 patient's:

 Appearance
 Speech
 Actions and
 Thoughts during the interview.
 There are no current biological markers to definitively validate
a patient’s symptoms.
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Mental Status Examination (MSE)
 Analogous /comparable to the physical examination
(PE) in physical medicine.
 Cross-sectional
 Like a PE , a MSE should be orderly and systematic.
 Can change from time to time (Unlike history )
 As with a PE the examiner should carry out a
complete MSE for every patient
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MSE…

 Most of the MSE is observational- objectively observed data

 Even when a patient is mute, is incoherent, or refuses to answer
wealth of information can be obtained via observation
 Can be made in the course of taking the history

 Record what is observed than what is inferred

 Observed data are always more reliable than inferred data

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Outline for Mental Status Examination
1. General description(Appearance, Attitude toward Examiner,
Overt Behavior and Psychomotor Activity)
2. Speech
3. Mood and affect
4. Thinking
 Form
 Content

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Outline for MSE…
5. Perceptions
6. Sensorium and cognition
 Alertness
 Orientation (person, place, time)
 Concentration
 Memory (immediate, recent, long term)
 Calculations, Fund of knowledge Abstract reasoning
7. Judgment
8. Insight
9. Physical examination (Medical, Neurological, Psychological, Lab. Ix)
10. Case summary, Dx, Prognosis, Formulation, Rx Plan 5
1. General Description-Appearance:
 Overall physical impression as reflected by posture, poise, gait,
clothing, and grooming, nails, hairs.
 Is the patient overdressed or underdressed?
 Is the patient wearing excessive, garish(colourfull, bright) make-
up?
 Is the patient disheveled, unkempt(untidy appearance), poorly
groomed?
 Common terms: poised(calm and confident), old looking, young
looking, dishevelled, childlike, and bizarre.
 general description of how the patient looks and acts during the
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interview
Appearance…
 Dress: might be untidy ,with buttons undone, or done
incorrectly, worn torn or it might be inadequate for the weather.
 Self neglect:
 Men may appear unshaven, the face may be unwashed, hair
uncombed.
 Women may wear no makeup or they may apply their
makeup carelessly.
 Finger nails might be long and dirty

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Appearance…
 Unusual accessories: patient sometimes pack thier
pockets with their belonging
 carry a large holders of personal possessions or paper
manuscripts
 Gait : Unusually slow, fast, unusual character of gait
gait -A person manner of walking

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Eye Contact
 The degree of eye contact the patient is making during the
interview.
 It could be described as
 Good (adequate),
 Poor (inadequate), or
 “patient avoids eye contact”

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Attitude towards the examiner
 Attitude to wards examiner can be described as:
 Cooperative, Friendly, over familiar
 Contemptuous/disrespectful , perplexed/confuse , suspicious
 Attentive, interested, indifferent
 Frank, seductive
 Defensive, hostile
 playful, evasive/avoidance or escape, guarded

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 Overt Behavior and Psychomotor Activity
 The quantitative & qualitative aspects of the patient’s motor behavior
 Psychomotor agitation Vs. retardation;

 Tics, Tardive Dyskinesia, Posturing, Negativism

 Stereotypes, Mannerism, wringing of hands
 Echopraxia, waxy flexibility,

 Any aimless, purposeless activity, etc…

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2. Speech
 Speed/Rate: fast/rapid, slow, pressured, hesitant, normal
 Volume: Loud/high, Low, Normal
 Quantity: Too little/much, scanty, talkative, copious/plentiful, mute or
normal
 Tone: Low pitched, high pitched
 Quality: prosodic(normal or usual), monotonous, slurred, stuttering,
coherent or not
 Spontaneity: spontaneous Vs non-spontaneous 12
 3. Emotion
 Mood: pervasive and sustained emotional state as described by the
patient (Subjective)
 Ask the patient how he or she feels? Common adjectives used:
 depressed, despairing/hopless, irritable, anxious, angry, expansive,
euphoric, empty, guilty, hopeless, frightened, and perplexed, Sadness,
euthymic,
 Is recorded in verbatim/the same words as used by the pt.:
 “I feel cheerful”
 “I am feeling anxious”
 “I feel good/ normal” 13
Mood…
 Mood is a central human behavior; it describes the way one
feels about oneself, the World and the future.

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Emotion…
 Affect: The patient’s present emotional expression inferred during
the interview (objective)
 Read it/inferred from facial expression of the patient:
 Quality: Smiling, anxious, tearful, apathetic, angry, etc
 Stability: Stable, Labile
 Intensity & range: Normal, constricted, blunted, or flat.
 Appropriateness: Assessed in the context of the subject discussed
May or may not be congruent with mood.
 Affect is often described with the following elements: quality, quantity, range,
appropriateness, and congruence 15
 Appropriateness of affect refers to how the affect correlates to the
setting.
 A patient who is laughing at a solemn moment of a funeral service is
described as having inappropriate affect.
 Affect can also be congruent or incongruent with the patient’s
described mood or thought content.
 A patient may report feeling depressed or describe a depressive theme
but do so with laughter, smiling, and no suggestion of sadness.

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 4. Thought
 Thought form (process)
 Refers to the way ideas are linked, not the ideas themselves.
 Normally thoughts are logically associated and goal directed.
 Flight of ideas, pressure of thought
 Circumstantiality, thought blocking
 Tangentially, loosing of association (derailment)
 Clang association
 Perseveration, Word salad, Neologism
 A patient can have normal thought process with significantly delusional thought 17
 Thought Process( thought form )
 it does not describe what the person is thinking

 Describes how thoughts are formulated, organized, and expressed

 Normal thought process is typically described as linear, organized, and goal directed.
 A patient can have normal thought process with significantly delusional
thought content
 there may be generally normal thought content but significantly impaired
thought process

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 Thought…
 Thought content
 What a person is actually thinking about: ideas, beliefs, obsessions
 Delusions, obsession, compulsion, idea of reference
 Overvalued idea, hopelessness, worthlessness,
 Suicidal/Homicidal ideation, preoccupation
 Phobias; Hypochondriacal symptoms
 Passivity Phenomenon
 Thought--- insertion, withdrawal, Broadcasting, Control, reading

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5. Perception
 Process of becoming aware of what is presented in
sense organ. Perceptual abnormalities include:
 Hallucination
 Illusions
 Depersonalization
 Derealization
 Deja vu
 Jamais vu
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 6. Sensorium and Cognition
A. Alertness and level of consciousness
 Disturbances of consciousness usually indicate organic brain impairment
 Describes the degree of wakefulness. Terms used :
 Alert-wakefulness/ awareness
 Clouding-very mild altered mental status (inattention & ↓ wakefulness)
 Somnolence-sleepy
 Lethargy-drowsiness, aroused by moderate stimuli & drift back to sleep
 Stupor-sleep like state (not unconscious), little/no spontaneous activity
 Coma-cant be aroused/ unresponsiveness, no response to stimuli
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Sensorium and Cognition…
B. Orientation: to time, place ,person.
 Any impairment usually appears in this order:
 sense of time is impaired before sense of place
 as the patient improves, the impairment clears in the
reverse order.
 What is your name? Who am I?
 What place is this? Where is it located?
 What city are we in?
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 Sensorium and Cognition…
C. Memory: The ability to register, store & retrieve information
Immediate/ registration: The ability to register information
 Repeat random numbers (digit span-1, 4, 9, 2, 5) or list of objects
Recent: Ability to remember information registered after 5 min.
 What did you have for breakfast?
Remote: The ability to remember things that happen before 2 wk.
 Asking place of birth?
 What was your address when you were in the third grade/ married?
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Sensorium and Cognition…
D. Concentration and attention
 Attention is the ability to focus
 Concentration is the ability to maintain attention
 Formal assessment:
+ Serial 7s; serial 3s;
+ Reciting days of the week backwards;
+ Reciting months of the year backwards;
+ Spell “WORLD” backwards
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Sensorium and Cognition…
E. Calculation :Ability to manipulate numbers mentally.
 Simple addition, subtraction, or multiplication questions.
F. Fund of knowledge: Questions about current events
 Depend on patient’s educational level
 Who is the current PM of Ethiopia?
 Distance b/n Dilla and your hometown?
G. Abstract thinking: the ability to deal with concepts
 Proverbs, Similarities of two things (Orange and Lamon)
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7. Judgment
 The patient's capability for social judgment:
 Can he/she understand the likely outcome of his/her behavior
 Is he or she influenced by this understanding?
 Predict what to do in imaginary situations (ability to make
rational decisions)
 e.g., smelling smoke in a crowded movie theatre?

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8. Insight
 The pt.'s degree of awareness and understanding about being ill.

1. Complete denial of illness

2. Slight awareness of being sick but denying it at the same time

3. Awareness of being sick but blaming on others, external/organic factors

4. Awareness that illness is caused by something unknown in the pt
5. Intellectual insight: pt's own particular irrational feelings/disturbances

6. True emotional insight:

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9. Further Diagnostic Studies
I. Physical Examination (Medical)
 Vital Signs
 HEENT
 Chest
 CVS
 Abdomen
 GUS
 Integumentary ……

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9. Further Diagnostic Studies…
II. Neurological examination
III.Neuropsychological tests
IV. laboratory tests (EEG, CT-Scan, MRI, Other lab. tests)
 In some institution lab or other investigations are done twice
a. Before settling the Dx to rule out any medical or substance
related conditions
b. After settling the Dx for treatment management (e.g. To choose
medication)
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10. Case summary (Summary of Findings)
 Important findings stated in short in one paragraph.
 Help the audience to remember all important findings.
 Facilitate diagnosis and treatment.
 Very important points from.
 ID
 HPI
 MSE
 Ixs
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Diagnosis
 DSM-IV Multi-Axial Diagnosis
 AXIS I: Clinical diagnoses
 AXIS II: Mental retardation
 Personality disorders
 Defense mechanisms
 AXIS III: Medical disorders
 AXIS IV: Psychosocial stressors
 AXIS V: Global assessment of functioning (GAF)
 DSM-5 non-Axial Diagnosis
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Psychosocial & Environmental Stressors
 Primary support group
 Social environment
 Educational
 Occupational
 Housing
 Economic
 Access to health care services
 Legal, including criminal
 Other 32
Prognosis

 Opinion about the probable future course

 Extent, and outcome of the disorder

 Good and bad prognostic factors

 Specific goals of therapy

33
Psychodynamic Formulation
 An intellectual analysis of findings from the hx, and the dx, to
identify; factors affecting the illness in good or bad way.
 Factors can be; Biological, Psychological or Social
 Bio-Psycho-Social Formulation
 These Factors can be Expressed in terms of:
 Predisposing
 precipitating
 perpetuating
 protective
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Formulation biopsychosocial
Biological psychological Social

Predisposing

precipitating

perpetuating

protective
Comprehensive Treatment Plan (Management)
 Is managing the patient properly with appropriate follow up
 Decide either Inpatient/outpatient Rx and duration of therapy.
 Modalities of treatment recommended:
 Medication: symptoms/problems should be defined.
 Psychotherapy: individual, group, or family therapy
 Initially, treatment must be directed toward:
 Any life-threatening situations such as
 suicidal risk or risk of danger to others (Hospitalization)

36
Progress Note
 Is a note following the evaluation of the patient after starting
your management
 Focuses on pertinent positives and their change with the
intervention
 Then follow evaluation and revision of plan
 Do not forget to assess; Suicide, Substance, Sleep and appetite,
appropriate use of the drug and Side effects
 P-S-O-A-P??
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Sample Video
 ..\Mania.FLV

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