Mental Status Exam

Ismail sadek

Remember to always do a PHYSICAL EXAMINATION !!!!• General observations: Vital signs:

HR, BP, RR, Temp: Autonomic arousal, tremor, sweating etc.

• Important features: scars, tattoos, signs of liver disease, signs of thyroid or Cushing’s disease, etc., Specific CVS, RS, GI, and CNS examination findings and important negative findings

Mental Status ExamWhat it is it?• The Mental Status Exam (MSE) is

the psychological equivalent of a physical exam that describes the mental state and behaviors of the person being seen.

What it is it?It includes both:• objective observations of the clinician and •subjective descriptions given by the patient.

Why do we do them?• The MSE provides information for

diagnosis and assessment of disorder and response to treatment.

• A Mental Status Exam provides a snap shot at a point in time

• If another provider sees your patient it allows them to determine if the patients status has changed without previously seeing the patient

• To properly assess the MSE information about the patients history is needed including education, cultural and social factors

• It is important to ascertain what is normal for the patient. For example some people always speak fast!

Components of the Mental Status Exam• Following Daniel & Crider (2003)

an MSE collates information about the client’s

• (i) physical• (ii) emotional• (iii) cognitive state

PHYSICAL

Appearance Motor Activity

Behavior

EMOTIONAL

Attitude Mood and Affect

COGNITIVE

Orientation Attention and Concentration

Memory Speech and Language

Thought (Form and Content) Perception

Insight and Judgment Intelligence and Abstraction

Components of the Mental Status Exam

• Appearance • Overt behavior • Attitude • Speech • Mood and affect • Thinking Form Content• Perceptions • Sensorium cognition Alertness Orientation (person, place, time) Concentration Memory (immediate, recent, long term) Calculations Fund of knowledge Abstract reasoning• Insight • Judgment

Appearance: What do you see?• Build, posture, dress, grooming,

hair, and nails, prominent physical abnormalities

Attitude • Attitude toward the examiner:

cooperative, uncooperative, friendly, attentive, interested, frank, seductive, defensive, perplexed, apathetic, hostile, playful, or guarded;

• any number of other adjectives can be used.

Speech

• Rate: increased/pressured, decreased/monosyllabic, latency

• Rhythm: articulation, prosody ( الشعر نظم , (علمdysarthria, monotone, slurred

• Volume: loud, soft, mute• Content: fluent, loquacious, paucity,

impoverished

Speech

الكالم، : • قليل فصيح، ثرثار، ك للمريض وصفه يمكنأثناء طبيعية بصورة لألشارات يستجيب أو يستجيب ال

بطيئا،. أو سريعا الخطاب يكون أن يمكن المقابلة ) ( ، ممل رتابة درامي، عاطفي، متردد، مضغوط،

. متقطع أو اللسان، ثقيل همس، عال، وبصوت . القسم هذا في مدرجة التأتأة، مثل الكالم، أعتالالت

Overt Behavior and Psychomotor Activity

• Eye contact: ex. poor, good, piercing• Included are mannerisms, tics,

gestures, twitches, stereotyped behavior, echopraxia, hyperactivity, agitation, combativeness, flexibility, rigidity, gait, and agility. Describe restlessness, wringing of hands, pacing, and other physical manifestations.

Describe both the quality and the types of actions observed• reduction in the level of movement

(psychomotor retardation)• slowed movement (bradykinesia)• decreased movement (hypokinesia)• absence of movement (akinesia)• increases in the overall level of

movement (psychomotor agitation)• tremor

Cognition• Level of consciousness

بالمالحظة•

Orientation االهتداء • Disorders of orientation are

traditionally separated according to time, place, and person.

• Any impairment usually appears in this order (i.e., sense of time is impaired before sense of place);

Orientationدلوقتى؟ • الوقت ايهاى • وفى ده؟ المكان وفين فين؟ احنا

؟ محافظةمين؟ • انا

Attention and concentration

• the ability to focus, sustain and appropriately shift mental attention

• ) بالعكس ) عالم كلمة حروف استهجاء طريق عن االنتباه• ، متكركبة حاجات الشقة فى لقيت بيتى داخل وأنا للمريض نقول

: ، تليفزيون التربيزة على خبط ، بتتاكل حاجة منهم تسمع لمالحمة ، عيش ، أطباق ، مكواة ، موز ، راديو ، خضار ، عنب ، كرسى

.طرح )• مواصلة المريض سؤال طريق عن وإن( 100من( )7التركيز

بطرح ) يقوم يستطيع (3لمي • من بداية بالعكس الهجائية الحروف سردبالعكس • السنة شهور سرد

الذاكرة•1 -Immediate memory Sensory = ) ( :الحسية اللحظية .الذاكرةتكررها : )) (( . . • عايز ولو ور1ايا وقولها أرقام لك حأقول له نقول بأن

مثال . . . . : ببعض1ها مرتبطة غير األر1قام تكون أن والبد كررها ، لهمن . . 259047 نقوله . . 6- 5وتكون ممكن متعلم غير كان ولو 3أرقام

قلم : )) . . . . (( . طبق كورة مثال ورايا ويقولها أش1ياء•2 -Intermediate :1المدى قصيرة الذاكرةيكون)) (( . . • أن والبد فيها حس1ألك الجلسة نهاية وفى1 قص1ه حقولك

جاى1 . . : )) وأنا كالتالى وتكون وأعداد ألوان و ومكان زمان فيهاتقولها القاعدة آخر وفى عليها أقولك حاجة حص1ل الصبح المس1تشفى1

الساعة . . العباس1ية ميدان فى1 وأنا عربيتين . . 9لى فى كان ، صباحاحادثة . . عملوا ، حمرا وواحدة ز1رقا و 2واحدة وراحوا 6ماتوا اتصابوا

المس1تشفى (( .•3 -Remote = Long-term memory :الم1دى بعيدة الذاكرةعن • شهر. . General knowledgeنس1أله فى كانت أكتوبر حرب مثل

؟ عربى كامبعد. . . . • اللى1 الرئيس أو ؟ مصر ضرب اللى الشهير الزلزال عن أو

؟ فاروق الملك

Mood• The prevalent emotional state the

patient tells you they feel• Often placed in quotes since it is what

the patient tells you• Examples “Fantastic, elated, depressed,

anxious, sad, angry, irritable, good”• Type: euthymic (normal mood), dysphoric

(depressed, irritable, angry), euphoric (elevated, elated) anxious

MOOD

* اسبوعين اخر فى ايه شكله مزاجك “greif* " الستبعاد حصلت حاجه فيه وكان

“temperment”* ايه شكله مزاجك كان عمرك طول* بيتغير وال واحد شكل على مزاجك

نفسك تاذى فكرت انك لدرجة متضايق انت ياترى

Affect• The emotional state we

observe•Range: full (normal) vs.

restricted, blunted or flat, labile•Congruency: does it match the

mood-(mood congruent vs. mood incongruent)

•Stability: stable vs. labile

Affect

“affect”* الجسم وتحركات الوجه تعبيرات مالحظة من والبد

“reaction”* يقول الطبيب وممكن بتضحكك اللى الحاجات ايهافضل نكته

Perceptionاالدراك

• Examples include illusions, hallucinations, derealization, depersonalization,

• Illusions: Misinterpretations of environment

• Hallucinations: False sensory perceptions. Can be auditory (AH), visual (VH), tactile or olfactory

• Derealization: Feelings the outer environment feels unreal

• Depersonalization: Sensation of unreality concerning oneself or parts of oneself

الهالوس عن السؤال

"سؤاله اوال عن سالمة اعضاء الحس "فى مشاكل فى ودنك او عينيكهل حصل وحد كلمك وانت قاعد لوحدك ؟ واخر مرة كان امتى؟"ولما حصل كنت صاحى ذى دلوقتى وال قبل النوم "ودروخوالصوت ده جى منين؟من بره دماغك وال من جوه دماغك؟صوت مين؟ ست وال راجل؟ كبير وال صغير؟الصوت بيقول ايه؟وانت عملت ايه لما سمعته؟ هل سمعته اتكرر عليك دلوقتى "اثناء الجلسه؟ علشان اقول عنده وال أل فى

"فقطhistoryالفحص واذا لم يحدث اذكره فى " وياترى اللى بيكلمك شوفته ؟ او بتحس بحاجه بتمشى عليك او شميت حاجه

غريبه محدش بيشمها غيرك؟

Thought Process• Describes the rate of thoughts, how

they flow and are connected. • Normal: tight, logical and linear,

coherent and goal directed• Abnormal: associations are not clear,

organized, coherent. Examples include circumstantial, tangential, loose, flight of ideas, word salad, clanging, thought blocking.

من • عنها التعليق يتم االعراض وهذهالكالم سياق

Thought Process: examples• Circumstantial: provide

unnecessary detail but eventually get to the point

• Tangential: Move from thought to thought that relate in some way but never get to the point

• Loose: Illogical shifting between unrelated topics

• Flight of ideas: Quickly moving from one idea to another- see with mania

• Thought blocking: thoughts are interrupted

• Perseveration: Repetition of words, phrases or ideas

• Word Salad: Randomly spoken words

Thought Content• Refers to the themes that occupy

the patients thoughts.• Examples include preoccupations,

ideas of reference, delusions

Thought Content: examples• Preoccupations: Suicidal or homicidal

ideation (SI or HI), perseverations, obsessions or compulsions

• Ideas of Reference (IOR): Misinterpretation of incidents and events in the outside world having direct personal reference to the patient

Delusions• Fixed, false beliefs firmly held in spite of

contradictory evidence• Control: outside forces are controlling

actions• Erotomanic: a person, usually of higher

status, is in love with the patient• Grandiose: inflated sense of self-worth,

power or wealth• Somatic: patient has a physical defect• Reference: unrelated events apply to them• Persecutory: others are trying to cause

harm

•: من كال فحص فى وتكون مباشرة اسئله هناك؟ • افكارك بتقول الناس ان اعتقدت و عليك مر هل

افكارك؟ • بيذيع التليفزيون او

• " سواء " ثابته افكار موجوده ضالالت اى عن نسالهاشاره او اضطهاديه

• " شغالك؟" فكره فيه هو

Abstraction• proverb interpretation

••Abstract or concrete: اجتماع±ى . • واخر بيولوجى± مثل ويكون± االمثال طريق عن

• : ميه ميبقى± الدم عمر مثل بيولوجى± مثل

الناس : • ميحدف±ش ازاز من بيته اللى مثل اجتم±اعى± مثل

بالطوب

Insight• Insight: awareness of one’s own

illness and/or situation

A summary of six levels of insight follows• Complete denial of illness• Slight awareness of being sick and

needing help, but denying it at the same time

• Awareness of being sick but blaming it on others, on external factors, or on organic factors

• Awareness that illness is caused by something unknown in the patient

A summary of six levels of insight follows• Intellectual insight: admission that the

patient is ill and that symptoms or failures in social adjustment are caused by the patient's own particular irrational feelings or disturbances without applying this knowledge to future experiences

• True emotional insight: emotional awareness of the motives and feelings within the patient and the important persons in his or her life, which can lead to basic changes in behavior.

Judgment• the ability to anticipate the

consequences of one’s behavior and make decisions to safeguard your well being and that of others

• During the course of history taking, the psychiatrist.

• Does the patient understand the likely outcome of his or her behavior, and is he or she influenced by this understanding?

• Can the patient predict what he or she would do in imaginary situations (e.g., smelling smoke in a crowded movie theater)?

Sample initial MSE of a patient with depression and psychotic features• Appearance: Disheveled, somnolent,

slouched down in chair, uncooperative• Behavior: psychomotor retarded, poor

eye contact• Speech: moderate latency, soft, slow

with paucity of content• Mood: ”really down“• Affect: blunted, mood congruent

MSE continued• Thought Process: linear and goal

directed with paucity of content• Thought Content: +SI, +AH,

+paranoia, -VH, -IOR, -HI• Cognition: Alert, focused, MMSE:24-

missed recall of 2 objects, 2 orientation questions, 2 on serial sevens

• Insight: fair• Judgment: poor

Summary• By the end of a standard psychiatric

interview most of the information for the MSE has been gathered.

• The MSE provides information for diagnosis and assessment of disorder and response to treatment over time.

• Remember to include both what your hear and what you see!