Miami Dade College School of Nursing

1. Miami Dade CollegeSchool of Nursing The Mental Status Examination (MSE) Roxana Orta MSN, ARNP

2. Mental Status • Mental status is the total expression of a person’s emotional responses, mood, cognitive function, and personality. • It is closely linked to the individual’s executive functioning, i.e. motivation, initiative, goal formation, planning and performing, self-monitoring, and integration of feedback.

3. The Mental Status Examination • This is the primary type of examination used in psychiatry. • Practitioners are expected to be expert observers, both of significant positive and negative findings on examinations. • The MSE should be limited to what is observed.

4. Neuro Review • Frontal lobe • Speech formation (Broca area) • Emotions/affect • Drive • Awareness of self • Short-term memory • Goal-oriented behavior

5. Neuro Review • Parietal lobe • Sensory perception • Spatial sense and navigation

6. Neuro Review • Temporal lobe • Perception and interpretation of sounds • Wernicke’s area • Integration of behavior, emotion, and personality • Long-term memory

7. Neuro Review • Limbic system • Survival behaviors (mating, aggression, fear, affection) • Reactions to emotions, and expression of affect is mediated by connections of the limbic system and the frontal lobe

8. Mental Status Examination • The MSE is one component of an exam and may be viewed as the psychological equivalent of the physical exam • It is an important component to a neurological evaluation

9. Factors affecting the MSE • Culture and educational background of the patient • What is abnormal for a person with high intellectual ability may be normal for a person of less education • Patients with ESL may have difficulty with some components of the exam

10. Major Components of the MSE • Appearance • Motor • Speech • Affect & mood • Thought Content • Thought Process • Perception • Intellect • Insight

11. Appearance • Age • Gender • Race • Body build • Posture • Eye contact • Dress • Grooming • Manner • Attentiveness to examiner • Emotional facial expression • Alertness

12. Motor • Behavior: Pleasant? Cooperative? Appropriate for the particular situation? • Hesitancy • Agitation • Abnormal movements • Gait • Catatonia

13. Speech • Rate • Rhythm • Volume • Amount • Articulation • Spontaneity

14. Affect and Mood • Mood is usually defined as the sustained feeling tone that prevails over time for a patient. • - Mood: patient reports sadness, depression, hopelessness, worthlessness, and struggles with irritability and anger. She is fearful when experiencing hallucinations. She appears interested and attentive. • Affect is usually defined as the behavioral/observable manifestation of mood. • - Affect:patient’s affect seems incongruent with mood. She appears calm and less sad then what she reports. She smiles frequently and displays a generally pleasant attitude toward others.

15. Affect and Mood • Affect: How do they appear to you? • Stability • Range • Appropriateness • Intensity • Mood: asks the patient directly how he/she feels

16. Thought • Usually, a description of a patient’s thoughts during the interview is subdivided into (at least) 2 categories: a description of the patient’s thought process, and the content of their thoughts

17. Suicidal ideation Death wishes Homicidal ideation Depressive cognition Obsessions Ruminations Phobias Paranoid ideation Magical ideation Delusions Overvalued ideas Thought Content Description of what the patient is thinking about

18. Thought process • Describes the manner of organization and formulation of thought. Coherent thought is clear, easy to follow, and logical. A disorder of thinking tends to impair this coherence, and any disorder of thinking that affects language, communication or the content of thought is termed a formal thought disorder.

19. Associations Coherence Logic Stream Clang associations Perseveration Neologism Thought blocking Attention Thought Process Description of the way in which the patient thinks

20. Disorders of Thought Process • Circumstantial thought: a lack of goal directedness, incorporating tedious and unnecessary details, with difficulty in arriving at an end point • Tangential thought: a digression from the subject, introducing thoughts that seem unrelated, oblique, and irrelevant • Thought blocking: a sudden cessation in the middle of a sentence at which point a patient cannot recover what has been said • Loose associations: a jumping from one topic to another with no apparent connection between the topics. • perseveration refers the patient's repeating the same response to a variety of questions and topics, with an inability to change his or her responses or to change the topic.

21. Disorders of Thought Process • Neologisms: words that patients make up and are often a condensation of several words that are unintelligible to another person. • Word salad: incomprehensible mixing of meaningless words and phrases. • Clang associations: the connections between thoughts become tenuous, and the patient uses rhyming and punning.

22. Perception • Hallucinations • Illusions • Depersonalization • Derealization • déjà vu • jamais vu

23. Perception • Hallucinations, which are perceptual experiences that have no external stimuli. • Illusion, which is a false impression that results from a real stimulus. • Depersonalization, which is a patients' feelings that he is not himself, that he is strange, or that there is something different about himself that he cannot account for. • Delusions can be defined as false fixed beliefs that have no rational basis in reality, being deemed unacceptable by the patient's culture.

24. Intellect • Global impression: average, above average, below average

25. Insight & Judgment • Refer to complex tasks that require a good deal of cognitive functioning (including conceptual thinking and abstract ability), though intact cognitive functioning alone is not adequate for good judgment and insight. • For example, a patient’s ability to make a particular medical decision requires both insight into their specific malady, as well as the judgment to weigh alternatives in the service of arriving at an appropriate decision.

26. The Cognitive Exam • Cognition refers to the ability to use the higher cortical functions: thinking, logic, reasoning, and to communicate these thoughts to others. • 1. Consciousness • 2. Orientation • 3. Attention and Concentration • 4. Memory • 5. Visuospatial ability • 6. Abstractions and conceptualization.

27. The Cognitive Exam • Consciousness may range from normal alertness to stupor and coma. • Orientation refers to the ability to understand one’s situation in space and time. Generally, orientation to place and time is tested. • Attention and Concentration. Attention refers to the ability to focus and direct one’s cognitive in a physiologically aroused state. Concentration refers to the ability to maintain attention for a period.

28. The Cognitive Exam • Memory refer to the process of learning involving the registering of information, the storage of that information, and the ability to retrieve the information later.

29. The Cognitive Exam • Memory is divided into registration, short-term memory, and long-term memory. • Registration refers to the ability to repeat information immediately • Short-term memory refers to the storage of information beyond the immediate (registration) period, but prior to the consolidation of memory into long-term memory. • Long-term memory is usually divided into procedural and declarative memory. Procedural memory refers to the ability to remember a specific set of skills. Declarative memory refers to the retention of data or facts, which can be verbal or nonverbal (i.e., sounds, images).

30. Visuospatial ability • Constructional Ability refers to the ability to recognize the relationship of different objects in the world. • The Folstein Mini Mental Status examination includes a constructional task in which a person is asked to draw intersecting pentagrams: a patient is expected both to draw the correct number of sides on both polygons as well as the two intersection points.

31. The Cognitive Exam • Abstraction and Conceptualization refer to higher intellectual functions. Abstraction involves the ability to understand the meanings of words beyond the literal interpretation.

32. Questions?