1. The Mental Status Examination
John Sommers-Flanagan University of Montana For free MSE materials, go to: johnsommersflanagan.com

2. Today’s Plan: Why the MSE?
The mental status examination (MSE) has a revered place in psychiatry and medicine
It’s of growing importance to counseling, psychology, and social work
It’s a language we need to be able to use and understand
This day focuses on the basic components of a psychiatric mental status examination

3. Today’s Plan: Learning Objectives
Get comfortable with the MSE terminology
List and define the nine “psychiatric domains”
Practice collecting, analyzing, and reporting data from each of the nine domains
Describe cultural and other validity problems

4. What Is a Mental Status Examination?
The mental status examination (MSE) is an assessment procedure
It is a semi-structured interviewing used to organize clinical observations pertaining to mental condition
The primary purpose is to evaluate current cognitive processes (how’s your brain?)

5. MSE – Medical Perspective
0:00 – 9:22

6. What Is a Mental Status Examination? II
Two types: Psychiatric and neurological
Two approaches: Formal and informal
It’s very common to medical settings
It results in one medium-length paragraph describing the client’s mental status

7. Sample MSE Report Let’s read this together and analyze it
Gary Sparrow, a 48-year-old heterosexual White male, was disheveled and unkempt upon arriving at the hospital emergency room. He wore dirty khaki pants, an unbuttoned golf shirt, and white shoes. He appeared slightly younger than his stated age. He looked agitated, frequently standing up and changing seats. He was impatient and sometimes rude. Mr. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15”).

8. Sample MSE Report (cont.)
His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Sparrow described grandiose delusions regarding his sexual and athletic performances. He reported auditory hallucinations (God had told him to quit his job to become a professional golfer). He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Mr. Sparrow was unreliable and had poor judgment. Insight was absent.

9. Assessment in a Nutshell
Assessment is judgment
It is an effort to know something about someone else
It is an effort to know something that is true and accurate/consistent about someone (valid and reliable)
The MSE is a particular assessment approach

10. Assessment in a Nutshell
Every effort to know the truth about someone else falls short Including the MSE
Therefore, although assessment is important, we should always be humble and collaborative in our assessment process and in reporting outcomes

11. Let’s Practice Volunteer for Mini Mental Status John administers
You all observe
Then you report in your observations and interpretations

12. What Was Your Assessment?
Observations
Hypotheses
Interpretations

13. Case Example I
You’re working with an 11-year-old girl. She has atrocious hygiene. She’s bullied. In your first 5 minutes you have her draw-a-person and she includes a penis:
Observations?
Hypotheses?
Interpretations or inferences?

14. Case Example II
You’re working with a 14-year-old boy. He got caught setting fires. He got caught throwing cats out an upstairs window. He has enuresis. You meet with him and he’s charming.
Observations?
Hypotheses?
Interpretations or inferences?

15. Case Example III
In The mental status examination and brief social history in clinical psychology Smith (2011) wrote:
A Fu-Manchu mustache suggests the wearer doesn’t mind being thought of as “bad,” whereas a handlebar mustache tells you the person may be somewhat of a dandy or narcissist. (p. 4)

16. Case Example IV He also wrote:
“If the person is unshaven, this may be a sign of depression, alcoholism, or other poor ability at social adaptation” (p. 4)
What mistake is he making?

17. Individual and Cultural Considerations
Thinking about Objectivity
Total objectivity is impossible
Your mood and beliefs can interfere with or help with your objective mental status evaluations
Be sure to keep your emotional sensitivity in your MSE process

18. Individual and Cultural Considerations II
Keep in mind the many ways individuals vary in their behavior and abilities
Normal behavior within one culture, may appear disturbed or irrational within another culture

19. The Danger of Single Symptom Generalization
What are some common single symptoms (other than type of mustache) that clinicians might be prone to overinterpret?
Do you have any particular biases about this?
Why is it so easy to be overconfident in our judgments?

20. Three Guidelines
When you spot a single symptom of interest, begin scientific-mindedness
Remember: Hypotheses are not conclusions
Don’t make wild inferential leaps without consulting first

21. Chinua Achebe (1994)
“After the singing the interpreter spoke about the Son of God whose name was Jesu Kristi. Okonkwo, who only stayed in the hope that it might come to chasing the men out of the village or whipping them, now said:

22. Chinua Achebe (1994)
“You told us with your own mouth that there was only one god. Now you talk about his son. He must also have a wife, then.” The crowd agreed.
“I did not say He had a wife,” said the interpreter, somewhat lamely . . .
The missionary ignored him and went on to talk about the Holy Trinity. At the end of it Okonkwo was fully convinced that the man was mad. (pp. 146–147)

23. 5 Minute Discussion
Consider the excerpt from the novel “Things Fall Apart”
What are your thoughts on how the author depicts Christianity as appearing “mad” to a native African?
Are there any religious or spiritual or cultural beliefs that you would consider “mad?”

24. Mini Mental State
Admin to each other and debrief

25. The Generic MSE Appearance Behavior/psychomotor activity
Attitude toward the examiner
Affect and mood
Speech and thought
Perceptual disturbances
Orientation and consciousness
Memory and intelligence
Reliability, judgment, and insight

26. Watch Carl Video
Use the MSE form to make notes in each category

27. Appearance Appearance in a MSE focuses on physical characteristics
Grooming
Dress
Make-up
Facial expressions
Weight/height
Body piercing/tattoos
Others?

28. Video Clip
Thom or Michele

29. Sample Appearance Description
Maxine Kane, a 49-year-old single, self-referred, Australian American female, appeared much younger than her stated age. She was tall and thin and arrived for the evaluation wearing sunglasses, a miniskirt, spike heels, heavy makeup, and a contemporary bleached-blonde hairstyle.

30. Behavior or Psychomotor Activity
Behavior or Psychomotor Activity in a MSE focuses on physical movement
Excessive or limited movement
Eye contact and eye movement
Grimacing or fidgeting
Gestures
Posture

31. Video Clip

32. Sample Behavior/Psychomotor Activity Description
The client scratched at her legs, back, and stomach throughout the interview. When asked about the scratching, she said “Oh, you wouldn’t believe the mosquito storm I got caught in when I took out the garbage last night. I think I counted 57 bites.”

33. Attitude Toward Examiner (Interviewer)
Attitude Toward the Examiner in a MSE refers to how the client behaves toward the interviewer; examples include:
Cooperative
Hostile
Indifferent
Manipulative
Open
Seductive
Suspicious

34. Video Clip

35. Sample Attitude Toward the Examiner Description
The client’s attitude toward the examiner was hostile as evidenced by (AEB) repeated eye-rolls, sarcastic comments, and intermittent use of the word “duh.”

36. Affect and Mood
Affect and Mood refers to moment-to-moment emotional tone as observed by the interviewer (affect) and the client’s subjective and self-reported mood state
Affect is usually judged in terms of content, range/duration, appropriateness, and depth/intensity
Mood is based on client self-report

37. Affect Content
Angry
Fearful
Sad
Guilty
Joyful
Happy
Surprise

38. Affect Range
Labile
Flat
Constricted
Blunted

39. Affect Appropriateness
Examples:
Possible indicator of:
Schizophrenia
Autism
Other?

40. Affect Intensity

41. Affect Terminology
Euphoric: the client claims omnipotence, exhibits increased psychomotor activity, and has exaggerated gestures).
Labile: the client shifts quickly from tears to laughter
Inappropriate: the client expresses euphoria over job loss and marital separation
Shallow: the client claims to be happy because “I smile” and “smiling takes care of everything”).

42. Video Clip

43. Sample Affect Description I
Throughout the examination, Ms. Brown’s affect was occasionally sad, but often constricted. Her affect was appropriate with respect to the content of her speech.

44. Sample Mood Description I
The client reported, “I feel miserable, unhappy, and Sample Mood Description II: The client’s current mood rating was a 4 on a 0–10 scale. He reported his 2-week low as a 3 and his 2-week high as a 5 and noted this range of 3 to 5 is pretty normal for him. He described his low mood as “irritable” rather than sad. angry most of the time.”

45. Speech and Thought Speech and Thought
Speech is evaluated on the basis of
Rate (speed)
Volume (loudness)
Amount (density)
Thought is evaluated in terms of both process and content

46. Thought Process Thought Process descriptors include: Blocking
Circumstantiality
Clanging
Loose Associations
Neologisms
Perseveration
Word salad

47. Thought Content Thought Content descriptors primarily include:
Delusions (of persecution, grandiosity, etc.)
Obsessions
Suicidal or homicidal thoughts

48. Video Clip

49. Sample Speech and Thought Description
The client’s speech was loud and pressured. Her communication was sometimes incoherent; she exhibited flight of ideas and neologisms as evidenced by her inability to stay on topic and use of words such as “Whaddingy” and “Ordinarrational.” She didn’t respond coherently to questions about obsessions, but appeared preoccupied with the contents of a small notebook.

50. MSE and Culture Activity

51. Perceptual Disturbances
Perceptual Disturbances include hallucinations, illusions, and flashbacks
Hallucinations may occur in any sensory modality, but are most commonly auditory
Illusions have some basis in reality
Flashbacks consist of sudden and vivid sensory-laden recollections of previous experiences

52. Asking About Perceptual Disturbances
Greasing the wheels to help the patient feel comfortable sharing information
Uncovering the logic associated with the delusional material
Determining the client’s insight and how much distance he/she has from the symptom

53. Video Clip

54. Sample Perceptual Disturbances Description
The client spontaneously reported hearing voices in a variety of different settings. These voices usually tell him to “crawl” or “get to your knees” because he is “bad.” He did not report illusions or flashbacks.

55. Orientation and Consciousness
Orientation and Consciousness refers to clients’ awareness of themselves and situation
Clients are evaluated in terms of orientation to person, place, time, and situation
Consciousness is rated from Alert to Comatose

56. Orientation Questions about orientation include:
What is your full name? How old are you? What is your date of birth?
Where are you (i.e., what city or where in a particular building)?
What is today’s date?
What’s happening right now? Or Why are you here?

57. Video Clip

58. Sample Orientation and Consciousness Description
The client’s consciousness was clouded; she was oriented to person (O x 1), but incorrectly identified the year as “1999” instead of 2016 and was unable to identify our location or the purpose of the interview.

59. Memory and Intelligence
It’s risky to assess Memory and Intelligence in a short interview
Only general statements are usually made
Remote, recent, and immediate memory can be assessed
Because intelligence is often based on verbal facility, special care should be taken when working with diverse clients

60. Memory Terminology
Confabulation refers to spontaneous and sometimes repetitive memory fabrication or distortion
When clients acknowledge memory problems it’s referred to as subjective memory complaints
Pseudodementia is used when depressed clients with no organic impairment suffer from emotionally-based memory problems

61. Memory and Concentration
Activity:
Get a partner or small group and practice administering serial sevens and digit span
Based on your experience doing these, identify what factors (other than memory and intelligence) might influence performance

62. Video Clip

63. Sample Memory and Intelligence Description
This client’s intellectual ability is probably at least in the above-average range. He completed serial sevens and other concentration tasks without difficulty. His response to social judgment and abstraction questions were sophisticated and nuanced. His remote, recent, and immediate memory appeared intact.

64. Reliability, Judgment, and Insight
Reliability refers to a client’s credibility or trustworthiness
Judgment involves client ability to make constructive or adaptive choices
Insight refers to the client’s understanding of his/her problems

65. Video Clip

66. Sample Reliability, Judgment, and Insight Description
Overall, this client appeared forthright and reliable. He was open about his drug abuse history and expressed interest in obtaining help. His responses to social judgment questions were positive; he described social relationships based on empathy and rational decision making. His insight and judgment were good.

67. Practice MSE: Longer Form

68. When to Use MSEs
MSEs are more appropriate as the client’s suspected level of psychopathology increases
MSEs must be used with great caution with culturally diverse clients
Like all evaluation procedures, MSEs are culturally biased in one way or another

69. When to Use MSEs
MSEs are more appropriate as the client’s suspected level of psychopathology increases
MSEs must be used with great caution with culturally diverse clients
Like all evaluation procedures, MSEs are culturally biased in one way or another

70. Summary Discussion What felt most important to you from this workshop?
What do you want to remember?
How can you apply the ideas from this workshop into your clinical work?