Mental Status Examination

MSE
Physical Emotional Cognitive
• Appearance • Attitude • Orientation
• Behaviour • Mood and Affect • Attention/concentration
• Motor activity • Thought and perception • Memory
• Insight and judgment • Speech/language
• Intelligence
• Abstraction
 General Appearance and Behavior
◈ OBSERVED
◈ Examiner should paint a portrait with a description that captures unique
features and affords the reader a clear mental image of the patient
◈ Aspects of appearance to be noted
? Gait
? Posture
? Grooming, hygeine and dressing
? Body-built
? Looking age appropriate- younger or older
? Level of consciousness (e.g, vigilant, alert, drowsy, lethargic, stuporous, asleep,
comatose, confused, fluctuating)
? Facial expression (e.g., perplexed, tense, frightened, impassive, mask-like, interested
etc.)
 General Appearance and Behavior
◈ Aspects to note in behavior
? Rapport
? Eye to eye contact
? Came by self/bought by others
? Attitude towards examiner (e.g, cooperative, hostile, open, secretive,
evasive, suspicious, apathetic, easily distracted, focused, defensive
◈ Aspects to note in motor behavior
? Any abnormal motor movement (mannerisms, tics, hyperactivity, tics,
echopraxia, waxy flexibility, posturing, akathisia, tremors)
? Psychomotor activity – motor movements related to affect (increased,
retarded, gestures)
 General Appearance and Behaviour
◈ Useful information to make comparisons across serial MSEs
◈ May give clue to diagnosis
◈ For example,
“ Mrs R was brought to the current setting by her son and
daughter-in-law. She entered the interview room reluctantly. During
the interview, she was restless, rising frequently from her chair, looking
at every painting on the walls, making comments about each of them,
doing essentially all the talking during the interview. She looked her
stated age of 53, but her clothes would have been appropriate only for a
much younger person. Although quite obese, she wore orange “hot
pants” and a halter top that showed a bare midriff. She wore old wooden
beach sandals with high spike heels. However, her general level of
grooming was very poor: Her short gray hair was matted on both sides
of an irregular part. Her fingernails were long and yellowed from
nicotine; her toenails were also very long, each painted a different
 Speech
◈ OBSERVED
◈ Not an evaluation of language or thought, but a
behavioral/mechanical evaluation of speech.
◈ Includes:
? Quantity (e.g, Talkative, spontaneous, expansive, paucity, poverty)
? Coherence/incoherence
? Relevance (answers questions relevantly)
? Pitch (variations in spoken speech-normal, high)/ Tone (how speech “appears”
e.g., soft spoken, monotone)/Volume/loudness (e.g., Loud, soft, monotone,
weak, strong)
? Rate (e.g., Fast, slow, normal, pressured)
? Reaction time
? Fluency (hesitant, slurred, stuttering, stammering, aphasia)
 Speech
◈ Important to understand whether deficit in speech is result of
organic brain damage or psychiatric issues
◈ Clinical relevance
? Manic patients often will interrupt or respond without pause with rapid,
pressured speech that parallels racing thoughts
? Aphasic speech vs disturbed speech in schizophrenia: inconsistency in
speech disturbance, presence of other pathognomic signs, ability to
follow simple instructions, name objects or repeat simple phrases.
 Mood and Affect
◈ OBSERVED
◈ Mood: Pervasive and sustained emotion that colors the person’s
perception of the world (internal)
? Subjective
? Objective – Robinson’s Model
◈ Euthymic
◈ Dysphoric
◈ Euphoric
◈ Angry/irritable
◈ Apprehensive
◈ Apathetic
 Mood and Affect
◈ Affect: External expression of emotion, inferred from patient’s facial
expression and behavior
? Appropriateness: how well the patient’s affect matches the circumstances and
topic of discussion. Affect is congruent if emotional expression matches
patients’ description of their mood and other verbalizations.
? Range: breadth of emotional expression demonstrated. Can be normal/full
showing varied emotions as topics of discussions shift. Can be on either
extremes of restricted or labile.
? Intensity: strength of emotional response. Normal intensity is defined in both
normative and contextual terms. Patient can deviate in either directions from
median
? Responsiveness: Normal intensity is defined in both normative and contextual
terms
 Mood and Affect
Quality of Affect Normal Abnormal
Appropriateness Congruent with context Incongruent with context
Range/variability Full, shows changes Restricted/constricted/Labile
Intensity Strength of emotional response Flat
typical for social interactions Blunted
Animated Exaggerated
Responsiveness Reacts appropriately to changes in Nonreactive
context Unresponsive
Extreme reactions
 Thinking and Thought Disorders
◈ Thinking: Goal-directed flow of ideas and associations initiated
by a problem and leading toward a reality-oriented conclusion. A
very complex and complicated psychic function.
◈ Thought disorder:
? any disturbance of thinking that affects language, communication, or
thought content
? the hallmark feature of schizophrenia
? manifestations range from simple blocking and mild circumstantiality to
profound loosening of associations, incoherence, and delusions
 Thought and Associated Disorders
◈ Assessed through questioning and Observed
◈ Internal dialog that occurs in the patient’s mind
◈ Thought Disorders primarily divided into:
? Process/form of thought disorder
? Content
◈ Can also be divided as:
? Process/form
? Stream
? Content
? Control of thinking/possession
 Process/form of Thought
◈ Formulation, flow, and organization of thought (Robinson, 2001)
◈ Assessment???
◈ Includes:
? Circumstantiality
? Tangentiality
? Flight of ideas
? Derailment
? Clang Association
? Word Salad
? Neologism
? Perseveration
 Process/Form of Thought
◈ Circumstantiality: mildest form of thought disorder (and a
personal style of many otherwise normal people). Responses are
over-elaborative, include much more detail than necessary but
eventually get to the point and ultimately are relevant.
? E.g.: begin with a detailed description of a conflict 10 years ago with his
mother “where it all began” and give excruciating detail of ensuing
events.
? may reflect normal conversation style, obsessive thinking, anxiety, or
below average intelligence
? Clinically found in dementia and temporal lobe epilepsy
 Process/Form of thought
◈ Tangentiality: train of thought that strays from the original topic
and never returns; the thoughts generally are logical, but digress
from the target and at best are minimally relevant
? For example: On being asked if the patient had any troubles sleeping? He
answers, “Sleep has always been an issue. I usually sleep on my bed, but
these days, I am sleeping on the sofa.”
? Does not have a psychiatric significance in itself.
 Process/Form of thought
◈ Flight of Ideas: Succession of multiple associations so that
thought appears to move abruptly from idea to idea.
? Often expressed through pressure of speech
? Ideas change continuously due to frivolous affect and easy distractibility
? Common in mania
? In hypomania: a milder form may be present – “Prolixity”
? E.g. “they thought I was in the kitchen with Lata. Lata is a very good
singer. Singer cannot afford to eat ice. I love ice. Ice melts in hot
temperature. Delhi has become very hot these days. Days are just flying
away. I love flying in an airplane….”
 Process/Form of Thought
◈ Loose Association/Derailment: Breakdown in both logical
connection between ideas and overall sense of
goal-directedness.
? Words make sense, sentences do not.
? Commonly seen in schizophrenia
? For example, “"My name? Well, I'd tell you my name except for the
weather, which is humid. Hot weather really bothers me, makes me want
to paint my car blue. I got fired last week. Chocolate is my favorite flavor
of pudding. entrally planned economies will always fail because no one
can regulate the temperature in that room you're going to admit me too."
 Process/Form of Thought Disorder
◈ Word Salad: most extreme form of thought process disturbance
in which even the logical association between words is lost and
the patient’s speech is a jumble of meaningless words and
nonsense words.
? Have to be distinguished from fluent aphasia
? Sure-shot sign of schizophrenia. Also known as schizophasia
? Example, “It was shockingly not of the best quality I have known all such
evildoers coming out of doors with the best of intentions!”
 Process/Form of Thought Disorder
◈ Neologism: Invention of new words or phrases or use of
conventional words in idiosyncratic ways.
? For example, “The only problem I have is my frustionating!”
? Commonly seen in schizophrenia; need to be distinguished from aphasia
? Keep into mind socio-cultural context.
 Process/Form of Thought
◈ Clang Association: Thoughts are associated by sound of words,
rather than their meaning.
? For example, “He went in entry in trying tieing sighing dying ding-dong
dangles dashing dancing ding-a-ling!”
? Another example, ““My pants are too loose. You must be Toulouse
Lautrec. I think I’ve seen you on Star Trek.”
? Commonly seen in schizophrenia
 Process/Form of Thought
◈ Perseveration: repetition of a word, phrase, or idea resulting
from failure to properly inhibit and cease a response when it no
longer is appropriate.
? Example
? Can be found in both organic brain disorders or schizophrenia
 Possession of Thought
◈ Also known as thought alienation
◈ Includes:
? Thought insertion
? Thought withdrawal
? Thought blocking
 Possession of Thought
◈ Made phenomenon/passivity
? Passivity of emotions: patient’s affective experiences does not seem to be
his/her own. He complains of being “made to feel it.”
? Passivity of impulses/made drives: Patient complains of “being made” to
act on an impulse or a drive
? Passivity of volition: Patient complains that he is “being made” to carry
out actions
? Somatic passivity: Outside influences are playing on the body. A
delusional belief that body is being influenced from outside the self.
 Content of thought
◈ Meaning conveyed by ideas
◈ Inquired and Observed
◈ Possible questions for patient:
? “What do you think about when you are sad/angry?”
? “What’s been on your mind lately?”
? “Do you find yourself ruminating about things?”
? “Are there thoughts or images that you have a really difficult time getting out
of your head?”
? “Are you worried/scared/frightened about something or other?”
? “Do you have personal beliefs that are not shared by others?”
? “Do you think someone or some group intend to harm you in some way?”
 Thought Content
◈ Obsessions and verbal compulsions
◈ Over-valued ideas
◈ Delusions
? Primary delusions (not very clear-cut, systematized, firm)
◈ Delusional mood
◈ Delusional perception
◈ Delusional ideas
? Secondary delusions (firm, systematized, due to some morbid
phenomenon)
◈ Bizarre
◈ Non-bizarre
 Thought Content
◈ Obsessions:
? persistent ideas, thoughts, impulses, or images that are experienced as
intrusive and inappropriate and that cause significant anxiety or distress
? Ego dystonic
◈ Phobia: Irrational fear of an object or situation that, usually, is
not threatening
? Agoraphobia
? Social phobia
? Specific phobia
◈ Other ideas: hopelessness, helplessness, worthlessness, suicidal,
homicidal, death wishes)
 Thought Content
◈ Over-valued ideas (Wernicke, 1906)
? Solitary, abnormal belief that is neither delusional, nor obsessional in
nature, but which is preoccupying to the extent of dominating patient’s
life
? Can cause distress to self/others
? Not false
? Vs obsession: not termed as “senseless”
? Vs delusions: isolated notion with string affect and abnormal personality.
Akin to passionate political, religious or ethical conviction
 Thought Content - Delusions
◈ Delusions
? firm, fixed idea or belief
? Out of keeping with patient’s educational, cultural and social
background
? Held with extraordinary conviction and subjective certainity
? Arises out of internal, morbid processes
◈ According to Jaspers (1959)
? Delusion as perverted view of reality, incorrigibly held. Three
components:
◈ Held with unusual conviction
◈ Not amenable to logic
 Thought Content- Delusions
◈ Kendler (1983)
? Conviction: degree to which patient is convinced of reality of delusional
belief
? Extension: degree to which delusional belief involves various areas of
patient’s life
? Bizarreness: degree to which delusional belief is “un-understandable”
? Disorganization: degree to which delusional beliefs are internally
consistent, logical and systematized
? Pressure: degree to which patient is preoccupies with expressed
delusional beliefs
? Deviant behaviors: acting out
 Thought Content- Delusions
◈ Primary delusions: not occurring in response to another
psychopathology, e.g., mood disorder
◈ Secondary delusions or delusion like ideas: “understandable” in
present circumstances. Can be traced for their origin to
circumstances, mood states, personality or social beliefs. Needs
elaborate and comprehensive history
 Thought Content - Delusions
◈ Types of primary delusions
? Autochthonous delusion/intuition: Arising “out of the blue”.
Phenomenologically, indistinguishable from sudden arrival of a new
idea.

? Delusional percept: attribution of new meaning, usually in self- reference

to a normally perceived object.
◈ Two-memberedness
◈ Vs. delusional misidentification
 Thought Content - Delusion
? Delusional atmosphere/mood: patient has knowledge that there is
something going around him that concerns him, but he does not know
what it is.
◈ Experiencing everything around him as sinister in an undefined kind of way
◈ Similar to prodromal phase in schizophrenia
◈ Patient feels perplexed, apprehensive and may actually be relieved when a
systemized delusion is formed
? Delusional memory: delusion retrojected in time. Event that happened in
past is remembered in a delusional way. For example, woman with
memory of seeing a “sad man”

◈ Difficult to distinguish various primary delusions

 Thought Content - Delusions
◈ Stages in development of delusions (Conrad):
? Trema: delusional mood
? Apopheny: search for and finding new meaning for events
? Anastrophy: heightening of psychosis
? Consolidation: Forming of a new world or psychological set based on
new meanings
? Residuum: Eventual autistic state
 Thought Content - Delusions
◈ Secondary delusions or delusion like idea
◈ Commonly found delusions:
? Delusion of persecution
? Delusion of infidelity/morbid jealousy
? Delusion of love/erotomania
? Grandiose delusions
? Delusion of poverty/nihilism
? Hypochondriacal delusions
 Thought Content - Delusions
◈ Other types of delusions
? Delusional misidentification/face processing disorder
◈ Capgras: someone close to patient has been replaced by imposter
◈ Fregoli: strangers are taken to be familiar persons
◈ Subjective doubles: another personal has been psychologically/physically
transformed into the patient
? Delusion of infestation/Ekbom’s syndrome: Patient believes he is infested
with small, microscopic organisms
 Perception
◈ Sensory distortion: Changes in perception due to changes in
? Intensity of stimuli. E.g., hyperesthesia
? Quality of stimuli: usually seen in hallucinogens
? Spatial form of perception: micropsia or macropsia
◈ Sensory deception
? Illusions
? Hallucinations and pseudo-hallucinations
 Perception - Illusions
◈ Stimuli from a perceived object + mental image = false
perception
◈ Various types
? Completion illusion: “Closure” principle of gestalt
? Affect illusions: affected by mood. E.g. shadows in alley
? Pareiodolic illusions: seeing images from shapes (e.g. children and
clouds)
 Perception - hallucination
◈ “A perception without an object” (Esquirol, 1817)
◈ Three operational criteria for hallucination (Slade, 1976)
? Percept-like experience in absence of external stimulus
? Percept-like experience which has full force and impact of a real
perception
? Percept-like experience that is unwilled, occurs spontaneously and
cannot be readily controlled by the client
 Perception - Hallucination
◈ Characteristics (Horovitz, 1975):
? Occur in form of images
? Derive from internal sources of information
? Appraised incorrectly as if from external sources of information
? Usually intrusive
 Perception - Hallucination
◈ Similar to true percept, which is:
? Substantial
? Appears in objective space
? Clearly delineated
? Constant and independent of will
? Full and fresh sensory elemant
◈ Different from mental image, which is:
? Incomplete
? Not clearly delineated
? Dependent on will
? Inconstant and have to be re-created
 Perception - Hallucinations
◈ Vs Pseudo-hallucinations
? Type of mental images, which are clear and vivid
? Lack the substantiality of perception
? Seen in full consciousness
? But located in subjective space
 Perception - Hallucination
Hallucination Pseudo-hallucination

Experience Concrete, tangible, objective, real “inner eye”, subjective

Location Outer objective space Inner subjective space

Definition Definite outline, complete sound - Same -

Vividness Full, fresh, bright - Same -

Volition Not under voluntary control Not under voluntary control

Insight Has quality of perception Has quality of idea

Relevance Relevant to emotions, needs, actions - Same -

Existance Object exists independent of observer Dependent on observer

 Perception - Hallucinations
◈ Auditory : Most common
◈ Voices = phonemes
◈ Elementary or well-formed
◈ Types
? Second person
? Third person (talking about patient, running commentary)
? Commanding (pathognomic sign of schizophrenia)
? Thought echo
 Perception - Hallucination
◈ Visual: Usually common in organic states such as tumors in
occipital lobe, dementia
? Elementary or well-formed
? Liliputian hallucination
? Anomalous perceptual experience: recognizing a face, but seeing it
distorted. Usually seen in schizophrenia
? Autoscopic: seeing oneself in external space. Variants include:
◈ Negative autoscopy
◈ Internal autoscopy
 Perception - Hallucinations
◈ Hallucinations of bodily sensations
? Superficial (e.g., sensation of hot and cold, dead body’s hand touching,
tingling sensation)
? Kinesthetic (twisting of limbs, muscles, joints)
? Visceral (involves inner organs, e.g., pain in uterus)
◈ Reflex hallucination: stimulus in one sensory filed causing
hallucination in another
 Perception - Hallucination
◈ Extracampine hallucination: within outside limit of sensory field
◈ Functional hallucination: occurring at the same time as
normal/true perception.
 Perception - Hallucinations
◈ Olfactory
◈ Gustatory
◈ Hypnogogic
◈ Hypnopmpic
 Perception
◈ Illusions
◈ Hallucinations
◈ Pseudo-hallucinations
◈ Depersonalization
◈ Derealization
 Perceptions
◈ “Do you ever feel detached/removed/changed/different from
others around you?” • “Do things seem unnatural/unreal to you?”
• “Do you ever see (visual), hear (auditory), smell (olfactory),
taste (gustatory), and feel (tactile) things that are not really there,
such as voices or visions?” (Hallucinations are false perceptions)
• “Do you sometimes misinterpret real things that are around
you, such as muffled noises or shadows?” (Illusions are
misinterpreted perceptions)
 Cognitive functions
◈ Orientation
◈ Attention and Concentration
◈ Memory
◈ Information and general intelligence
◈ Abstraction
◈ Judgment
◈ Insight
 Orientation
◈ Inquired
◈ Awareness of personal identity, time, location, and
circumstances
◈ Includes:
? Time
? Place
? Person
◈ Clinical condition: Delirium, severe cases of dementia
 Attention and Concentration
◈ Inquired
◈ Attention: ability to focus cognitive processing on the appropriate
target and avoid being distracted by irrelevant stimuli.
◈ Concentration: sustaining attention over a longer period of time or
manipulating and processing the contents of what is attended to
◈ Gateway
◈ Clinical conditions: traumatic, brain injury, cortical and subcortical
dementias, delirium, ADHD, anxiety, depression, psychosis
◈ Observable signs: motor restlessness, attending to extraneous sounds,
being distracted by stimuli and doing something else while the
examiner is attempting to engage in conversation.
 Attention and Concentration
◈ Tests
? Digit repetition (can pick from PGI-MS)
◈ 20-64 year old: 6-8 DF and 5-7 DB
? Serial 7’s (note more than 2 errors)
? Days of the week backwards (no errors)
 Memory
◈ Complex cognitive ability that involves the recall or recognition
of previous experience
◈ formation of new memories involves recognition and
registration of the initial sensory input, retention and storage of
the information, and recall or retrieval of the stored information
(Strub & Black, 2000)
◈ Inquired
◈ Clinical conditions: most commonly seen in brain dysfunctions
like dementia
 Memory
◈ Immediate: 4- object recall (e.g., (railgaadi, bindi, paisa, pen)
◈ Recent: Breakfast, dinner, who came to meet them yesterday,
4-object recall after 5 minutes
◈ Remote
? Last to show deterioration
? Asking personal historical facts. Needs corroboration
? Historical facts (Independence? who succeeded X PM?)
 Intelligence and General Fund of Knowledge
◈ Best demographic predictors of an individual’s intelligence are
education and occupation
◈ VAIS items
? Shape of ball
? Sunrise
? Kuran/bible
? 5 PMs of India
? 5 rivers of India
◈ Arithmetic
? 4+5 =
? If a man spends 7.50 out of 18 rupees, how much is left?
? If two pencil costs rs 5, how much will 12 pencils cost?
 Abstract thinking
◈ Capacity to recognize and comprehend relationships that are
not immediately or concretely apparent
◈ Disturbance can be present in manner in which patients
conceptualize ideas
◈ Concrete or literal thinking – limited use of metaphor without
understanding its nuances
 Abstract thinking
◈ Proverbs: Should be based on client’s socio-cultural background.
At least three should be given:
? pet mein choohe daudna
? nau-do-gyaarah ho jaana
? naach na jaane aangan tedha
? Doodh ka jala chaach bhi phoonk phoonk ke pita hai
? Bhains ke aage been bajaana
? Bagal mein chora, gaon mein dhindhora
◈ Similarities (apple-oranges, aeroplane-bird, katori-chammach).
At least a 2-point response
 Judgment
◈ Complex mental process whereby a person forms an opinion,
makes a decision, or plans an action after first analyzing the issue
and comparing choices with acceptable behaviours.
◈ Includes understanding of advantages and disadvantages of
various options, the likely outcomes for self and others, what is
morally right and wrong, and long-term consequences.
? Test judgment (Inquired)
? Social judgment - Observed (basic knowledge of social situation,
knowledge of socially appropriate responses and ability to apply socially
correct responses)
? Personal judgment – Observed (understanding of situation, future plans)
 Insight
◈ Consists of:
? extent to which the patient recognizes he has a problem
? Recognizes the nature and various elements of the problem
? understands that the problem represents a departure from what is
considered normal or at least desirable
? Understands the negative effects of the problem for self and others and,
? accepts the need for treatment (Scheiber, 2004; Robinson, 2001).
◈ Inquired during the interview