mental status examination mental status examination the mental status examination (mse) is an important part of the clinical assessment process in neurological and psychiatric practice. it is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. there are some minor variations in the subdivision of the mse and the sequence and names of mse domains. not to be confused with mini–mental state examination. mental status examinationicd-9-cm94.09, 94.11 the purpose of the mse is to obtain a comprehensive cross-sectional description of the patient's mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning. the data are collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information, focused questions about current symptoms, and formalised psychological tests. the mse is not to be confused with the mini–mental state examination (mmse), which is a brief neuropsychological screening test for dementia. theoretical foundations the mse derives from an approach to psychiatry known as descriptive psychopathology or descriptive phenomenology, which developed from the work of the philosopher and psychiatrist karl jaspers. from jaspers' perspective it was assumed that the only way to comprehend a patient's experience is through his or her own description (through an approach of empathic and non-theoretical enquiry), as distinct from an interpretive or psychoanalytic approach which assumes the analyst might understand experiences or processes of which the patient is unaware, such as defense mechanisms or unconscious drives. in practice, the mse is a blend of empathic descriptive phenomenology and empirical clinical observation. it has been argued that the term phenomenology has become corrupted in clinical psychiatry: current usage, as a set of supposedly objective descriptions of a psychiatric patient (a synonym for signs and symptoms), is incompatible with the original meaning which was concerned with comprehending a patient's subjective experience. application the mental status examination is a core skill of qualified (mental) health personnel. it is a key part of the initial psychiatric assessment in an outpatient or psychiatric hospital setting. it is a systematic collection of data based on observation of the patient's behavior while the patient is in the clinician's view during the interview. the purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. further, information on the patient's insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. it is carried out in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition. the mse can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental-health settings. information is usually recorded as free-form text using the standard headings, but brief mse checklists are available for use in emergency situations, for example, by paramedics or emergency department staff. the information obtained in the mse is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan. domains appearance clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. colorful or bizarre clothing might suggest mania, while unkempt, dirty clothes might suggest schizophrenia or depression. if the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. clothing and accessories of a particular subculture, body modifications, or clothing not typical of the patient's gender, might give clues to personality. observations of physical appearance might include the physical features of alcoholism or drug abuse, such as signs of malnutrition, nicotine stains, dental erosion, a rash around the mouth from inhalant abuse, or needle track marks from intravenous drug abuse. observations can also include any odor which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication. weight loss could also signify a depressive disorder, physical illness, anorexia nervosa or chronic anxiety. attitude attitude, also known as rapport or cooperation, refers to the patient's approach to the interview process and the quality of information obtained during the assessment. behavior abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's eye contact and gait. abnormal movements, for example choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder. a tremor or dystonia may indicate a neurological condition or the side effects of antipsychotic medication. the patient may have tics (involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of tourette's syndrome. there are a range of abnormalities of movement which are typical of catatonia, such as echopraxia, catalepsy, waxy flexibility and paratonia (or gegenhalten). stereotypies (repetitive purposeless movements such as rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism. more global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as psychomotor agitation or hyperactivity) which might reflect mania or delirium. an inability to sit still might represent akathisia, a side effect of antipsychotic medication. similarly, a global decrease in arousal and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression or a medical condition such as parkinson's disease, dementia or delirium. the examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient's emotional state). lack of eye contact may suggest depression or autism. mood and affect the distinction between mood and affect in the mse is subject to some disagreement. for example, trzepacz and baker (1993) describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas sims (1995) refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". this article will use the trzepacz and baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation. mood is described using the patient's own words, and can also be described in summary terms such as neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. alexithymic individuals may be unable to describe their subjective mood state. an individual who is unable to experience any pleasure may have anhedonia. vincent van gogh's 1889 self portrait suggests the artist's mood and affect in the time leading up to his suicide. affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior (anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and mobility. affect may be described as appropriate or inappropriate to the current situation, and as congruent or incongruent with their thought content. for example, someone who shows a bland affect when describing a very distressing experience would be described as showing incongruent affect, which might suggest schizophrenia. the intensity of the affect may be described as normal, blunted affect, exaggerated, flat, heightened or overly dramatic. a flat or blunted affect is associated with schizophrenia, depression or post-traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated affect might suggest certain personality disorders. mobility refers to the extent to which affect changes during the interview: the affect may be described as fixed, mobile, immobile, constricted/restricted or labile. the person may show a full range of affect, in other words a wide range of emotional expression during the assessment, or may be described as having restricted affect. the affect may also be described as reactive, in other words changing flexibly and appropriately with the flow of conversation, or as unreactive. a bland lack of concern for one's disability may be described as showing la belle indifférence, a feature of conversion disorder, which is historically termed "hysteria" in older texts. speech the patient's speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions. this heading is concerned with the production of speech rather than the content of speech, which is addressed under thought process and thought content (see below). when observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech. many acoustic features have been shown to be significantly altered in mental health disorders. a structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. simple language tests also form part of the mini-mental state examination. in practice, the structured assessment of receptive and expressive language is often reported under cognition (see below). language assessment will allow the recognition of medical conditions presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. people with autism spectrum disorders may have abnormalities in paralinguistic and pragmatic aspects of their speech. echolalia (repetition of another person's words) and palilalia (repetition of the subject's own words) can be heard with patients with autism, schizophrenia or alzheimer's disease. a person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them. speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner. thought process the paintings of the outsider artist adolf wölfli could be seen as a visual representation of formal thought disorder. thought process in the mse refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. form of the thought is captured in this category. one should describe the thought from as thought directed a→b(normal) vs formal thought disorders. a pattern of interruption or disorganization of thought processes is broadly referred to as formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, or knight's move thinking. thought may be described as circumstantial when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. regarding the tempo of thought, some people may experience flight of ideas (a manic symptom), when their thoughts are so rapid that their speech seems incoherent, although in flight of ideas a careful observer can discern a chain of poetic, syllabic, rhyming associations in the patient's speech. (i.e. i love to eat peaches, beach beaches, sand castles fall in the waves, braves are going to the finals, fee fi fo fum. golden egg.) alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. poverty of thought is a global reduction in the quantity of thought and one of the negative symptoms of schizophrenia. it can also be a feature of severe depression or dementia. a patient with dementia might also experience thought perseveration. thought perseveration refers to a pattern where a person keeps returning to the same limited set of ideas. circumstantial thinking might be observed in anxiety disorders or certain kinds of personality disorders. thought content a description of thought content would be the largest