The mental status examination assesses the function of the brain. The purpose is to evaluate mental functions and behaviors. A good mental status examination helps assess many mental health/central nervous system disease states. A good mental status examination can be used to monitor a patient’s severity of illness over time.
The first step in the mental status examination involves determining the patient’s degree of arousal. Is the patient alert, sleepy, attentive or unresponsive? Is the patient-oriented to person, place and time or is the patient confused?
How does the patient look? Is the patient well groomed? Is the eye contact appropriate? Things to note include poor hygiene, inappropriate dress, and lack of concern for appearance. Poor grooming indicates a potential psychiatric problem. Posture that is stooped and poor eye contact suggests depression. Colorful clothes/unusual clothing may be present in manic states.
Behavior and motor activity should then be assessed. Is the patient calm and relaxed or is there any indication of restless, agitation or lethargy? In addition, note any abnormal motor movements such as unusual facial expressions, tremors or tics. Tremors or tics suggest a neurological disease, medication side effect or anxiety. Excessive body movements suggest mania, anxiety or abuse of stimulants. Repeated motor movements suggest obsessive-compulsive disorder. Little body movement may be seen in depression, catatonic schizophrenia or drug abuse.
The mood/affect should also be evaluated. Asking patients how they are feeling is a simple way to assess mood. Is the patient’s emotional response to the situation appropriate? The mood can be assessed by observing the verbal/non-verbal behaviors during the physical exam. Disturbances in the mood may be demonstrated by feelings inappropriate to the situation. Euphoria, agitation, depressed mood, flat affect, anxiety, labiality (shifting from one affect to another rapidly), irritability, excessive rage, indifference, carelessness, inability to sense emotions, and lack of sympathy should all be noted.
The speech pattern is an important part of the psychosocial assessment. The patient’s voice should be clear, strong, fluent, and articulate with a clear expression of thought. Abnormalities in speech to be noted include: nonverbal, slurred speech, soft speech, loud speech, pressured speech, limited interaction, incoherent speech, halting speech or rapid speech. Slurring of words suggests intoxication. Pressured speech is seen in mania. Those with depression will often have poverty of speech.
The patient’s attitude should also be noted. Is the patient cooperative, uncooperative, guarded, suspicious or hostile?
The thought process is how individuals self-express and is observed through speech. It is not the content of the speech but the patterns of verbalization. It may range from normal to any of the terms in Table 2. A normal thought process is logical, relevant, sequential and coherent?
Table 2: Terms to Describe Thought Process
|Term||Definition||What it may suggest|
|Flight of ideas||Frequently changing topics||Mania|
|Tangential||Going away from a topic and not returning||Schizophrenia/psychosis/anxiety|
|Circumstantial||Provides unnecessary detail, but eventually gets to the point||Schizophrenia/psychosis/obsessive-compulsive disorder|
|Neologisms||Making up new words||Schizophrenia/psychosis|
|Looseness of association||Illogically shifting between topics||Schizophrenia/psychosis|
|Word salad||Nonsensical responses||Schizophrenia/psychosis|
|Clanging||Rhyming words, speech makes no sense||Schizophrenia/psychosis|
|Thought blocking||Speech is stopped||Schizophrenia/psychosis|
|Poverty of speech||Limited content of speech||Depression|
Thought content is the themes that take up the patient’s thoughts and shows how coherent and logical the individual thinks. Disorders that suggest abnormalities include: phobias (a morbid fear along with extreme anxiety), hypochondriasis (obsessed with the idea of having a serious or life-threatening disease which is not diagnosed), obsessive thoughts (unwelcome idea, impulse or emotion that is continually forced into the conscious mind), hallucinations, delusions (fixed false belief) or other preoccupations (thoughts that are prominent in the mind of the patient such as thoughts of death, suspicion or fear).
Assess the patient for specific delusions and hallucinations. A hallucination is something that the patient perceives but is not there. Hallucinations are suggested in those who hear voices, see images, feel bugs crawling on the skin, or smell offensive odors without evidence of them being present. Inquire about any command-type hallucinations and what the patient is being commanded to do and if the patient complies or is considering complying with the command.
Assess the type of delusion that the patient is having. Table 3 gives questions to ask to determine if the patient is having hallucinations or delusions. Delusions are classified in multiple ways (see Table 4).
Table 3: Questions to ask to elicit the presence of hallucinations/delusions
- Can you see things that no one else can see?
- Do you hear voices when no one else is around?
- Do you have any mysterious sensations such as smells, sounds, or feelings?
- Do you have any unusual powers or abilities?
- Do you have any believes that others consider strange?
- Does the television or radio give you special messages?
Table 4: Type of Delusions
|Type of delusion||Definition|
|Grandiose||A belief that the person is someone of extreme importance|
|Persecutory||A false belief that the person is being followed, is under surveillance, being ridiculed or treated unfairly|
|Jealousy||Belief that the individual's sexual partner is unfaithful|
|Religious||Belief of a special status with God|
|Somatic||Belief that there is a physical defect or general medical condition when none exists|
|Ideas of reference||Belief that things in the environment refers to them, when they do not|
|Thought insertion||Belief that someone is putting ideas or thoughts into their mind|
|Thought broadcasting||Thinking that one's thoughts are being" broadcasted" to the outside world|
Impulse control can be assessed by asking the patient if they do activities without planning or thinking about them. Those who have poor impulse control have limited ability to resist temptation or the urge to do something that may be harmful to themselves or others. Many disorders are linked to poor impulse control such as substance abuse, antisocial personality disorder, bipolar disease, schizophrenia and impulse control disorder. Behaviors that may be noted in those with poor impulse control include: pathological gambling, excessive substance use/abuse, aggression, binge eating and excessive, unsafe sexual behavior.
Judgment can be assessed by asking a made up scenario to determine if there is an appropriate response. For example, if there is a fire in a crowded theater, what should you do? Doing nothing would suggest poor judgment. Calling 911 or getting help suggests good responses. Other methods to assess judgment include looking at the patient’s lifestyle. Poor judgment is likely present in those who are involved in illegal activity or in relationships with those that are destructive. Judgment is impaired in those who are schizophrenic, psychotic, intoxicated, manic, in some personality disorders or those who have a low intelligence quotient.
Assessment of cognition can be as simple as evaluating how the patient responds to questions asked during the assessment. More specific questions may be asked to provide a detailed analysis of the patient’s cognitive ability. The use of the Mini-Mental State Examination is a common way to assess cognition.
The first part of a cognitive assessment is to determine if the patient is oriented to person, place and time.
Attention is the ability to focus, direct thinking and not get distracted. Concentration is the ability to maintain attention over a period of time. A patient who is unable to maintain attention will have other problems in cognitive performance especially executive function and memory, making a full assessment of mental status challenging.
Lack of attention will be demonstrated by patients who lose their train of thought, become easily distracted or those who ramble. Attention can be assessed by having the patient repeat a string of digits. An adult should be able to repeat 5-9 digits.8 Another way to assess attention includes having a patient spell a word backward (W-O-R-L-D is often used) or repeat the months of the year in reverse order. Those who have a demonstrated deficit in attention may have a toxic metabolic encephalopathy or an acute psychiatric disorder.
The assessment of memory is the next step in the mental status examination. The immediate memory is tested by asking the patient to repeat a string of digits or asking the patient the time and place or asking about recent events.
Another test of recent memory involves telling the patient three words and then having the patient repeat the three words to assure there is normal attention. Ask the patient to repeat the words five minutes later after they have been distracted by another task. A normal adult can remember all three words after five minutes. Offering the patient clues to help them remember can be done to assess the degree of memory impairment. Remote memory can be tested by asking about personal life events or important historical events (such as the names of the presidents of the United States in reverse order).
The content of speech is assessed by noting the presence or absence of any language errors during speech. Naming is assessed by having the patient name objects shown to them. Show the patient three objects such as a pencil, watch and apple and make sure they can name them. Reading and writing are assessed by having clients read a section of words and writing a sentence. Repetition is assessed by having a patient repeat a common phrase. One that is often used is “no ifs, ands or buts”.
Visual spatial perception is assessed by having the patient copy an object (such as overlapping pentagons – Table 5), drawing an object or building something. Having the patient draw a clock and telling them to make a certain time on the clock is another tool to assess visual-spatial perception. This test is often used as a screening test for dementia. Individuals with visual spatial perception deficits may have a difficult time with navigation, get lost frequently or often lose objects.
Table 5: Interlocking Pentagons
Praxis is learned motor movements and is demonstrated by the patient being able to perform learned, skilled motor movements such as feeding or dressing. To assess praxis the patient is given a step-wise series of coordinated tasks. It can be demonstrated by asking a patient to take a piece of paper, fold it in half, put it in an envelope and hand it to the examiner. Apraxia can be seen in corticobasal degeneration.9
Assessing the patient’s ability to calculate is done by having the patient perform simple mathematical problems. Calculation assessment can be done by having the patient start at 100 and subtract seven serially (100, 93, 86, 79, 72, 65). The ability to perform this test is affected by educational level and anxiety level.
Executive function is a set of mental abilities that are synchronized in the frontal lobe of the brain and helps people accomplish goals. It is hard to assess from exam alone. It may take getting a good history from the patient and family or neuropsychological testing to fully assess executive function. It includes the ability to organize, plan, remember details, switch focus, manage time, suppress inappropriate behavior/speech and merge past experiences with present action. Individuals who have impaired executive function may not be able to function independently. Executive dysfunction can be seen in dementia, head injuries, strokes, depression, attention deficit disorder or learning disabilities.
The executive function is assessed in the history part of the exam when determining if a patient can function well in everyday life. Clients who demonstrate problems with judgment or insight may have executive dysfunction. Abstract reasoning can be used to assess executive function. Can the patient explain a proverb such as, “a rolling stone gathers no moss”? Can the patient describe an idiom or can a patient interpret differences and similarities (child-midget)? .
Some clinicians will determine estimated intelligence and general fund of knowledge. In order to do this accurately, more extensive testing is required. It is best left for more advanced assessment such as neuropsychological testing.
Mental status examinations are often done with standardized assessment tools. Standardized tests are helpful because they can follow a patient over time and can be done by many health care providers with similar results.