Mental Status Exam Copy

The mental status exam (MSE) is a brief semi-structured interview that involves asking questions and making observations about a number of areas. The mental status exam evaluates current signs and symptoms and does not assess history or context in depth. Therefore, the MSE is not diagnostic – additional information is needed to diagnose and formulate a treatment plan.

The areas that are assessed by the mental status exam can be more easily remember through the use of the following mnemonic ABC STAMP LICKER.

Appearance	Note anything unusual in the person’s self care, dress, or personal belongings. Be attentive to any evidence of self-mutilation.
Behavour	Look for abnormal movements, level of motor activity, signs of agitations, eye contact, mannerisms and posture.
Cooperation	Note the person’s attitude toward the interview
Speech	Look for abnormalities in ability to express and comprehend language. Is the speech very rapid (pressure of speech) or very slow?
Thought	Assess for thought form and process (the way the thought is constructed). Is the person’s thinking easy to follow or is there evidence of unusual beliefs, delusions or obsessional thinking. Ask questions to better understand the nature of these thoughts and their frequency and intrusivenesss.
Affect	Note unusual or excessive affect. Does the individual have a lack of affective responses to emotionally laden topic (flat affect or blunted affect)? Determine whether affect matches thought content.
Mood	Ask about depressive, anxious or euphoric feelings. Determine the intensity and stability of any mood symptoms. Ask if the individual has had difficulty experiencing pleasure from usually enjoyable activities (Anhedonia).
Perception	Ask about perceptual disturbances or hallucinations in all sensory modalities.
Level of Conciousness	Note how alert the person is during the interview. Look for any fluctuations in level of counsciousness.
Insight and Judgement	Determine judgement on specific and practical issues. Determine the person’s insight into symptoms and need for treatment.
Cognitive Functioning	Consider a mini-mental status exam as a screening tool for any cognitive problems.Orientation – Ask about memory problems. Note whether the person has any difficulties remembering recent or remote events. Give the person a 3 to 5 word list and ask them to repeat it five minutes later.Attention and Concentration – Note whether the person attends to your questions. Ask about the ability to focus on a TV show or a book.Reading and Writing – Ask about reading ability. Ask the person to read several sentences aloud and to write a sentence.Obvious difficulties on this cognitive screen call for further testing and a referral to a neuropsyychologist should be made if possible.
Knowledge Base	As part of the cognitive screen, note whether the person seems to have significant gaps in their current knowledge. Ask about significant dates or recent events.
Endings	Inquire about both suicidal and homicidal ideation. If any ideation, do a thorough risk assessment. Ask about plans, intent and lethality of method. Consider whether there are factors that increase risk(for example, drug or alcohol abuse, command hallucinations, impulsivity, history, etc).
Reliability	Note whether the information obtained from the MSE seems reliable. Ask yourself if you felt the person was being open and honest in responding to your questions.

In addition to these areas, do a review of somatic functioning. Ask questions about sleep, appetite, and level of energy.

A template for the Mental Status Exam is located in the care pathway. Click on the care pathway icon to access this.

Clinical Practice

The information gathered during the mental status exam questioning must be considered in context of findings of physical and medical history, laboratory tests, cognitive testing and cultural considerations. The assessor can use a variety of personal interview styles to elicit evidence of the signs and symptoms associated with psychosis. Confirming historical or collateral information can provide an indication of the client’s reliability and memory.

Forming a therapeutic alliance is the initial step in conducting a thorough examination. Choosing where and when to conduct the interview, clarifying your role and specifying the rules regarding confidentiality are essential when interviewing a young person. Always ask the young person where they prefer to be seen – their home, their school, at your office or some other location. It is best to see the client in the client’s preferred environment whevever possible. If safe to do so, interviewing the young person in their own home may be preferred. This choice often allows the young person to feel more comfortable, gives you access to their living conditions and often encourages the family to participate. Issues of personal safety must always be considered in making the choice as to where and when to interview. Some young people will want a parent, sibling or friend to be part of the interview. It is important for the interviewer to explain to anyone attending the interview, the purpose and possible outcomes of the interview.

When working with a young person with emerging psychosis, more than one interview may be necessary. Their stamina may not permit them to attend to the rigor of an interview so frequent breaks may be necessary. It is important to make the young person and their family aware that the purpose of the interview is to assist the young person to get relief from something that is distressing them. The interview must be seen as the start of a process although if psychosis is suspected then delay in treatment is not appropriate.

While the process of the interview may take different forms it is important that the interviewer remain flexible while focusing on both content and process. Non-verbal behaviour, demeanour, cultural norms and narrative are all important variables in the overall assessment. Your own theoretical orientation to clinical work will influence your approach however considering normative developmental considerations can prove helpful goal posts to crafting questions and reflecting on any responses.

David – A Case Study

Below are several video clips including components of a Mental Status Exam (MSE) with David (note: David is an actor portraying an individual with psychosis). To open the videos, click on the picture of the video. You will need a Windows Media Player, a sound card, and speakers or headphones to watch these videos. Be patient as it may take some time to download these videos depending on your connection speed.

It is recommended that you take notes if you are planning to base any of your assignments on this “master case” (i.e., if you are not currently seeing any clients with early psychosis). The first four videos are relatively brief – they illustrate parts of a MSE done by a psychiatrist to to illustrate specific points. The last video is a more complete MSE done by a clinical social worker – this video is about an hour in length so please be patient while it downloads. Watching this one hour video is optional although recommended if you are planning to base your assignments on this case.

Here is some additional information on the Mental Status Exam with David. Read the two pages on David’s MSE by clicking here. You may find it helpful to read over these pages before watching the videos. If you are having difficulty hearing the audio, below the videos you may read a transcript of the discussion.

Be aware that psychosis can present in many different forms. You will likely find that for referrals coming from the community (as opposed to from the hospital) that the psychosis is often not readily apparent. The variety of presentations is striking and in many cases depression or anxiety may initially be the predominant feature. Careful questioning, sometimes over several sessions, may be needed to determine if a psychosis is occuring.