The mental status exam can serve as the basis for diagnosis and provide a foundation for the dynamic understanding of the client’s current level of psychological and emotional functioning.
By definition, the mental status gleans information on the immediate and current level of an individuals functioning at the time of the interview. It should be conducted with sensitivity and respect for the individual. Much of the information can be gained though natural observation and sensitive inquiry into the individual’s difficulties. Some of information must be directly requested and ideally, will naturally flow with the interview.
In the last several installments, we have been focusing on schizophrenia. Now we turn to integrating the mental status exam (MSE) with the assessment of schizophrenia. This discussion will cover the following areas of the MSE: Appearance-Behavior and Attitude, Characteristics of Speech, Mood and Affects, Orientation and Intellectual Ability, Memory, Thought Processes/Content, Hallucinations, Insight, Impulse Control.
To illustrate the important areas of the MSE, we will look at some clinical vignettes and apply the MSE to the examples.
You see a woman in the intake department of a psych hospital. She wears wrinkled clothing and has one missing stocking. Her hair is unkempt. She has trouble sitting still, almost violently shakes her leg and holds her hands up as if making a box in the air. She seems fearful and accuses you of having a gun when you open a desk drawer to get a pencil.
Much important information can be gained from simple observation. The following are suggestions for areas to consider in conducting the MSE. However, the descriptions in this article are not exhaustive and the areas described are more involved and detailed. Many publications and texts give very good descriptions of the MSE and different professionals need to decide what works best for them.
1) Appearance: Acutely psychotic individuals generally do not pay much attention to attire, grooming or hygiene. They may be disheveled and odiferous (unless family has taken the responsibility). This woman is generally unkempt and oddly dressed. Unless there is a good reason for the missing stocking, this could indicate significant confusion.
2) Excessive motor activity and odd mannerisms that are repeated over and over may indicate agitation or extreme disorganization (think about Disorganized Subtype). Alternatively, the individual may be rigid in posture (catatonic rigidity) or exhibit waxy flexibility (limbs can be moved into any position and will remain for extended periods of time). The latter is suggestive of Catatonic Subtype. One should also look for unusual motoric activity (parkinsonian tremors, etc)
3) Interpersonal behavior: This woman exhibits fear and paranoia. Since it may not be so apparent in all cases, asking if the individual is ever “frightened or worried that someone will hurt her” or “concerned that people are sometimes watching her” is a good way to determine level of paranoid ideation. Observing her way of engaging you and your countertransference reaction can lead to better understanding of general interpersonal relationships as well as mood, level of dangerousness, motivation, etc. Other important observations include:
4) Facial Expression: Facial expression may give important clues as to emotional expression or lack thereof, mood affect, level of fear, etc.
5) General behavior: In this case, the woman before you is quite agitated (violent shaking of her leg). This appears to be indicative of agitation. However, gait problems, ticks, or lethargy and somnolence should be noted.
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