642 Mental Status Exam

Mental Status Exam (MSE)

  • The Mental Status Exam (MSE) is a critical tool used to gather history and evaluate the mental health condition of clients.

  • It encompasses observations of client behaviors and communication regarding their current and past symptoms and information.

  • The MSE includes the following components:

    • Cognition

    • Appearance

    • Behavior

    • Motor Activity

    • Eye Contact

    • Speech

    • Mood/Affect

    • Thought Process/Perceptions (including delusions, hallucinations, suicidality)

    • Thought Content

    • Insight/Judgment

Cognition

  • Cognitive assessment assesses a client's level of awareness, attention, concentration, and memory.

  • Evaluation of cognition monitors levels of awareness which include:

    • Oriented

    • Alert

    • Distant

    • Somnolent

    • Drowsy

    • Comatose

  • Screening Tools for Cognition:

    • Mini-Mental State Exam (MMSE)

    • A 30-point questionnaire, it measures cognitive impairment across areas of orientation, attention, memory, language, and visual-spatial skills (Folstein et al., 1975).

    • Benefits:

      • Easy to administer

      • Available in multiple languages

      • Requires no special equipment

      • Can detect functional deterioration over time

    • Limitations:

      • Results may be influenced by client age, education, and sensory impairments.

    • Montreal Cognitive Assessment (MoCA)

    • Assesses multiple cognitive domains including short-term memory, visuospatial abilities, executive functions, attention, language, and orientation (MOCA, 2023).

    • Mini-Cog

    • Scores range from 0 to 5, calculated by adding 3-item recall and clock drawing scores.

      • Total scores of 0, 1, or 2 indicate a higher likelihood of clinically important cognitive impairment.

      • Total scores of 3, 4, or 5 suggest a lower likelihood of dementia but could indicate some degree of cognitive impairment (Mini Cog, 2023).

Appearance

  • Evaluating appearance is crucial in assessing a client's mental health.

    • Appearance that is disheveled or poorly groomed can suggest underlying conditions such as depression.

    • Poor grooming could be indicative of depressive disorders.

    • Tattoos could symbolize cultural identity or personal significance.

Eye Contact

  • Appropriate eye contact is characterized by intermittent behavior, where the client looks at the speaker while occasionally looking away.

  • Intermittent eye contact reflects interest and engagement in the conversation.

Behavior

  • Assessments of behavior gauge how a client presents themselves:

    • Are they able to sit still during the appointment?

    • Are they actively listening?

    • Presence of any abnormal mannerisms?

Speech

  • The assessment of speech is vital in the mental health exam, with specific evaluations of:

    • Rate

    • Rhythm

    • Latency

    • Volume

    • Other speech patterns:

    • Absence

    • Nonsensical speech

    • Pressured speech: Indicative of acute substance intoxication or a manic episode.

    • Slurred speech: May indicate intoxication.

    • Dysarthria: Potentially signifies motor dysfunction related to speech.

Motor Activity

  • Motor Activity review is essential for identifying neurological disorders or effects of medications.

  • Speed of movements is classified as:

    • Normal

    • Slow (Retardation or Bradykinesia)

    • Fast (Agitation or Hyperkinesia)

  • Gait analysis includes:

    • Stiff

    • Shuffling

    • Ataxic

Abnormal Involuntary Movement Scale (AIMS)

  • Register for the free AIMS interactive evaluation modules for a comprehensive understanding of movement disorders and practice with the AIMS assessment scale.

Mood and Affect

  • Mood refers to the client's state of mind as reported, examples include being angry, agitated, or anxious.

  • Clients may rate their mood on a scale of 1 to 10.

  • Affect is the physical manifestation of the emotional state as observed by the provider.

    • Categories include euphoria, blunted affect, or abnormal affect.

    • Example of congruency in mood and affect:

    • If a patient claims their mood is “great” accompanied by smiling, the affect is congruent and happy.

    • If the same patient expresses “great” while crying, the affect is incongruent (tearful). (Voss and Das, 2022)

Thought Process

  • Evaluation of thought processes occurs through listening and identifying:

    • Hallucinations

    • Delusions

    • Suicidal thoughts

    • Characteristics of the thought flow:

    • Connectivity and logical progression or lack thereof.

    • Speed of thoughts (fast or slow)

  • Types of Thought Processes:

    • Circumstantial: Thoughts remain connected but deviate before returning to the main topic.

    • Tangential: Thought processes deviate without returning to the topic.

    • Flight of Ideas: Similar to tangential but connections are less obvious.

    • Loose or Disorganized: Thoughts lack any coherent connectivity, representing a disorganized stream of consciousness.

Delusions

  • Four Types of Delusions (DSM-5):

    1. Bizarre delusions: Implausible scenarios like alien abduction.

    2. Non-bizarre delusions: Beliefs that could realistically occur, like being cheated on.

    3. Mood-congruent delusions: Consistent with the individual's mood (e.g., feelings of abandonment).

    4. Mood-incongruent delusions: Not affected by mood (e.g., beliefs about the world ending).
      (Pugle, 2021)

  • Specific Delusions:

    • Capgras delusion: Believing a loved one has been replaced by an imposter.

    • Cotard delusion: Believing oneself is dead or parts are non-existent.

    • Delusion of control: Thinking an external entity controls personal thoughts/behaviors.

    • Delusion of grandiosity: Exaggerated self-importance. E.g., claiming to be a famous influencer with no following.

    • Delusion of guilt or sin: Unfounded feelings of remorse for something perceived as wrong.

    • Delusion of thought insertion/broadcasting: Ideas inserted into one’s mind or broadcasted to others.

    • Delusion of persecution: Believing one is unfairly mistreated or watched.

    • Delusion of poverty: Fear of impending destitution.

    • Delusion of reference: Believing a neutral stimulus holds personal significance.

    • Delusional jealousy: Believing one's partner is unfaithful.

    • Erotomanic delusion: Believing a person, typically famous, is in love with oneself.

Hallucinations

  • Types of Hallucinations:

    • Auditory: Hearing sounds or voices not present (the most common type).

    • Visual: Seeing non-existent entities or shapes.

    • Gustatory: Experiencing tastes without a source (rarest type).

    • Presence: Feeling someone’s presence when alone.

    • Proprioceptive: Feeling limbs moving when they are stationary.

    • Tactile: Sensations of bugs crawling or being touched when not experiencing it.

    • Olfactory: Smelling substances that do not exist (less common).
      (Purse, 2022)

  • Other Hallucination Types:

    • Hypnopompic: Occurring upon waking from sleep.

    • Hypnagogic: Occurring during the transition into sleep.

Suicidality

  • Suicide risk assessment is crucial in evaluating potential risks of a client attempting self-harm or suicide.

  • Utilization of screening tools such as C-SSRS (Columbia-Suicide Severity Rating Scale) or ASQ (Ask Suicide-Screening Questions) fosters effective risk appraisal using evidence-based methodologies.

Suicide Risk Levels and Actions

  • If ACTIVE PREPARATION is identified:

    • Immediate removal of lethal means and contacting emergency services (911) or local emergency facilities for urgent inpatient care is mandatory.

  • If PLAN TO ACT is indicated:

    • The individual has a specific suicide plan without current actions; recommend contacting the National Suicide Hotline or a similar crisis line, possibly leading to inpatient or partial hospitalization.

  • If having THOUGHTS but NO PLAN:

    • Seek intensive outpatient treatment or individual counseling; establish a safety plan and hotline contacts for escalating thoughts.

  • If having VAGUE THOUGHTS:

    • Describe passive thoughts such as “Maybe I’d be better off dead” without dwelling on them; pursue in-office therapy to explore thought origins while preparing safety plans for any escalation.

  • If NO THOUGHTS exist:

    • Repeat assessments indicate no recent or historical suicidal thoughts; recommend standard therapy to address broader concerns as necessary.

Risk Factors for Suicide

  • Previous history of:

    • Suicide attempts

    • Substance abuse

    • Physical disabilities or chronic illnesses

    • Relationship problems

    • Recent losses, including family or close friends

    • History of mental health conditions

    • Exposure to bullying or ongoing distressing situations.

Columbia Suicide Severity Rating Scale (C-SSRS)

  • The C-SSRS is a brief questionnaire suited for quick administration with recommended but not mandatory training for practitioners.

  • Certification for administering C-SSRS is available through training options which include an interactive presentation (approx. 30 min) followed by Q&A, or DVD access encompassing the same material.

  • The certification holds for a duration of two years, guiding effective practice in clinical settings via http://c-ssrs.trainingcampus.net/

PHQ-9 Depression and Suicide Screening Tool

  • The Patient Health Questionnaire (PHQ-9) serves as a primary screening tool for suicidal ideation which includes:

    • Item 9: “In the past two weeks, have you had thoughts that you would be better off dead, or thoughts of hurting yourself in some way?“

  • This item is recommended as an integral part of clinical interviews for assessing suicidal ideation (PHQ-9 resource).

Suicide Prevention Resources

  • American Foundation for Suicide Prevention: https://afsp.org

  • National Suicide Prevention Lifeline: 1-800-273-TALK (8255) | https://suicidepreventionlifeline.org

  • Suicide Prevention Resource Center: https://www.sprc.org

Depression Screening Tools

  • Beck Depression Inventory (BDI)

  • Geriatric Depression Screening

  • Edinburgh Postnatal Depression Scale (EPDS)

  • Children's Depression Inventory (CDI)

Anxiety Screening Tools

  • Hamilton Anxiety Rating Scale (HAM-A)

  • Beck Anxiety Inventory (BAI)

  • Trait Anxiety subscale/State-Trait Anxiety Inventory (STAI-T)

  • Generalized Anxiety Disorder Questionnaire IV (GADQ-IV)

  • Generalized Anxiety Disorder 7 (GAD-7)

  • Overall Anxiety Severity and Impairment Scale (OASIS)

  • Hospital Anxiety and Depression Scale (HADS)

GAD-7 Anxiety Screening Tool

  • The Generalized Anxiety Disorder scale-7 (GAD-7) is a validated seven-item diagnostic tool, useful in both primary care and general population contexts.

Homicidal Ideations

  • Assessment and Identification of Homicidal Ideations:

    • Always ask clients probing questions regarding:

    • Intentions

    • Attempts

    • Planning

Insight and Judgment

  • Insight: Refers to the client’s awareness of their illness or overall situation.

  • Judgment: The capacity to anticipate the potential outcomes of one's behaviors and safeguard well-being.

  • Assessment of insight and judgment can range from good, limited, to poor and is influenced by past and current experiences.

  • Individuals with substance use disorders may exhibit poor insight and judgment or denial regarding their situations.

References

  • Carlat, D. J. (2017). The psychiatric interview (4th ed.) Wolters Kluwer.

  • EPS. (2023). EPS image slide 9. Extrapyramidal symptoms - Bing images.

  • Mini Cog. (2023). Mini Cog Instrument. Download the Mini-Cog© Instrument – Mini-Cog©.

  • MoCA. (2023). MoCA Test. | MoCA Test (mocacognition.com).

  • Nelson, L. & Stoner, S. (2023). AIMS Assessment Scale. Tips to Conducting the AIMS | aapp.org.

  • Norris, D. & Clark, M. (2021). The Suicidal Patient. The Suicidal Patient: Evaluation and Management | AAFP.

  • Open Counseling. (2023). Suicide Risk Assessment.

  • Pugle, M. (2021). Delusions. Delusions: Types, Themes, Causes, Diagnosis (verywellhealth.com).

  • Purse, M. (2022). What are hallucinations. Hallucinations: Symptoms, Types, Causes, Treatment (verywellmind.com).

  • Sapra et al. (2020). Using the GAD2 and GAD 7. Using Generalized Anxiety Disorder-2 (GAD-2) and GAD-7 in a Primary Care Setting - PMC (nih.gov).

  • Townsend, M. & Morgan, K. (2020). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (8th ed.). F.A. Davis Company.

  • Voss, R. & Das, J. (2022). Mental Health Examination. NIH Stat Pearls. Mental Status Examination - StatPearls - NCBI Bookshelf (nih.gov).