mental status exam descriptors

3 min read 15-01-2025

The mental status exam (MSE) is a cornerstone of psychiatric evaluation. It's a systematic assessment of a patient's cognitive and emotional state at a specific point in time. Accurate MSE documentation relies heavily on precise descriptors. This guide provides a comprehensive overview of key descriptors used in various aspects of the MSE.

I. Appearance and Behavior

This section describes the patient's observable characteristics.

A. Appearance

Descriptors for Grooming and Hygiene: Well-groomed, disheveled, unkempt, neglectful, meticulously groomed, appropriate to the season, inappropriate to the season, clean, dirty, etc. Note any unusual features like tattoos or piercings.
Descriptors for Attire: Neatly dressed, inappropriately dressed (e.g., wearing heavy clothing in summer), revealing clothing, tattered clothing, etc. Consider cultural context.
Descriptors for Posture: Slumped, rigid, erect, tense, relaxed, guarded. Note any unusual postures or mannerisms.
Descriptors for Motor Activity: Restless, agitated, lethargic, catatonic (stupor, waxy flexibility), akathisia (inner restlessness), psychomotor retardation, tremors, tics.

B. Behavior

Descriptors for Demeanor: Cooperative, uncooperative, guarded, suspicious, hostile, aggressive, anxious, withdrawn, friendly, apathetic, euphoric, labile (rapid mood swings).
Descriptors for Eye Contact: Good, poor, absent, fleeting, intense, avoiding. Consider cultural norms.
Descriptors for Speech: Pressured (rapid, difficult to interrupt), hesitant, slow, mumbled, slurred, loud, soft, clear, incoherent, dysarthric (difficulty articulating).
Descriptors for Affect: Observe the outward expression of emotion. Descriptors include: appropriate, inappropriate, constricted (limited range), blunted (severely reduced), flat (absence of emotional expression), labile (rapid shifts), euthymic (normal mood), elevated (excessive happiness), depressed, anxious, irritable. Note the intensity and stability of the affect.

II. Mood and Affect

This section distinguishes between mood (the patient's subjective emotional state) and affect (the observable expression of mood).

A. Mood

Descriptors for Mood: Depressed, euphoric, anxious, irritable, angry, apathetic, guilty, ashamed, hopeless, empty, fearful, elated, expansive. Use the patient's own words when possible.
Intensity: Mild, moderate, severe.
Duration: Transient, fluctuating, persistent.

B. Affect (already discussed above in Appearance and Behavior)

III. Thought Process and Content

This section assesses how the patient thinks and what they think about.

A. Thought Process

Descriptors for Thought Process: Linear (logical and goal-directed), circumstantial (includes unnecessary detail but eventually reaches the point), tangential (never reaches the point), loose associations (thoughts shift abruptly), flight of ideas (rapid, continuous shifts), thought blocking (sudden interruption of thought), perseveration (repetitive thoughts or phrases), derailment (shifting to unrelated topics).

B. Thought Content

Descriptors for Thought Content: Delusions (fixed, false beliefs), obsessions (recurrent, intrusive thoughts), suicidal ideation (thoughts of self-harm), homicidal ideation (thoughts of harming others), paranoia (suspiciousness and distrust), hallucinations (sensory perceptions without external stimuli), phobias (excessive fears), ruminations (repetitive negative thoughts), preoccupations (persistent focus on specific thoughts), nihilistic delusions (belief that nothing exists), grandiose delusions (exaggerated sense of self-importance). Specify the content of delusions or obsessions.

IV. Cognitive Function

This section assesses various aspects of cognitive ability.

A. Orientation

Descriptors for Orientation: Oriented to person, place, time, and situation (Ox4). Specify any deficits (e.g., disoriented to time).

B. Memory

Descriptors for Memory: Assess immediate recall (repeat a series of numbers), short-term memory (recall information after a brief delay), long-term memory (recall events from the past). Descriptors include intact, impaired, recent memory loss, remote memory loss, anterograde amnesia (inability to form new memories), retrograde amnesia (inability to recall past memories).

C. Attention and Concentration

Descriptors for Attention and Concentration: Assess using tasks such as serial 7s subtraction, spelling "WORLD" backward, digit span. Descriptors include: intact, impaired, distractible, difficulty concentrating.

D. Language

Descriptors for Language: Assess fluency, comprehension, repetition, naming, reading, and writing. Note any aphasias (language disorders).

E. Executive Functioning

Descriptors for Executive Functioning: Assess higher-order cognitive abilities such as planning, problem-solving, abstract thinking, judgment, insight. Use tasks like proverbs interpretation, set-shifting tasks. Descriptors include intact, impaired, poor judgment, poor insight.

V. Insight and Judgment

This section assesses the patient's awareness of their illness and their ability to make sound decisions.

A. Insight

Descriptors for Insight: Complete insight (full awareness of illness), partial insight (some awareness but denial of severity), poor insight (minimal awareness), no insight (complete lack of awareness).

B. Judgment

Descriptors for Judgment: Good, poor, impaired. Assess based on the patient's responses to hypothetical situations or their recent decision-making.

VI. Risk Assessment

This is a crucial part of the MSE, assessing potential risks to the patient or others. This often involves specific questions and is documented separately.

This guide provides a comprehensive list of descriptors. Remember to always document observations objectively and avoid making interpretations. Use precise language and quantify observations whenever possible. The specific descriptors used will vary depending on the patient and the clinical context. Always refer to your clinical training and institutional guidelines for appropriate documentation practices.