OnExam

  • Vital signs
  • The Mental Status Exam (MSE) is the observational equivalent of the physical exam for the psychiatric system. It can be completed throughout the interview and further evaluated with specific testing. Physical/organic causes for any psychiatric symptom should always be considered in a differential diagnosis. These can be investigated by performing appropriate physical examinations and investigations of other body systems:

Appearance

  • Apparent age
  • Dress/grooming
  • Apparent physical health
  • Abnormal involuntary movement including psychomotor agitation/retardation, rigidity/posturing, gait
    • Specifically watch for movements specific to psychiatric pathology or drug toxicity such as repetitive gestures (e.g. tics in Tourette’s syndrome) or tardive dyskinesia (involuntary movement of the tongue, a sign of antipsychotic toxicity)

Behaviour

  • Appropriateness of behaviour
  • Eye contact
  • Openness, approachability, reaction to others and to the surroundings
  • Rapport & cooperation with the interviewer

Speech

  • Volume, rate and tone
  • Quantity, spontaneity, and fluency; aphasia
  • Abnormal associations, such as clang associations
  • Flight of ideas

Mood and Affect

  • Mood: the subjective emotional state described by the patient in his or her own words
  • Affect: the objective description of the patient’s range of expression by the examiner (e.g. depressed, elevated, full, restricted, flat)

Perception

  • Hallucinations: Perceptual distortion for which there is no external stimulus (visual, auditory, tactile, gustatory, olfactory)
  • Illusions: False impression that results from a real stimulus (e.g. a hospitalized delirious patient mistaking his IV tubing for a snake)

Thought Process and Content

  • Process: How does a patient come to a conclusion
    • Circumstantiality: indirect thinking, delay in reaching the point of a thought, unnecessary detail
    • Flight of ideas: abrupt, accelerated change from one topic to the next;
    • Blocking: sudden abrupt cessation of speech in midsentence, before an idea is completed
    • Perseveration: repetition of ideas or words
    • Echolalia: repetition of what others are saying
    • Derailment/Loose associations: the patient shifts between topics that are loosely related or unrelated
    • Clanging: the patient chooses words based on sounds instead of meaning, such as rhyming
    • Neologisms: the patient invents words or distorts the meaning of existing words
    • Incoherence: largely incomprehensible speech
  • Content: What the patient is thinking
    • Any delusions, obsessions, compulsions, preoccupations, phobias, suicidal ideation

Cognition

  • Alert or drowsy
  • Orientation to time, place, and person
  • Attention and concentration

Insight and Judgement

  • Insight: Patient’s degree of awareness and understanding of nature of his/her illness and the need for help
  • Judgment: Is the patient able to understand the outcome of his/her behaviour and to act accordingly

References

  1. 1. Folstein M, Folstein S, & McHugh P. “Mini-mental state” – a practical method for grading the cognitive state of patients for the clinician. J. psychiat. Res. 1975;12(3):189-198.
  2. 2. Holsinger T, Deveau J, Boustani M, et al. Does this patient have dementia? JAMA 2007;297(21):2391-2404.
  3. 3. Shulman K, & Silver I. Assessment of older adults. In: Goldbloom D, ed. Psychiatric Clinical Skills. Philadelphia, PA: Elsevier Mosby; 2006: 315-325.
  4. 4. Powsner S, & Powsner D. Cognition, copyright, and the classroom. Am J Psychiatry 2005;162:627-628.
  5. 5. Crum R, Anthony J, Bassett S, & Folstein M. Population-based norms for the mini-mental state examination by age and educational level. JAMA 1993;269(18):2386–2389.
  6. 6. Lin, D., Martens, J., Majdan, A., & Fleming, J. (2003). Initial psychiatric assessment: A practical guide to the clinical interview. British Columbia Medical Journal, 45(4), 172-173. Retrieved October 5, 2013, from http://www.bcmj.org/sites/default/files/PsychAssessform.pdf
  7. 7. Ministry of Long-Term Care. 2000/12. Form 1 – Application by Physician for Psychiatric Assessment. Retrieved on October 5th, 2013 from http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-6427-41~1/$File/6427-41_.pdf
  8. 8. Ministry of Long-Term Care. 2000/12. Form 42 – Notice to Person under Subsection 38.1 of the Act of Application for Psychiatric Assessment under Section 15 or an Order under Section 32 of the Act. Retrieved October 5th, 2013, from http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-1787-41~1/$File/1787-41_.pdf