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The Mental Status Exam

Definition
The MSE is the psychiatric history and physical or the physical examination of psychiatry. It is the
observing (inspection), touching on (palpation), sounding out (percussion), and listening to (auscultation)
psychiatric signs and symptoms. The MSE is analogous to placing a stethoscope on the brain and
assessing cognitive functions. The set of standardized questions and observations are designed to
evaluate:
1. Sensorium

2.

3.

4.
5.

LOC; attentiveness; orientation to person, place, and time; attention; concentration;


memory; knowledge; intelligence; and capacity for abstract thinking
Perception
Disorders of sensory input where the stimulus is absent (hallucination); where a stimulus
is misperceived (illusion); or there is an altered bodily experience (depersonalization)
Thinking
Speech; thought content or what is said; thought form or how something is said; suicidal
and homicidal ideation; insight and judgment
Feeling
Affect (objective, visible emotional cues) and mood (subjective, emotional experiences)
Behavior
Appearance; agitation or retardation of movement; degree of cooperation with the
interview

The information and data gathered in these five domains are used to establish a diagnosis and a treatment
plan. All psychiatric diagnoses are made clinically in an interview situation. There are no blood work
studies or diagnostic imaging procedures to assist with the process.
Almost half of the MSE is obtained free through observation and listening to what is being said in other
parts of the interview.
Free Parameters
Level of consciousness
Appearance
Behavior
Cooperation
Reliability
Affect
Thought form

Parameters to Ask About


Orientation
Cognitive functions
Suicidal/homicidal ideation
General knowledge
Perception
Mood
Thought content

Integration of the History and the MSE


Psychiatric History

MSE Component

Identifying Data and Chief Complaint

Appearance
Behavior
Orientation
LOC

History of Present Illness


Use open ended questions for 5-10 minutes

Cooperation
Thought Form
Thought Content

Exploration of Symptoms from the Above History


Use closed questions for a more focused
assessment

Affect
Mood
Suicidal/Homicidal Ideation
Elements of Cognitive Function

Direct Testing of Other MSE Components

General Knowledge
Perception
Insight & Judgment
Formal Cognitive Teaching

Psychiatric Physical Findings


Head and Neck
Altered pupil size
Dental caries
Parotid gland enlargement

Drug intoxication/withdrawal
Eating disorders from vomiting
Anorexia/bulimia nervosa

Skin

Callus/laceration on knuckles
Scars from slashing
Scars from trauma
Needle marks/tracks
Cigarette burns
Dermatitis or excoriated skin
Unusual pattern of hair loss
Lanugo hair
Edema

Musculoskeletal & Nervous System


Tremor

Repeated movements

Eating disorder (from self-induced vomiting)


Borderline personality disorder
Antisocial personality; alcohol abuse
IV drug user
Dementia; alcohol abuse; self harm
OCD compulsive handwashing; may occur on knees
from cleaning in a kneeling position
Trichotillomania or pulling out of hair
Anorexia nervosa
MAOI drugs, anorexia nervosa
Lithium use, caffeine intoxication, alcohol withdrawal,
anxiety disorders
Tourettes disorder, autism, tardive dyskinesia, OCD,
mental retardation

Alcohol abuse

Muscle atrophy

Thought Content Disorders


Content Disturbance
Delusions

Nature of Disturbance

A false belief that is inconsistent with cultural beliefs and values, is not
altered with proof to the contrary, preoccupies the patients thoughts, is not
resisted by the patient, and ranges from implausible to impossible
They are mood congruent when a depressed patient expresses themes of guilt,
worthlessness, and hopelessness
They are mood incongruent when a depressed patient expresses delusions of
grandeur and omnipotence
Egosyntonic symptoms are not foreign or distressing to the patient
Egodystonic symptoms are alien and unwanted by the patient

Overvalued Ideas

Different from delusions in that they are less firmly held and not as absurd
They preoccupy the patients mind and drive their behavior
Examples include superstitions or magical thinking

Obsessions

Recurrent and persistent thoughts, images, and impulses that cannot be


controlled by the patients will
Can be very disruptive as they take over the patients life
Recognized as illogical and irrational

Phobias

Thoughts of Harm to Self or


Others

Marked and persistent fears that are viewed by the patient as excessive and
unreasonable
Related to clearly defined objects and situations
Exposure to the object or situation causes such great distress and anxiety that
the patient will do almost anything to avoid
Patients who have lost parents to suicide may suffer from anniversary
reactions where they unconsciously act in a self-destructive manner at the
same age the parent was when s/he died
Some of the most compelling stressors are family death (includes pets), loss
of a friend, divorce/separation, serious medical illness, financial ruin, firing
from a job, or retirement

Continuum of Thought Processes from Normal to Severe Disturbance


Tightness of Thought

Well organized, tangential, loosely connected, or incoherent

Flow of Speech

Spontaneous, hesitant, interrupted, or halting

Directness of Replies

Informative and relevant, embellished, or overinclusive

Flow of Ideas

Logical and with variability, restricted, or repetitive

Vocabulary

Descriptive, restricted, or idiosyncratic use of words

Flow of Information

Good exchange, adequate, vague, or disorganized

Thought Process Disorders


Process Disturbance

Nature of Disturbance

Circumstantiality
Tangentiality

Tight linkage between ideas


Sentence structure is maintained
Overinclusive of detail (circumstantiality) or does not address the point
(tangentiality)

Flight of Ideas

Sentences are maintained


Ideas remain connected
Rapid and frequent shifts in topic

Rambling

Clusters of sentences remain goal-directed but are interspersed with groups


that are not goal-directed

Loose Associations

Sentences are maintained


Phrases and sentences are still properly constructed
The connection between ideas is unclear or nonsensical

Thought Blocking
Thought Derailment

Syntax remains intact, but speech suddenly halts (blocking) and then shifts
(derailment)
Patients may or may not return to the previous topic and are unaware a block
has occurred
I think the Packers will win the Super Bowl this year, they have made some good
changes..I have to catch a plane to England

Fragmentation

Words are intact but phrases become disconnected


I have to.what is my..gone today.near and far..flip, flop, and fly

Verbigeration

Repetition of words and phrases


I parked it, it, it.. parked it, it, it

Jargon

Syntax remains intact but speech becomes meaningless, there is no


communicative value
Principles forth at once, try delayed transparency

Word Salad

Words are intact, all syntax is lost


Ah, to, but, not, when, if, that, my, never, fuller, clip

Incoherence

Clang Associations

Echolalia
Preservation

Words are unintelligible, speech is garbled

Made on the basis of sound; it is typically done by rhyming the last word in
the sentence
I have to go you know

Automatic repetition of others speech

The automatic repetition of a response despite changing questions


Where did you park your car? Garage
How long have you been in town? Garage

Neologisms

Made up words or phrases that occur in syntactically correct places as if they


are words others should know

Comparison of Thought Process Disorders

5
4
3
Answer
Question

&

Posed

Goal

2
2

Goal directed logical thought that addresses the point and answers the question directly.

Circumstantial thought contains a mass of digressions, subsidiary clauses, and talking around
the point. People are sometimes aware of their wordiness and that their style of speech
(thought) is an impediment to direct goal attainment.

Tangential thought is not goal directed, though it starts out being relevant and generally stays
in the vicinity of the topic. However, the point or question is never addressed and the thought
process is overly detailed.

Flight of Ideas is a form of accelerated speech. As such, it takes off more quickly and radically
than tangential speech. Rapid, uncensored associations are made due to increased distractibility
and a sense of pressure to keep talking.

Loosening of Associations is the loss of meaningful connections between words and phrases.
Transitions in topics are not based on logical connections between ideas.

Movement Abnormalities
Akathisia

A state of inner tension to keep moving; side effect of drugs. Patients have to get
up and move around, appear ill at ease, or move their legs rhythmically.

Automatisms

An automatic involuntary movement that can be simple or complex. Occur during


an altered state of consciousness. Actions include lip smacking or uttering words,
fumbling with clothing, eye blinking or unwavering stare. Patients may be
partially aware of their surroundings, dont seem quite right, and are amnesic for
the episode.

Catatonia

A term applied to a diverse number of postural and movement disturbances; may


be either decreased or increased levels of activity. They are described as weird and
peculiar movements that exhibit the following characteristics: Rigidity,
Echopraxia (copying someones body movement), Negativism (automatic
opposition to all requests), Catalepsy (waxy flexibility), Echolalia (repeating the
words of others), and stupor or immobility.

Choreiform

Involuntary movements of the face and arms that are jerky, irregular, spasmodic,
and quasi-purposeful. For example, the persons hand shoots up to the face and
s/he incorporates this into an adjustment of the hair.

Athetoid

Movements are slow, writhing, and twisting.

Ballismus

Represents an accelerated athetoid movement that is more violent and of larger


amplitude. It usually occurs on only one side of the body.

Compulsions

Repetitive behavior that is carried out to reduce stress and prevent a dreaded
event. Not grounded in reality; follows an obsession.

Extrapyramidal Symptoms
Dystonia
Pisa Syndrome
Rabbit Syndrome

A sustained torsion or contraction of muscles


Posture resembles the Leaning Tower of Pisa
An alternating perioral movement that resembles the action of a rabbits
mouth

Tardive Dyskinesia

Involuntary movement associated with prolonged neuroleptic use. Tardive means


delayed onset (months to years after starting medication). Dyskinesia is a
distortion of voluntary muscles and involves choreoathetoid movements. Body
areas affected include the face, extremities, and trunk. The Abnormal
Involuntary Movement Scale or AIMS was developed to assess for TD.

Tic

Involuntary, sudden, rapid, recurrent, movement or vocalization. Includes blinking


or blepharospasm, facial twitches, grimaces, head jerking, shrugging or shoulder
rotation, grinding teeth or bruxism, hitting or biting self, head shaking, jumping,
kicking, touching or smelling objects, coughing, humming, grunting, gurgling,
clearing throat, clicking, clacking, sneezing, sniffling, snorting, snuffling, uttering
inappropriate words or syllables, saying or shouting obscenities or copralalia, and
repeating ones own phrases or palilalia.

Tremors

Involuntary, regular, rhythmic movements related to tricyclic antidepressants and


SSRIs.