Components of the Mental Status Examination

THE MENTAL STATUS EXAMINATION

I. Appearance (Observed) - Possible descriptors:
 Gait, posture, clothes, grooming.

Behavior (Observed) - Possible descriptors:

I. Appearance (observed) II.
 Mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow
II. Behavior (observed) commands/requests,compulsions.

III. Attitude (observed) III. Attitude (Observed) - Possible descriptors:

 Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive.
IV. Level of Consciousness (observed)
V. Orientation (inquired) IV. Level of Consciousness (Observed) - Possible descriptors:
 Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating.
VI. Speech and Language (observed)
Orientation (Inquired) – Possible questions for patient:
VII. Mood (inquired) V.
 “What is your full name?”

VIII. Affect (observed)  “Where are we at (floor, building, city, county, and state)?”
 “What is the full date today (date, month, year, day of the week, and season of the year)?”
IX. Thought Process/Form (observed/inquired)  “How would you describe the situation we are in?”

X. Thought Content (observed/inquired) VI. Speech and Language (Observed)

XI. Suicidality and Homicidality (inquired) A. Quantity - Possible descriptors:

 Talkative, spontaneous, expansive, paucity, poverty.
XII. Insight and Judgment (observed/inquired) B. Rate - Possible descriptors:

XIII. Attention Span (observed/inquired)  Fast, slow, normal, pressured.

C. Volume (Tone) - Possible descriptors:
XIV. Memory (observed/inquired)  Loud, soft, monotone, weak, strong.
D. Fluency and Rhythm - Possible descriptors:
XV. Intellectual Functioning (observed/inquired)  Slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic.

VII. Mood (Inquired): A sustained state of inner feeling – Possible questions for patient:
 “How are your spirits?”
 “How are you feeling?”
 “Have you been discouraged/depressed/low/blue lately?”
 “Have you been energized/elated/high/out of control lately?”
 “Have you been angry/irritable/edgy lately?”
VIII. Affect (Observed): An observed expression of inner feeling. - Possible descriptors:
 Appropriateness to situation, consistency with mood, congruency with thought content. XII. Insight and Judgment (Inquired/Observed) – Possible questions for patient:
 Fluctuations: Labile, even.  “What brings you here today?”
 Range: Broad, restricted.  “What seems to be the problem?”
 Intensity: Blunted, flat, normal intensity.  “What do you think is causing your problems?”
 Quality: Sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated,  “How do you understand your problems?”
irritable.
 “How would you describe your role in this situation?”
 “Do you think that these thoughts, moods, perceptions, are abnormal?”
IX. Thought Processes or Thought Form (Inquired/Observed): logic, relevance, organization, flow and coherence
 “How do you plan to get help for this problem?”
ofthought in response to general questioning during the interview. - Possible descriptors:
 “What will you do when occurs?”
 Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing, blocking,
perseveration, neologisms.  “How will you manage if happens?”
 “If you found a stamped, addressed envelope on the street, what would you do with it?”
X. Thought Content (Inquired/Observed) – Possible questions for patient:  “If you were in a movie theater and smelled smoke, what would you do?”
 “What do you think about when you are sad/angry?”
 “What’s been on your mind lately?” XIII. Attention (Inquired/Observed) - Possible descriptors:
 “Do you find yourself ruminating about things?”  Attend, concentration, distractibility.
 “Are there thoughts or images that you have a really difficult time getting out of your head?” A. Digit Span (forward and reverse) - Suggested patient instructions:
 “Are you worried/scared/frightened about something or other?”  “I will recite a series of numbers to you, and then I will ask you to repeat them to me, first forwards
and then backwards.” [Begin with 3 numbers – not consecutive numbers, and advance to 7-8
 “Do you have personal beliefs that are not shared by others?” (Delusions are fixed, false, unshared beliefs.)
numbered sequence.]
 “Do you ever feel detached/removed/changed/different from others around you?”
B. Spelling Backwards - Suggested patient instructions:
 “Do things seem unnatural/unreal to you?”
 “Spell the word ‘world.’ Now spell the word ‘world’ backwards.”
 “What do you think about the reports in papers such as The National Enquirer?”
C. Calculations - Suggested patient instructions:
 “Do you think someone or some group intend to harm you in some way?”
 (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep subtracting 7 from that number as
 [In response to something the patient says] “What do you think they meant by that?” far as you can go.”
 “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into your head? Does  (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3 from that number as far
it ever seem like your own thoughts are broadcast out loud?” as you can go.” [Monitor for speed, accuracy, effort required, and monitor patient reactions to the
request]
 “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile) things that are
not really there, such as voices or visions?” (Hallucinations are false perceptions)  “Add these numbers: (15 + 12 + 7)”
 “Do you sometimes misinterpret real things that are around you, such as muffled noises or shadows?”  “Multiply these numbers: (25 x 6)”
(Illusions are misinterpreted perceptions)
 “If something costs 78 cents and you give the cashier one dollar, how much change should you get
back?”
XI. Suicidality and Homicidality
A. Suicidality – Possible questions for patient:
 “Do you ever feel that life isn’t worth living? Or that you would just as soon be dead?”
 “Have you ever thought of doing away with yourself? If so, how?”
 “What would happen after you were dead?”
B. Homicidality – Possible questions for patient:
 “Do you think about hurting others or getting even with people who have wronged you?”
 “Have you had desires to hurt others? If so, how?”
XIV. Memory (Inquired) References
A. Recent Memory – Possible questions for patient:
 “What is my name?” Tomb DA. Psychiatry for the House Officer. Williams & Wilkins. (1995).
 “What medications did you take today?” American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
American Psychiatric Association Press. (1994).
 “What time was your appointment with me for today?”
Kaplan HI, Saddock BJ. Synopsis of Psychiatry, Eighth Edition, Williams & Wilkins. (1998).
B. Remote Memory – Possible questions for patient:
Scully JH. NMS Psychiatry, Third Edition, Williams & Wilkins. (1996).
 “Where were you when President Kennedy was shot?” (For patients over 40)
Endicott J, Spitzer RL. A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen
 “What is your Social Security number?”
Psychiatry 35:837-844 (1978).
 “What were the dates of your graduation from high school, college, graduate school?”
Nurnberger JI Jr, Blehar MC, Kaufmann CA, York-Cooler C, Simpson SG, Harkavy-Friedman J, Severe JB, Malaspina
 “When and where did you get married?” D, Reich T. Diagnostic interview for genetic studies. Rationale, unique features, and training. NIMH Genetics Initiative.
Arch Gen Psychiatry 51:849-59 (1994).
C. Immediate Memory (also see XIII.-A. above) and New Learning - Suggested patient instructions:
 “I am going to ask you to remember three words (color, object, animal – e.g., blue, table, and horse)
and I will ask you to repeat them to me in 5 minutes. Please repeat them now after me: blue, table,
and horse.” – 5 minutes elapse – “What were those three words I asked you to remember?” [Monitor
accuracy of response, awareness of whether responses are correct, tendency to confabulate or
substitute other words, ability to correct themselves with category clue and multiple choice]. THE CAGE SCREENING TOOL

XV. Intellectual (Inquired/Observed)

A. Information and Vocabulary - Suggested patient instructions:  “Have you ever felt that you should Cut down on your drinking?”
 “Name the last 5 presidents.” (Clinton, Bush, Reagan, Carter, Ford, Nixon, …)  “Have people Annoyed you by criticizing your drinking?”
 “Name 5 of the largest cities in the country.” (New York City, Los Angeles, Chicago, Houston,  “Have you ever felt bad or Guilty about your drinking?”
Philadelphia)
 “Have you ever had a drink first thing in the morning to steady you nerves or get rid of a hangover
 “Name the current president, vice president, governor, and mayor.” (Bill Clinton, Al Gore, George
(Eye-opener)?”
Ryan, Richard M. Daley)
B. Vocabulary - Possible descriptors:
 Scoring: Two or more positive responses correlate with substance abuse.
 Grade school level, high school level, fluent, consistent with education.
C. Abstraction - Possible questions for patient:
1. Similarities – “How are the following items similar?”
 “an apple and an orange” (round ~concrete, fruit ~abstract)
Ewing JA. Detecting alcoholism: The CAGE questionnaire. JAMA 252:1905-1907 (1995)
 “a chair and a table” (made of wood ~concrete, furniture ~abstract)
 “a watch and a ruler” (measurement instruments ~abstract)
2. Proverbs – “How would you describe the meaning of the following sayings?”
 “People living in glass houses should not throw stones.”
 “A bird in the hand is worth two in the bush.”
 “You shouldn’t cry over spilt milk.”
 “Two heads are better than one.”