Mental Status Examination

The mental status exam, or MSE, is a clinical evaluation of a patient's current mental capacity through data collected on their psychiatric and cognitive abilities.  It is used to guide appropriate diagnosis of mental illness, including mood disorders, thought disorders, and cognitive impairment.

During the MSE, the examiner assesses the salient aspects of the patient's mental state, including behavior, speech, mood, affect, thought process and content, insight, judgment, and cognitive abilities. The MSE differs from other forms of physical examination in that it requires a combination of directed questions and passive observation.

The exam starts with observing the patient's appearance, behavior, and mood. Considering speech, the rate, volume, fluency, and tone of speech may indicate conditions such as anxiety, substance abuse, or neurocognitive disorder.  Next, the affect is inferred, that is, the patient's emotional state based on how they engage in a conversation with the examiner.  

The examiner also assesses the patient's thought content and process, which can include essential elements like suicidal or homicidal thoughts, obsessions, and delusions. Usually, this is accomplished by carefully observing the patient's responses to the specific questions. A patient's insight and judgment about their illness are evaluated by the choices the patient makes about their physical health.

Proficiency in the cognitive portions of the MSE is vital while caring for patients with suspected cognitive impairment from illnesses like dementia, delirium, and substance intoxication.  Examination of cognitive function is based on the patient's responses to directed questions and the performance of specific tasks according to the clinician's instructions.

The examiner may start a cognitive function test by determining the patient's level of orientation, that is, their ability to correctly tell their own name, their present place, and the date and month of the year, among other details.

Patients may also be asked to recall three objects after five minutes and to subtract sevens serially from 100, as tests of short-term memory, and arithmetic ability.  Additionally, examiners can administer tests such as long-term memory, attention and concentration, verbal fluency, and object recognition to evaluate cognitive function.

It is also important to equitably administer the examination for patients from various socioeconomic, educational, and cultural backgrounds. For example, when interviewing patients who are non-native speakers of English, it is important to appreciate that the patient's mechanics of speech and findings should not necessarily be interpreted as pathologic.  Cultural beliefs and education level may impact how patients relate their understanding of their current clinical scenario. Specific emotional effects may also be culturally normative and should not be misinterpreted.

In this video, example scenarios demonstrate both the cognitive and psychiatric portions of the MSE, and considerations for how to equitably administer the examination for patients from various socioeconomic, educational, and cultural backgrounds are discussed.

To begin, observe the patient's attire, grooming, and hygiene. For example, are the patient's clothes well-suited for the weather? Are clothes disheveled? Is there evidence of soiling or inadequate bathing? Responses may range from well-groomed to disheveled, good to fair to poor hygiene, and appropriate or inappropriate attire. For example, if a patient is dressed in a heavy coat and gloves on a sunny, hot day, then their attire may be described as 'well-groomed, good hygiene, inappropriate to weather.

It is important to remain mindful that patients from various backgrounds may wear attire that differs from our own, but that would still be considered appropriate and well-groomed.

Next, assess whether the patient appears well-nourished or malnourished. Signs of malnourishment include muscle wasting in small and large muscle groups, loss of subcutaneous fat, sores at the edges of the lips, sunken eyes, and a variety of other features. Also, note any remarkable aspects of their physical appearance, like dysmorphia, wounds or marks, or scars. Many of these details should be observed passively while conducting various other aspects of the physical exam.

Next, examine motor activity by assessing whether the patient appears relaxed, restless, or somewhere in between. A patient is described as "restless" if they are tapping their legs, fidgeting with their hands, or pacing the room.

For interpersonal skill assessment, first, take note of how frequently the patient is making eye contact with the examiner throughout the assessment, and the responses can be classified as good, fair, and poor eye contact.

Then, assess the attitude of the patient by observing how they are relating to the examiner throughout the encounter. Some patients may be engaging, while others may be shy and reserved. Patients can also be dismissive, irritable, or angry, and some of them even maybe uncooperative with the exam. For example, a patient sitting calmly in a chair, looking down, and making poor eye contact would be described as "reserved, shy, cooperative, with limited eye contact."

Be aware that patients may demonstrate culturally-normative differences in how they relate to medical providers. For example, patients from minoritized backgrounds who have experienced healthcare discrimination may show reserved behavior or make less eye contact. Be mindful not to unintentionally and prematurely pathologize behavior with labels like "suspicious" or "uncooperative," which risks perpetuating health disparities.

Take a note of the volume of the patient's voice throughout the encounter. Assess whether it is normal, loud, or soft. Then, take note of the speed at which the patient is talking. Observations range from "slow speech" to "normal rate" to "rapid speech" to "pressured speech". Rapid speech is faster than normal but still possesses natural pauses, whereas pressured speech is characterized by speaking that is nearly nonstop and difficult to interrupt due to the lack of natural pauses. Gauge the fluency of a patient's speech, and if it flows freely. Patients may demonstrate speech latency if there is a significant delay in initiating speech or they may stutter or have other dysrhythmias.

Next, observe whether the patient's tone of speech demonstrates normal inflection or monotony. Take note of whether the patient's speech is clear or not. Dysarthria, also known as slurred speech— occurs when a patient has motor difficulty articulating speech, and can occur as a result of a functional abnormality, such as a stroke or prior injury that causes muscle weakness or paralysis.

Substance intoxication is a common cause of slurred speech. Use the context and other clues throughout the clinical exam to determine if a patient's slurred speech might result from substance intoxication. For example, emergency room visits might have a urine drug screen available for review.

When interviewing patients who are non-native speakers of English, it is important to appreciate that the patient's mechanics of speech may be different than those of a native English speaker. Caution should be exercised against interpreting diverse speech patterns as pathological before such concerns are validated elsewhere throughout the patient history or clinical exam.

Many patients spontaneously reveal their emotional state via relationship-centered medical interviewing, such as Smith's patient-centered interviewing method. If it's not possible to gauge the patient's mood, simply ask them how they are feeling today, or what their mood is like.

Affect refers to the emotional state that examiners infer that a patient is feeling based upon observing their appearance, behavior, and manner of engagement. Affect includes several elements, including quality, range, stability, intensity, appropriateness to context, and congruence to stated mood. Patients may appear euthymic, dysphoric, anxious, irritable, scared, or more.

Contextually appropriate, full range, and mood-congruent affect is sometimes described as "normal" for a given situation, though clinicians can still describe the elements they observe. The following scene displays an example of this.

Doctor: "How are you feeling today?"

Patient 1: "Well… Actually, it's been really rough. Last week my best friend and I were in a car accident coming back from class. We were hit by this ugly yellow car, and she had to have emergency surgery, and she is still in the ICU. So, I'm completely just a mess. But! I'm trying to stay positive! At least for her. So I visit her every day and try to tell her jokes about the ugly yellow car to make her feel better. I am OK. I guess"

This patient describes their mood as "pretty rough". The patient's affect is congruent with their mood; that is, it appears to be experiencing a negative emotion, and it is appropriate to the content of the conversation. The range may be considered as full, as their expressivity was mostly upset due to the circumstances, but they do have the ability to have appropriate, small amounts of humor.

A patient's affect that seems contextually inappropriate, mood-incongruent, constricted in range, that is, limited variation and unstable, for example, rapidly fluctuating, may be described as abnormal and should be described in terms of the elements that are notable. The following exchange is an example.

Doctor: "How are you feeling today?"

Patient 2: "I'm horrible! I mean, it is a little bit stressful here and there. My best friend, she was just in a car accident last week, and she is in the surgical ICU. I mean, we were coming home from class, and this car…poof! It hit us! Right, right as… It was the funniest color – Oh my god! It was this ugly yellow car, this ugly yellow car that hit us. My friend is now in the surgical ICU – but! We are still laughing because that car was the funniest ugliest color that we have ever seen."

This patient describes their mood to be horrible, but their affect is incongruent, as their smiles and laughter do not match the expressed upset. In the context of this vignette, where the major trauma occurred barely a week ago, the appropriateness of the patient's labile affect could be noted as semi-appropriate. Should the car accident have happened three years ago, such emotional reactivity would be considered as fully inappropriate.

Affective stability is a domain that sometimes warrants comment, particularly when a patient seems to vacillate between emotional states quickly or erratically. Such an affect can be described as labile. It can be present in bipolar disorder, substance intoxication, borderline personality disorder, or post-trauma states.

Doctor: "How are you feeling today?"

Patient 2: "Oh! I'm terrible! My friend had to be hospitalized for a car accident last week!" 

Doctor: "I'm very sorry to hear that. How can I best support you right now?

Patient 2: "What can you do? I mean… what can you do? She is in the hospital, in the surgical ICU, and the…and the staff would hardly tell me anything that's happening to her. I mean…what can you do?"

Doctor: "I hear your frustration about wanting to take care of your loved one. You must be very frsutrated right now."

Patient 2: "Yeah… I do.  It was so funny! We're just…we were coming home from work, from…and from…we were coming home from class…we were coming from class and then just poof! This car and it was like…Oh my God! It was the funniest, ugliest shade of yellow you have ever seen. You know we were listening to our favorite song! In…In the car, before..I  wanna soak up the sun. I wanna tell everyone to lighten up….and poof!"

Doctor: "Oh! I'm sorry!"

Patient 2: "I'm trying to visit her just once a week, I'm trying to help her."

This patient's range of affect would be described as 'labile' as they vacillate from crying to irritability to singing loudly in a manner that does not match the social setting. Care must be made not to label a person who is able to express multiple emotions like sadness and humor appropriately in the course of conversation as someone with a labile affect, which is unstable and inherently abnormal. 

Remain mindful that certain cultures have a different range of acceptable emotional content and intensity than others, with some cultures accepting more reserved behavior and others accepting more intensity of affect.

Additionally, health disparities literature extensively documents how clinicians' own racial bias tends to unjustly ascribe "violent" or "hostile" behavior to racially minoritized groups, particularly African Americans, without objective evidence. Caution must be exercised against misinterpreting culturally normative emotional experiences and behavior.

Thought content is "what" a person is thinking. The thought process is "how" a person is thinking. Thought content may include a variety of elements, such as concerns, beliefs, and ideations. It should comment on certain elements, for instance, the presence of suicidal ideation, even when negative.

Assess for suicidal ideation by asking the patient about thoughts of wanting to be dead or killing themselves. An example conversation is shown in the following scenario.

Doctor: "Have you ever wished that you could go to bed and not wake up?"

Patient 2: "No, not really."

Doctor: "Have you ever thought that you were better off dead or that you could hurt yourself in some way?"

Patient 2: "Yeah…actually I…I thought about it a little bit last week."

Doctor: "Thank you for sharing such a difficult thing with me. Did it ever get to a point where you thought about how you would kill yourself?"

Patient 2: "No…no, no, I never…I never delved into it."

A positive response during any portion of the suicidal ideation conversation or on a related question on a screening instrument like the Patient Health Questionnaire-9 or PHQ-9, requires additional medical attention.

In certain circumstances, screening for obsessive thoughts may also be helpful by asking questions such as the following.

Doctor: "Do you ever have thoughts that are difficult to get rid of sometimes, or that keep happening over and over and cause you worry?"

Patient 2: "You know…I…I, yeah! Sometimes I feel like I…I forget to take the stove off. You know I keep checking it, I keep checking to see I've taken the stove off. And then sometimes I even…I've left for work, and I've…I've been late because I have had to come back and check to make sure I've turned the stove off."

The presence of certain kinds of delusions or fixed false beliefs such as paranoia and grandiosity are examined by asking questions such as the following.

Doctor: "Do you ever feel like someone is trying to hurt you or harm you in some way?"

Patient 2: "No, everybody adores me."

Doctor: "Do you ever feel like you have a very special purpose or something that makes you very important?"

Patient 2: "Yeah, I mean I am a billionaire. I own the most impressive record label in all of the world."

In some cases, clinical racial bias may unjustly pathologize culturally normative expressions of distrust in racially minoritized groups, resulting in overdiagnosis and misdiagnosis of psychosis in these groups, particularly paranoid schizophrenia. Take caution against pathologizing instances when a racially minoritized patient expresses distrust that is plausibly rooted in experiences of systemic and medical discrimination.

Next, examine the thought process—the organization, formulation, and flow of thoughts. It is assessed by paying attention to a patient's conversation and flow of logic throughout the entire clinical exam. It can be classified as "organized," which is sometimes described as "logical, linear, goal-directed".

A thought process can also be classified as "disorganized". There are many types of thought disorganization, and clinicians should describe any such abnormality more specifically. The disorganized thought process may be tangential, circumferential, perseveration, or disorganized in other ways.

For example, many encounters begin with the clinician asking the patient why they have come to see them. A patient with an organized, linear, and logical thought process would be able to describe the circumstances bringing them to the office in a concise manner where ideas naturally flow from one to the other. 

Doctor: "How are you feeling today?"

Patient 1: "Well, doc, actually last time I was here, you increased my blood pressure pill, and I've noticed a few times since taking it that I've felt dizzy. And you know, I work in construction and in heat…supervising…anyway! I am concerned that my blood pressure medication is just too high."

A tangential thought process begins with one topic. However, the patient will often use the end of the preceding idea to pivot into a slightly related but different idea without ever returning to answer the original question. In extreme cases when loosely connected thoughts are rapidly spoken one after another, one may call this "flight of ideas," which may be seen in mania.

Doctor: "How are you feeling today?"

Patient 1: "So, last time I was here, you increased my blood pressure pill, and I have to tell you! I had the hardest time getting that prescription pill, because the line at the pharmacy was so long! And it was made worse because I was already running late because my car broke. Right! I run over a nail and my tyre deflates, and that's the second tyre that I have lost in the span of one 1 year. So, all I do is work and work and work, to pay for these surprise bills, and then I got to work and they hire all these new people who have no idea what they are doing, and I have to train them. There is particularly this one guy, Eric, who is just a hot mess…Let me tell you about raising blood pressure!"

A circumferential thought process is exactly as it sounds; it circles around the topic before completing. Here, patients include a lot of extra details that are not particularly related to the question, but do eventually answer. This might be a normal variant, especially in the elderly population.

Doctor: "How are you feeling today?"

Patient 1: "Well! Last time I was here, you increased my blood pressure medication, and I have noticed that I've gotten dizzy at work a few times since after taking it. And, I work outside supervising construction, and it's been hotter than blazes lately. So, the days are long, and I have to sit down to take a break because I'm dizzy! And I have all these people who I am supervising and trying to keep safe, and they have no idea what they are doing, so, I feel responsible for them. So, if I'm dizzy I can't do my job. So, I guess I'm worried that may be the medication is too high!."

A perseverative thought process means that a patient gives the same response to several different questions. In the following example, the patient has a difficult time changing topics or ideas to provide clear answers to the doctor's questions. While not always pathological, perseverative thought processes may be seen across a variety of mental health disorders, including anxiety and mood disorders.

Doctor: "Tell me about what brings you in today?"

Patient 2: "Well, doc, the last time I was here you gave me some blood pressure medication. You increased it, and I've been feeling dizzy ever since. So, I…I think it's too strong."

Doctor: "Oh goodness! Okay, well, let's work together to figure this out. Did you take the pill this morning?"

Patient 2: "No!, I didn't take it this morning because I knew I was doing to feel dizzy because it's too strong!"

Doctor: "Hmm! You know it's been really hot outside recently, more than usual. You work outside, yes?"

Patient 2: "Yeah. Yeah. I always work my 10 hours a day outside, and that's the other reason why I can't take the medication because it's just too strong!"

Doctor: "You know sometimes when people get too much time in the sun, they can get too thirsty, might get dehydrated, and that can make them dizzy. Were you able to get any breaks in the shade, or drink any extra water while you are at work?"

Patient 2: "Yeah, and I'm drinking the water all the way I usually do it, and it's still…I know the pills are just too strong."

The loose association is described as a significantly disorganized thought process that lacks cohesion. Responses to questions may be poorly related to the question. It is oftentimes a symptom of psychosis.

Doctor: "What brings you in today?"

Patient 2: "It's really hot outside. The sun. I'm kind of thirsty. I don't like the heat. I don't like the heat at all! Is there a restaurant around here? Are they open now? What time is it? Did you know my favorite drink is orange juice?"

A perception exam evaluates whether a patient is experiencing auditory or visual hallucinations. Of particular importance is an auditory hallucination that instructs the patient to do something, so-called "command hallucinations." Begin by asking the patient if they are seeing things that others cannot see or hearing things that other people cannot hear. If the answer is yes, follow up by asking what the content of the hallucinations is.

Doctor: "Do you ever see things that other people can't see with you? Or maybe even hear things that other people can't hear with you?"

Patient 2: "Yeah! I mean…sometimes I hear voices. Like music."

Doctor: "Do you ever know what the voices are saying? Or do they even tell you to do anything at times?"

Patient 2: "No! I…I can't understand what they are saying. And sometimes…sometimes the music is pretty though."

Sometimes a doctor may notice that a patient seems to be responding to stimuli that the doctor does not perceive. A doctor can voice this observation to the patient to discover more information.

Doctor: "I notice you've looked to the left a couple of times recently. Is there anything that you are experiencing that I'm not experiencing with you right now?"

Patient 2: "Yeah! Sometimes I, I hear this, this woman. She is telling me to commit suicide. Its terrifying!"

Insight refers to how well a patient has self-reflection into and understanding of their medical illness, and it can range from "good" to "fair" to "poor." Judgment refers to the soundness of choices a patient makes while navigating their physical health, and again, this can range from "good" to "fair" to "poor."

Consider the following example of good insight and good judgment, in which the physician is informing the patient that their kidney function has worsened and may soon require dialysis.

Doctor: "Mr. Jones, I'm so sorry. I wish I had better news. The results of your test came back, and I'm concerned that it may only be a matter of time before we might have to consider dialysis to keep you well. Can you tell us some thoughts and feelings, about what you're experiencing right now?"

Patient 3: "You know Dr. Black, I've been around a while. I hear you that I might have to try dialysis, so that I, I can live longer. I know I have to think about it a little bit. I've had a good life, and I don't think I want to spend the rest of my days hooked up to a machine. Can you tell me about some other options?"

This patient demonstrated good insight because they can think critically and recognize that worsening kidneys means an increased risk of death. They have good judgment because they are making reasonable choices for more information about other treatment options and expressing a desire to take time to think about them further.

Conversely, the following scenario provides an example of good insight, but poor judgment.

Doctor: Mr. Jones, I'm so sorry. I wish I had better news. The results of your test came back, and I'm concerned that it may only be a matter of time before we might have to consider dialysis to keep you well. Can you tell us some thoughts and feelings, about what you're experiencing right now?"

Patient 3: "You know Dr. Black, I've been around a while. I hear you that I might have to try dialysis so that I can live longer. But, if I'm going to get sicker, I might as well stop coming to these appointments, because you have nothing else to offer me."

As with the first scenario, this patient demonstrates good insight. In this example, however, the ultimate conclusion that the patient reaches in the moment is poor, in choosing to disengage from treatment versus attempting to discuss treatment options that are more aligned with their values and preferences.

The following interaction provides an example of poor insight, and fair judgment.

Doctor: "Mr. Jones, I'm so sorry. I wish I had better news. The results of your test came back, and I'm concerned that it may only be a matter of time before we might have to consider dialysis to keep you well. Can you tell us some thoughts and feelings, about what you're experiencing right now?"

Patient 3: "You know Dr. Black, I've been around a while. I have never been sick a day in my life before now! I don't think there is anything wrong with me at all! But you're lucky! The only reason I come to these appointments is because my wife keeps bugging me. Coming to this appointment is not that big a deal, but I don't believe either one of you." 

This patient demonstrates poor insight due to not being able to critically manipulate information or acknowledge their sickness. Judgment might be described as fair because they choose to comply with appointments due to the external motivation of a trusted loved one, even if they would not attend on their own.

In the next example, the response is demonstrating poor insight, and poor judgment.

Doctor: "Mr. Jones, I'm so sorry. I wish I had better news. The results of your test came back, and I'm concerned that it may only be a matter of time before we might have to consider dialysis to keep you well. Can you tell us some thoughts and feelings, about what you're experiencing right now?"

Patient 3: "You know Dr. Black, I've been around a while. I never had a sick day in my life before now! I don't think there is anything wrong with me at all! I'm going to stop coming to these appointments because I think you're making things worse. My wife has been begging me, but she's just as bad at trying to scare me as you are!" 

This patient shows both poor insight because they do not believe they are sick, and poor judgment because they are not making healthy choices from either an internal or external motivator.

Finally, bear in mind that there are many normative ways for patients to respond to complex health and psychosocial needs. Therefore, it is important to refrain from labeling instances as "poor insight" or "poor judgment" when a patient's choices simply differ from our own.

 There are many methods to perform office-based cognitive testing, including a number of validated instruments. Here we offer one example.

Before beginning the assessment, it is important to consider that the mental status exam is most commonly administered in English in American healthcare settings, but there are a significant number of patients who are most fluent in a language other than English.

Certain portions of the cognitive evaluation may be difficult to perform when the provider and patient are language-discordant, including the word-finding task or writing tests. Popular written cognitive assessments like the Montreal Cognitive Assessment are available in a variety of languages and can be administered with the help of a certified interpreter.

Begin by introducing yourself to the patient. Ensure the patient is seated comfortably and that there is a pen, paper, and hard surface available for writing.

Next, assess for barriers to communication by asking the patient what language they speak most regularly and fluently and offer to provide services with a certified interpreter if appropriate. Ensure the patient has their hearing aids if necessary.

For short-term memory assessment, tell the patient 3 words that you would like them to remember: for example, rainbow, ball, and theater. Make sure that they understood the three words you were saying by asking them to repeat them back to you. Ask the patient to repeat those 3 words again after 5 minutes.

Next, assess the patient's long-term memory by asking the patient something about their childhood, like the name of their best friend growing up, or the name of the street that they lived on as a child.

Then, examine the patient's attention and concentration by asking them to start at 100 and count backward by 7 until they reach 72.

While assessing attention and concentration, math proficiency needs to be considered. Counting backward by 7 is not a commonly performed task, and therefore, it may not be an equitable or valid assessment of cognitive function in persons who are unable to complete this task due to a lack of high school math exposure.

In such cases, less complex methods of assessing attention and concentration can be indicated, such as reciting the days of the week backwards, or counting backwards by a more common increment, like 5 or 1.

After that, ask the patient to spell a common word that is about 5 letters long, such as "CROWN". Then have the patient spell it forwards and backwards.

Next, evaluate if the patient is well oriented, by asking their full name, year of birth, present city location, and the reason for the visit. Also, ask the patient the month, the day of the week, the date of the month, and the year. Make sure that patients are not obtaining clues from calendars or clocks that may coincidentally be in the room.

Now evaluate for object recognition by pointing to three common objects and asking the patient to name each one, for example, clock, table, ring. Make sure that the objects are not related to each other in form or function, such as "clock and watch".

Assess the patient's writing skills by asking them to write a sentence with a subject and a verb.

Next, evaluate the patient's spatial orientation by drawing a 3-D shape or design on a piece of paper, like a cube, and then asking the patient to copy that design.

To assess the patient's executive function, now ask the patient to draw a clock with hands set to a specific time.

Then evaluate abstract reasoning by asking the patient to name something that a car, train, and bicycle have in common. The answer should be that they are all forms of transportation.

Finally, ask the patient to recall the three words given as part of the short-term memory exam.