The Mental Status Examination

1. The Mental Status Examination John Sommers-Flanagan University of Montana For free MSE materials, go to: johnsommersflanagan.com

2. Today’s Plan: Why the MSE? • The mental status examination (MSE) has a revered place in psychiatry and medicine • It’s of growing importance to counseling, psychology, and social work • It’s a language we need to be able to use and understand • This day focuses on the basic components of a psychiatricmental status examination

3. Today’s Plan: Learning Objectives • Get comfortable with the MSE terminology • List and define the nine “psychiatric domains” • Practice collecting, analyzing, and reporting data from each of the nine domains • Describe cultural and other validity problems

4. What Is a Mental Status Examination? • The mental status examination (MSE) is an assessment procedure • It is a semi-structured interviewing used to organize clinical observations pertaining to mental condition • The primary purpose is to evaluate current cognitive processes (how’s your brain?)

5. MSE – Medical Perspective • Medical perspective • https://www.youtube.com/watch?v=VjWVYgf2UcU • 0:00 – 9:22

6. What Is a Mental Status Examination? II • Two types: Psychiatric and neurological • Two approaches: Formal and informal • It’s very common to medical settings • It results in one medium-length paragraph describing the client’s mental status

7. Sample MSE Report • Let’s read this together and analyze it • Gary Sparrow, a 48-year-old heterosexual White male, was disheveled and unkempt upon arriving at the hospital emergency room. He wore dirty khaki pants, an unbuttoned golf shirt, and white shoes. He appeared slightly younger than his stated age. He looked agitated, frequently standing up and changing seats. He was impatient and sometimes rude. Mr. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15”).

8. Sample MSE Report (cont.) • His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Sparrow described grandiose delusions regarding his sexual and athletic performances. He reported auditory hallucinations (God had told him to quit his job to become a professional golfer). He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Mr. Sparrow was unreliable and had poor judgment. Insight was absent.

9. Assessment in a Nutshell • Assessment is judgment • It is an effort to know something about someone else • It is an effort to know something that is true and accurate/consistent about someone (valid and reliable) • The MSE is a particular assessment approach

10. Assessment in a Nutshell • Every effort to know the truth about someone else falls short . . . Including the MSE • Therefore, although assessment is important, we should always be humble and collaborative in our assessment process and in reporting outcomes

11. Let’s Practice • Volunteer for Mini Mental Status • John administers • You all observe • Then you report in your observations and interpretations

12. What Was Your Assessment?

13. Case Example I • You’re working with an 11-year-old girl. She has atrocious hygiene. She’s bullied. In your first 5 minutes you have her draw-a-person and she includes a penis: • Observations? • Hypotheses? • Interpretations or inferences?

14. Case Example II • You’re working with a 14-year-old boy. He got caught setting fires. He got caught throwing cats out an upstairs window. He has enuresis. You meet with him and he’s charming. • Observations? • Hypotheses? • Interpretations or inferences?

15. Case Example III • In The mental status examination and brief social history in clinical psychology Smith (2011) wrote: • A Fu-Manchu mustache suggests the wearer doesn’t mind being thought of as “bad,” whereas a handlebar mustache tells you the person may be somewhat of a dandy or narcissist. (p. 4)

16. Case Example IV • He also wrote: • “If the person is unshaven, this may be a sign of depression, alcoholism, or other poor ability at social adaptation” (p. 4) • What mistake is he making?

17. Individual and Cultural Considerations • Thinking about Objectivity • Total objectivity is impossible • Your mood and beliefs can interfere with or help with your objective mental status evaluations • Be sure to keep your emotional sensitivity in your MSE process

18. Individual and Cultural Considerations II • Individual and Cultural Considerations • Keep in mind the many ways individuals vary in their behavior and abilities • Normal behavior within one culture, may appear disturbed or irrational within another culture

19. The Danger of Single Symptom Generalization • What are some common single symptoms (other than type of mustache) that clinicians might be prone to overinterpret? • Do you have any particular biases about this? • Why is it so easy to be overconfident in our judgments?

20. Three Guidelines • When you spot a single symptom of interest, begin scientific-mindedness • Remember: Hypotheses are not conclusions • Don’t make wild inferential leaps without consulting first

21. Chinua Achebe (1994) • “After the singing the interpreter spoke about the Son of God whose name was Jesu Kristi. Okonkwo, who only stayed in the hope that it might come to chasing the men out of the village or whipping them, now said:

22. Chinua Achebe (1994) • “You told us with your own mouth that there was only one god. Now you talk about his son. He must also have a wife, then.” The crowd agreed. • “I did not say He had a wife,” said the interpreter, somewhat lamely . . . • The missionary ignored him and went on to talk about the Holy Trinity. At the end of it Okonkwo was fully convinced that the man was mad. (pp. 146–147)

23. 5Minute Discussion • Consider the excerpt from the novel “Things Fall Apart” • What are your thoughts on how the author depicts Christianity as appearing “mad” to a native African? • Are there any religious or spiritual or cultural beliefs that you would consider “mad?”

24. Mini Mental State • Admin to each other and debrief

25. The Generic MSE • Appearance • Behavior/psychomotor activity • Attitude toward the examiner • Affect and mood • Speech and thought • Perceptual disturbances • Orientation and consciousness • Memory and intelligence • Reliability, judgment, and insight

26. Watch Carl Video • Use the MSE form to make notes in each category

27. Appearance • Appearance in a MSE focuses on physical characteristics • Grooming • Dress • Make-up • Facial expressions • Weight/height • Body piercing/tattoos • Others?

28. Video Clip • Thom or Michele

29. Sample Appearance Description • Maxine Kane, a 49-year-old single, self-referred, Australian American female, appeared much younger than her stated age. She was tall and thin and arrived for the evaluation wearing sunglasses, a miniskirt, spike heels, heavy makeup, and a contemporary bleached-blonde hairstyle.

30. Behavior or Psychomotor Activity • Behavior or Psychomotor Activity in a MSE focuses on physical movement • Excessive or limited movement • Eye contact and eye movement • Grimacing or fidgeting • Gestures • Posture

31. Video Clip

32. Sample Behavior/Psychomotor Activity Description • The client scratched at her legs, back, and stomach throughout the interview. When asked about the scratching, she said “Oh, you wouldn’t believe the mosquito storm I got caught in when I took out the garbage last night. I think I counted 57 bites.”

33. Attitude Toward Examiner (Interviewer) • Attitude Toward the Examiner in a MSE refers to how the client behaves toward the interviewer; examples include: • Cooperative • Hostile • Indifferent • Manipulative • Open • Seductive • Suspicious

34. Video Clip

35. Sample Attitude Toward the Examiner Description • The client’s attitude toward the examiner was hostile as evidenced by (AEB) repeated eye-rolls, sarcastic comments, and intermittent use of the word “duh.”

36. Affect and Mood • Affect and Mood refers to moment-to-moment emotional tone as observed by the interviewer (affect) and the client’s subjective and self-reported mood state • Affect is usually judged in terms of content, range/duration, appropriateness, and depth/intensity • Mood is based on client self-report

37. Affect Content • Angry • Fearful • Sad • Guilty • Joyful • Happy • Surprise

38. Affect Range • Labile • Flat • Constricted • Blunted

39. Affect Appropriateness • Examples: • Possible indicator of: • Schizophrenia • Autism • Other?

40. Affect Intensity

41. Affect Terminology • Euphoric: the client claims omnipotence, exhibits increased psychomotor activity, and has exaggerated gestures). • Labile: the client shifts quickly from tears to laughter • Inappropriate: the client expresses euphoria over job loss and marital separation • Shallow: the client claims to be happy because “I smile” and “smiling takes care of everything”).

42. Video Clip

43. Sample Affect Description I • Throughout the examination, Ms. Brown’s affect was occasionally sad, but often constricted. Her affect was appropriate with respect to the content of her speech.

44. Sample Mood Description I • The client reported, “I feel miserable, unhappy, and Sample Mood Description II: The client’s current mood rating was a 4 on a 0–10 scale. He reported his 2-week low as a 3 and his 2-week high as a 5 and noted this range of 3 to 5 is pretty normal for him. He described his low mood as “irritable” rather than sad. angry most of the time.”

45. Speech and Thought • Speech and Thought • Speech is evaluated on the basis of • Rate (speed) • Volume (loudness) • Amount (density) • Thought is evaluated in terms of both process and content

46. Thought Process • Thought Process descriptors include: • Blocking • Circumstantiality • Clanging • Loose Associations • Neologisms • Perseveration • Word salad

47. Thought Content • Thought Content descriptors primarily include: • Delusions (of persecution, grandiosity, etc.) • Obsessions • Suicidal or homicidal thoughts

48. Video Clip

49. Sample Speech and Thought Description • The client’s speech was loud and pressured. Her communication was sometimes incoherent; she exhibited flight of ideas and neologisms as evidenced by her inability to stay on topic and use of words such as “Whaddingy” and “Ordinarrational.” She didn’t respond coherently to questions about obsessions, but appeared preoccupied with the contents of a small notebook.

50. MSE and Culture Activity