Mental status exam (MSE)

• Definition: A clinical tool used for a systematic assessment of cognitive and emotional functioning of an individual.
• Anatomy or system affected: Brain, nervous system, psycho-emotional system.

Overview

Mental status exam (MSE) is a clinical tool used for a systematic assessment of cognitive and emotional functioning of an individual. MSE is often incorporated into a health history interview but can also be performed separately. It is very useful for determining an individual's general mental health and eliciting possible problems such as a mood disorder, psychiatric illness, or a physical condition that affects mental status. It is important to remember that certain factors may influence a patient's performance and a clinician's interpretation of the MSE. They include chronic diseases, some medications, educational level, individual behavioral pattern, stress, sleep habits, and the use of alcohol or drugs.

Components

The components of the MSE can often be divided into four main categories: appearance, behavior, cognition, and thought. These categories and their components are described below.

Appearance. An individual's appearance can provide a wealth of information. It is a broad term that includes elements such as posture, position, hygiene, grooming, and dress. Normal posture is usually erect while one's position is relaxed. Abnormal findings may include uneven standing position, sitting slumped in a chair, visible facial or general muscle tension, sitting on the edge of a chair, or lying curled in bed. Hygiene and grooming should also be considered. Some patients with a history of a stroke may present with unilateral neglect, a condition characterized by complete inattention to one side of the body.

Poor hygiene and inappropriate dress may be indicative of depression, dementia, frontal lobe dysfunction, delirium, or schizophrenia. On the other hand, excessive makeup or flamboyant attire may indicate a manic state or schizophrenia, while meticulous or fastidious grooming may suggest obsessive-compulsive disorder. General appearance such as cachexia or obesity may occur in conjunction with a systemic disease or a mental health disorder such as anorexia nervosa or binge eating disorder.

Behavior. The most important components of behavior include level of consciousness, emotional state, body movements, speech, facial expressions, and general manner of behavior. Level of consciousness (LOC) is one of the most important components of the MSE. A person with a normal LOC is awake, alert, aware of internal and external stimuli, and shows appropriate responses to such stimuli. Impaired consciousness expressed by somnolence, lethargy, stupor, or coma may indicate a neurologic or medical emergency.

Emotional state is expressed by an individual's mood and affect. Mood is a subjective and internal emotional state whereas affect is a clinician's objective evaluation of such. Mood can be assessed by asking a person about the way they feel at this time and most recently. Body language, vocal tone, and facial expressions may assist in determining a patient's affect. Affect can be characterized by emotional range (broad or restricted), intensity (blunted, flat or normal), and stability. It may be congruent with mood or may be different.

Evaluation of body movements is another key element of the MSE. General slowing of physical and emotional reactions and signs of apathy are present in depression, schizophrenia, or organic brain disease. Increased agitation, restlessness, and squirmy movements can occur with bipolar disorder or anxiety. Dragging of feet may be seen in depression or organic brain disease while unusual posturing and odd gestures may be signs of schizophrenia. Changes in body movements over a period of time can occur due to progression of an illness or caused by side effects of certain medications.

When examining speech, it is important to note its overall quality, spontaneity, pace, word choice, sentence structure, and articulation. The manner in which a person speaks is more important than the actual content in this part of the MSE. Speech that is slow and monotonous can occur in conjunction with depression or Parkinson's disease. Loud, pressured, or rapid speech is common in manic syndrome. Absence of speech may indicate selective mutism, vegetative state, locked-in syndrome, or a brain lesion.

Facial expressions of a healthy person are proper to the situation and change appropriately with the topic. The eye contact is comfortable. Flat and mask-like facial expression is common in patients with depression or Parkinson's. Frowning and vigilant or darting eyes is a common observation in patients with anxiety or hyperthyroidism.

Cognition. Cognitive assessment includes orientation, attention span, recent memory, remote memory, language, new learning ability, visual spatial skills, judgment, and executive function. Orientation to time, place, person, and situation are often tested during MSE by asking a question such as “Do you know what today's date is?” Disorientation may take place in disorders of organic origin such as dementia or delirium. It is most common for disorientation to occur in the following sequence: first to time, then to place, and finally to person.

Attention span is an individual's ability to focus and complete thoughts without digression. Problems with attention are manifested by irrelevant responses to questions as well as quick distractibility by new stimuli. One test of attention span is to provide a series of simple directions and ask to follow them. For example: “Please open the table drawer, take out the red key with your right hand, shift it to your left hand, and put the key in your pocket.” Confused states, fatigue, anxiety, and drug intoxication may impair attention.

Memory is assessed in terms of recent and remote memory as well as the ability to form new memories. Recent memory can be evaluated by asking the patient to describe their life events in the past twenty-four hours. Remote memory is assessed by inquiring about important historical or patient's own life events. New learning and recall can be tested by asking a patient to remember three to four unrelated words (such as apple, yellow, grass, and winter). During the interview, the examiner asks the patient to repeat the words at ten and thirty minutes. Deficits in recent memory take place mostly in disorders of organic origin, such as dementia, delirium, amnestic syndrome, or Korsakoff's syndrome in patients with chronic alcoholism. Remote memory shortage can occur due to cerebral cortex damage, which is present in dementia and other diseases.

The most commonly used tests of visual spatial skills are constructional and copying tasks. They include drawing a clock and reproducing figures such as a circle, intersecting circle, and triangle or other figures. Patients with executive dysfunction exhibit poor planning skills. Oftentimes a clock face is too small to contain all the necessary numbers. Those with unilateral neglect ignore half of the clock face. Disturbances in drawing of the figures are often encountered in patients with degenerative disorders, focal brain damages, or toxic and metabolic encephalopathy.

Judgment is an ability to compare alternatives and identify the consequences of actions. It can be evaluated by offering hypothetical daily situations pertinent to a particular patient, and asking for possible solutions. For example, “What would you do if you realized that you lost the keys for your house?” Impaired judgment is often manifested by impulsive or unrealistic decisions and is common in neurologic conditions, schizophrenia, organic brain diseases, and intellectual disability.

Executive function is a set of capabilities such as volition, planning, problem-solving, reasoning, and effective performance of tasks. The overall executive functioning can be extrapolated from the interview and by asking about everyday functioning. Eliciting the tasks that require assistance or direction can be helpful. Impairment of judgment or insight (patient's awareness of their condition and need for treatment) can serve as an early indication of executive dysfunction.

Thought. The main areas of thought processes found on the MSE are thought content, perceptions, and screen for suicidality. Thought content describes particular thoughts that an individual experiences. Healthy thought content is consistent, logical, and realistic. Abnormal findings include obsessions, compulsions, delusions, and thoughts about suicide or homicide. Delusions are common in patients with Lewy body and vascular dementia, Alzheimer's disease, Huntington's disease, and schizophrenia. Delusions that are acute in nature can occur in alcohol or drug intoxication.

Also, it is important to assess for the presence of any perceptual disturbances such as hallucinations or illusions. Hallucinations can involve any of the senses and either have a specific form or be formless. Visual and auditory hallucinations arise with organic brain disease, schizophrenia, bipolar disorder, severe unipolar depression, psychedelic drugs, or alcohol withdrawal.

Screening patients for suicidal ideation is an integral aspect of the MSE. It is usually performed when the patient expresses or portrays feelings of sadness, loneliness, helplessness, hopelessness, grief, or despair. This part of the exam is particularly important in patients with chronic diseases, mental health disorders, or history of prior suicide attempts. A good approach is to begin by asking general questions about the person's feelings and overall outlook on life.

If a clinician remains concerned, then it is important to ask more direct questions such as “Have you ever felt so sad that you wanted to hurt yourself?” or “Do you have a plan and the means (gun, pills etc.) to hurt yourself?” Even if the patient says that they will not kill themself but has suicidal thoughts and a specific plan using a lethal method, it is considered to be high risk.

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