., abstract responses are given in brackets

Differences being an easier task are always presented before similarities

Differences:
The instructions are as follows: I will be presenting to you some pairs of words listen
carefully and tell me in what they are different from each other.
Stone - Potato (not edible - edible/hard-soft)
Fly - Butterfly (small-large/not colourful-colourful)
Cinema - Radio (audio-visual-audio)
Iron - Silver (heavy-light-dull-bright)
Praise - Punishment (Positive-negative/pleasant-unpleasant)

Proverbs:
The patient is asked the following questions
a) Whether he knows what a proverb is
b) An example of a proverb and what is means

If it is clear that the patient has the concept of a proverb the following may be asked
1) Slow and steady wins the race
2) A barking dog never bites
3) As you sow, so shall you reap
4) All that glitters is not gold or all that is white is not milk
5) Where there is a will there is a way
6) Empty vessels make more noise
7) Every potter praises his pot
8) It is useless to cry over spilt milk
The response of patient is to be noted verbatim and judged to be correct/incorrect.
JUDGMENT

Is assessed in the following areas

1) Personal
2) Social
3) Test
Personal: Judgment is assessed by inquiries about the patient’s future plans
Social: Judgment is assessed by observing behavior in social situations
Test Judgment: The following 2 problems are presented to the patient in a manner in
which he can comprehend.
1. Fire problem: If the house in which you are catches fire, what is the
first thing you will do?
(correct answer – try to put if off with water)
2. Letter problem: If when you are walking on the roadside you see a
stamped and sealed envelope with an address on it which someone
had dropped, what will you do?
(correct answer post it in a letter box, or give it to the post man)

SUMMARY
The purpose of a summary is to provide concise description of all the important aspect
of the case to enable others who are unfamiliar with the patient to grasp the essential
features of the problem. The summary should be presented in the same format as
described in the previous pages.

FORMULATION
This is the student’s own assessment of the case rather than as restatement of the
facts. Its length layout and emphasis will vary considerably from one patient to
another. It should always include a discussion of the diagnosis, of the etiological
factors which seem important, a plan of management and an estimate of the
prognosis, regardless of the uncertainty or complexity of the case, a provisional
diagnosis should always be specified using the ICD. A complete physical examination
is mandatory for each patient.

INVESTIGATION, TREATMENT AND FOLLOW-UP

Biochemical, radiological or psychometric investigations should be carried be out
wherever
appropriate all aspects of management viz physical, psychological and social
interventions should be included in the treatment package though the relative
emphasis may differ from case to case.

Progress notes should be systematically recorded.

 EXAMINATION OF NON-CO-OPERATIVE OR STUPOROSE PATIENTS
(Kirby, 1921)

The difficulty of getting information from non-Co-operative patients should not discourage
the physician from making and recording observations. These may be of great important in
the study of various types of cases and give valuable data for the interpretation of different
clinical reactions. It is hardly necessary to say that the time to study negative reaction is
during the period of negativism, the time of study a stupor is during the stupoose phase. To
wait for the clinical picture to change or for the patient to become more accessible is often to
miss an opportunity and leave a serious gap in the clinical observation. Obviously it is
necessary in the examination of such cases to adopt some other plan than that used in making
the usual `mental status.’ The following guide was devised to cover in a systematic way the
important points for purposes of clinical differentiation.

I. GENERAL REACTION AND POSTURE

A. Attitude voluntary or passive

B. Voluntary postures comfortable, natural, constrained or awkward.
C. What does the patient do if placed in awkward of uncomfortable positions?
D. Behavior toward physicians and nurses, resistive, evasive, irritable, apathetic,
complaint
E. Spontaneous acts: any occasional show to playfulness, mischievousness or
assaultiveness; Defence movements when interfered with or when pricked
with pin; eating and dressing; Attention to bowels and bladder. Do the
movements show only initial retardation or are they consistent throughout?
F. To what extent does the attitude change?

II. FACIAL EXPRESSION:

Alert, attentive, placid, vaunt, stolid, sulky, scowling, averse perplexed distressed,
etc. Any play of facial expression or signs or emotion tears, smiles, blushing,
perspiration. On what occasions?

III. EYES:
Open or closed if close, resist having lid raised. Movement of eyes absent or obtained
on request: give attention and follow the examiner or moving objects or show only
fixed gaxing, furtive glances or evasion.
Rolling of eyeballs upward. Blinking, flickering, or tremors of lids. Reaction to
sudden approach to threat to stick in eye. Sensory reaction of pupils (dilation from
painful stimuli or irritation to skin of neck).

IV. REACTION TO WHAT IS SAID OR DONE:

Commands show tongue, move limbs, grasp with hand (clinging, clinching, etc.,).
Motions slow or sudden. Reaction to pin-pricks. Automatic obedience: tell patient to
protrude the tongue to have pin stuck into it.

V. MUSCULAR REACTIONS:
Test for rigidity, muscles relaxed or tense when limbs or body is moved. Catalepsy,
Waxy flexibility, Negativism shown by movement in opposite direction on springy or
cogwheel resistance.
Test head and neck by movement forward and backward and to side
Test also the jaw, shoulders, elbows, fingers and the lower extremities
Does distraction or command influence the reactions?
Closing of mouth, prolusion of lips (`Schnauzkrampf”) Holding of saliva, drooling.

VI. EMOTIONAL RESPONSIVENESS:

Is feeling shown when talked to of family or children?
Or when sensitive points in history are mentioned or when visitors come?
Note whether or not acceleration of respiration or pulse occurs also look for flushing,
perspiration, tears in eyes, etc., Do jokes elicit any response?
Effect of unexpected stimuli (clap hands, flash of electric light)

VII. SPEECH:
Any apparent effort to talk, lip-movements, whispers, movements of head. Note exact
utterances with accompanying emotional reaction (may indicate hallucinations)

VIII. WRITING:
Offer paper and pencil. Unresponsive or partially stuporose patients will often write
when they fail to talk.
 Mini Mental Status Examination (MMSE)
 A tool that can be used to systematically and thoroughly assess mental status.
 An 11-question measure that tests five areas of cognitive function: orientation,
registration, attention and calculation, recall, and language.
 The maximum score is 30. A score of 23 or lower is indicative of cognitive
impairment.
 The MMSE takes only 5-10 minutes to administer.
Maximu Score
m
Orientation
5 ( ) What is the (year) (season) (date) (day) (month)
5 ( ) Where are we (state) (country) (town) (hospital) (floor)
Registration
3 ( ) Name 3 objects: 1 second to say each. Then ask the patient all 3 after you
say them. Give 1 point for each correct answer. Then repeat them until
he/she learns all 3. Count trials and record.
Trials ___________

Attention and calculation

5 ( ) Serial 7’s. 1 point for each correct answer. Stop after 5 answers.
Alternatively, spell “world” backward.
Recall
3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct answer.
Language
2 ( ) Name a pencil and watch.
1 ( ) Repeat the following “No ifs, ands, or buts”
3 ( ) Follow a 3-stage command:
“Take a paper in your hand, fold it in half, and put it on the floor.”
1 ( ) Read and obey the following: CLOSE YOUR EYES
1 ( ) Write a sentence
1 ( ) Copy the design shown.

Total score
ASSESS level of consciousness along a continuum__________

Alert Drowsy Stupor Coma

MINI-MENTAL STATE’” A practical Method for grading the cognitive state of patients for the
CLD
Journal of Psychiatric research, 12(3): 189-198, 1975. Used by permission