Mental Status Examination (MSE)

What is Mental Status Examination

The mental status examination is a structured way to assess a patient’s thinking and behavior. It involves observing the patient’s appearance and behavior, including their level of awareness and ability to pay attention. The examiner also evaluates motor activity and speech. The patient’s mood, emotions, thoughts, and perceptions are carefully described. The examiner’s own observations and reactions are noted as well. Lastly, higher-level thinking abilities are assessed. The most important cognitive areas examined include alertness, language, memory, constructional skills, and abstract thinking.

Techniques Used in Mental Status Examination

Mental status testing can make patients feel uneasy and requires a great deal of cooperation. For this reason, examiners often perform it toward the end of the evaluation, when the patient is more relaxed and a trusting relationship has already been established. Unlike other parts of the medical examination, the mental status exam is harder to organize into a strict structure and does not easily follow a step-by-step format.

Even so, a patient’s mental state greatly influences how accurate and reliable the medical history is. Ideally, doctors would like to assess mental status before taking the full history so they can better judge the accuracy of the information that follows.

Skilled clinicians rely on ongoing, informal observations throughout the patient interview and physical examination. From these interactions, they gather important details about the patient’s appearance, behavior, level of alertness, speech, activity, mood, and attitude—often based on how the patient describes their current illness.

One key approach in mental status testing is to add structure to these observations, thereby transforming general impressions into meaningful clinical descriptions. A formal evaluation of specific cognitive abilities is usually done near the end of the visit. When signs of serious mental illness appear—such as unusual thoughts or behavior, neurological problems, or difficulties in daily social or work functioning—prompt attention is necessary. To ensure cooperation, clinicians carefully introduce the examination and provide a brief explanation of its purpose to the patient.

Components of MSE

Parts of the mental status examination are as follows:

Appearance and general behavior

The examiner gets a general idea of the patient from these factors. Relevant observations include the patient’s posture, eye contact, attire, grooming, and physical appearance. Behavior observation makes it easy to understand some specific syndromes, such as unilateral spatial neglect and the frontal lobe syndrome’s disinhibited behavior.

Speech and motor activity

The examiner collects useful information by listening to the patient’s speech. This happens as the patient answers open-ended questions. The examiner can find problems with speech or how it sounds. This includes different types of speech. There is the quiet voice in Parkinson’s disease. Some people may speak slowly when they have trouble finding words. Others may speak quickly and tensely when they are excited or under the influence of drugs. It’s also important to record general motor activity, including any tics or odd behaviors. For instance, Akathisia, or motor restlessness, may indicate an extrapyramidal syndrome caused by phenothiazine use. In contrast, slowness and loss of spontaneous movement may signal subcortical dementia or depression.

Affect and mood

Mood describes the patient’s longer-term emotional composition, whereas affect describes the patient’s immediate emotional expression. Patients exhibit a spectrum of affect that can be characterized as flat, labile, restricted, or broad. Affect and mood can be classified as either euphoric, euthymic, or dysphoric.

Moreover, the examiner must judge affect in the context of the setting and prior observations. For example, a startled-looking patient with wide eyes and beads of perspiration may initially appear anxious. However, when the examiner notes reduced movement, diminished eye blinking, and seborrhea, the signs point to Parkinson’s disease.

Thought and perception

One of the characteristics of psychotic thinking is the incapacity to process information properly. Therefore, a crucial psychiatric evaluation is how the patient interprets and reacts to stimuli. Does the patient have reasonable worries, or are they exaggerated to the point of unreasonable fear? Is there no observable basis in reality for the patient’s beliefs or behavior, or is the patient reacting exaggeratedly to real-life events? Patients may have noticeable somatization tendencies or struggle with intrusive and obsessive thoughts. The more seriously ill patient might display overt illusions or delusions.

Since patients often hide these experiences, it is good to ask guiding questions. For example, you might ask, “Have you ever seen or heard things that others could not see or hear?” Have you ever seen or heard things that later turned out not to be there?” It is also important to interpret positive responses carefully. Sometimes, people may think they hear their name or have strange visions just before sleep. These experiences are normal.

Evaluating a possible thought disorder is one of the hardest parts of the mental status exam. It needs a lot of experience. The primary-care physician will frequently desire formal psychiatric consultation in patients exhibiting such disorders.

Attitude and insight

We call the way a patient feels about the examiner, other people, or their illness their attitude. It could imply animosity, rage, powerlessness, pessimism, exaggeration, selfishness, or passivity. The patient’s perspective on the illness is also a significant factor. Is the patient a complainer who refuses assistance? Or is the illness considered psychiatric or nonpsychiatric by the patient? and the patient is willing to suffer in silence, or seek improvement? Throughout the interview, the patient’s attitude frequently shifts, and it’s critical to record any such shifts.

Attention

The testing of attention is a more refined consideration of the state of wakefulness than the level of consciousness. An ideal test of attentiveness should assay concentration on a simple task, placing minimal demand on language function, motor response, or spatial conception. Reaction times are frequently slowed in patients who have diminished attentiveness. This may become evident early in the course of examination that the examiner is dealing with decreased attentiveness. One test often recommended is the ability to listen to digit spans of increasing length and repeat them back to the examiner.

Another is to have the patient listen to a digit span and then repeat it backward. Perhaps a better test is to have the patient listen to a string of letters in which one letter is repeated frequently but randomly and to tap each time that letter is heard, for example, “Please tap each time you hear the letter K.”

T L K B K M N Z K K T K G B H W K L T K …

The number of errors the patient makes is noted. Another test might be to have the patient count the number of times a given letter appears on a page full of randomly ordered letters.

Language

Most right-handed people and more than half of left-handed people use the left perisylvian cortex for language. This area of the brain controls most language functions. Therefore, in approximately 95% of cases, an aphasia indicates left hemisphere damage. Assessments of spontaneous speech, understanding of spoken instructions, reading proficiency, reading comprehension, writing, and repetition should all be part of a basic language function examination. When the patient responds to open-ended questions, this assessment looks for paraphasic errors, abnormalities of content, disorders of output, and disorders of articulation.

The examiner asks the patient to repeat sentences containing several nouns and pronouns, such as “That’s what she said to them yesterday” and “No ifs, ands, or buts,” to evaluate repetition.

Evaluation

To evaluate comprehension, several response levels are employed. The patient is first asked complex yes-or-no questions, like “Do you take off your clothes before taking a shower?” to lessen the need for motoric and speech acts. Second, a simple gesture can be used to respond to questions like “Point to where people may sit down in this room.” Finally, the patient is given the following command with a motor response: “Squeeze my fingers.”

When a patient’s spontaneous speech stops while they look for the right word, it may be a sign of a word-finding disability. The examiner asks the patient to name several items from different categories. These items can be common or uncommon. This helps to assess the patient’s ability. Moreover, psychologist also tests the naming of object parts, such as the lead of a pencil or the crystal of a watch, to further evaluate this skill.

The examiner checks word fluency by asking the patient to generate as many words as possible in a set category within a limited time. Common examples include naming “items found in a supermarket.” Another test involves producing words that begin with the letters F, A, and S.

Also, the examiner tests reading by asking the patient to read aloud, assessing comprehension by having the patient follow a written command. For instance, “Close your eyes.” The examiner may also ask the patient to read standardized short stories and later recall them. It helps in scoring the performance based on the remembrance of key items.

Further, writing is tested by having the patient sign his name, generate spontaneous sentences, or describe an object in writing.

Memory

A common complaint that frequently manifests as a symptom in older people is memory disturbance. Immediate recall, short-term memory, and long-term storage are the three basic subunits of memory.
The most clinically relevant and crucial memory to test is short-term memory. To remember information for a short time, patients need to process and store it. This way, after completing the second task, they can recall what they learned. A short sentence, a five-part name and address, or four random objects can be used to test short-term memory in a patient. The patient is then asked to recall the information three to five minutes after completing another unrelated mental task.

Orientation largely reflects recent memory function. Questions such as, “Where are we right now? City? Today’s date? What time is it right now (to the nearest hour)?” are pertinent questions

The examiner tests immediate recall by asking the patient to repeat digit spans, both forward and backward. And,he evaluates long-term memory by asking the patient to recall remote personal or historical events. The examiner may also assess it with select questions from the WAIS information subtest. When asking about personal events, the examiner uses known details to judge the accuracy of the patient’s response. When asking about personal events, the physician must already know the correct details. Hence, this ensures that the accuracy of the patient’s response can be judged.

Constructional ability and praxis

The inability to execute previously learned motor acts—not because of weakness—is known as apraxia. The most common type is ideomotor apraxia. In this condition, the patient can move and handle objects. However, they cannot mimic certain actions. To test this, the examiner asks the patient to do some tasks. For example, they might say, “Light an imaginary cigarette.” Or they could ask, “Use pretend scissors.” The patient may also be asked to “sew on an imaginary button” to assess this ability. The breakdown of higher-ordered step sequencing in the manipulation of actual objects is known as torty apraxia. Serial step commands, such as “Take this piece of paper in your left hand, then fold it up, place it in the envelope, and seal the envelope,” are used to test it.

Losing the ability to create line drawings or work with block designs based on visual or verbal instructions is known as constructional incapacity. In order to test the patient, line drawings with increasing levels of complexity are shown, and they must be reproduced. The patient is then instructed to create images from memory, such as “Draw a clock face; put in the numbers; draw hands on the clock to say 8:20.” Lastly, the patient might be asked to replicate stimulus designs by manipulating blocks, which are multicolored cubes from WAIS-R.

References

Geschwind N. Disconnection syndromes in animals and man. Brain. 1965;88:237–94. ,585–644.

Detre TP, Kupfer DJ. Psychiatric history and mental status examinations. In: Freedman A, Kaplan H, Sadock B, eds. Comprehensive textbook of psychiatry. Baltimore: Williams and Wilkins, 1975;1:724–35.

Plum F, Posner JB. The diagnosis of stupor and coma. 3rd ed. Philadelphia: FA Davis, 1980