Question

Describe the major objectives and typical procedures of the mental status exam. Be sure to include the typical activities of the examiner and the intended outcomes of the process.

Answer 1

Mental Status Examination (MSE) iss a standardised format in which the clinician records psychiatric signs (objectice observation by the diagnostician) and symptoms ( patient's subjective discription) present at the time of the interview. MSE reveals concious mental experiances ( phenomonological data ) and several of them rely on the subjective information provided by the patient. MSE conducted efficiently generate reliable data of high diagnostic utility. But on the other hand the artificial context in which the patient's behavior is being assessed tends to limit the scope of MSE.

The mental status exam is esssentially the evaluation of the patient’s current mental functioning. Originally it wa a part of the traditional neurological examination, but now it is a staple of the initial mental health examination. The mental status exam is usually divided into several parts.To obtain the behavioral material, clinician doesn't need to ask special questions or perform tests. Mostly this is recorded out of observation of speech and behavior while talking to the patient (although in the area of mood, there are some questions to ask). The behavioral aspects are as follows:
1. General appearance and behavior
2. Mood
3. Flow of thought

The cognitive portions of the mental status exam are concerned with what the patient is thinking (talking) about. Their evaluation demands more activity on the part of the clinician. They include the following:
1. Content of thought
2. Perception
3. Cognition
4. Insight and judgment

For General appearance and behavior following aspects like physical charecteristics, clothing and hygeine , motor activity , facial expression , voice, alerness and attitude towards the examiner is noted down. Alerness is recorded along a continuum as to normal alertness, drowsiness and clouding of consciousness, stupor and coma. In clothing and hygeine following aspects are noted. Is your patient’s clothing clean and well cared for or dirty and tattered? Is it casual or formal? Contemporary or out of date? Is it appropriate to the climate and to the circumstances of your meeting?Bright colors may suggest mania; something as ordinary as a misbuttoned shirt or coat could indicate dementia. Bizarre dress, such as an adult wearing a Boy Scout uniform, suggests psychosis. If the patient is disheveled or malodorous, serious illness such as schizophrenia or substance dependence is suspected. In motor activity dominant body attitude is assessed as to : Is it one of apparent relaxation,
or does the patient sit tensely on the edge of the chair. True immobility is rare and can be due to catatonia. Classically described as a feature of schizophrenia, immobility is actually encountered in a variety of other psychiatric conditions and in frontal lobe brain dysfunction with various physical causes. Behaviors like fidgetting, jigglling a leg up and down, or frequently
arising from the chair to pace etc may be due to akathisia, a side effect of the older type of antipsychotic drugs, which may still be used to control psychosis. Sometimes akathisia can become so severe that a patient literally cannot sit still and spends much time pacing restlessly around the room. Occasional uneasy shifting of position is more likely to be the consequence of
simple anxiety.   One possible explanation of behaviours like inappropriate scratching, touching, or rubbing in public is delirium, which can have a variety of physical or chemical causes. One type is delirium tremens (DTs), found in severe alcohol dependence. A fixed, motionless facial expression could indicate senility, the rigidity common in Parkinson’s disease, or pseudoparkinsonism from antipsychotic drugs. A psychotic patient may stare fixedly while in depression, the gaze may seem riveted to the floor. Characteristics of the tone of voice may indicate whether the patient is friendly, angry, or sad.

Mood (or affect) is described in several dimensions: type, lability, appropriateness, and intensity. Patients with somatization disorder may show dramatic swings of mood from ecstasy to tears, all in a matter of minutes. A patient with manic euphoria may suddenly burst into bitter tears, then rapidly return to bubbling good nature (the term microdepression is sometimes used to described this phenomenon). In the dementias, rapid mood swings can be so severe
(the term affective incontinence may be used). Lack of response to environmental stimuli is called flattening of mood which occurs in schizophrenia.  Relative immobility of mood is also found in severe depression and in Parkinson’s disease and other neurological conditions. Blandness of affect, in which nothing much ever seems to ruffle the patient, classically occurs in the dementias. Appropriateness of mood is the estimate of how well the patient’s mood
matches the situation and the content of thought. Someone who giggles or laughs while, for example, describing something sad (such as the death of a close relative) may be suffering from schizophrenia, disorganized type. Pathological affect (either inappropriate laughing or weeping) may be encountered in pseudobulbar palsy, which can have a variety of causes, including multiple sclerosis and strokes. Patients with somatization disorder will sometimes talk about their physical incapacities (paralysis, blindness) with a nonchalance more appropriate to a weather report. This special type of inappropriate mood is called la belle indifférence.

Flow of thought can be grouped into two overall categories: (1) defects of association and (2) abnormal rate and rhythm. Derailment is a breakdown of thought association in which one idea seems to run into another. The two ideas may be related or unrelated. Here one can understand
the sequence of words, but their general direction seems to be governed not by logic but by rhymes, puns, or other rules that might not be apparent to an observer. A special type of derailment is flight of ideas, in which a word or phrase from one thought stimulates the patient to take off on another. Patients with mania often have flight of ideas associated with push of speech. In tangentiality the patient gives an answer that seems irrelevant to the question being asked. Derailments and tangentiality are classically encountered in psychosis, often schizophrenia, but patients with mania can also exhibit these symptoms. Poverty of speech is a marked reduction from normal in the amount of spontaneous speech. The patient answers briefly when elaboration is expected and unless prompted may say nothing for long periods.
When this behavior is carried to the extreme of muteness, there is little or no speech at all. Patients with depression may show poverty of speech. Muteness is more characteristic of schizophrenia, but it is sometimes found in somatization disorder. It must be distinguished from aphonia of neurological origin. In Thought blocking the train of thought stops suddenly. The patient can usually give no explanation more adequate than that the thought has been “forgotten.” In Alliteration a phrase or sentence intentionally contained with multiple
repetitions of the same or similar sounds like: “I ran the risk, Doctor dear, of recognizing revolting rabbits racing in the roadster.” In Clang associations the choice of individual words is governed by rhyming or other similarity of sound, not by the requirements of communication. In echolalia the patient unnecessarily repeats words or phrases of the interviewer. Push of speech is usually associated with decreased latency of response, in which the period of time between the question and the patient’s response is markedly reduced. Sometimes the response seems
to come almost before you have asked your question. Push of speech and decreased latency of response are classically found in patients with mania, who may tell you that their words cannot keep up with their rapid thoughts. Increased latency of response is characteristic of severe depression.  When the timing of syllables deviates from normal, disorders of rhythm of speech occur. Stuttering is one such disorder. In cluttering, the patient speaks rapidly and becomes tangle-tongued and disorganized. Patients with cerebellar lesions may utter each syllable at the
same pace as the last, yielding a rate that is too precisely even. In circumstantial speech that much extraneous material is included with the principal message. In distractible speech, the speaker’s attention may be diverted by stimuli that are extraneous to the conversation. Distractible speech is usually normal, but it can also be encountered in mania.

The mental status exam properly concerns only current behaviors, experiences, and emotions. However, it is often convenient to cover related historical data at the same time. In cognitive aspects of the MSE following aspects are considered. Whatever the speaker is focused on at the moment constitutes the content of thought. During the history of the present illness, this will usually concern the problems that caused the patient to seek treatment. A delusion is a fixed, false belief that the patient’s culture and education cannot account for. The presence of mood-congruent delusions warrents a closer look into a mood disorder where as mood-incongruent delusions are more typical of schizophrenia. Delusions of grandeur are typically found
in mania, but may also occur in schizophrenia. Delusions of guilt are found especially in severe depression and in delusional disorder. Delusions of ill health and somatic delusions are occasionally found in severe depression or schizophrenia. Delusions of jealousy are classically seen in alcoholic paranoia, but are also encountered in paranoid schizophrenia and delusional disorder. Delusions of reference are especially common in paranoid schizophrenia, but may be found in other psychoses as well. In Thought broadcasting the patient’s thoughts seem to be transmitte locally or across the continent. Thought broadcasting is found in schizophrenia. In Thought control patient feels that thoughts, feelings, or ideas are put into his/her mind or are withdrawn from it.

Hallucinations are false sensory perceptions that occur in the absence of a related sensory stimulus. Hallucinations can involve any of the five senses. Among mental health patients, auditory hallucinations are by far the most common; visual hallucinations are next. Hallucinations are screened by asking questions like “Do you ever hear voices or other sounds when there is no one around to produce them?” “Do you ever see things other people cannot see?” Hallucinations that occur only when a patient is reliving trauma also suggest diagnoses
other than schizophrenia. I may reassure such a patient that this sort of experience likely doesn’t mean anything dire. Hallucinations should be characterized as to severity. Auditory hallucinations, for example, can be graded on a continuum: Vague noises mumbling ? understandable words?phrases?complete sentences. Audible thoughts constitute a special form of auditory hallucination, in which patients hear their own thoughts spoken so loudly that
others can hear them. Visual hallucinations can also be graded: Points of light ? blurred
images ? formed people (what size?) ? scenes or tableaus. Visual hallucinations are especially characteristic of cognitive psychoses. Tactile (touch), olfactory (smell), and gustatory (taste) hallucinations are uncommon in mental health patients. These symptoms usually suggest psychosis due to such disorders as brain tumor, toxic psychosis, or a seizure disorder.
Visual, auditory, and tactile experiences may also occur in normal people when they are falling asleep or awakening. They are easily discerned from actual hallucinations by their exclusive time of occurrence.

An obsession is a belief, idea, or thought that dominates the patient’s thought content and persists, despite the fact that the patient realizes it is unrealistic and may try to resist it.Compulsions are acts performed repeatedly in a way that the patient realizes is neither useful nor appropriate. Often they are performed in response to (or to cope with) an obsession.

Attention and concentration are assesed in a more formal way from calculations, which assess the ability to focus on a stimulus by asking the patient to subtract 7 from 100. Once done, request another subtraction of 7 from the result, and so on toward 0.

( Note further eloboration of MSE aspects need much more time than available on the current window. please feel free to contact [email protected])