Mental Status Exam in Psychiatry

Appearance and behaviour are the most free-form part of the MSE. This section communicates how you found the patient to be during the interview. I'll start with a few examples. A patient can be agitated and dishevelled, or calm and cooperative, or even sedated! Another patient may be calm, fidgety, or anxious. You can also discuss physical features you find noteworthy such as hair colour, nail polish, tattoos, body habitus, hygiene, and appropriateness of clothing to weather. It's important to not get carried away and include too many irrelevant details. Try your best to include things that you would think are relevant. You can then ask for help in clarifying from your colleagues or preceptors (if you have one).

As an example, for a patient who complains of severe depressive symptoms and has been unable to keep up with hygiene, it would be important to note hygiene status as part of the MSE. This information can either negate or corroborate the reports and can further bolster your impression and argument for the management of your choice. A patient who complains of psychotic symptoms may be agitated and paranoid, demonstrating bizarre behaviour in the emergency room which needs to be documented in detail. Some patients may be hesitant to give you any information and may not be forthcoming with answers, or may not want to elaborate on their answers even when you ask. All these scenarios demonstrate the importance of communicating relevant details of how you found the patient at the time of interview.

In the outpatient setting where things are generally calm, I often find myself reporting patients to be "calm, cooperative, and forthcoming during the interview". Few times, I found myself commenting on nail polish colour in more detail than I care to admit, and even the highlight used in a patient's hair.

This is not to say you should comment on everything all the time - you'd be dictating an MSE for over an hour. Just include what you, as a person and as a judge, find interesting. It's crucial to embrace your inner sixth sense and communicate your thoughts genuinely. I'd like to add that it's OK to be judgmental - in a helpful way - when communicating your MSE.

A note on agitation: Far too many times I have seen "agitation" as part of the MSE. I, too, have used that term before without further clarification. Agitation is used too often as a catch-all term which encompasses a spectrum of behaviours from subtle fidgeting to outright anger outbursts requiring 4-point restraints and constant observation status. Whenever you find yourself wanting "agitation" as part of your MSE report, attempt to elaborate. You could instead refer to the patient pacing around the room, frequently looking out the windows, feeling apprehensive, shouting or screaming, demonstrating rude behaviour to staff, and anything else as you see fit.

Feel free to be creative and don't let a pre-structured notion of what goes into this part of MSE prevent you from expressing your thoughts and even your feelings about how the patient presented. This holds true for any part of the MSE.

When we discuss speech in MSE, we specifically discuss the mechanics of speech: tone, rate, rhythm, volume, and fluency. This part of the MSE is more structured and is more limiting in how creative you can be. As long as you comment on the above, you will be fine.

As an example, speech can be pressured with high rate, variable volume, and wrinkled rhythm. Some patients present with speech that has good tone, but slow rate and low volume which is otherwise fluent. Even from that brief description you can probably limit your differential diagnoses. Such is the power of MSE.

Some schools of thought avoid including Emotion/Mood in the MSE and yet others insist on its inclusion. Consider this part optional, but including it is always better than not. What is required is affect, which describes the expression of one's current emotional state as viewed by you - the interviewer. Affect can be thought of as being on a continuum, but a few words are commonly used to describe it:

• Bright: On one side of the spectrum is the bright affect. A bright affect demonstrates happiness and charm. This is how you know your patient has been doing well!
• Reactive: Describes a patient who responds to the varied emotions inherent in the conversation. They become visibly sad and even tearful when speaking about a difficult time, and brighten up when discussing a pleasant event or memory. When the expression of mood is appropriately varied and is within expectation (considering cultural norms), we call that reactive. Affect reacts to its environment.
• Restricted: Some reactivity is evident, but not nearly to the extent expected. Expectation is subjective, but it should not refer to what you expect based on patient's reported mood. The expectation here refers to how you would expect a well person to behave. A depressed patient could show restricted affect if their range of emotional expression is not within expectation for a well person. Conversely, someone concerned about depressive symptoms could show reactive or even bright affect.
• Blunted/Flat: Blunted and flat both refer to lack of reactivity. Flat more so than blunted. I have seen these terms used interchangeably, but they relay slightly different information. It is best not to get caught up in the specifics. If you find yourself scratching your head trying to come up with the best term for an encounter, it is best to elaborate. You would not be wrong in reporting a "restricted" affect but which "brightens" at specific topics of conversation, or a dominantly "reactive" affect which becomes "downcast" part way through the interview. As with all parts of the MSE, and I reiterate here, you don't need to pigeon-hole a term if you feel it doesn't adequately describe your experience of the interview.

Other terms that I haven't mentioned can also be used. This is also where you can spend many creative points!

Perceptual disturbances refers to hallucinations. This is not only what the patient reports, but also - and perhaps more importantly - what you see for yourself during the interview. You can integrate the two sources of information - patient report and observation - in the MSE by mentioning both or either. For example, you could document that the patient reports auditory hallucinations and that you see responses to internal auditory stimuli.

An example would include an interview that is going smoothly where suddenly the patient says "hush" and starts listening even though there is no noise. Patient could then ask you if you're "hearing it". You could also find a patient who appears distracted by something on the wall behind you, but there is nothing there. Someone else might keep repeatedly looking at a specific location in the room. These are all clear examples of perceptual disturbances which should be noted in MSE.

Thought process refers to thoughts and how they attach together. Imagine a string of beads where the string forms the connections and the beads are the thoughts. Thought process can be described in a few generic ways, but again, there is much room for elaboration and creativity.

• Linear and logical: This how a well person might speak. Their ideas are connected together logically and you can follow the conversation with minimal effort. One idea leads naturally to the next and the connection makes sense.
• Circumstantial: A circumstantial thought process is generally described as one where a lot of detail is included that may be irrelevant. I also think of it as a looped rollercoaster where the patient takes you for a ride. They start answering your question, but then derail and include things that are only tangentially relevant or not relevant at all. They eventually come back to the question, but not until your page is full and you're wondering how you got there.
• Tangential: Tangential thought process refers to the circumstance where the patient starts answering your question but derails quickly into the realms never-before-seen and never comes back to the original topic. Here you may need to redirect the conversation - sometimes multiple times - in order to get the answer you need. You could also use shorter and more directed questions to enhance the flow of the interview.
• Flight of ideas: Nothing makes sense, the thoughts have no connection and only jump in large leaps from one to the next with no appreciable sense of continuity.

It is important to distinguish flight of ideas from pressured speech, one is how the thought is formed, the other how it is mechanically expressed.

I have found two components are important when discussing thought content: delusions and suicidal/homicidal ideation. Once again, this is what you observe and not what the patient reports. An example of a delusion which can be observed would be paranoid delusions. In such cases, the patient appears apprehensive and keeps looking out the window. You might engage the patient and ask why that is, the answer to which can illuminate the thought disorder.

delusion vs overvalued idea: make sure to differentiate the two. A delusion is fixed and immovable even in the face of strong evidence. You cannot nudge a delusion.

An example I like to give when talking about suicidality and MSE is where a patient denies suicidality but reports they are not regretful of their most recent attempt. Or if they report they would attempt suicide as soon as they were discharged, but during the interview they denied when asked about suicide. This doesn't occur too often, but suicidality in MSE should be judged by the interviewer and not merely be copied from history.

I like to think of insight assessment as a miniature capacity assessment. When assessing for insight, I like to know if the patient understands their illness or diagnosis and whether they appreciate its impact on their life. I also like to know if they are aware of the treatment they are receiving and whether they know the benefits and drawbacks of it. Lastly, if they are refusing treatment, whether they understand the implications.

Once all that is done, I often categorize the insight as "excellent""good", "fair", "poor""lacking" and follow up with a more detailed explanation of why I think the insight should be categorized as documented.

For example, I may say "Patient has good insight as they understand the diagnosis and treatment." This includes all the above information summarized in one sentence.

Judgment is a related concept which refers to a reasoned (not necessarily what you may consider reasonable) judgment. If the patient understand the implications of their choice and appreciates the consequences, that constitutes a reasoned judgment. I refer to judgment as "good", "fair", "poor" and then justify with an additional sentence if there is something relevant to note.

The MSE is then concluded with what I think would be the most important part of the entire interview. It's the grand finale of your interview: was the patient you just interviewed cognitively intact?

In an ideal world, every patient would receive a MoCA or MMSE assessment and the score would be noted here. However, depending on your impression of the interview process, that may not be necessary. At this point, I often comment that a formal assessment of cognition was not done, but the patient's cognition was "grossly" intact, and he/she was alert and oriented to person, place, and time.