August 7, 2023
Carlene MacMillan, M.D.
I still vividly remember my days as a medical student, especially those spent under the mentorship of my senior psychiatry residents. The prospect of conducting a comprehensive psychiatric assessment felt daunting, especially the mental status exam section.
Whether you’re a newcomer just starting your journey or an experienced professional, this guide is designed to be an invaluable resource.
A Mental Status Exam, often referred to as MSE, is a crucial component of any psychiatric assessment. It involves a systematic collection and observation of data, which helps to identify various psychiatric disorders and guide treatment planning.
The length of an MSE can vary depending on several factors. These include the complexity of the patient's condition, the context of the assessment, and the clinician's individual style. However, a thorough MSE should succinctly cover all the mnemonic components detailed below. The write-up may span a few paragraphs to a full page, depending on the amount of detail necessary to accurately capture the patient's mental status.
The mnemonic to remember is "Good Mental Status Exams Must Assess Thought Process and Content ?" This tool is simple yet profoundly effective, aiding in a systematic and thorough assessment of a patient's mental status.
Here's the breakdown:
G for General Appearance and Behavior - Start by observing the patient’s overall demeanor. Assess aspects like their dressing, hygiene, posture, and any notable behaviors. These observations can provide valuable insights into the patient's self-care and potentially indicate conditions such as depression, mania or psychosis.
M for Motor Activity - Next, focus on the patient's psychomotor activity. Are their movements slow, agitated, or restless? Are there any repetitive, purposeless movements or signs of akathisia? Observations here can help identify conditions like depression, anxiety, ADHD or side effects of certain medications like antipsychotics.
S for Speech - Pay attention to the patient's speech. Is it slow or rapid, monotonous or fluctuating? Is their speech clear, or do they exhibit any slurring, stammering, or other speech disorders? The speech can provide hints about various conditions such as mania (rapid, pressured speech) or depression (slow, monotonous speech).
E for Eye Contact - Evaluate the patient's eye contact, which can convey a lot about their mental state. Avoidance of eye contact could signal social anxiety, autism, or paranoia, while excessive or inappropriate eye contact could suggest mania or certain personality disorders.
M for Mood - Ask the patient about their feelings. Their self-reported emotional state can provide a lot of insight into their current mental condition. Remember, moods can fluctuate, and this provides a snapshot of their emotional state at the time of the interview. Describe the mood using the patient’s own words.
A for Affect - While mood is a subjective experience, affect is its external expression. Assess it through the patient's facial expressions, tone of voice, and body language. Affect is described in terms of range (restricted, broad), intensity (blunted, intense), and appropriateness to the context.
T for Thought Content - Document what the patient is thinking about. Ask about any delusions or other psychotic material like hallucinations, phobias, obsessions, and suicidal and homicidal or violent ideation. Document if there is any future orientation that is elaborated on. These discussions can provide clues about mental illnesses like schizophrenia, depression, and anxiety disorders.
P for Thought Process - Here, assess how a patient's thoughts are organized and linked together. Are their thoughts logical, coherent, and goal-directed? Or do they display derailment, tangentiality, or circumstantiality? An illogical or disorganized thought process could indicate conditions like schizophrenia, delirium or mania.
C for Cognition - Evaluate the patient's cognitive abilities such as their orientation, memory, concentration, and information processing. This evaluation can help identify conditions like dementia, delirium, or cognitive impairment due to other psychiatric conditions.
? for Insight & Judgment - Lastly, assess the patient's insight (their understanding of their own mental state and its consequences) and judgment (their ability to make decisions leading to appropriate outcomes). Document if there a high levels of impulsivity. Poor insight and judgment may suggest serious mental illnesses like schizophrenia, bipolar disorder, or may be seen in cognitive disorders. Document if their insight and judgment is stable, improving or worsening.
This "Good Mental Status Exams Must Assess Thought Process and Content ? mnemonic serves as an anchor, especially in situations where you don't have a template or checklist in front of you. It is a tool that has stuck with me throughout my journey from medical student to seasoned psychiatrist, and it remains a critical part of my mental toolkit to this day. Hopefully it can become a crucial part of your toolkit as well!
To provide a clearer picture of how to document a Mental Status Exam in your psychiatry notes, let's consider a fictional patient, "John," who has come in for an evaluation due to concerns about his declining academic performance and increasing social isolation.
Mental Status Exam (MSE)
General Appearance and Behavior (G): John arrived dressed in casual attire, slightly unkempt but appropriate for the weather. Maintained steady posture but seemed disinterested at times.
Motor Activity (M): His movements appeared to be slow. There was no sign of any agitated or repetitive movements.
Speech (S): Speech was monotonous and slow with increased latency at the start of each sentence. Replies were brief and required prompting.
Eye Contact (E): Eye contact was minimal. He frequently looked down or out the window.
Mood (M): When asked about his mood, John reported, "I just feel empty, like nothing really matters anymore."
Affect (A): His affect was restricted and flat, with minimal variation in facial expression or tone of voice.
Thought Content (T): John denied having any hallucinations, delusions, obsessions, or homicidal ideations. He reported frequent feelings of worthlessness and occasional thoughts of 'being better off dead,' but denied any active plans or intent to harm himself. He was future oriented about an upcoming exam he planned to study for.
Thought Process (P): His thoughts seemed coherent and linear.
Cognition (C): John was fully oriented to time, place, and person. He had no difficulty with recall, and his attention and concentration appeared adequate during the interview.
Insight & Judgment (?): John showed good insight into his situation, admitting he hasn't been himself lately and willing to participate in treatment, but felt unsure about how to change his current circumstances. His judgment seemed intact, as evidenced by his decision to seek help despite his feelings of hopelessness and there was no evidence of unusual impulsivity.
This MSE forms an integral part of John's overall psychiatric evaluation and helps in formulating a treatment plan. It's important to note that every patient is unique, and therefore, the MSE should be individualized for each patient's presenting concerns and symptoms.
Be careful about simply carrying forward the same MSE from note to note and take a few moments to document any notable changes. Do not just write “within normal limits” as it is better to provide descriptions of what you have observed. The mnemonic serves as a guide but should be adapted according to the specific context of each patient's assessment.
Documenting the MSE in your notes becomes even smoother with the use of Electronic Health Records (EHR) systems that specialize in mental health, like Osmind.
EHRs like Osmind are equipped with templates based on the very content outlined in our mnemonic, thereby making it easier to ensure a comprehensive mental status examination. Additionally, it helps in streamlining documentation, saving time, and ultimately allowing for better patient care. So, whether you're a seasoned professional or a young resident, remember - an efficient MSE is just a mnemonic and an EHR away!
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