Mental Status Exam - Lehrmann

Question 1

In general, what does a Mental Status Exam (MSE) describe?

What is the bottom line regarding how a MSE should be written up?

Answer 1

• The patient’s **present **state
• Not the patient’s past history of symptoms
• Should be written up with thorough enough descriptions and explanations that another person reviewing your notes is able to quickly know what your patient is like overall [kind of obvious, but seemed pertinent to include]

Question 2

What is the 8-point outline of an MSE?

Answer 2

1. Appearance, Attitude, & Behavior
2. Speech
3. Mood & Affect
4. Thought Form/Process & Content
5. Perception
6. Sensorium/Cognition
7. Insight
8. Judgment

Mnemonic: A Snake Moves Toward Prey Silently In Jungles

Question 3

How are Appearance, Attitide, and Behavior described for an MSE?

Answer 3

• Appearance
  
  • Overall apperance. Emphasize abnormalities.
  • e.g. “Disheveled, long beard & nails, body odor, dressed in rags, talking to self”, etc.
• Attitude
  
  • Attitude toward examiner
  • e.g. “Friendly and cooperative” vs. “Suspicious & hostile”, etc.
• Behavior
  
  • Physical behavior
  • e.g. “Sitting motionless w/o facial expression”, “rocking in chair, weeping”, “restrained on gurney, threatening to kill staff”, etc.

Question 4

How is Speech described for an MSE?

What phrase is often used to describe normal speech?

Answer 4

• Describe the qualities of speech, not speech content
  
  • Rate, tone, rhythm, and volume
  • Emphasize abnormalities
  • e.g. “loud, pressured, but fluent & understandable”, “slow, quiet, slurred, hard to understand”, “monotonous, but fluent and of normal volume”
• Normal speech:
  
  • “Fluent, with normal rate, rhythm, and volume”

Question 5

How are Mood and Affect described for an MSE?

Answer 5

• Mood
  
  • Patient’s subjective, internal state of feeling
  • Quote the patient on their own description of mood
  • e.g. euphoric, elated, depressed, hopeless, irritable, anxious, frightened, etc.
• Affect
  
  • Patient’s objective, external appearance of feeling.
  • i.e., your interpretation of the patient’s mood based on their actions & appearance

Question 6

What is important to note regarding the relationship of mood with affect?

What phase is often used to describe a normal mood and affect?

Answer 6

• Mood & Affect are normally congruent
  
  • ​aka patient’s description of mood is appropriate to their outward affect
  • In some psychiatric syndromes, mood and affect are incongruent
    
    • e.g. Schizophrenic patient states they feel sad, but are laughing uncontrollably
• Normal mood & affect:
  
  • “Euthymic, appropriate, and congruent”

Question 7

How is Thought Form (aka Thought Process) described on an MSE?

How is normal thought form often described?

Answer 7

• How, not what, the patient is thinking
• Normal: logical, linear, & goal-oriented

Question 8

(1 of 2) Name each abnormality of thought form described below:

1. Patient’s mind frequently goes blank
2. Very little thought appears to be occuring overall
3. Patient takes a long time to get to the point
4. Patient’s thoughts are logical, but they never get to the point

Answer 8

1. Thought blocking
2. Poverty of thought
3. Circumstantiality
4. Tangentiality

Question 9

(2 of 2) Name each abnormality of thought **form **described below:

1. Logical connections between thoughts break down (as the observer, you have difficulty seeing the connections between the patient’s thoughts as they speak)
2. Thoughts are expressed through sounds rather than meaning (e.g. compulsive rhyming or alliteration without actual logical meaning behind the word choices)
3. Patient invents new words or phrases
4. Patient is stuck on a single thought
5. Patient rapidly jumps from one thought to another (as the observer, you are able to notice the loose connections - e.g. “I’m feeling kind of excited today. Oh, football is exciting though! My favorite team is the Lions. Lions are really interesting animals, aren’t they? Speaking of animals…”)

Answer 9

1. Loose associations (aka derailment)
2. Clang associations / clanging
3. Neologisms
4. Perseveration
5. Flight of ideas
   
   • N.B. As you might expect, this is often seen in mania

Question 10

How is Thought Content described on an MSE?

Answer 10

• What the patient is thinking
• Explore and document abnormalities

Question 11

(1 of 2) Name each abnormality of thought content described below:

1. Fixed, false beliefs impervious to disproof or argument
   
   • grandeur, persecution, somatic, paranoid, etc.
2. Belief that the TV, radio, etc. is talking to or about the patient
3. Belief that another person or force is controlling some aspect of the patient’s thoughts or behaviorr
4. Upsetting, unstoppable thoughts
5. Irresistible urge to act on obsessional thoughts

Answer 11

1. Delusions
2. Ideas of reference
3. Ideas of influence
4. Obsessions
5. Compulsions

Question 12

(2 of 2) Name each abnormality of thought **content **described below:

1. Irrational, troublesome fears
2. Consuming bodily concerns without a medical cause, but are not delusional
   
   • aka patient is worried but not convinced beyond argument that they are right

What is important to do regarding thoughts of suicide or violence?

Answer 12

1. Phobias
2. Hypochondriacal symptoms

• Suicidal and violent thoughts should be inquired about, documented in careful details, and intervened with if necessary.

Question 13

What part of the MSE are hallucinations and illusions abnormalities of?

Compare and contrast hallucinations with illusions.

Answer 13

• Abnormalities of perception
• Hallucinations
  
  • Most common perceptual disturbance
  • Often seen in schizophrenia
  • Sensory perceptions in any modality that are internally generated. To the patient, they are as real as the *externally *generated perceptions that everyone experiences
    
    • Modalities include auditory, visual, tactile, olfactory, gustatory
• Illusions
  
  • Misinterpretations of externally generated perceptions that are often vague
    
    • e.g. the patient thinks that one thing (which IS there) is something else (aka a chair looks like a monster, etc.)

Question 14

Name three abnormalities of perception other than hallucinations and illusions.

Answer 14

• Depersonalization
  
  • Wiki: “It consists of a feeling of watching oneself act, while having no control over a situation. Subjects feel they have changed, and the world has become vague, dreamlike, less real, or lacking in significance.”
• Derealization
  
  • Wiki: “An alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one’s environment is lacking in spontaneity, emotional coloring and depth.”
  • Deja vu is common.
• Tunnel Vision

Question 15

What part of the mental status exam includes the following components? Describe how each component is tested.

1. Abstract Reasoning
2. Reading
3. Writing
4. Visuospatial ability
5. Estimated intelligence

Answer 15

Sensorium / Cognition (AGAIN)

1. **Abstract Reasoning: **Interpretation of proverbs, similarities
2. **Reading: **Doctor writes “close your eyes”, then patient reads and does it
3. Writing: Patient is asked to write a complete sentence
4. Visuospatial ability: Pt asked to draw a clock face, interlocking pentagons, or a cube
5. Estimated intelligence: e.g. “above / below / about average”

Question 16

What part of the mental status exam includes the following components? Describe how each component is tested.

1. Alertness
2. Orientation
3. Concentration
4. Memory
5. Calculation
6. Fund of Knowledge

Answer 16

Sensorium / Cognition

1. Alertness: e.g. somnolent, obtunded, clouded, fluctuating, etc.
2. Orientation: to person, place, time, situation
3. Concentration: serial 7s or 3s, revers spellings (e.g. WORLD, DLROW)
4. Memory: Immediate (retention & recall), recent, long-term
5. Calculation: everyday money questions work well
6. Fund of Knowledge: e.g. geography, current events

Question 17

What is the Folstein Mini-Mental Status Exam (MMSE)?

What part of the MSE does it focus on? What patients is it likely to identify as abnormal?

What is it scored out of? What is a “normal” score?

Answer 17

• A one-page, structured test the covers most of the sensorium MSE items.
  
  • Takes about 10 minutes to complete
  • Emphasis is on cognition
    
    • Delirious patient will likely score low
    • But a psychotic patient may (or may not) score well
  • Scored out of 30 points. 27 or greater is considered normal (not impaired) cognition.

Question 18

What is insight in terms of an MSE?

What patients often lack insight?

Answer 18

• Broadly, describes a patient’s capacity for self-reflection, awareness of their illness, understanding of their present situation, etc.
• Often lacking in patients with chronic psychotic disorders (e.g. schizophrenia), delirium, or severe personality disorders
• e.g. A schizophrenic patient has been told their diagnosis many times, and knows to tell the doctor that. But on close questioning it becomes apparant the patient has little idea of what the diagnosis means, or even believes (s)he has the illness.

Question 19

A patient with a chronic psych disorder that is lacking in what component of the MSE is more difficult to treat and has a worse prognosis?

Answer 19

Insight

Question 20

How is judgment assesed during an MSE?

In what ways can judgment be impaired?

Answer 20

• Patient’s ability to make reasonable decisions
  
  • e.g. “What would you do if you found a stamped, addresssed letter on the ground next to a mailbox?”
  • However, judgment or lack thereof is often evident in the patient’s recent behavior
• Impairment can be temporary (e.g. intoxication) or chronic (e.g. dementia)

Question 21

What pertinent negatives should always be included in a patient’s MSE?

(i.e. what normal findings should you make sure to specifically mention?)

Answer 21

• Lack of psychotic symptoms
  
  • Esp. hallucinations
• Lack of suicidal & violent thoughts or impulses