MENTAL STATUS EVALUATION
Mental Status Examination Interview is conducted to assess the presence of cognitive,
emotional, or behavioral problems.
The mental status examination (MSE) has been used predominantly in psychiatry, clinical
psychology, and psychiatric social work for several decades, but is being increasingly used by
counselors in work settings requiring assessment, diagnosis, and treatment of mental disorders.
The MSE is used to obtain information about the client’s level of functioning and self-
presentation. Generally conducted (formally or informally) during the initial or intake interview,
the MSE can also provide counselors with a helpful format for organising objective
(observations of clients) and subjective (data provided by clients) information to use in
diagnosis and treatment.
A mental status examination can be used as part of a formal psychological assessment for a
variety of reasons. A brief mental status examination might be appropriate before assessment
to determine the appropriateness of more formal psychological testing.
For example, a patient was unable to determine where he or she was and had significant
memory impairments, testing with most instruments might be too difficult and could result in
needless distress. Brief screenings might also be used to determine basic case management
issues, such as hospitalization or placing a patient under close observation. A mental status
examination can be used as part of an assessment using formal psychological tests. The “raw”
data from the exam can be selectively integrated with general background information to
present a coherent portrait of the person and assist in diagnosis.
Numerous sources in the psychiatric literature provide thorough guidelines for conducting a
mental status exam has provided a review of the more structured mental status exams. This
literature indicates that practitioners vary widely in how they conduct mental status
examinations. The most unstructured versions involve merely the clinician’s use of the mental
status examination as a set of general guidelines. The more structured versions range from
comprehensive instruments that assess both general psychopathology and cognitive
impairment to those that focus primarily on cognitive impairment.
Mini–Mental State Examination (MMSE), which is a brief neuropsychological
screening test for dementia. The Mini-Mental State Examination (MMSE) or Folstein test
is a 30-point questionnaire that is used extensively in clinical and research settings to
measure cognitive impairment. It is commonly used in medicine and allied health to
screen for dementia.
Components Of Mental Status Examinations
The mental status examination accesses behavioral and cognitive functioning.
Behavioral components include, appearance and general behavior, level of
consciousness, motor and speech activity, mood and affect, thought and perception,
attitude and insight, and the reaction evoked in the examiner. Cognitive components
include alertness, language, memory, constructional ability, and abstract reasoning.
There are many versions of mental status examination, which differ around the world
but there is a broad commonality.
BEHAVIORAL COMPONENTS
Appearance and General Behavior
These variables give the examiner an overall impression of the patient. The patient's physical
appearance (apparent vs. stated age), grooming (immaculate/unkempt), dress (subdued/riotous),
posture (erect/kyphotic), and eye contact (direct/furtive) are all pertinent observations. Certain
specific syndromes such as unilateral spatial neglect and the disinhibited behavior of the frontal
lobe syndrome are readily appreciated through observation of behavior.
Level of Consciousness
The level of consciousness refers to the state of wakefulness of the patient and depends both on
brainstem and cortical components. Levels are operationally defined by the strength of stimuli
needed to elicit responses, and the scheme of Plum and Posner (1980) is widely accepted.
A normal level of consciousness is one in which the patient is able to respond to stimuli at the
same lower level of strength as most people who are functioning without neurologic
abnormality. Clouded consciousness is a state of reduced awareness whose main deficit is one of
inattention. Stimuli may be perceived at a conscious level but are easily ignored or
misinterpreted. Delirium is an acute or subacute (hours to days) onset of a grossly abnormal
mental state often exhibiting fluctuating consciousness, disorientation, heightened irritability,
and hallucinations. It is often associated with toxic, infectious, or metabolic disorders of the
central nervous system. Obtundation refers to moderate reduction in the patient's level of
awareness such that stimuli of mild to moderate intensity fail to arouse; when arousal does occur,
the patient is slow to respond. Stupor may be defined as unresponsiveness to all but the most
vigorous of stimuli. The patient quickly drifts back into a deep sleep-like state on cessation of the
stimulation. Coma is unarousable unresponsiveness. The most vigorous of noxious stimuli may
or may not elicit reflex motor responses.
When examining patients with reduced levels of consciousness, noting the type of stimulus
needed to arouse the patient and the degree to which the patient can respond when aroused is a
useful way of recording this information.
Speech and Motor Activity
Listening to spontaneous speech as the patient relates answers to open-ended questions yields
much useful information. One might discern problems in output or articulation such as the
hypophonia of Parkinson's disease, the halting speech of the patient with word-finding
difficulties, or the rapid and pressured speech of the manic or amphetamine-intoxicated patient.
Overall motor activity should also be noted, including any tics or unusual mannerisms. Slowness
and loss of spontaneity in movement may characterize a subcortical dementia or depression,
while akathisia (motor restlessness) may be the harbinger of an extrapyramidal syndrome
secondary to phenothiazine use.
Affect and Mood
A client’s mood refers to the dominant emotion reported during the interview, whereas affect
refers to the client’s outwardly projected range of emotions. Information related to affect is
inferred from the content of the client’s speech, facial expressions, and body movements. The
type of affect can be judged according to variables such as its depth, intensity, duration, and
appropriateness. The client might be cold or warm, distant or close, labile, or, as is
characteristic of schizophrenia, his or her affect might be blunted or flattened. The client’s
mood might also be euphoric, hostile, anxious, or depressed, and an examiner should note the
level of congruence between mood and affect.
Thought and Perception
The inability to process information correctly is part of the definition of psychotic thinking. How
the patient perceives and responds to stimuli is therefore a critical psychiatric assessment. Does
the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear?
Is the patient responding in exaggerated fashion to actual events, or is there no discernible basis
in reality for the patient's beliefs or behavior?
Patients may exhibit marked tendencies toward somatization or may be troubled with intrusive
thoughts and obsessive ideas. The more seriously ill patient may exhibit overtly delusional
thinking (a fixed, false belief not held by his cultural peers and persisting in the face of objective
contradictory evidence), hallucinations (false sensory perceptions without real stimuli),
or illusions (misperceptions of real stimuli). Because patients often conceal these experiences, it
is well to ask leading questions, such as, "Have you ever seen or heard things that other people
could not see or hear? Have you ever seen or heard things that later turned out not to be there?"
Likewise, it is necessary to interpret affirmative responses conservatively, as mistakenly hearing
one's name being called, or experiencing hypnagogic hallucinations in the peri-sleep period, is
within the realm of normal experience.
Of all portions of the mental status examination, the evaluation of a potential thought disorder is
one of the most difficult and requires considerable experience. The primary-care physician will
frequently desire formal psychiatric consultation in patients exhibiting such disorders.
Attitude and Insight
The patient's attitude is the emotional tone displayed toward the examiner, other individuals, or
his illness. It may convey a sense of hostility, anger, helplessness, pessimism, overdramatization,
self-centeredness, or passivity. Likewise, the patient's attitude toward the illness is an important
variable. Is the patient a help-rejecting complainer? Does the patient view the illness as
psychiatric or nonpsychiatric? Does the patient look for improvement or is he or she resigned to
suffer in silence?
Patient attitude often changes through the course of the interview, and it is important to note any
such changes.
Examiner's Reaction to the Patient
The feelings aroused in the examiner by the patient are often a source of very useful information.
These data are sometimes subtle and easily overlooked as the examiner, in an attempt to remain
objective, fails to note how he or she is responding to the patient.
A developing sense of dysphoria in the examiner may be the first clue that the physician is
dealing with a depressed patient. Frustration may be the response to the help-rejecting
complainer while a feeling of being off-balance and slightly out of touch with the conversation
may be an early indication that one is dealing with a schizophrenic patient.
COGNITIVE COMPONENTS
The preceding sections of the mental status examination provide a Gestalt view of the patient
and his illness. A structured examination of specific cognitive abilities is a more reductionistic
approach to the patient and pays careful attention to neuroanatomic correlates. Such testing
logically follows a hierarchic ordering of cortical function with attention and memory being the
most basic functions on which higher-ordered abilities of language, constructional ability, and
abstract thinking are layered.
Attention
The testing of attention is a more refined consideration of the state of wakefulness than level of
consciousness. An ideal test of attentiveness should assay concentration on a simple task, placing
minimal demand on language function, motor response, or spatial conception. Reaction times are
frequently slowed in patients who have diminished attentiveness. This may become evident early
in the course of examination and provide an important clue that the examiner is dealing with
decreased attentiveness. One test often recommended is the ability to listen to digit spans of
increasing length and repeal them back to the examiner. Another is to have the patient listen to a
digit span and then repeat it backward. Perhaps a better test is to have the patient listen to a string
of letters in which one letter is repeated frequently but randomly and to tap each time that letter
is heard, for example, "Please tap each time you hear the letter K."
TLKBKMNZKKTKGBHWKLTK…
The number of errors the patient makes is noted. Another test might be to have the patient count
the number of times a given letter appears on a page full of randomly ordered letters.
Language
The left perisylvian cortex mediates most aspects of language function in 99% of right-handed
individuals and over half of left-handed individuals. Thus, an aphasia implies damage to the left
hemisphere about 95% of the time. Basic examination of language function should include an
assessment of spontaneous speech, comprehension of spoken commands, reading ability, reading
comprehension, writing, and repetition.
The assessment of spontaneous speech is performed as the patient supplies answers to open-
ended questions. In this evaluation one looks for disorders of articulation, abnormalities of
content, disorders of output, and paraphasic errors. Phonemic errors are mistakes in
pronunciation; semantic errors are errors in the meaning of words; neologisms are meaningless
nonwords that have a specific meaning for the patient.
Repetition is tested by having the patient repeat sentences with several nouns and pronouns, for
example, "That's what she said to them yesterday," and "No ifs, ands, or buts."
Comprehension is tested with several levels of responses. First the patient is asked complex yes
and no questions such as, "Do you take off your clothes before taking a shower?" thereby
minimizing the need for motoric and speech acts. Second, questions where gesture alone can be
an adequate response are asked, for example, "Point to where people may sit down in this room."
finally, the patient is asked to follow a command with a motor response: "Squeeze my fingers."
Word-finding disability may be suspected when spontaneous speech is halting in nature as the
patient searches for the proper word. To test this ability, the patient is asked to name a number of
objects of several categories ranging from the everyday to the more unusual. To stress this ability
further the naming of parts of objects, for example, the crystal of a watch, the lead of a pencil, is
also tested. Word fluency is more specifically tested by having the patient generate as many
words in a given category as he or she is able in a fixed time period. Standard tests ask for such
things as "items found in a supermarket" or "words beginning with the letters F, then A, then S."
Reading is tested by having the patient read out loud, listening for errors and testing reading
comprehension by having the patient follow a written command, for example, "Close your eyes."
Standardized short stories are available that patients can be asked to read and then later recall.
These are scored on the remembrance of key items.
Writing is tested by having the patient sign his name, generate spontaneous sentences, or
describe an object in writing.
Memory
Memory disturbance is a common complaint and is often a presenting symptom in the elderly.
Memory can be grouped simplistically into three subunits: immediate recall, short-term memory,
and long-term storage.
Short-term memory is the most clinically pertinent, and the most important to be tested. Short-
term retention requires that the patient process and store information so that he or she can move
on to a second intellectual task and then call up the remembrance after completion of the second
task. Short-term memory may be tested by having the patient learn four unrelated objects or
concepts, a short sentence, or a five-component name and address, and then asking the patient to
recall the information in 3 to 5 minutes after performing a second, unrelated mental task.
Orientation largely reflects recent memory function. Questions such as, "Where are we right
now? What city are we in? What is today's date? What time is it right now (to the nearest hour)?"
are pertinent questions.
Immediate recall can be tested once again by having the patient repeal digit spans, both forward
and backward. Long-term memory can be tested by the patient's ability to recall remote personal
or historic events (e.g., the naming of previous presidents, major wars, date of the bombing of
Pearl Harbor) or answer select questions from the WAIS information subtest. Obviously, in
asking remote personal events, the physician must be privy to accurate information to judge the
accuracy of the patient's response.
Constructional Ability and Praxis
Apraxia is the inability, not due to weakness, to perform previously learned motor acts. The more
common of these are ideomotor apraxias wherein the patient can initiate movements and
manipulation of objects but is unable to pretend a given action. This modality is tested by asking
the patient to "sew on an imaginary button," "use an imaginary scissors," or "light an imaginary
cigarette."
Ideatory apraxia is the breakdown of higher-ordered sequencing of steps in the manipulation of
real objects. It is tested by serial step commands, for example, "Take this piece of paper in your
left hand, then fold it up, place it in the envelope, and seal the envelope."
Constructional inability is loss of the capacity to generate line drawings or manipulate block
designs from verbal command or visual reproduction. Geschwind (1965) has pointed out that the
older term "constructional apraxia" is insufficient to describe this ability as it involves integration
of occipital, parietal, and frontal lobe functions and is therefore more complex than the word
"praxis" would indicate. The patient is tested by being shown line drawings of increasing
complexity and being asked to reproduce them. Next, the patient is asked to generate pictures
from memory, for example, "Draw a clock face; put in the numbers; draw hands on the clock to
say 8:20." Finally, the patient may be asked to manipulate blocks (multicolored cubes from
WAIS-R) to reproduce stimulus designs.
