Week 2: Mental Status Exam

What is an analogy for the MSE?

It is to the mind what a physical is to the body

What is the purpose of the MSE?

To provide a summative, systematic evaluation of the psychiatric patient's cognition, emotional state, and behavior at the time of the interview. You want to make sure you are in a space free of distraction and you have enough time, as it requires a lot of objectivity.

What does the MSE begin with?

Observing the client, sitting with the person. The bulk of the MSE is simple observation (e.g. assessing affect and appearance)

What is important to do in the MSE?

Go with where the client begins. If the client says “I can’t remember baseball stats like I used to” go with questions about Memory. If the client says, “I keep thinking about the same things over and over,” go with questions about thought content and thought processes

What is wise for a professional to do when giving the MSE?

Memorize, or at least become exceedingly familiar with) the MSE your agency uses so you can keep your focus on the client and not on documentation

What are techniques for starting the MSE?

Begin with explaining your role and the limits of confidentiality. Observe the client’s appearance, his/her affect - guarded, suspicious, open? Why is the client coming to see you now?! Thinking about what’s going on right now, or why the client came to see you at this point in their life automatically gets you to where the client is. What’s the history of the presenting complaint? Go ahead and structure the interview but let the client tell you as much as he/she can first. Although you want the client to be comfortable with you, you also want the client to show you/demonstrate what is going on in their life. Begin with simple structured questions first and then progress in difficulty to minimize anxiety.

What is a good mnemonic for MSE?

AMSITS

What is A in AMSITS?

Appearance, speech, behavior.

What are aspects of appearance?

does the client appear to be their stated age? Sometimes people with schizophrenia present as older. Does he/she appear ill or in distress? People with SUD may be experiencing subtle signs of feeling ill due to withdrawal. How are his/her communication skills? Clients with neurocognitive disorders and TBIs may have difficulty forming words. How does he/she relate to you? Clients with delusional disorders may appear untrusting while those with personality disorders may appear overly ingratiating. How is his/her motor activity? Clients with anxiety appear anxious and clients with depression appear lethargic/listless

What is the M in AMSITS?

Mood and affect. Mood can be incongruent with affect.

What is mood?

How we feel internally. Because it’s an internal state, you might have to ask them how they are feeling. It is important to remember that “fine” is not a feeling. If they are guarded, prompt them - “I see that you are a little upset. Can you tell me more?”

What are examples of mood?

Depressed, Elated, Anxious, Angry, Hostile, Belligerent

What is affect?

what we show to the outside world

What is full (broad) affect?

the variable of change in affect that is appropriate to the content of the speech.

What is blunted (constricted) affect?

The display of a single affect throughout the exam, or a limited display of a number of affects.

What is flat affect?

The absence of emotional display. People with schizophrenia often have no affect. Antidepressants can reduce affect. People with neurocognitive disorders can have a waxy look to them.

What is labile affect?

Emotional displays that shift rapidly and are unpredictable and unprovoked. Nothing external prompts emotional change

What is the first S in AMSITS?

Sensorium

What is COMA?

It is an acronym for sensoirum.

What is the C in COMA?

Consciousness: alert, somnolent, lethargic, stuporous, comatose. People with sleep disorders or narcolepsy have a waxing and waning consciousness.

What is O in COMA?

Orientation: Person, place, time, and situation. Often written as oriented x 4. People who are disoriented are typically not disoriented to person, usually its place, time, or event. Time should be within a day or two, if it’s a year off, then that’s a problem. People with schizophrenia might say that the event is something regarding suspicion.

What is M in COMA?

Memory: Immediate recall, recent memory, and remote memory. Think about people with neurocognitive disorders

What is A in COMA?

Attention: Focused, alert, distractible. Think about people with ADHD, TBI, SUD

What is I in AMSITS?

Intellectual function: An estimation based on vocabulary, educational history, and general fund of information. Usually requires specific information for diagnostic purposes and therefore a psychologist is really needed.

How can SW get a preliminary idea of intellectual function?

Think about how the client expresses themselves, think about their fluency in word choice, notice if the client appears to understand you and what you are asking, notice if the client is able to formulate direct questions as well as responses to your questions

What is the T in AMSITS?

Thought content, thought process

What are different thought contents?

suicidality/homicidality, perceptual disturbances, delusions - delusional disorders, judgement - impaired or intact, abstract ability, insight

What are perceptual disturbances?

Illusions, hallucinations. Schizophrenia, SUD, neurocognitive disorders

What are hallucinations?

They are of the 5 senses. Audio and visual are most common for people with schizophrenia. People with SUD most commonly experience olfactory and tactile. The elderly or people on meds can lose their sense of taste and may think their food is poisoned bc things aren’t tasting right

What are illusions?

You are looking at something and you have a misrepresentation of the thing you are looking at. Brain is misinterpreting stimuli

What are delusions?

Unreal thoughts - people think their life is different than what is actually happening. People with delusional disorders typically have real-life delusions - “The IRS is after me.” People with schizophrenia have grandiose of these

What impacts judgment?

Major depression, oppositional defiant disorder, conduct disorder, antisocial personality disorder often lack judgement. Do you know what you're doing and the impact on others? Do you know what you are getting yourself into? Do you have insight into what’s going on?

What is abstract ability?

“A rolling stone gathers no moss” “People who live in glass houses shouldn’t throw stones”  - What does that mean to you? Is the thought concrete?

What is included in insight?

Does the client appear to be able to self-reflect on the decisions they made? Do the decisions make sense, given the options available to them? People with Bipolar I disorder often lack this- they are impulsive.

How do you rate insight?

Excellent, good, fair, or poor. It is often based on your clinical assessment

What are thought processes?

The actual process of one’s thinking. It can include normal or abnormal

What is a normal thought process?

Logical, sequential, goal-directed. You can follow along

What are abnormal thought processes?

Flight of ideas, circumstantial, tangential

What is a flight of ideas?

Jumping around various points. The client can be jittery, anxious, and very excited. Expect in kids with ADHD, bipolar, schizophrenia

What is a circumstantial thought process?

Overly detailed thought process. Think about people with OCD. Giving every detail of making your bed

What is a tangential thought process?

Not goal directed instead, talking around the point diverging from one topic to another without clear connection between thoughts. Although the client may understand your questions, they seem unable to answer directly. Think about peopl with ADHD, TBI, schizophrenia

What are formal thought disorders?

a condition that affects a person's ability to think and communicate logically. It's characterized by disorganized speech and thinking that's difficult to follow. It can include broadcasting, withdrawal, insertion, loosened associations, derailment, and blocking. It is often seen in people with severe and persistent mental illnesses such as schizophrenia, bipolar disorder, and delusional disorder

What is broadcasting?

The delusional belief that others can hear or be aware of another person’s thoughts or ideas. “The russians can read my mind”

What is thought withdrawal?

The delusional belief that thoughts can be taken out of one’s mind. “I invented the printing press. Gutenberg took the credit for it”

What is thought insertion?

The delusional belief that thoughts are not one’s own, but belong to someone else. “I didn’t want to harm that person, it’s because of Gerry putting those thoughts there”

What are loosened associations?

Discussions in which the sequence of unrelated (or only slightly related) ideas are connected from one sentence to the next. There is no connection. “I like to go to the movies. Everyone has knees, but my boss laid me off. Tomorrow I will go to the deli.”

What is thought derailment?

Marked by frequent interruptions in thought. Then jumping from one idea to another unrelated or indirectly related idea but the person keeps going on with the new thought. There is some connection, but then the person goes off onto the next topic. “I was at the clinic over Memorial Day weekend, my mother finished baking the bread, my fav lemon poppyseed, warm with a little bit of butter, the viscosity of oil in my new car breaks down really fast - much faster than the owner’s manual otherwise indicates.”

What is thought blocking?

A person stops speaking suddenly and without explanation in the middle of a sentence. “My boss told me to complete this assignment so that I could…

What is the second S in AMSITS?

Somatic functioning - sleep - people with depression, anxiety, sleep disorders; libido - depression, somatic disorders, sexual dysfunction; Appetite and weight - depression, eating, and TBI disorders; energy level - depression, ADHD, SUD, neurocognitive disorders

What are limitations in the MSE?

Rarely can a diagnosis be made solely on the MSE. The MSE should guide us to further questions that will help us to figure out a diagnosis. The context is very important. You’re important. You bring yourself to the diagnostic evaluation setting. If you are Asian American and the client has issues with race. If you’re gay and the client has issues with sexual orientation

What are confounding factors for the MSE?

Intelligence - think about whether or not the client is able to attend to you during the MSE, Anxiety - think about setting, time of day, other interruptions, Culture - think about the questions you’re asking and if they are eurocentric, Interpersonal Factors - you and the client, are there populations that can’t work with you/are there populations you prefer not to work with?, Patient Cooperation - clients with personaltiy disorders or paranoia might not cooperate with you

What are IQ tests?

WISC-R and WAIS-R - Verbal, Performance, Full-Scale

What are projective tests?

Unstructured; Reactive; Attitudes, Motives, and Conflicts. There is no right or wrong. Helpful with impasses.

What are tests people create?

TAT, Draw-a-Person (DAP), House-Tree-Person (HTP), Kinetic Family Drawing (KFD)

What is an organic test?

Bender gestalt - assess for visual-motor functioning