This document provides an overview of conducting a comprehensive mental status exam (MSE). It discusses the purpose and uses of an MSE in estimating a client's functioning. The MSE assesses general description, emotion, thought, cognition, judgment and insight. It also discusses factors that may affect findings, ways to conduct an MSE through interviewing and specific tasks, and screening tools that can be used. Common areas assessed include appearance, speech, mood, affect, thought process and content, suicidal ideation, orientation, memory, and insight. The document emphasizes the importance of rapport building and directly asking about suicidal thoughts.

1. NRS208:
Health Assessment
Comprehensive Mental Status EXAM
The Foundation of the Mental Health Assessment
Teresa Chahine RN, MSN, PMHNP-BC
Oakland University, School of Nursing

2. Purpose
Provides an estimate on the quality of client’s
functioning

3. Uses
Estimate functioning to determine need for further
testing
Estimate functioning to determine treatment needs
Assess progress when functioning has declined in an
emergency situation
Periodically assess insidious decline in functioning
(e.g., dementias)

4. Overview
General Description
Emotion
Lethality
Thought
Cognition
Judgment and Insight
Reliability

5. What an MSE isn’t
An intelligence test
A detailed memory test
A fully precise measure of cognition, affect, and
behavior

6. Prior to testing . . .
Rapport - building is important in order to obtain the
client’s cooperation and best effort in responding to
the examination

7. Factors That May
Affect Findings
Illnesses or health problems
Current medications or substance use
Depression
Educational and behavioral level
Sensory Perceptual limitations of the aging process

8. Ways to Conduct a MSE
These components are assessed while interviewing
the client about her concerns, circumstances, and
history:
Thought form and content
Nature, expression, and appropriateness of affect
Behavior strengths and weaknesses (or adaptive
behaviors)

9. Ways to Conduct a MSE
These functions may be assessed informally during
the interview, or formally through specific questions
and tasks:
Amnestic functions
Cognitive processing and intellectual functions

10. General Description
Appearance
Motor Behavior
Speech
Attitudes

11. General Description
Appearance
Prominent features
"such that a portrait…”
Eye contact
Dress and grooming
Age/appearance

12. General Description
Motor Behavior
Gait
Freedom of movement
Firmness and strength of handshake
Any involuntary or abnormal movements
Pace of movements
Purposefulness of movements
Degrees of agitation

13. General Description
Speech
Rate
Spontaneity
Intonation
Volume
Defects

14. General Description
Attitudes
How the patient related
"degree of cooperativeness“
Evaluator’s attitude

15. Mood
Definition
Patient report versus inference

16. Emotion
Affect
Definition

17. Assessment of Affect
Range of affect:
Restricted
Dull
Blunted versus flat
labile

18. Predominant Affect
Describes the types of affect exhibited during
interview, verbal and nonverbal
Can exhibit more than one emotion during
examination

19. Thought
Process
Content
Perceptions

20. Thought
Process
Manner of organization and formulation of thought
Stream of Thought
Goal directedness/Continuity
Other Abnormalities of Thought Process
Connectedness/Organization
Circumstantiality
Tangentiality
Loose Association
Word Salad

21. Assessing Thought
Form
Blocking
Confusion/delirium
Confabulation
Poverty of speech
Flat speech

22. Thought
Content
Perceptual disturbances
Delusions
Other

23. Content of Thought
What are pervasive themes or ideas in client’s
thoughts, such as:
Hopeless thinking
Helpless thinking
Blaming/abdication of responsibility
Negativistic thinking
(Cleopatra Syndrome (queen of denial)
Positive thoughts

24. Lethality
Self Harm
Assaultive Behavior
Destruction to Property
Please give specific examples and quote client’s
statements.

25. ASK EVERY CLIENT IN EVERY INITIAL INTERVIEW ABOUT
SUICIDAL THOUGHTS, FEELINGS OR ACTIONS
Acutely suicidal feelings are usually temporary, and it is our
job to help get clients through crisis periods.
Suicide

26. Suicide is the 11th leading cause of death in the U.S., with 11
deaths per 100,000 caused by suicide
8-25 attempts take place for each completed suicide
4 times as many men complete suicide as women; women
attempt more
Men use more certainly lethal methods, particularly
firearms
Non-Hispanic whites and Native Americans have the
highest suicide rates
Blacks, Asian/Pacific Islanders, and Hispanics have the
lowest rates
(NIMH, 2009)
Suicide

27. Talking about suicide WILL NOT incite it
NOT talking about suicide could cause you to miss the
chance to prevent it
People who are having suicidal thoughts WILL usually tell
someone, especially if asked directly
Directly ask client, “Have you ever had thoughts about
hurting yourself?”
Suicide

28. If you’re concerned a client is suicidal, assess for the
following risk factors:
Diagnosis
Dx that includes depressive or intensely anxious mood
(MDD, Bipolar in a depressive episode, PTSD)
Dx that includes impulsivity, poor judgment, antisocial or
suicidal tendencies (Borderline, substance abuse,
Antisocial Personality, binging anorexia, gambling)
Mental Status Exam
Do a current, direct assessment: ask directly, but also
assess indirect signs
Assessing for Suicide Risk

29. Predominant Mood
Depressed
Overly calm, especially if it’s a significant change
History
Personal history of attempts
Family history of suicide or attempts
History of psychotic or dissociative Sx (delusions, hallucinations,
depersonalization)
Substance Use
Can be disinhibiting
Can be a sign of severe distress
Assessing for Suicide Risk

30. Determine level of risk of near-term attempt
When did they last have suicidal thoughts?
How often do they have suicidal thoughts?
Is client comfortable with having these thoughts?
Has client attempted before?
If yes, How physically and psychologically serious was client?
Why didn’t it succeed?
Were substances involved?
Does client have a plan? What is level of premeditation?
Does client have means to carry out plan?
Why is client suicidal now?
Assessing for Risk of Suicide
Attempt

31. Take clinical steps to prevent attempt
Alert your supervisor to your concerns
Contract: written or verbal
Increase frequency of contact with you
Alert someone in client’s life to the potential danger
Consider emergency psychiatric evaluation
Consider hospitalization if you feel client won’t be safe
under any other circumstances
Document everything you do scrupulously
Managing Suicidality

32. Content of Thought
Content of thought assessment also includes:
Hallucinations (visual, auditory [including command],
various others)
Delusions (reference, grandeur, persecution, jealousy,
guilt, nihilistic, various others)
Poverty of thought content
Low thought complexity

33. The Cognitive Exam
Consciousness
Orientation
Concentration and attention
Calculations
Memory
Intelligence

34. The Mini-Mental Status
Examination
A brief measure of amnestic and cognitive
processing functions, used to
assess short-term changes in mental functioning in
hospitals
assess changes in cognitive functioning in
emergencies (e.g., injuries on the ball field)
Assess progressive changes in cognitive
functioning in long term care settings
Obtain a “snapshot” of client’s functioning in
outpatient mental health settings
(Folstein, Folstein, & McHugh, 1975)

35. MMSE
MMSE assesses:
Orientation
Short, recent, remote, remote memory
Sustained concentration
Executive functions
Recognition
Registration
Sequencing and organization
Comprehension
Perceptual - motor skills

36. Mental Status Scores
Simple scoring system (point per item)
Scores range from 0 - 30
Scores below 24 indicative of dementia or cognitive
deficit
Lower scores indicate greater deficits
Scores obtained from small sample of Caucasian males
and females from middle US

37. Appropriateness and
Responsiveness
Assess appropriateness of affect to topics discussed
Is client responsive to encouragement? Levity?

38. Behaviors and
Symptoms
Describe behaviors exhibited during the interview
Assess dominant symptoms described by client, even
if you don’t observe them
See “Assessment Report” handout for representative
symptoms
If needed, survey adaptive behaviors

39. Insight
Patient’s capacity to
Acknowledge/Appreciate illness
Associated implications
Consequences

40. Insight
Drugs/alcohol
Dementia/cognitive problems
Psychosis
Severe mood problems
Somatoform disorders

41. Judgement
The process of
Consideration
Formulation
Leading to a
Decision
Action

42. Judgement
Requires
Insight
Cognitive functioning
Other abstract abilities
Conceptualization
Forward thinking
Appreciation of what “rational people” would do.

43. Reliability
Intellect
honesty and motivations
psychosis/organic defects
magnification/understatement

44.  You will probably be able to assess most of the areas covered
in the MSE during the natural course of your interview
without specifically asking
 If you have doubts, ask the client
 Always ask specifically about suicidal/homicidal ideation
 Problems in the areas covered in MSE will usually be fairly
obvious: you are looking for the unusual, the remarkable.
 If you observe something notable, investigate further
 Be as objective as possible. Don’t make judgments as to why
the client is presenting a certain way
Mental Status Exam

45. Screening Tools

46. Screening Tools
Depression- Patient Health Questionnaire-9 (PHQ-9)
Anxiety- Generalized Anxiety Disorder (GAD-7 )
Cognitive- Mini Mental Status Exam (MMSE)
Suicide Risk – SAD PERSONS scale
Alcohol & Substance Use-
Alcohol Use Disorders Identification Test (AUDIT)
CAGE Questionnaire
Alcohol Withdrawal-
Clinical Institute Withdrawal Assessment of Alcohol Scale
(CIWA)

47. CAGE Questionnaire to Assess for
Substance Abuse

48. AUDIT Questionnaire for Alcohol Abuse

49. CIWA Scale
Nausea and Vomiting
Tactile disturbances
Tremor
Auditory Disturbances
Paroxysmal sweats
Visual Disturbances
Anxiety
Headache, Fullness in Head
Agitation
Orientation and clouding of sensorium

50. ALCOHOL WITHDRAWAL
SYNDROME
Acute:
Delirium Tremens
Chronic
Wernicke’s-Korsakoff’s syndrome

51. WERNICKE’S
PSYCHOSIS
Cause: Thiamine deficiency
Onset: Chronic
Other s/sx:
Confusion
Ataxia
Thiamine deficiency

52. KORSAKOFF’S
PSYCHOSIS
Cause: Thiamine and Niacin deficiency
Onset: Chronic
Feature: Memory disturbances (confabulation)
Other s/sx:
Retrograde Amnesia (past)
Anterograde Amnesia (recent)
Thiamine and Niacin deficiency

53. Mnemonics

54. Depression Assessment
Tool
SIGECAPS- Sleep, Interest, Guilt, Energy,
Concentration, Appetite, Psychomotor
activity, Suicidal thoughts.
SADAFACES- Sleep, Appetite, Dysphoric
mood, Anhadonia, Fatigue, Anxiety,
Concentration, Esteem, Suicidal
thoughts.

56. Anxiety Assessment–
AND I C REST

57. END