The Mental Status Examination (MSE) is an essential part of every psychiatric note, and thus it’s important that every medical student rotating through psychiatry know at least the basics. The MSE is a clinician’s method of assessing the psychiatric patient in a structured manner through observations and answers from the patient elicited by both open and closed ended questions. The MSE provides information about the patient’s symptoms, mental state, and helps with making treatment decisions. I will share with you what I have learned from various attendings, residents, and studying for board and shelf exams during my 3rd and 4th years of medical school.

Appearance: What does the patient look like? Remember that the next person who reads your note might be the weekend call doctor who would appreciate your helping them to visualize and identify your patient. Describe the patient’s ethnicity, apparent age, apparent weight, clothing, anything that stands out/makes the patient unique, etc.

Example: short, thin, Caucasian male who appears older than stated age, wrinkled tanned skin, missing teeth, wearing baggy street clothes. Visible neck and forearm tattoos.

Interaction: How does the patient interact with you?

  • cooperative: is it an easy conversation?
  • guarded: do you get a sense that the patient is holding back information?
  • hostile, irritable: does the patient get angry or annoyed with you and your questions?
  • other descriptors: apathetic, easily distracted, focused, etc.

Example: patient is guarded with most questions and gets hostile when asked about his hx of drug use, yelling “it’s none of your business!”

Eye contact: Pretty self-explanatory. Descriptors: appropriate, intermittent, stares at the floor, stares at the interviewer, stares blankly at the wall, stares blankly at interviewer, eyes closed.

Example: patient stares blankly at this writer, hardly blinking

Psychomotor: When you are interviewing the patient, observe the patient’s motions, including gait.

  • EPS (extrapyramidal sx):
    • dystonia: sustained muscle contractions
    • akathisia: restlessness
    • parkinsonism: stiffness, reduced facial expressions, bradykinesia, tremors
    • tardive dyskinesia: involuntary movements of the tongue (eg tongue thrusting), lips (eg lip smacking), jaw (eg chewing motions), limbs (eg flailing), and trunk (eg abnormal posturing)
  • fidgety, restless: does the patient keep moving around during the interview? Do you notice the patient moving one part of the body more than others? Eg: hand wringing, shaking legs, finger tapping
  • pacing: does the patient walk back and forth around the room?
  • psychomotor retardation: does the patient not move at all like a motionless statue?
  • gait: stumbling, shuffling, steady, normal

Example: patient fidgets throughout interview, readjusting in his chair multiple times. Gait is normal, no difficulty walking.

Speech: Think about all the different aspects of a person’s speech that could be affected by his/her mental state.

  • volume: barely audible, decreased, increased, loud, yelling
  • rate: slow, fast
  • pressured (inability for speech to be interrupted) vs. non-pressured speech
  • content: spontaneous (normal), paucity/poverty of speech (only speaks when answering a question, with minimal words)
  • clarity: clear/coherent, slurring, stuttering, incoherent
  • normal vs. increased latency: does the patient respond to questions right away or does it take a while?
  • repetition: echolalia (patient repeats what someone else says); palilalia: patient repeats a word or phrase over and over

Example: patient speaks very loudly, almost yelling. pressured speech with normal latency

Mood: For this one, you must ask the patient how his/her mood is. Frequently I’ve been answered with “okay” or “I don’t know,” or an answer that is not descriptive of mood at all, such as “I want to go home.” Unless your patient actually gives you a mood descriptor, you can prod a bit further, “How’s your mood…(patient responds with a non-mood answer)… Do you feel anxious? depressed? angry? irritable? apathetic? I also like to ask how his/her mood has changed since the previous day. Did it get better or worse or is it the same? Type the answer in the patient’s own words, in quotations.

Example: patient’s mood described as “depressed… more than yesterday” or “depressed… 10/10”

Affect: While “mood” is how the patient describes his/her emotions, “affect” is what you observe the patient’s emotions to be. There are various ways to describe affect

  • the patient’s visible emotions: sad, dysthymic, dysphoric, angry, irritated, happy, euphoric
  • the congruence to the patient’s stated mood: congruent (mood described as “sad” and patient appears sad) or incongruent (mood described as “sad” but patient looks happy)
  • appropriateness to the interview content: appropriate (patient looks sad when talking about the death of a loved one) or inappropriate (patient laughs while talking about the death of a loved one)
  • the level of the affect: labile (patient’s emotions reach both extremes – one second, he/she is laughing, the next he/she is sobbing), full, constricted (patient shows emotion but not to its full capacity), blunted (in between constricted and flat), flat (patient shows no emotions at all)

Example: patient’s affect is flat, shows no emotion when discussing the traumatic experience of seeing his brother killed in front of him; incongruent to mood reported “happy”; inappropriate to content of interview

Thought content: Like mood, you must directly ask your patient questions to elicit the content of their thoughts. Many patients will not outright tell you they are having delusions or thoughts of harming themselves. Ask both open-ended and specific questions. Keep in mind that you may have to ask “leading questions” to get the truth out of them. Remember what Dr. Liran wrote in his “The Psychiatric Interview – Starter Pack” post – be a private detective. I’ll give you several examples.

  • suicidal ideation (SI) and homicidal ideation (HI)
    • SI: Don’t ask “Are you having suicidal ideation?” Instead, ask “Are you having thoughts of killing yourself?” or “Are you having thoughts of harming yourself?” If the patient answers yes, ask more questions about their thoughts: Can you tell me more about these thoughts? Do you have a plan of how you would want to harm yourself?
      • SI can be active or passive. Active means the patient has thoughts of killing or harming him/herself with a plan. Passive means the patient has thoughts of dying or being dead, with no actual plan to kill him/herself.
    • HI: It’s important to know if the patient has thoughts about wanting to harm or kill others. Ask, “Do you have thoughts about hurting others?” or “Do you have thoughts about killing others?” If yes, keep asking questions: Who do you want to hurt/kill? Why? If the patient wants to kill a specific person, it would be in that person’s best interest to be warned.
  • delusions
    • Delusions might be apparent from the first sentence that comes out of your patient’s mouth: “Hi, my name is God.” (Yes, I actually had a patient say this). Other times, you will have to ask specific questions to uncover your patient’s delusions. Always be in private detective mode.
    • bizarre vs. non-bizarre delusions:
      • bizarre: the delusion is clearly a delusion, something that is implausible: “I can control the sun and the moon.”
      • non-bizarre: the delusion could possibly be true: “The FBI has been following me for months.”
    • persecutory delusions: the patient believes harm is going to occur to him/her. Do you feel that people are out to get you? Do you think people are talking about you? Is everyone conspiring against you? (If the patient answers yes, ask more questions about it – who is out to get you and why?)
    • grandiose delusions: Do you have special powers? Can you read people’s minds? Do you have a special connection to God that no one else has?
    • ideas of reference: the patient believes that things happening around him/her are specifically connected to him/her. Does the TV or computer send you special messages? Does the TV talk about you? Are there news articles about you? Do any of your electronic devices (cell phones, laptops, tablets, etc.) have special messages specifically for you (that no one else can see or understand)?
    • thought broadcasting: the patient believes others can read his/her thoughts. Can anyone read your mind? Can anyone hear your thoughts?
    • thought insertion: the patient believes others’ thoughts are inserted into his/her mind. Are you hearing other people’s thoughts in your mind? Do you feel that your thoughts aren’t your own but someone else’s? Are there other people’s thoughts being inserted into your mind?
    • capgras (pronounced kapgra’): the patient believes those around him/her are imposters. Eg, I had a schizophrenic patient who believed everyone who lived in his house with him (family members) were actors/actresses pretending to be his family. I was able to elicit this information by asking my patient what his living situation was. Who do you live with? Is anyone around you pretending to be someone else? Is anyone around you an imposter?
    • There are plenty more delusions, but these are the most common ones I encountered on my psychiatry rotations.

Thought perception: Does the patient have any perceptual disturbances?

  • auditory hallucinations (AH) and visual hallucinations (VH)
    • AH: Don’t ask, “Are you having auditory hallucinations?” Instead, ask, “Do you hear voices when you are alone?” “Do you hear sounds or noises when nothing else is around?” When I know the patient has already reported having +AH (from interviewing them the previous day or reading the nursing reports) or when I think the patient is minimizing or lying, I instead ask a leading question, “What did the voices say today?” Delve even further after the patient reports +AH. How many voices are there? Who are these voices? What do they say? How often do you hear these voices (on and off or constant)? Are these voices coming from inside your head or outside your head? Are these voices your own thoughts? Does it sound like your own thoughts are being spoken out loud? Do the voices talk to you or do they talk to each other? Are the voices commanding you to do something (command AH)? Do they tell you to hurt yourself or hurt others?
    • VH: again, don’t ask, “Are you having visual hallucinations?” Instead, ask, “Do you see anything unusual?” or “Do you see things that stand out?” or “Do you see things that other people say they can’t see?”
  • tactile hallucinations and olfactory hallucinations
    • Although these hallucinations are not as common as AH and VH, they should also be addressed. You can ask your patient: “Do you ever feel anything unusual on your skin? Does it feel like ants are crawling on your skin? Do you smell anything unusual? Do you smell anything burning?”

Thought process: You should be able to determine the patient’s thought process through his/her responses to questions and the conversation in general.

  • linear: the patient answers your questions appropriately; responses are succinct and direct, get straight to the point
  • circumstantial: the patient eventually gets to the point, only after talking about other unnecessary things
  • tangential: the patient moves from one topic to the next, never getting back to the point
  • loose associations: the patient talks about various topics that have no connection to one another
  • flight of ideas: the patient talks rapidly about various topics that have minimal connection to one another
  • blocking: the patient suddenly stops talking due to being distracted by responding to internal stimuli
  • perseveration: the patient repeats the same thought, even when asked a different question

Example: patient perseverative on discharge from hospital. patient responds to every question with responses related to d/c “When can I leave?” “When is my d/c?” “I want to go home.”

Orientation: person, place, time, situation: A&Ox4

Memory: You can determine the patient’s memory from talking about recent events, medical hx, social hx, etc.

Insight: Does the patient understand or recognize that he/she has a psychiatric disorder and is in need of treatment? If you’re not sure, ask questions to see how much or how little insight the patient has.

  • What brings you to the hospital? Why are you in the hospital? Do you think you need medication? Do you know why you are taking these medications?
  • Have you been given a psychiatric diagnosis? Do you agree with it? Do you know what the diagnosis means?
  • If the patient has +AH, asking questions about the voices can reveal insight: Where are the voices coming from?

Example: patient has poor insight – she continues to believe she has no need for medications despite being disturbed by auditory hallucinations

Example: patient has fair insight – she states she realizes her auditory hallucinations are abnormal

Judgment: Does the patient make good decisions and/or state he/she will make good decisions? I like to ask my patients what their plans are after d/c.

  • What will you do after d/c? Will you continue taking your medications every day? What will you do if you have suicidal or homicidal thoughts?

Example: patient has poor judgment – she states she will stop taking her medications as soon as she is discharged

Example: patient has improved judgment – she states she will comply with medications after d/c and f/u with outpatient psychiatry every month

Impulse control: This is similar to “judgment” but is specific to your patient’s ability to control his/her impulses. If you aren’t sure about the patient’s current impulse control ability, present a scenario to the patient that is relevant to his/her situation: If you’re offered meth by a friend right after d/c, what will you do? If you’re feeling down and having thoughts of killing yourself, what will you do? If someone makes you angry, what will you do? Besides asking these questions, take a look at events in the past day or two: have there been any incidents with the patient losing control, yelling at staff, attempting to self-harm, making threatening remarks, etc.?

Example: patient has poor impulse control – when pt was not given double portions for dinner, she got angry with staff, made threatening gestures and made threatening remarks

Example: patient has fair impulse control – got irritated with staff but was able to calm down by writing in her journal and talking it out calmly.

– End MSE –

I hope you found this post helpful! Please feel free to add comments below –  your edits, suggestions, and tips are welcome!

Introduction to the Mental Status Exam

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