The Mental Status Exam (MSE)

In actual practice, providers (with the exception of a psychiatrist or neurologist) do not

regularly perform an examination explicitly designed to assess a patient's mental status.
During the course of the normal interview, most of the information relevant to this
assessment is obtained indirectly. This review provides an opportunity to consciously
think of the elements contained within the MSE.

In the day to day practice of medicine (and, in fact, throughout all of our interactions)
we continually come into contact with persons who have significantly impaired cognitive
abilities, altered capacity for memory, disordered thought processes and otherwise
abnormal mental status. First and foremost, the goal is to be able to note when these
abnormalities exist (you'd be surprised at how frequently they can be missed) and then
to categorize them as specifically as possible. If a person seems "odd, confused or not
quite right" what do we mean by this? What about their behavior, appearance, speech,
etc. has lead us to these conclusions? In some instances, the patient's condition (e.g.
markedly depressed level of consciousness, intoxication) will preclude a complete,
ordered evaluation of mental status, so flexibility is important. Knowing when to "cut
your losses" and abandon a more detailed examination obviously takes a bit of
experience! The formulation of actual diagnoses, the final step in this process is, for the
most part, beyond the scope of this discussion (I've included two of the most commonly
encountered ones at the end of this section as examples). In fact, even if you had the
experience and knowledge to generate diagnoses, this still may not be possible after a
single patient encounter. The interview provides a "snap shot" of the patient, a picture
of them as they exist at one point in time. Frequently, and this applies to the physical
examination as well, several interactions are required along with information about the
patient's usual level of function before you can come to any meaningful conclusions
about their current condition. The components of the MSE are as follows:

1. Appearance: How does the patient look? Neatly dressed with clear attention to
detail? Well groomed?
2. Level of alertness: Is the patient conscious? If not, can they be aroused? Can they
remain focused on your questions and conversation? What is their attention
span?
3. Speech: Is it normal in tone, volume and quantity?
4. Behavior: Pleasant? Cooperative? Agitated? Appropriate for the particular
situation?
5. Awareness of environment, also referred to as orientation: Do they know where
they are and what they are doing here? Do they know who you are? Can they tell
you the day, date and year?
 6. Mood: How do they feel? You may ask this directly (e.g. "Are you happy, sad,
depressed, angry?"). Is it appropriate for their current situation?
7. Affect: How do they appear to you? This interpretation is based on your
observation of their interactions during the interview. Do they make eye contact?
Are they excitable? Does the tone of their voice change? Common assessments
include: flat (unchanging throughout), excitable, appropriate.
8. Thought Process: This is a description of the way in which they think. Are their
comments logical and presented in an organized fashion? If not, how off base are
they? Do they tend to stray quickly to related topics? Are their thoughts
appropriately linked or simply all over the map?
9. Thought Content: A description of what the patient is thinking about. Are they
paranoid? Delusional (i.e. hold beliefs that are untrue)? If so, about what? Phobic?
Hallucinating (you need to ask if they see or hear things that others do not)?
Fixated on a single idea? If so, about what. Is the thought content consistent with
their affect? If there is any concern regarding possible interest in committing
suicide or homicide, the patient should be asked this directly, including a search
for details (e.g. specific plan, time etc.). Note: These questions have never been
shown to plant the seeds for an otherwise unplanned event and may provide
critical information, so they should be asked!
10. Memory: Short term memory is assessed by listing three objects, asking the
patient to repeat them to you to insure that they were heard correctly, and then
checking recall at 5 minutes. Long term memory can be evaluated by asking
about the patients job history, where they were born and raised, family history,
etc.
11. Ability to perform calculations: Can they perform simple addition, multiplication?
Are the responses appropriate for their level of education? Have they noticed any
problems balancing their check books or calculating correct change when making
purchases? This is also a test of the patient's attention span/ability to focus on a
task.
12. Judgment: Provide a common scenario and ask what they would do (e.g. "If you
found a letter on the ground in front of a mailbox, what would you do with it?").
13. Higher cortical functioning and reasoning: Involves interpretation of complex
ideas. For example, you may ask them the meaning of the phrase, "People in
glass houses should not throw stones." A few common interpretations include:
concrete (e.g. "Don't throw stones because it will break the glass"); abstract (e.g.
"Don't judge others"); or bizarre.

Diagnoses are made on the basis of a pattern of responses to the above evaluation. Two
commonly occurring disorders are described below:
1. Delirium: Also referred to as Altered Mental Status, Delta MS, Acute Confusional
State, or Toxic Metabolic State. This is a very common condition (particularly
among hospitalized patients) notable for an acute, global change in mental status
that can be the result of physiologic derangement anywhere within the body.
Causes include: infection, hypoxia, toxic ingestion, impaired ability of the body to
handle endogenously produced toxins (e.g. liver or kidney failure), etc. There is a
wide spectrum of presentations, ranging from unarousable to extremely agitated.
Patients may appear quite ill, with markedly abnormal vital signs that in
themselves can suggest the cause of the delirium (e.g. hypotension, infection).
They are frequently confused, disoriented, agitated and uncooperative. Formal
evaluation of mood, affect, memory, judgment or insight can be hopeless.
Thought process is disordered and content notable for delusions, paranoia and
hallucinations. In general, the diagnosis is suggested by the time course of the
illness (i.e. the change is acute). Treatment is dictated by the underlying insult,
which can generally be determined after a detailed history (usually with the help
of others who are familiar with the patient), review of medications, thorough
examination, and appropriate use of lab and radiologic testing. The elderly as
well as those with multiple medical problems (conditions which frequently
coexist) are at the highest risk for developing this condition. Delirium in this
patient sub-set can be provoked by seemingly minor precipitants. Initial
presentation of psychotic disorders as well as dementia can be mistaken for
delirium (and vice versa). This can only be sorted out with time and appropriate
testing, though these distinctions are extremely important.

For Additional Information See: Digital DDx: Delirium

2. Dementia: A final common pathway for multiple disorders characterized by its

slow, progressive nature, taking months to years to develop. While quite
uncommon under 50, the incidence increases markedly with age. Patient's
appearance and behavior vary with the extent of involvement. This ranges from
well groomed, alert and cooperative to agitated, unable to care for themselves
and incapable of answering even simple questions. Mood and affect can range
widely, and may or may not be appropriate for the given situation. Thought
process and content have similar variability. Memory, judgment and higher
cortical function deteriorate with time. As this is a progressive disease,
presentation will depend on the level of advancement. Contributions from other
acute, reversible medical problems must be ruled out on the basis of history,
examination and laboratory testing.

For Additional Information See: Digital DDx: Dementia

 The Mini Mental Status Examination (MMSE) is a brief bedside test that is an excellent
means of quantifying cognitive function and decline. A newer validated tool for
quantifying cognitive performance is the Saint Louis University Mental Status
Examination (SLUMS).

Many aspects of the MSE are extremely subjective. There is tremendous potential for our
own cultural exposure and background to color these assessments. Realize that there is
a major distinction between "different" and "abnormal." Proverbs, for example, are not
necessarily a part of any communal experience. Thus, a "failure" to provide a correct
interpretation may in fact have nothing to do with an individual's intellectual function
but rather may simply reflect a different upbringing or background. Similarly, tests of
memory which require the subject to recite past U.S. Presidents may not be an
appropriate measuring tool depending on a person's country of origin, language skills,
educational level, etc. These situations are unavoidable in the extremely diverse
community in which we live. Quantifying and defining the nature of a specific
abnormality is an important part of the practice of medicine. While it is reasonable to
expect that people be aware of certain basic facts (e.g. their name, the year, the purpose
of their visit to the hospital, etc.) it is also important to recognize that our observation
and interpretation of patient behavior and responses is colored by our own life
experiences.

What questions are asked in a mental health assessment?

Your doctor will ask questions about how long you've had your symptoms, your
personal or family history of mental health issues, and any psychiatric treatment
you've had. Personal history. Your doctor may also ask questions about your lifestyle
or personal history: Are you married? What sort of work do you do?

What are 4 things that the mental status test evaluate?

The Mental Status Examination.
• Level of Consciousness. ...
• Appearance and General Behavior. ...
• Speech and Motor Activity. ...
• Affect and Mood. ...
• Thought and Perception. ...
• Attitude and Insight. ...
• Examiner's Reaction to the Patient. ...
• Structured Examination of Cognitive Abilities.
Robert M. House M.D. 1. What is the mental status examination? The mental status examination (MSE)
is a component of all medical exams and may be viewed as the psychological equivalent of the physical
exam. It is especially important in neurologic and psychiatric evaluations. The purpose is to evaluate,
quantitatively and qualitatively, a range of mental functions and behaviors at a specific point in time.
The MSE provides important information for diagnosis and for assessment of the disorder’s course and
response to treatment. Observations noted throughout the interview become part of the MSE, which
begins when the clinician first meets the patient. Information is gathered about the patient’s behaviors,
thinking, and mood. At an appropriate point in the evaluation the formal MSE is undertaken to compile
specific data about the patient’s cognitive functioning. Earlier informal observations about mental state
are woven together with the results of specific testing. For example, the interviewer will have
considerable information about attention span, memory, and organization of thought from the process
of the interview. Specific questions during the formal exam clarify more precisely the degree of
attention or memory dysfunction. Case. A 55-year-old man presented with recent complaints of sadness
and fear of being alone. He also expressed thoughts about death. As he presented his concerns, he
rambled to unrelated topics and seemed to lose track of the interviewer’s questions. During the formal
inquiry he was able to recall only 1 of 3 objects he was asked to memorize and made several mistakes in
serial subtractions of 7 from 100. Specific questioning about suicidal wishes and actions revealed that he
had overdosed with aspirin 1 month earlier and still experienced suicidal thoughts and wishes to die.
The cognitive tests were compatible with mild dementia, and the differential diagnosis included major
depression. Further work-up and treatment supported this diagnosis. Cognitive functioning improved
with antidepressants. 2. Is the MSE a separate part of the patient evaluation? No. The MSE must be
interpreted along with the presenting history, physical exam, and laboratory and radiologic studies.
Separate interpretation makes you vulnerable to erroneous conclusions. Collateral information from
families and friends is also invaluable to confirm or supply missing data. Case. A 27-year-old man
presented to the psychiatric emergency department with somewhat grandiose behavior, pressured
speech, irritability, and psychomotor agitation. The initial diagnostic impression was bipolar disorder,
manic or druginduced mania. The patient denied drug abuse. However, questioning his wife uncovered
a history of substance abuse, and laboratory evaluation revealed the presence of amphetamine
metabolites. The correct diagnosis was amphetamine-induced mood disorder. 3. What key factors
should be considered along with the MSE? To assess properly the patient’s mental status, it is important
to have some understanding of the patient’s social, cultural, and educational background. What may be
abnormal for someone with more intellectual ability may be normal for someone with less intellectual
ability. Patients for whom English is a second language may have difficulty understanding various
components of the MSE, such as the proverbs. Age may be a factor. In general, patients over the age of
60 years tend to do less well on the cognitive elements of the MSE. Often this is related to less
education rather than to aging alone. 4. What are the major components of the MSE? Components vary
somewhat from author to author. However, most detailed MSEs include information about appearance,
motor activity, speech, affect, thought content, thought process, perception, intellect, and insight.