Approach to Patients with Behavioral and Mental Changes

Reynold A. Wong, MD, FPNA

Mental State Examination

– A template that assists a physician to collate and organize clinical information about a client’s emotional and
cognitive function.
– Based on verbal and non-verbal behavior
– Aims to increase the reliability of the data upon which subsequent diagnoses and case formulation are made.
– Daniel & Crider (2003) an MSE collates information about patient's:
(i) physical
(ii) emotional
(iii) cognitive states
– Presents key features that describes the patient
– Frames the presenting problem within a context of who the patient is
– Description begins with a statement about age, gender, relationship status, referrer and presenting problem
(i.e., the reason for presentation at the service on the particular occasion)
o E.g., “Gill, a 35-year old, single, woman was referred by her medical practitioner who had suggested
treatment for her obesity that was contributing to hypertension.”

PHYSICAL
1. Appearance 3. Motor Activity
2. Behavior
EMOTIONAL
4. Attitude 5. Mood and Affect
COGNITIVE
6. Orientation 10. Attention and Concentration
7. Memory 11. Speech and Language
8. Thought (Form and Content) 12. Perception
9. Insight and Judgment 13. Intelligence and Abstraction

PHYSICAL
1. Appearance - a summary of patient's physical presentation to paint a clear mental portrait
- dress, grooming, facial expression, posture, eye contact, any noteworthy aspect of appearance

2. Behavior
May make reference to:
– Level of consciousness: alert, drowsy, clouding of consciousness, stupor (lack of reaction to
environmental stimuli) and delirium (bewildered, confused, restless, and disoriented), coma
(unconsciousness)
– Degree of arousal (e.g., hypervigilance to environmental cues and hyperarousal such as observed in
anxious and manic states)
– Mannerisms (e.g., tics and compulsions)

3. Motor Activity
Describes both the quality and the type of actions observed
– reduction in the overall level of movement (psychomotor retardation)
– increase in the overall level of movement (psychomotor agitation)
– slowed movement (bradykinesia)
– decreased movement (hypokinesia)
– absence of movement (akinesia)
– tremors
EMOTIONAL
4. Attitude
– Description: open, friendly, cooperative, willing, and responsive or closed, guarded, hostile, suspicious, passive
– Describes also attentiveness, responses to questions, expression, posture, eye contact, tone of voice

5. Mood and Affect

 Affect (an external expression of an emotional state) is potentially observable
 Mood (internal emotional experience that influences perception of the world and behavioral responses)
Terms: euphoric, dysphoric, hostile, apprehensive, fearful, anxious, suspicious
– Stability of mood can also be noted, with shifting between extreme emotional states being referred to
as emotional lability

 Affect
Range, intensity, and variability of affect can be variously portrayed:
– Restricted (i.e., low intensity or range of emotional expression)
– Blunted (i.e., severe declines in range and intensity of emotional range and expression)
– Flat (i.e., absence of emotional expression,)
– Exaggerated (i.e., an overly strong emotional reaction)
Appropriateness (expression is congruent with verbal descriptions and behavior)

COGNITIVE
6. Orientation
Awareness of time, place, and person
– Orientation for time: patient’s ability to indicate the current day and date (with acceptance of an error
of a couple of days)
– Orientation for place: behavior should also be consistent with that expected in the setting in which they
have arrived
– Orientation for person: ability to know who you are, which can be assessed by asking the patient their
name and about the names of family members or friends.

7. Attention and Concentration

 Working memory (Baddeley, 1986; 1990), term now used in psychology to refer to the constructs called
attention and concentration.
 To describe the extent to which a client is able to focus their cognitive processes upon a given target and not
be distracted by non-target stimuli
 Tests:

– Digit span (the ability to recall in forward- or reverse- order increasingly long series of numbers
presented at a rate of one per second)
– Normal individuals will recall around 6-8 numbers in digits forward and 5-6 in digits backwards
– “Serial sevens” in which seven is sequentially subtracted from 100. Typically people will make only a
couple of errors in 14 trials.

8. Memory
 Recent or short-term memory
– ask about a recent topic/event or who the President or Prime Minister is
– listen to three words, repeat them, and then recall them some time later in the interview. Most people
will usually report 2-3 words after a 20-minute interval
 Visual short-term memory
– copy and then reproduce from memory complex geometrical figures
 Long-term memory can be assessed by asking about childhood events.
9. Thought (Form and Content)
 Forms of thought: are evident in terms of
– (i) Quantity and speed of thought production
– (ii) Continuity of ideas (circumstantiality or tangentiality) or may perseverate with the same idea, word,
or phrase
– They may show a loosening of associations, where the logical connections between thoughts are
esoteric or bizarre.
 Content of thought:
– Delusions are profound disturbances in thought content in which the client continues to hold on to a
false belief despite objective contradictory evidence, despite other members of their culture are not
sharing the same belief.
 Persecutory (others are deliberately trying to wrong, harm, or conspire against another)
 Grandiose (an exaggerated sense of one’s own importance, power, or significance)
 Somatic (physical sensations or medical problems)
 Reference (belief that otherwise innocuous events or actions refer specifically to the individual)
 Control, influence and passivity (belief that thoughts, feelings, impulses, and actions are
controlled by an external agency or force)
 Nihilistic (belief that self or part of self, others, or the world does not exist)
 Jealous (unreasonable belief that a partner is unfaithful)
 Religious (false belief that the person has a special link with God)
– More frequent issues:
 Phobias (excessive and irrational fears)
 Obsessions (repetitive, and intrusive thoughts, images, or impulses)
 Preoccupations (e.g., with illness or symptoms)

10. Perception
 Hallucination
– A perceptual disturbance in which people have an internally generated sensory experience, so that they
hear, see (visual), feel (tactile), taste (gustatory), or smell (olfactory) something that is not present or
detectible by others
– The most frequent hallucinations are auditory and typically involve hearing voices, calling, commanding,
commenting, insulting, or criticizing
– Hallucinations can also occur when falling asleep (hypnagogic) or when awakening (hypnopompic).
– Other perceptual disturbances include:
 external world is unreal, different, or unfamiliar (derealization)
 self is different or unreal in that the individual may feel unreal, that the body is distorted or being
perceived from a distance (depersonalization)
– Perceptions can also be dulled or heightened

11. Insight and Judgment

Insight
 A dimension that describes the extent to which clients are aware that they have a problem
– A strong lack of insight can be an important indicator of unwillingness to accept treatment
– Insight refers also to an awareness of the nature and extent of the problem, the effects of their problem
on others, and how it is a departure from normal
Judgment
 The ability to make sound decisions
 Can be compromised for a number of reasons
– Poor decisions are the result of problems in the cognitive processes involved in the decision making
process, motivational issues, or failures to execute a planned course of action
12. Speech and Language
Speech
 Described in terms of:
– Rate (e.g., slow, rapid)
– Intonation (e.g., monotonous)
– Spontaneity
– Articulation
– Volume
– Quantity of information conveyed
 Mutism (i.e., absence of speech)
 Poverty of speech (i.e., reduced spontaneous speech)
 Pressured speech (i.e., rapid speech that is hard to interrupt and understand)
Language
 Includes reading, writing, and comprehension
 Disturbances such as aphasia
– Non-fluent aphasia, in which speech is slow, faltering, or effortful)
– Fluent aphasia speech is normal in terms of its form (rhythm, quantity, and intonation), but is a
meaningless perhaps including novel words (i.e., neologisms).

13. Intelligence and Abstraction

Intelligence
 Can be gained from the amount of schooling a person has had:
– failure to complete high school indicating below average
– completion of high school indicating average intelligence
– college or university education indicating high intelligence
Abstraction
– The ability to recognize and comprehend abstract relationships
– To extract common characteristics from a group of objects (e.g., in what way is an apple/banana or
music/sculpture alike?), interpretation (e.g., explaining a proverb).

VERSIONS OF MSE
● Mini Mental State Exam (Folstein, et al., 1975)
– 11-items, measures orientation, registration, attention & calculation, recall, language, and praxis
– Scores ranges from 0-30 and lower scores indicate greater impairment
– less sensitive for cases with milder impairment
– scores influenced by educational level
● Cognitive Capacity Screening Examination (CCSE; Jacobs, et al., 1977)
– 30-item screener to detect diffuse organic disorders; more appropriate for cognitively intact individuals
● High Sensitivity Cognitive Screen (HSCS; Faust & Fogel, 1989)
– 15-item scale; valid and reliable indicator of cognitive impairment
● Mental Status Questionnaire (MSQ; Kahn, et al., 1960)
– 10-item scale that shares the same weaknesses as MMSE but omits some key domains of function (e.g.,
retention and registration)
● Short Portable Mental Status Questionnaire (SPMSQ; Pfeiffer, 1975)
– 10-item scale for community or institutional residents; reliable indicator of organicity.