Mental Status Exam

A. Appearance (observed)

A person's appearance provides useful clues to their quality of self-care, lifestyle, and daily living skills. Assessment is observed in the following domains:

1. Grooming and dress

2. Level of hygiene

3. Pupil dilation or constriction

4. Facial expression

5. Height, weight, nutritional status

6. Presence of body piercing or tattoos, scars, etc.

7. Relationship between appearance and age

B. Behaviour (observed)

Along with noting what a person is actually doing during the examination, attention should be given to nonverbal communication, which reveals much about a person’s emotional state and attitude.

1. Excessive or reduced body movements

2. Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, mannerisms, balance and gait)

3. Abnormal movements (e.g., tardive dyskinesia, tremors)

4. Level of eye contact (keep cultural differences in mind; see Chapter 8)

5. Rapport (openness to the interview; e.g., if the patient is resistive versus open)

C. Speech (observed)

Speech can be a particularly revealing feature of a person's mental state and should be described behaviourally as well as having its content considered (see also "E. Thought"). Unusual speech is sometimes associated with mood and anxiety problems, schizophrenia, and organic pathology.

1. Rate (e.g., slow, rapid, pressured, normal)

2. Volume (e.g., loud, soft, normal)

3. Tonality (e.g., monotone, tremulous, varied)

4. Articulation (e.g., slurring, stuttering, mumbling)

5. Organization (e.g., disorganized, tongue-tied speech)

6. Quantity (e.g., poverty of speech, minimal, plentiful, voluminous)

D. Mood (observed and inquired)

The relationship of emotional affect and mood can be considered as being similar to that of the weather (affect) and the season (mood). Affect refers to immediate expressions of emotion (observed), whereas mood refers to emotional experience over a more prolonged period of time (inquired).

1. Affect (observed):• Range (e.g., restricted, blunted, flat, expansive)• Appropriateness (e.g., appropriate to conversation or setting, inappropriate, incongruous)• Stability (e.g., stable, labile)

2. Mood (inquired): sad, euphoric, duration, degree, stability• Tone (e.g., sad, euphoric, depressed, elevated, lowered)• Degree (e.g., extreme, moderate, mild, minor)• Irritability (e.g., explosive, irritable, calm)• Stability or duration (e.g., rapid, delayed)

E. Thought (observed and inquired)

Thinking is generally evaluated according to a person’s thought content or nature and thought form or process.

1. Thought content (e.g., delusions such as grandeur, jealousy, thought control/withdrawal/insertion; obsessions or preoccupations)

2. Thought process (e.g., disorganized, coherent, flight of ideas, neologisms, thought blocking, circumstantiality)

F. Perception (observed and inquired)

Assessment of perceptual disturbance is critical for detecting serious mental health problems like psychosis, severe anxiety, organic brain disorders, and mood disorders. It is also important in trauma or substance use. Perceptual disturbances are typically notable and may be disturbing or frightening. Consider the nature, timing, and triggers or precursors.

1. Hallucinations• Sensory involvement (e.g., auditory, visual, tactile, gustatory)• Content of auditory hallucination (e.g., conspiratory, command hallucinations telling a person to do something such as harm oneself or others)• Level of discernment of reality (e.g., questions the reality of the hallucination, hallucination is undistinguished from reality)• Level of associated distress (e.g., amused, distracted, fearful, extreme fear)

2. Illusions (similar to hallucinations but involving misperception of a real stimulus; e.g., perception of insects coming from pattern in wallpaper)

3. Dissociations (e.g., derealization, or feeling that the world or one's surroundings are not real; depersonalization, or feeling detached from oneself)

G. Cognition (inquired)

Cognitive assessment is in reference to a person's current capacity to process information. It is important because it is often sensitive (though in young people usually secondary) to mental health problems. Note that insight and judgement are particularly important in evaluating safety.

1. Orientation to reality (expressed as orientation to time, place, and person; e.g., awareness of the time/day/date, where they are, ability to provide personal details)

2. Level of consciousness (e.g., alert, drowsy, confused, clouded, stuporous, unconscious, comatose)

3. Memory functioning (e.g., immediate or short-term memory, memory for recent and remote information or events)

4. Fund of knowledge or intelligence (e.g., general knowledge as compared to the average person in a given society)

5. Language (e.g., naming objects, following instructions)

6. Abstraction (e.g., ability to describe similarity between two things—i.e., an apple and an orange; ability to explain the meaning of simple proverbs—i.e., "measure twice, cut once")

7. Attention and concentration: performance on serial sevens (counting down from 100 by increments of 7), serial threes (counting down from 20 by increments of 3), digit span tests (recalling in order a series of digits)

8. Visual or spatial processing (e.g., copying a diagram, drawing a bicycle, drawing a clock with the hands at 9 o'clock)

9. Insight (e.g., patient's acknowledgement and understanding of problems; potential pathological events—e.g., hallucinations, suicidal thoughts, and potential treatment. Evaluated by exploring questions such as "What do you believe is contributing to the problems you are experiencing or that others are identifying?"

10. Judgement (e.g., patient's general problem-solving ability. Evaluated by exploring recent decision making or by posing a practical dilemma such as

H. Ideas of Harming Self or Others (inquired)

Every mental status examination requires an assessment of thought content regarding self-harm and suicidal and homicidal ideation. The same must be documented. Further, if police are notified or children's aid is notified, this must be documented as well. Ideation, intent, and plan are all examined and explore the following (described in further detail in Chapter 22):

1. Target of ideation (e.g., the person—self or other, i.e., wife, boss, etc.)

2. Frequency of ideation (e.g., fleeting, constant, preoccupying)

3. Intent (an evaluation of whether the ideation is a reflection of wishing or thinking about death or harm versus an intent to kill oneself or another; e.g., general thoughts, presence of a plan)

4. Plan

a. Level of specificity (e.g., vague, general, detailed, specific, secretive)

b. Lethality of means (e.g., violent, lethal method)

c. Means to carry out the plan (e.g., possesses a gun and ammunition, possesses a vehicle, has stockpiled medication)

d. Opportunity to carry out the plan