The Mental Status Examination

Michael Blumenfield, M.D.

Professor of Psychiatry,
Medicine & Surgery

Department of Psychiatry
New York Medical College
Valhalla, New York
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Mental Status Examination
A systematic
organization and
documentation of the
quality of mental
functioning at the time
of the interview.
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Mental Status Examination
Much of information is
obtained informally
during other parts of
the interview.
It is usually necessary
to ask the patient some
formal questions to
evaluate all the
categories of the
examination
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Categories of Mental Status Examination
(can be broken down in different ways)

Appearance & Behavior
Thought (Form & Content)
Mood & Affect
Memory & Intellectual Functioning
Insight & Judgment
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Appearance & Behavior
attractiveness vs
unattractiveness
healthy vs sickly
older vs younger
( than stated age)
angry, puzzled,
frightened, ill-at-ease,
apathetic,
contemptuous, etc.
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Appearance & Behavior
Mannerisms,gestures,combativeness,
psychomotor retardation ,rigidity,
twitching, handwringing,pacing
Suspiciousness, cooperative
seductiveness,laughing, joking,
seriousness,dramatic flair , etc.

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Behavior & Apperance
Clinical Examples:
People with psychois such as schizophrenia may
be poorly groomed or dressed in bizarre manner

Depressed person may show decreased
psychomotor activivity , handwringing

Swollen neck may be evidence of hypothyroidism
and perspiration may be evidence of
hyperthyroidism both of which can have mental
status findings

Confused behavior can point to cognitive deficits





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Thought - Form
Formal Thought Disorder - Is speech logical,
coherent, relevant?

Loose Associations - thoughts unrelated and patient
unaware of this
tangentiality,circumstantiality ,derailment,evasiveness,blocking
Flight of Ideas- jumping from idea to idea but with
understandable but often tenuous associations
pressured speech, overinclusiveness , clang associations
Other Unusual Speech
echolalia- patient mimics words back to interviewer
neologisms-patient makes up new words
perserveration-needless repetition of the same thought or
phrase




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Thought- Form
Clinical Examples:
Loosening of Association(LOA) with tangentiality or
derailment is characteristic of schizophrenia as are blocking
neologisms and echolalia when they occur

Flight of Ideas(FOI) frequently occurs with pressure of speech
and with overinclusiveness which is characteristic of mania
but can be seen in drug intoxication

Perseveration is found in dementia and is indicative of
memory difficulties


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Thought- Content
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Thought - Content
Refers to what the patient thinks and talks about
Hallucinations- Totally imagined sensory perceptions
auditory , visual, olfactory, tactile,
can be accusatory, threatening or commanding

Illusions - Misinterpretation of of sensory stimuli
Delusions- Fixed false beliefs not congruent with patients culture
Obsessions - recurrent persistent unwanted thoughts, impulses, images
Compulsions-need to do repetitive,purposeless behavior to ward off
unwanted happenings
Phobias- intense unreasonable fear leading avoidance of feared object
Depersonalization-the feeling that one has changed in a bizarre way
Rerealization- the feeling that the environment has changed
Dj Vu- sense of familiarity with a new perception
Suicidal & Violence Towards Others - see mood for suicidal ideation


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Thought - Content
Delusions

Bizarre, confused delusions
Persecutory delusions
Grandiose delusions
Delusions of influence-patient believes that he can control events
through telepathy
Delusions of reference-patient is convinced that there are special
meaning to events and actions which are directed specifically
towards himself
Delusions of thought broadcasting- the belief that others can hear
the patients thoughts
Delusions of thought insertions-the belief that someone elses
thoughts have been inserted into the patients mind
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Thought- Content
Clinical Examples:
Delusions that are understandable and fit with content are more
likely to be related to depression ie, patient believes that he or she
has cancer or is persecuted because he or she is a bad person
Delusions that are not understandable and are bizarre are more
likely to be due to schizophrenia ie. Patient believes that he or she
has superhuman powers or believes their thoughts can be read by
others or others are inserting their thoughts into their mind
Visual Hallucinations - are more common in organic disorders
particularly with delirium ,can occur with psychedelic drugs and
less likely with schizophrenia
Auditory Hallucinations- Most common with schizophrenia but can
occur with alcoholic hallucinosis and affective disorders
Olfactory Hallucinations- Associated with temporal lobe seizures
Tactile Hallucinations- (including formications-which is sensation of
insects crawling under or in skin ) can occur in drug intoxication,
delirium tremens and sometimes schizophrenia
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Thought - Content
Ability to Think abstractly vs Concrete
Thinking

Similarities: What do the following
have in common?
Chair and desk?
Apple and pear?
Poem and statue?

Proverbs: What do people mean when
they say..?
Dont cry over spilled milk
A rolling stone gathers no moss
When the cats away the mice will play
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Thought- Content
Clinical Examples:
You must take into account a persons intelligence when
evaluating the ability to abstract

Concrete thinking especially when it is bizarre suggests a
psychotic disorder such as schizophrenia

Inability to abstract especially if the answers are vague
suggests that the patient is failing and it could be due to
delirium or early dementia.
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Lets Go To The Video Tape !!!
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Mood and Affect
Mood refers to the patients words
describing his/her internal emotional state
sad, depressed,gloomy
happy,euphoric,ecstatic
angry,irritable ,anxious)
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Mood and Affect
Affect is the externally observed emotion

appropriate vs inappropriate to reported mood ,
content of thought and situation
flat, blunted , contricted or full range
labile, intense

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Mood and Affect

When evaluating depression it is
customary to ask about vegetative
symptoms
sleep- falling asleep,staying asleep and
early morning awakenings
(also a good time to ask about dreams )
appetite- change in appetite and weight
change

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Mood and Affect
Suicidal Ideation

When evaluating depression it is often
a smooth transition to ask about
suicidal ideation
It is myth to believe that asking about
suicidal ideation will give the patient
the idea of doing it
Failure to evaluate for suicidal
ideation is a very serious omission
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Mood & Affect- Clinical Examples:

Inappropriate and flat affects are often associated with schizophrenia

Labile mood and labile affect are often seen in patients with disorders
which are charcterized by damaged brain function

Extreme distress or pain described with an indifferent affect is called
la belle indifference and is associated with conversion disorder

The clinicians own emotional response to the mood and affective
response of the patient can be a good indication of the underlying
condition
ie. If examiner does not feel some sadness during report of extremely
depressed mood, there is something wrong with affect of patient which may be
indicative a conditon other than major depression
ie.If examiner finds one self smiling and almost laughing as patient reports
material, the underlying mood may be mania or hypomania
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Lets Go To The Video Tape !!!
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Memory and Intellectual Functioning
Orientation
Time- disoriented if more than one day off of the week
and more than several days off date or the wrong year
(except around the New Year )

Place- disoriented if gives wrong hospital,wrong city ,
wrong setting

Person- if doesnt know who they are
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Memory

Immediate- serial 7s, alternative can be to ask how
many nickels in $1.10. Spell WORLD backwards
(also tests attention , concentration and intellect)

Short-term- recalling 3 objects 5 minutes later

Recent-recalling events of past week or month

Remote- recalling a famous news event of many
years ago or naming their first grade teacher
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Intellectual Functioning

Must interpret with understanding of patients
educational, cooperativeness and mood state
Ask questions which are appropriate for specific
individual, if not sure ask persons interest

Examples :
Name the past 6 presidents?
What does the heart do?
How far is it from New York to San Francisco?
What happens to a caterpillar ?
Math questions noted above also test intellectual function
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Memory & Intellectual Functioning -Clinical Examples
Disorientation for time and place are usually due to delirium but can
occur with severe dementia

Disorientation for person is unusal even in dementia and malingering
should be suspected. Rare case of dissociative state is possible

Disturbances of attention, concentration, immediate and short-term
memory is usually due to delirium and can be characterized by
fluctuations

Recent memory is more severly impaired than remote memory in
dementia and persist when there is no delirium
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Lets Go To The Video Tape !!!
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Insight

Insight: The patient knows that he or she was or
has a psychiatric illness . If hallucinating, the
patient knows that he/shes mind is playing
tricks on him/her
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Judgment
An estimate of the patients real life problem
solving skills.Is the patient realistic about
limitations and life circumstances? It is a
complex mental functioning

Examples of Questions to Evaluate Judgment
What would you do if you found a self addressed
envelope?
What will you do when you leave the hospital ?

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Insight & Judgment--Clinical Examples
Insight is often lacking with schizophrenia and other psychotic states
but not this is not always the case. Similarly patients with organic
impairment such as delirium and dementia will have absent or
diminished insight.
Insight can be described on a relative scale with terms such as absent,
limited, poor fair and good
The term insight is used in somewhat different manner when
discussing patients without major psychiatric disorder in regard to
their ability to accept , understand and utilize interpretation of behavior
and unconscious dynamics

Judgement is regularly impaired in dementia, delirium and psychosis
including schizophrenia as well as at times with mental retardation
Assessment of judgement helps determine the patients capacity for
independent functioning
When mental illness is shown to impair a patients judgment so
he/she is not capable of signing a consent form or handling finances ,
a court will declare a patient as incompetent for that task
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Example of Poor Judgment
The Mental Status Examination
Michael Blumenfield, M.D
Professor of Psychiatry,
Medicine & Surgery

Department of Psychiatry
New York Medical College
Valhalla, New York