creation date: 2025-06-17 15:10
tags: Assessments
Mental Status Examination
Background
The mental status examination (MSE) is utilized to assess different aspects of mental function to provide insight on objective and subjective components of mental illness.
The exam is elicited, in conjunction with the components of a standard patient encounter, when a patient’s presenting complaint raises suspicion for a change in mental status, altered mental status, or when assess for improvement or deterioration of a condition.
It is extremely important to have the suicidal ideation/risk component included in documentation for medicolegal purposes.
Examination Categories
Appearance
Consists of objective observation from clinician, often immediately at the start of an encounter.
Details to note include:
- Whether patient appears more youthful than stated age (eg. developmental delay, age inappropriate dressing)
- Whether patient appears older than stated age (eg. substance abuse, poorly controlled illness)
- Grooming and hygiene (and if deteriorated, what was rate of deterioration)
- Scars and tattoos (may give insight on sense of style, history of harm by self or others, etc.)
Behaviour
Description of behaviour is established throughout the interview. This consist of both objective evaluation and subjective history from the patient.
Details to note include:
- General behaviour (eg. distressed, uncomfortable)
- Description of interactions (eg. cooperative, agitated, avoidant, refusing to talk, unable to be redirected)
- Behaviour with and without caregiver present
Motor activity
This component describes the patient’s movement and the movement’s characteristics.
Details to note include:
- Speed of movement (normal, psychomotor retardation/bradykinesia, or psychomotor agitation/hyperkinesia)
- Posture (sustained/catatonic, akathisia)
- Other indicators (eg. tics, rigidity, tremours)
Symptoms may be better monitored using the Abnormal Involuntary Movement Scale (AIMS).
Speech
Evaluated passively throughout the interview.
Qualities of speech to note include:
- Amount of verbalization
- Fluency (ie. language skills)
- Rate and rhythm
- Volume
- Tone (eg. child-like, or indicates mood)
Other details to note include:
- Delayed speech response time
- Slurred speech
- Dysarthria (difficulty due to weak muscles)
If possible, the amount of speaking compared to a baseline or established personality is important.
Mood
Subjective description from the patient of their feelings in their own words. This is often documented with quotations verbatim.
Affect
The clinician’s interpretation of a patient’s observed expression through their non-verbal language.
Examples (very non-exhaustive) of descriptions include:
- Happy
- Sad
- Irritated
- Blunted
- Euphoric
It may also be beneficial to specify the degree (eg. slightly vs. extremely), the range of emotions (eg. dysthymic vs. euthymic), whether the affect is appropriate for the situation, and/or whether it is congruent to the patient’s mood.
Thought process
This component describes how a patient organizes their expressed thoughts. A normal thought process is linear and goal-directed.
Irregular thought processes can be:
- Circumstantial (connected but go off-topic before returning to original subject)
- Tangential (series of connected thoughts that go off-topic but do not return)
- Flight of ideas (similar to tangential but connection between thoughts is less obvious)
- Loose (no connection between thoughts)
- Perservation (returning to same topic or question repeatedly)
- Thought blocking (interruption in thoughts making it difficult to start or finish a thought; observed in psychosis)
Thought content
This refers to the subject matter of thoughts which is determined through listening during the interview.
Specific points to note include:
- Particular preoccupation (eg. if they have a perservation-type thought)
- Suicidal ideation
- Whether its passive (wishing to be dead) or active (wanting to take own life)
- If a plan has been made and if there is intent to act on the thoughts
- Homicidal ideations
- Passive or active
- Plans and intent
- Delusions (eg. bizarre, grandiose, paranoia, persecutory, somatic)
Note that when discussing certain thought contents, it may be pertinent to inquire indirectly, especially with delusions. Cultural competency may be required to evaluate certain beliefs as what may be considered delusions in one culture may be a norm in another.
Perception
Clinician assesses by asking patient what they perceive.
Abnormal perceptions include:
- Hallucination (perception of something in absence of any external stimuli)
- Auditory, visual, olfactory, tactile, or gustatory
- For auditory, sound vs. voice is a important distinction
- Illusion (misperception of an actual stimulus)
Note, hallucinations when waking up, prior to sleep, or during sleep paralysis may be considered normal. In some context, other hallucinations may be within the realm of normal, such as seeing the ghost of a recently deceased loved one.
Cognition
The most common areas of cognition evaluated are:
- Alertness (level of consciousness)
- Orientation (patient’s awareness of their situation and surrounding, eg. their name, current location, date)
- Concentration (how well a patient can focus on questions asked or spelling words backward)
- Memory (immediate recall, delayed recall, recent memory, and long-term memory)
- Abstract reasoning (ability to infer meaning and concepts, eg. what two objects have in common)
Assessment of cognition can be administered with a number of tools such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MOCA)
In many cases, documentations can be “cognition was grossly normal but not formally assessed” with or without A&Ox3.
Insight
This category refers to the patient’s understanding of their illness and functionality.
Insight should be described as poor, limited, or fair. Additionally, previous comparisons should indicate whether it is improving or deteriorating.
Judgement
Judgement refers to a patient’s ability to make good decisions. A clinician evaluates this by asking patients how they would respond to scenarios.
Example questions to ask are:
- “If you found a stamped, addressed envelope on the street, what would you do?”
- “If you saw a fire in a crowded building, what steps would you take?”
- “What would you do if you were at home and smelled gas?”
- “If you ran out of your prescription medication, what would you do?”
Suicidal/Homicidal Ideation
An assessment of suicidality should be made at every appointment and documented.
Components of the suicide risk include:
- Passive vs. active suicidal ideation
- Chronic vs. acute
- Is there plan or intent
- Are they future oriented (has plans relating to life vs. “it doesn’t even matter”)
- Protective factors