Mental Status Examination Study Guide

Mental Status Examination

Introduction

  • Mental status examination is an important topic for patient's brain health and psychiatric considerations.

  • The lecture aims to provide tools for taking a good psychiatric history from patients with common problems.

Why?

  • Human beings are valuable and should be taken care of, including their mental health.

  • Systematically evaluating a patient's mental condition during interviews helps establish signs of a disorder.

  • The goal is to move towards diagnosis using these tools, which haven't been covered extensively before.

How?

The mental status examination involves:

  • Observation of the patient (general inspection).

  • Using the history, patient's account, and other information.

  • Asking specific questions to explore mental functioning.

  • Short tests of cognitive function.

Focus:

  1. How to take a mental status examination history.

  2. Tools to assess specific aspects of mental health:

    • Screen for dementia.

    • Screen for depression.

    • Screen for anxiety disorders.

Appearance

  • Assessing appearance informs the assessment of mental status.

  • Consider:

    • Attire

    • Signs of self-neglect

    • Facial expressions

    • Scars, tattoos

    • Signs of physical disease

    • Evidence of self-injuries

Behavior

Characterizing patient behavior can include:

  • Agitation: Purposeless motor activity.

  • Compulsive actions: Repetitive actions with no purpose.

  • Disinhibition: Lack of normal social behavior.

  • Motor retardation: Slowed behavior and movement.

  • Posturing: Unusual limb positions or gait.

Example:

  • Huntington's disease leading to chorionic movements of limbs

Speech

Note the following aspects of speech:

  • Articulation: Ability to form words.

  • Quantity: Is it normal, too much, or too little?

  • Rate: Is it too fast or too slow?

  • Volume: Is it too loud or too quiet?

  • Tone and quality: Accent, emotional tone (appropriate or inappropriate).

  • Fluency: Staccato, hot potato speech, or monotonous tone.

  • Abnormal Language: Making up words, inability to find words, or clanging (using words that sound similar but aren't connected by meaning).

Mood

  • Mood disorders and mood changes are common.

Examples of questions to assess mood:

  • How has your mood been lately?

  • Have you noticed any changes in your emotions recently?

  • Has your family commented on your mood recently?

  • Do you still enjoy things that normally give you pleasure?

Classify:

  • Flat

  • Blunted

  • Lability

Thought Form

Assess thought through history taking.

  • Rate of thoughts: Too fast or too slow?

  • Flow: Normal, flight of ideas (rapid shifts), perseverating (stuck on one idea)?

  • Sequencing: Loosening of association (no logical sequence of ideas).

  • Abstract thinking: Concrete thinking (inability to think abstractly).

Thought Content

  • Assess what the patient is thinking about.

Examples of questions to assess thought content:

  • What have your main worries been recently?

  • What has been on your mind lately?

  • Do you have any particular thoughts you keep coming back to?

Examples:

  • Hypochondriacal

  • Morbid thinking

  • Phobias

Abnormal Beliefs

  • Delusions: Abnormal belief held with total conviction despite contradictory proof.

  • Magical thinking: Irrational belief that actions and outcomes are linked.

Examples:

  • Paranoid

  • Hyper-religious

  • Grandiose

Questions to assess beliefs:

  • Have there been times when you thought something strange is going on?

  • Do you ever think you're being followed or watched?

  • Do you ever feel other people can interfere with your thoughts or actions?

Perception

  • Depersonalization: Feeling unreal.

  • Derealization: Feeling that the surrounding environment is not real.

  • Hallucinations: False perception without a valid external stimulus, e.g., seeing or hearing something that isn't there.

  • Illusions and pseudo-hallucinations: False perception is part of internal experience.

Assessing perception:

  • Do you ever hear voices when nobody is talking? What do those voices say? Where do they come from?

  • Have you had any visions or seen things that other people aren't seeing?

  • Have you ever felt you were not real or that the world around you wasn't real?

Cognition

Assess:

  • Level of consciousness (comatose, fully awake).

  • Orientation.

  • Memory (long-term and short-term).

  • Attention and concentration.

  • Intelligence (formal testing or informal assessment).

Insight

  • Assessing insight via questions:

    • Do you think anything is wrong with you?

    • What do you think is the matter with you?

    • If you are ill, what do you think needs to happen to make you better?

  • Poor insight indicated when patient denies any problems.

Risk Assessment

  • Assess risk to self and others.

Self-Harm/Suicide

  • How do you feel about the future?

  • Have you thought about ending your life?

  • Have you made plans to end your life?

  • Do you have the means to carry out that plan?

  • Have you attempted to end your life?

Harm to Others

  • Are there people you know who would be better off dead?

  • Have you thought about harming them?

  • Have you been told to harm anyone else?

  • Do you have a plan to actually harm someone?

General Screening

Anxiety Disorder

  • What physical symptoms have you been experiencing?

  • How relaxed have you been feeling recently?

  • Have there been any particular concerns or worries on your mind recently?

Depression

  • How has your mood been recently?

  • Are you still enjoying things the way you used to?

  • How do you view the future right now? Do you feel hopeless?

Schizophrenia

  • Have you had any beliefs that you think other people might find odd?

  • Have you had any unusual experiences recently?

  • Have you had any difficulty controlling your thinking? Does it feel like you aren't in charge of your thinking?

  • Have you heard people's voices when there's no one around? Where do you think those voices come from? What do they say?

Specific Screening Tools

  • Mini Mental Status Examination (MMSE)

  • Mini-Cog

  • PHQ-9 (Patient Health Questionnaire-9)

  • GAD-7 (Generalized Anxiety Disorder 7-item scale)

Mini Mental State Examination (MMSE)

  • Assess education level and date of birth.

  • Orientation to Time: date, month, year, day of the week, season.

  • Orientation to Place: room, city, county, state.

  • Memory: immediate recall of words (e.g., ball, flag, tree).

  • Attention: count backwards from 100 by sevens.

  • Graphical task: drawing a complex shape.

Mini-Cog

  • Validated in different cultural settings and languages.

  • Simple to use with good screening utility.

Steps

  1. Give three words (e.g., banana, sunrise, chair) and ask the person to repeat them and try to remember.

  2. Ask the person to draw a clock, including all numbers and setting the hands to ten past eleven.

  3. Ask the person to recall the three words from step one.

Scoring

  • Word Recall: one point for each word recalled without hints.

  • Clock Draw: 0 or 2 points. Normal clock = 2 points (all numbers in the right spots with appropriate sequencing; hands pointed to eleven and two).

  • Total score: 0-5 points. A score less than 3 indicates dementia.

PHQ-9 (Patient Health Questionnaire-9)

  • Screen for depression based on DSM criteria.

  • Quantify severity of symptoms.

Questions

How often have you been bothered by the following over the past two weeks?

  • Little interest or pleasure in doing things.

  • Feeling down, depressed, or hopeless.

  • Trouble falling or staying asleep, or sleeping too much.

  • Feeling tired or having little energy.

  • Poor appetite or overeating.

  • Feeling bad about yourself, or that you're a failure or have let yourself or your family down.

  • Trouble concentrating on things.

  • Moving or speaking so slowly that other people could have noticed; or being so fidgety or restless that you have been moving around a lot more than usual.

  • Thoughts that you would be better off dead, or of hurting yourself in some way.

  • How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? (Not part of the scoring).

Scoring and Interpretation

  • Scores indicate severity of depression.

  • 15-19: Moderately severe depression.

  • Above 20: Severe depression.

  • Assess suicide risk in patients who respond positively to item nine.

GAD-7 (Generalized Anxiety Disorder 7-item scale)

  • Screen for clinically significant anxiety disorders (specific phobias, PTSD, panic disorder, or generalized anxiety disorder).

Questions

Over the last two weeks, how often have you been bothered by the following problems?

  • Feeling nervous, anxious, or on edge.

  • Not being able to stop or control worrying.

  • Worrying too much about different things.

  • Trouble relaxing.

  • Being so restless that it's hard to sit still.

  • Becoming easily annoyed or irritable.

  • Feeling afraid as if something awful might happen.

  • How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? (Not part of the scoring).

Scoring and Interpretation

*Scores indicate severity of anxeity.

  • Scores indicate severity of anxiety.

  • 5-9: Mild, just monitor them. Maybe provide them some counsel, provide a listening ear, so they can just talk to you and get some things off of their mind.

  • Between 10 and 14: there's a moderate symptom severity, we're worried they have a clinically significant anxiety disorder.

  • Above 15: they're severe, you probably want to treat those people.

  • For panic disorder, social phobia, and PTSD, a cutoff score of eight may be used to optimize sensitivity and specificity.

Conclusion

Skills to practice:

  • Taking a mental status history.

  • Administering the Mini-Cog.

  • Administering the PHQ-9.

  • Administering the GAD-7.