The Mental Status Examination

Michael Blumenfield, M.D.Professor of Psychiatry, Medicine & Surgery

Department of PsychiatryNew York Medical CollegeValhalla, New York

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Mental Status Examination

A systematic organization and documentation of the quality of mental functioning at the time of the interview.

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Mental Status Examination

Much of information is obtained informally during other parts of the interview.

It is usually necessary to ask the patient some formal questions to evaluate all the categories of the examination

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Categories of Mental Status Examination (can be broken down in different ways)

Appearance & Behavior Thought (Form & Content) Mood & Affect Memory & Intellectual Functioning Insight & Judgment

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Appearance & Behavior

attractiveness vs unattractiveness

healthy vs sickly older vs younger

( than stated age) angry, puzzled,

frightened, ill-at-ease, apathetic, contemptuous, etc.

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Appearance & Behavior Mannerisms,gestures,combativeness,

psychomotor retardation ,rigidity, twitching, handwringing,pacing

Suspiciousness, cooperative seductiveness,laughing, joking, seriousness,dramatic flair , etc.

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Behavior & ApperanceClinical Examples:

People with psychois such as schizophrenia may be poorly groomed or dressed in bizarre manner

Depressed person may show decreased psychomotor activivity , handwringing

Swollen neck may be evidence of hypothyroidism and perspiration may be evidence of hyperthyroidism both of which can have mental status findings

Confused behavior can point to cognitive deficits

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Thought - Form Formal Thought Disorder - Is speech logical,

coherent, relevant?

Loose Associations - thoughts unrelated and patient unaware of this

tangentiality,circumstantiality ,derailment,evasiveness,blocking

Flight of Ideas- jumping from idea to idea but with understandable but often tenuous associations

pressured speech, overinclusiveness , “clang” associations

Other Unusual Speech echolalia- patient mimics words back to interviewer neologisms-patient makes up new words perserveration-needless repetition of the same thought or

phrase

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Thought- Form Clinical Examples:

Loosening of Association(LOA) with tangentiality or derailment is characteristic of schizophrenia as are blocking neologisms and echolalia when they occur

Flight of Ideas(FOI) frequently occurs with pressure of speech and with overinclusiveness which is characteristic of mania but can be seen in drug intoxication

Perseveration is found in dementia and is indicative of memory difficulties

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Thought- Content

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Thought - Content Refers to what the patient thinks and talks about Hallucinations- Totally imagined sensory perceptions

auditory , visual, olfactory, tactile, can be accusatory, threatening or commanding

Illusions - Misinterpretation of of sensory stimuli Delusions- Fixed false beliefs not congruent with patient’s culture Obsessions - recurrent persistent unwanted thoughts, impulses, images Compulsions-need to do repetitive,purposeless behavior to ward off

unwanted happenings Phobias- intense unreasonable fear leading avoidance of feared object Depersonalization-the feeling that one has changed in a bizarre way Rerealization- the feeling that the environment has changed Déjà Vu- sense of familiarity with a new perception Suicidal & Violence Towards Others - see mood for suicidal ideation

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Thought - Content Delusions

Bizarre, confused delusions Persecutory delusions Grandiose delusions Delusions of influence-patient believes that he can control events

through telepathy Delusions of reference-patient is convinced that there are special

meaning to events and actions which are directed specifically towards himself

Delusions of thought broadcasting- the belief that others can hear the patient’s thoughts

Delusions of thought insertions-the belief that someone else’s thoughts have been inserted into the patient’s mind

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Thought- Content Clinical Examples:

Delusions that are understandable and fit with content are more likely to be related to depression ie, patient believes that he or she has cancer or is persecuted because he or she is a bad person

Delusions that are not understandable and are bizarre are more likely to be due to schizophrenia ie. Patient believes that he or she has superhuman powers or believes their thoughts can be read by others or others are inserting their thoughts into their mind

Visual Hallucinations - are more common in organic disorders particularly with delirium ,can occur with psychedelic drugs and less likely with schizophrenia

Auditory Hallucinations- Most common with schizophrenia but can occur with alcoholic hallucinosis and affective disorders

Olfactory Hallucinations- Associated with temporal lobe seizures Tactile Hallucinations- (including formications-which is sensation

of insects crawling under or in skin ) can occur in drug intoxication, delirium tremens and sometimes schizophrenia

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Thought - Content Ability to Think abstractly vs Concrete

Thinking

Similarities: What do the following have in common?

Chair and desk? Apple and pear? Poem and statue?

Proverbs: What do people mean when they say…..?

Don’t cry over spilled milk A rolling stone gathers no moss When the cat’s away the mice will play

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Thought- Content Clinical Examples:

You must take into account a person’s intelligence when evaluating the ability to abstract

Concrete thinking especially when it is bizarre suggests a psychotic disorder such as schizophrenia

Inability to abstract especially if the answers are vague suggests that the patient is failing and it could be due to delirium or early dementia.

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Let’s Go To The Video Tape !!!

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Mood and Affect

Mood refers to the patient’s words describing his/her internal emotional state sad, depressed,gloomy happy,euphoric,ecstatic angry,irritable ,anxious)

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Mood and Affect

Affect is the externally observed emotion

appropriate vs inappropriate to reported mood , content of thought and situation

flat, blunted , contricted or full range labile, intense

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Mood and Affect

When evaluating depression it is customary to ask about vegetative symptoms sleep- falling asleep,staying asleep and early

morning awakenings (also a good time to ask about dreams )

appetite- change in appetite and weight change

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Mood and AffectSuicidal Ideation

When evaluating depression it is often a smooth transition to ask about suicidal ideation

It is myth to believe that asking about suicidal ideation will give the patient the idea of doing it

Failure to evaluate for suicidal ideation is a very serious omission

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Mood & Affect- Clinical Examples:

Inappropriate and flat affects are often associated with schizophrenia

Labile mood and labile affect are often seen in patients with disorders which are charcterized by damaged brain function

Extreme distress or pain described with an indifferent affect is called “ la belle indifference” and is associated with conversion disorder

The clinicians own emotional response to the mood and affective response of the patient can be a good indication of the underlying condition

ie. If examiner does not feel some sadness during report of extremely depressed mood, there is something wrong with affect of patient which may be indicative a conditon other than major depression

ie.If examiner finds one self smiling and almost laughing as patient reports material, the underlying mood may be mania or hypomania

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Let’s Go To The Video Tape !!!

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Memory and Intellectual Functioning

Orientation Time- disoriented if more than one day off of the week and more

than several days off date or the wrong year (except around the New Year )

Place- disoriented if gives wrong hospital,wrong city , wrong setting

Person- if doesn’t know who they are

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Memory

Immediate- serial 7s, alternative can be to ask how many nickels in $1.10. Spell WORLD backwards (also tests attention , concentration and intellect)

Short-term- recalling 3 objects 5 minutes later

Recent-recalling events of past week or month

Remote- recalling a famous news event of many years ago or naming their first grade teacher

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Intellectual Functioning

Must interpret with understanding of patient’s educational, cooperativeness and mood state

Ask questions which are appropriate for specific individual, if not sure ask person’s interest

Examples :Name the past 6 presidents?What does the heart do?How far is it from New York to San Francisco?What happens to a caterpillar ?Math questions noted above also test intellectual function

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Memory & Intellectual Functioning -Clinical Examples

Disorientation for time and place are usually due to delirium but can occur with severe dementia

Disorientation for person is unusal even in dementia and malingering should be suspected. Rare case of dissociative state is possible

Disturbances of attention, concentration, immediate and short-term memory is usually due to delirium and can be characterized by fluctuations

Recent memory is more severly impaired than remote memory in dementia and persist when there is no delirium

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Let’s Go To The Video Tape !!!

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Insight

Insight: The patient knows that he or she was or has a psychiatric illness . If hallucinating, the patient knows that he/she’s mind is playing tricks on him/her

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Judgment

An estimate of the patient’s real life problem solving skills.Is the patient realistic about limitations and life circumstances? It is a complex mental functioning

Examples of Questions to Evaluate JudgmentWhat would you do if you found a self addressed

envelope?What will you do when you leave the hospital ?

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Insight & Judgment--Clinical Examples Insight is often lacking with schizophrenia and other psychotic states

but not this is not always the case. Similarly patient’s with organic impairment such as delirium and dementia will have absent or diminished insight.

Insight can be described on a relative scale with terms such as absent, limited, poor fair and good

The term insight is used in somewhat different manner when discussing patient’s without major psychiatric disorder in regard to their ability to accept , understand and utilize interpretation of behavior and unconscious dynamics

Judgement is regularly impaired in dementia, delirium and psychosis including schizophrenia as well as at times with mental retardation

Assessment of judgement helps determine the patient’s capacity for independent functioning

When mental illness is shown to impair a patient’s judgment so he/she is not capable of signing a consent form or handling finances , a court will declare a patient as “ incompetent” for that task

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Example of Poor Judgment

The Mental Status Examination

Michael Blumenfield, M.DProfessor of Psychiatry, Medicine & Surgery

Department of PsychiatryNew York Medical CollegeValhalla, New York