This page focuses on high-yield clinical aspects of performing the MSE. It also lists specific strategies for assessing children.
Components of MSE
These are the essential/common elements of the Mental Status Exam (MSE) and some examples of terms useful for documentation:
- Appearance: comment on age (actual and apparent), posture, dress (neatly dressed, sloppy), cosmetics ( if excessive), self-care/hygiene(e.g. bizarre, disheveled, sickly, malodorous)
- child: parental care will reflect child's hygiene, appearance;
- Behavior and activity: psychomotor activity: (e.g. restless/rocking/pacing > calm/poised > motionless/slowed/expressionless), unusual motor patterns (posture, tics, stereotypies, catatonia, compulsions, akathisia, dystonia, tremor);
- child: comment on ease of separation from caregiver, spontaneous activity: e.g. started drawing;
- pre-schooler's capacity for joint attention is important in screening for PDDs.
- with infants and toddlers, it's important to comment on caregiver's attunement and responsiveness to child's behavior and emotions.
- Attitude: (confident vs. inhibited/shy, forthcoming/over-sharing vs. guarded or evasive); other useful terms include: cooperative, friendly, attentive, interested, frank, seductive, defensive, apathetic, hostile, playful, ingratiating, childish, superficially cooperative, eager to please;
- child: comment on reaction to meeting clinician, separation from parent, reaction upon being directed/rediirected by the caregiver and by the doctor.
- Speech: comment on rate of speech (slow<average<rapid<pressured); volume, articulation/fluency, amount (few words vs verbose); tone: e.g. angry, pleading, monotonous < expressive/normal < dramatic/theatrical.
- Child: comment on whether speech clarity, vocabulary, and grammar is age-appropriate: e.g. Pt. uses 3-word sentences, 75% understandable;
- Fluency and clarity of speech can be affected by stuttering, cluttering, and speech impediments.
- Mood is a pervasive, sustained emotion that colors person’s perception of the world. One way to assess this is to ask: "How are you feeling now?" or "How is your mood now?" A fair strategy is to use 1-10 scale to track severity and progress of a mood disorder. Some commonly used terms to describe mood: depressed, despairing, angry, expansive, euphoric, empty, guilty, euthymic (non-depressed, reasonably positive mood), self-contemptuous, frightened, etc.
- Affect is patient’s emotional responsiveness during the interview as inferred by the examiner.
- Quality refers to depth, intensity or range of affect; another way to think about is is the amplitude of a feeling state, or the "y-axis" of affect graphical representation. Terms include: flat (none) < blunted (shallow) < constricted (limited) < full < intense; (e.g. affect is blunted in the euthymic range);
- Motility refers to how readily the affect shifts on the "x-axis." Terms include: sluggish < supple < labile. Being "irritable" is a specific manifestation of affect lability.
- Is the affect appropriate to content.
- Is it congruent with mood, speech?
- Modulation is a term sometimes used to describe patient's apparent level of control over his affect. Terms include: over-controlled<normal<labile. Isolation of affect is an extreme form of a over-controlled affect.
- Thought process, speed: Terms include: logical, goal-oriented, linear, loosening of associations, tangentiality (pt. goes off on a tangent), circumstantiality (pt remembers the gist of the question, but takes forever to get to the answer), word salad (rambling, but not making any sense), thought blocking, neologisms; speed can be described as: poverty of thought, long latency, flight of ideas.
- Concrete thought process refers to logical thought process that lacks some capacity for abstract thinking
- Child: Piaget stages of cognitive development can be mentioned here: e.g. age-approprite concrete operational...
- Thought content: mutism, perseveration (poverty of content), delusions (ego-syntonic thoughts, may be intrusive); elaborate on type of delusions (persecutory, grandiose, delusional guilt, ideas of reference (mind control)); obsessions (ego-dystonic intrusive thoughts), phobias, suicidal and homicidal ideations. * Child: magical thinking, night fears may be appropriate.
- Perceptions: hallucinations: type (auditory, visual, tactile), and whether they are mood congruent, illusions, depersonalization experiences. Déjà vu is a feeling of familiarity or having experienced a situation, place or person. Jamais vu describes any familiar situation which is not recognized by the patient.
- Insight: full (intellectual and emotional), fair, poor, denial; defense mechanisms; child: ask about other’s point of view, or theory of mind, especially if you are suspecting PDD; for an adolescent, a fair question to assess insight is: what will make your life come together? A psychiatrist can ask the patient what mental diagnosis has been given to her in the past, and what that means.
- Judgment is patient's capacity to make sound, reasoned and responsible decisions.
- A question of the type "What would you do with a stamped envelope you found on the street?" is often found in textbooks, but may be too rigid and confusing to adequately assess judgement.
- In children, reaction to a false statement, a joke may give an indication of judgement capacity: e.g. a balding male psychiatrist comments on a a 6-year-old girl's colorful braids and states that he used to have braids just like that.
- Sensorium/Cognition/Intellect: Ask a child to name age-appropriate letters, spell, count to x, recite the days of the week, do simple math; assess ability to classify, categorize (‘round fruits’). Piaget stages of cognitive development can be mentioned here: e.g. age-approprite concrete operational...
- Memory: A 3-words recall is a short-term verbal memory test
- A college student may be given longer and more abstract words then the words offered to a 10-year-old.
- Serial 7’s is a test of sustained attention, not of mathematical ability; if subtracting 7's from 100 is challenging, offer the pt. smaller numbers. The idea is for the patient to complete the task without forgetting the initial instructions. Spelling "world" backwards is similarly a test of attention, not spelling.
- To avoid the confounding of mathematical and reading (in-)ability in evaluation of attention, ask patient to recite months of the year, forward and then backwards.
- Child: particularly if suspecting ADHD, comment on sustained activity, need for redirection/repeating, distractibility, goal-directed activity: e.g. child is aimlessly exploring the office, moving from toy to toy, climbing chairs, while brother is sitting on the floor building Legos.