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News Gram™ June 2006

June 2006 ~ Volume 12, No. 11

The mental status examination (MSE) is analogous to the physical examination. Just as the physician will examine the regions of the head, eye, ear, nose, throat, chest, abdomen and extremities, so too will the psychiatrist examine various aspects of mental function. By taking this approach, the psychiatrist achieves a uniformity of clinical information in its most helpful form.

Let’s take a look at the details of MSE. Without the necessary findings on this exam, it is very likely that no diagnosis can be justified. Therefore, it is well for every reader of a psychiatric report to understand the structure of the MSE and the significance of each of its components.

Appearance/Demeanor: This first part of the exam takes account of the way the whole person behaves. The psychiatrist pays attention to how the person is dressed, how she walks, whether they appear to be in pain and whether or not his behavior makes sense. That is, does propriety attach to the person? Are there physical deformities?. Does he have a limp? Is there a missing limb? Does she require the use of a cane, crutches, walker, wheelchair, hearing aid, exceptional visual device or other appliance? The psychiatrist is particularly interested in the level of activity and thinking. Often, in the case of depression, a patient will display psychomotor retardation, or slowing of thought and action.

Speech/Language: Most of the human brain is involved in the production and comprehension of language. Therefore, the MSE seeks to determine the state of the central nervous system when the area of speech and language is scrutinized. The starting point is that of articulation. Can the patient speak clearly? Is there a specific speech defect such as a sybilant ‘S’? One major area of concern is the possibility of an aphasic disorder, i.e., a dysfunction in language comprehension, expression or both. The examiner looks at the patient’s ability to comprehend the spoken and written word,  the clarity of expression, the spontaneity of the person’s linguistic responses, repetition and his or her prosody, i.e., the melodic component of their speech. If all of these spheres are intact, it is not likely that the person is suffering from an aphasic disorder.

The psychiatrist will also look for anomia, the inability to name an object, or apraxia, the inability to follow a command. A simple way to measure this is to ask the person to fold a piece of paper in half and then in half again. The doctor can also ask the patient to draw a geometric figure.

Affect/Mood: A person’s affect is the external or behavioral expression of his or her internal state. Many times, a person will cover over a negative mood with a bright affect. The psychiatrist must measure the patient’s behavior over the course of the entire interview to make such a judgment and determine if the affect is appropriate to the content of speech. To talk about the loss of a loved one and laugh at the same time would, in most cases, be inappropriate.

Mood is the underlying, physiologically and neurologically driven emotional experience of the person. It is regarded as a vegetative condition of the person since it is so closely linked to the individual’s biology. That said, one cannot simply make a determination on the basis of what the person tells the psychiatrist. Sometimes testing is necessary.

Cognition/Perception: In this arena, the psychiatrist attends to several aspects of the thinking process: e.g., tangentiality, i.e., the drifting of thoughts into vague and poorly related cul de sacs, circumstantiality, i.e., failure to get to the point, circumferentiality, i.e., going around in a circle, loosening of associations, i.e., strange ways of relating one idea to another, the ability to abstract, a defect found in schizophrenia.

With respect to perception, the presence of hallucinations and delusions are the central concerns. Usually, psychiatrists are concerned with hearing voices. Sometimes, visual hallucinations indicate the possibility of organic dysfunction. Three other essential areas are judgment, concentration and memory. There are specific tests for each function.

Physiological Functioning: This part of the exam is concerned with the integrity of the person’s bodily function. The examiner wants to determine the presence of tremors, fasciculations, twitches or other abnormal movements of the musculature. Is the person pale or are his pupils constricted or dilated. Does his mouth appear to be dry? Is his heart rate increased?

A brief perusal of the data gathered in an MSE indicates just how powerful it can be. Again, it behooves anyone charged with reading a psychiatric evaluation to understand the interstices of this central part of the psychiatric evaluation.

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