Tag Archives: mental status examination

The Mental Status Examination: Key Terms and Resources

At first, conducting a mental status examination (MSE) can feel “different” and daunting to non-medical mental health professionals. However, even though the MSE is a modernist medical-psychiatric assessment tool, it’s also possible to conduct MSEs more collaboratively.

To help address a recent listserv request, below, I’ve pasted some Tables from the MSE chapter in Clinical Interviewing. These Tables are not comprehensive, but along with other resources provide relatively good coverage of how and when to administer an MSE and some useful vocabulary words.

In addition to the Tables below, Dr. Thom Field from City University of Seattle has a set of training videos. You can find them here: http://www.thomfield.com/mental-status-exam-training.html

Also, there are several other resources posted on this blog. In fact, the most viewed of all posts on this blog is titled “Two Sample Mental Status Examination Reports” https://johnsommersflanagan.com/2012/08/10/two-sample-mental-status-examination-reports/

In addition, there is a nifty (IMHO) MSE protocol here: https://johnsommersflanagan.com/mental%20status/

And another sample MSE report: https://johnsommersflanagan.com/2012/11/23/another-sample-mental-status-examination-report/

And an interesting post on “Psychic Communications . . . and Cultural Differences in Mental Status” https://johnsommersflanagan.com/2013/01/02/psychic-communications-and-cultural-differences-in-mental-status/

And a short MSE video clip: https://johnsommersflanagan.com/2013/02/28/mental-status-examination-video-clip/

Okay. Enough tangential speech from me. The Tables are below:

Table 8.1. Descriptors of Client Attitude Toward the Examiner
Aggressive: The client attacks the examiner physically or verbally or through grimaces and gestures. The client may “flip off” the examiner or simply say to an examiner something like, “That’s a stupid question” or “Of course I’m feeling angry, can’t you do anything but mimic back to me what I’ve already said?”
Cooperative: The client responds directly to interviewer comments or questions. There is a clear effort to work with the interviewer to gather data or solve problems. Frequent head nods and receptive body posture are common.
Guarded: The client is reluctant to share information about himself. When clients are mildly suspicious they may appear guarded in terms of personal disclosure or affective expression.
Hostile: The client is indirectly nasty or biting. Sarcasm, rolling of the eyes in response to an interviewer comment or question, or staring off into space may represent subtle, or not so subtle, hostility. This behavior pattern can be more common among young clients.
Impatient: The client is on the edge of his seat. The client is not very tolerant of pauses or of times when interviewer speech becomes deliberate. She may make statements about wanting an answer to concerns immediately. There may be associated hostility and competitiveness.
Indifferent: The client’s appearance and movements suggest lack of concern or interest in the interview. The client may yawn, drum fingers, or become distracted by irrelevant details. The client could also be described as apathetic.
Ingratiating: The client is overly solicitous of approval and interviewer reinforcement. He may try to present in an overly positive manner, or may agree with everything the interviewer says. There may be excessive head nodding, eye contact, and smiles.
Intense: The client’s eye contact is constant, or nearly so; the client’s body leans forward and listens closely to the interviewer’s every word. Client voice volume may be loud and voice tone forceful. The client is the opposite of indifferent.
Manipulative: The client tries to use the examiner for his or her own purpose. Examiner statements may be twisted to represent the client’s best interests. Statements such as “His behavior isn’t fair, is it Doctor?” are efforts to solicit agreement and may represent manipulation.
Negativistic: The client opposes virtually everything the examiner says. The client may disagree with reflections, paraphrases, or summaries that appear accurate. The client may refuse to answer questions or be completely silent. This behavior is also called oppositional.
Open: The client openly discusses problems and concerns. The client may also have a positive response to examiner ideas or interpretations.
Passive: The client offers little or no active opposition or participation in the interview. The client may say things like, “Whatever you think.” He may simply sit passively until told what to do or say.
Seductive: The client may move in seductive or suggestive ways. He or she may expose skin or make efforts to be “too close” to or to touch the examiner. The client may make flirtatious and suggestive verbal comments.
Suspicious: The client may repeatedly look around the room (e.g., checking for hidden microphones). Squinting or looking out of the corner of one’s eyes also may be interpreted as suspiciousness. Questions about the examiner’s notes or about why such information is needed may signal suspiciousness.
Table 8.2. Thought Process Descriptors
Blocking: Sudden cessation of speech in the midst of a stream of talk. There is no clear reason for the client to stop talking and little explanation. Blocking may indicate that the client was about to associate to an uncomfortable topic. It also can indicate intrusion of delusional thoughts or hallucinations.
Circumstantiality: Excessive and unnecessary detail provided by the client. Very intellectual people (e.g., college professors) can become circumstantial; they eventually make their point, but don’t do so directly and efficiently. Circumstantiality or overelaboration may be a sign of defensiveness and can be associated with paranoid thinking styles. (It can also simply be a sign the professor was not well-prepared for the lecture.)
Clang Associations: Combining unrelated words or phrases because they have similar sounds. Usually, this is manifest through rhyming or alliteration; for example: “I’m slime, dime, do some mime” or “When I think of my dad, rad, mad, pad, lad, sad.” Some clients who clang are also perseverating (see below). Clanging usually occurs among very disturbed clients (e.g., schizophrenics). As with all psychiatric symptoms, cultural norms may prompt the behavior (e.g., clang associations among rappers is normal).
Flight of Ideas: Speech in which the client’s ideas are fragmented. Usually, an idea is stimulated by either a previous idea or an external event, but the relationship among ideas or ideas and events is weak. In contrast to loose associations (see below), there are logical connections in the client’s thinking. However, unlike circumstantiality (see above), the client never gets to the point. Clients who exhibit flight of ideas often appear over-active or overstimulated (e.g., mania or hypomania). Many normal people exhibit flight of ideas after excessive caffeine intake—including one of the authors.
Loose Associations: Minimal logical connections between thoughts. The thinking process is nearly, but not completely random; for example: “I love you. Bread is the staff of life. Haven’t I seen you in church? I think incest is horrible.” In this example, the client thinks of attraction and love, then of God’s love as expressed through communion, then of church, and then of an incest presentation he heard in church. It may take effort to track the links. Loose associations may indicate schizotypal personality disorder, schizophrenia, or other psychotic or pre-psychotic disorders. Extremely creative people also regularly exhibit loosening of associations, but are able to find a socially acceptable vehicle through which to express their ideas.
Mutism: Virtually total unexpressiveness. There may be signs the client is in contact with others, but these are usually limited. Mutism can indicate autism or schizophrenia, catatonic subtype. Mutism may also be selective in that young clients will be able to speak freely at home, but become mute and apparently unable to speak at school or with professionals (see DSM-5, **).
Neologisms: Client-invented words. They’re often spontaneously and unintentionally created and associated with psychotic disorders; they’re products of the moment rather than of a thoughtful creative process. We’ve heard words such as “slibber” and “temperaturific.” It’s important to check with the client with regard to word meaning and origin. Unusual words may be taken from popular songs, television shows, or a product of combining languages.
Perseveration: Involuntary repetition of a single response or idea. The concept of perseveration applies to speech and/or movement. Perseveration is often associated with brain damage and psychotic disorders. After being told no, teenagers often engage in this behavior, although normal teenagers are being persistent rather than perseverative; that is, if properly motivated, they’re able to stop themselves voluntarily.
Tangential speech: Tangential speech is similar to loose associations, but connections between ideas are even less clear. Tangential speech is different from flight of ideas because flight of ideas involves pressured speech.
Word Salad: A series of unrelated words. Word salad indicates extremely disorganized thinking. Clients who exhibit word salad are incoherent. (See the second half of the preceding “Dear Bill” letter for an example of word salad.)
  Table 8.3. Characteristics of Different Perceptual Disturbances
  Hallucinations Illusions Flashbacks
Definition False sensory experiences Perceptual distortions Sudden and vivid sensory-laden recollections of previous experiences
Diagnostic Relevance Auditory hallucinations are most common and usually associated with schizophrenia, bipolar disorder, or a severe depressive episode Illusions are more common among clients who have vivid imaginations, who believe in the occult, or have other schizotypal personality disorder symptoms Flashbacks are most common among clients with post-traumatic stress disorder
Useful Questions Do you ever hear or see things that other people can’t see or hear?

When and where do you usually see or hear these things (checking for hypnogogic or hypnopompic experiences)?

Does the radio or television ever speak directly to you?

Has anyone been trying to steal your thoughts or read your mind?

What was happening in your surroundings when you saw (or experienced) what you saw (or experienced)?

Did the vision (or image or sounds) come out of nowhere, or was there something happening?

Have you had any similar experiences before in your life?

Sometimes when people have had very hard or bad things happen to them, they keep having those memories come back to them. Does that happen to you?

Was there anything happening that triggered this memory or flashback to the past?

Table 8.4. Mental Status Examination Checklist
Category Observation Hypothesis
Appearance    
Behavior/Psychomotor Activity    
Attitude Toward Examiner    
Affect and Mood    
Speech and Thought    
Perceptual Disturbances    
Orientation and Consciousness    
Memory and Intelligence    
Judgment, Reliability and Insight    

 

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The 6th Edition of Clinical Interviewing is Now Available

Way back in 1990, a university book salesman came by my faculty office at the University of Portland. He was trying to sell me some textbooks. When I balked at what he was offering, he asked, “Do you have any textbook ideas of your own?” I said something like, “Sure” or “As a matter of fact, I do.” He handed me his card and a paper copy of Allyn & Bacon’s proposal guidelines.

Not having ever written a book, I never thought they’d accept my proposal.

They did. But after three years, A & B dropped our text.

Lucky for us.

Two  years later, Rita and I decided to try to resurrect our Clinical Interviewing text. We polished up a proposal, sent it out to three excellent publishers, and immediately got contract offers from W. W. Norton, Guilford, and John Wiley & Sons.

We went with Wiley.

Here we are 18 years later in the 6th edition. It’s been fun and a ton of work. Over the past five years we’ve started recording video clips and interviewing demonstrations to go along with the text. For the 6th edition, we got some pretty fantastic reviews from some pretty fancy (and fantastic) people. Here they are:

“I’m a huge admirer of the authors’ excellent work.  This book reflects their considerable clinical experience and provides great content, engaging writing, and enduring wisdom.”
John C. Norcross, Ph.D., ABPP, Distinguished Professor of Psychology, University of Scranton

“The most recent edition of Clinical Interviewing is simply outstanding.  It not only provides a complete skeletal outline of the interview process in sequential fashion, but fleshes out numerous suggestions, examples, and guidelines in conducting successful and therapeutic interviews.  Well-grounded in the theory, research and practice of clinical relationships, John and Rita Sommers-Flanagan bring to life for readers the real clinical challenges confronting beginning mental health trainees and professionals.  Not only do the authors provide a clear and conceptual description of the interview process from beginning to end, but they identify important areas of required mastery (suicide assessment, mental status exams, diagnosis and treatment electronic interviewing, and work with special populations).  Especially impressive is the authors’ ability to integrate cultural competence and cultural humility in the interview process.  Few texts on interview skills cover so thoroughly the need to attend to cultural dimensions of work with diverse clients.  This is an awesome book written in an engaging and interesting manner.  I plan to use this text in my own course on advanced professional issues.  Kudos to the authors for producing such a valuable text.”
—Derald Wing Sue, Ph.D., Professor of Psychology and Education, Teachers College, Columbia University

“This 6th edition of Clinical Interviewing is everything we’ve come to expect from the Sommers-Flanagan team, and more!  Readers will find all the essential information needed to conduct a clinical interview, presented in a clear, straightforward, and engaging style.  The infusion of multicultural sensitivity and humility prepares the budding clinician not only for contemporary practice, but well into the future.  Notable strengths of the book are its careful attention to ethical practice and counselor self-care. The case studies obviously are grounded in the authors’ extensive experience and bring to life the complexities of clinical interviewing.  This is a ‘must-have’ resource that belongs on the bookshelf of every mental health counselor trainee and practitioner.”
Barbara Herlihy, PhD. NCC, LPC-S, University Research Professor, Counselor Education Program, University of New Orleans

You can check out the text on Amazon https://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1119215587/ref=dp_ob_title_bk  or Wiley http://www.wiley.com/WileyCDA/WileyTitle/productCd-1119215587.html  or other major (and minor) booksellers.

 

 

Powerpoint Slides from the ACES Clinical Interviewing Presentation in Denver

This post includes a link to the powerpoiint slides for our presentation at the Association for Counselor Education and Supervision in Denver, CO. For this we offer a BIG THANKS to Sidney Shaw, Ed.D. who presented on our behalf so we could be in Erie, PA for the birth of our new granddaughter, Nora Flanagan Bodnar. Thanks Sidney!!

ACES clinical interview

Mental Status Examination Video Clip

Historically, the mental status examination (MSE) has held a revered place in psychiatry and medicine. In recent years, professional competence in conducting MSEs has expanded to include all mental health professionals, especially those who work within medical settings.As an example of how MSE skills have become more cross-disciplinary, the latest accreditation standards for professional counselors require coverage of MSE concepts and skills within master’s level counseling programs (Council for Accreditation of Counseling and Related Educational Programs, 2009). Overall, the MSE offers physicians, psychologists, counselors, and social workers a unique method for evaluating the internal mental condition of patients or clients.

Very recently, our publisher, John Wiley and Sons, posted a clip from a training DVD we filmed on MSE skills. Check it out at: http://www.youtube.com/watch?v=1lu50uciF5Y

 

Another Sample Mental Status Examination Report

Mental Status Examination (MSE) reports can be more or less detailed. More detailed reports are necessary when patients or clients exhibit a complex array of psychiatric symptoms, affect, and behavior. Less detailed reports are more common when the situation is less complex and the patient or client displays affect and behaviors that are generally within what might be considered a broad range of normal.

In most cases MSEs are imbedded within a clinical or psychiatric interview. As a consequence, as an evaluator, sometimes you may obtain more information about certain areas of functioning than others. This may or may not be intentional and it may or may not be reflected in your report. For example, in the example below, the purpose of the interview was to screen an individual for advanced placement in a Job Corps setting. Because Job Corps is a social and vocational setting, you may notice the MSE report writer emphasizes social functioning. You may also notice that the writer is EXPLICITLY clearly giving the client a “clean” mental status.

Keep in mind that like all MSE reports, this report is designed as a relatively objective appraisal of mental functioning. Nevertheless, subjective judgment and inference is always a part of MSEs and MSE reports.

MSE Sample Report: Example of Positive Functioning

Lucia Rodriguez, a 24-year-old Latino female, was open, pleasant, and cooperative during our meeting. She was well-groomed and looked somewhat younger than her stated age. She was fully oriented and alert. Her speech was clear, coherent, and of normal rate and volume. Her affect was euthymic and stable. She rated her mood as an “8” on a 0-10 scale, with 0 being completely down and depressed and 10 being as happy as possible. She further indicated that she is typically in a “positive mood.” Lucia has no current obsessional thoughts or psychotic symptoms. She has no significant mental health history. Her intellectual ability is probably at least in the above average range. She completed serial sevens and other concentration tasks without difficulty. Her cognitive skills, including memory and abstract thinking were intact. Her responses to questions pertaining to social judgment were positive and well-developed. Overall she appeared forthright and reliable. Her insight and judgment were good.

Practicing Humility When Conducting Mental Status Examinations

Perhaps more than any other assessment task, conducting a balanced mental status examination requires that professionals resist the natural temptation to make sweeping judgments about clients on the basis of appearance, specific behaviors, or single symptoms. For example, in a recently published book titled The mental status examination and brief social history in clinical psychology, Smith {{5681 III 2011;}} stated:

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)

After reading the preceding excerpt, I decided to conduct a small research study by surveying men in Montana with Fu-Manchu mustaches. Whenever I saw men sporting a Fu-Manchu, I asked them to rate (on a seven-point Likert scale) whether they minded being thought of as “bad.” In contrast to Smith’s (2011) observations, I found that most men with Fu-Manchu’s actually thought they looked good and reported wearing the mustache in an effort to look attractive. Of course I didn’t really conduct this survey, but the fact that I thought about doing it and imagined the results carries approximately the same validity as the wild assumption that a mental status examiner can quickly “get into the head of” all clients with Fu-Manchu (or handlebar) mustaches and interpret their underlying personal beliefs or intentions, or even worse, extrapolate from a physical feature to a personality disorder diagnosis.

Although I’m poking fun at the sweeping generalizations that Smith (2011) made in his text, my intent is to point out how easy it is to grow overconfident when conducting MSEs. Like Smith, I’ve sometimes found myself making wild and highly personalized assumptions about the psychopathological meaning of very specific behaviors (some years ago I had my own personal theory about “tanning” behaviors being linked to narcissism).

The key to dealing with this natural tendency towards overconfidence is to use Stanley Sue’s (2006) concept of scientific mindedness. A single symptom should be viewed as a sign that the sensitive and ethical mental status examiner considers a hypothesis to explore. Another example from Smith (2011) may be helpful as another caution of the dangers of over-interpreting single symptoms. He stated: “If the person is unshaven, this may be a sign of depression, alcoholism, or other poor ability at social adaptation” (p. 4).

Smith may be correct in his hypotheses about unshaven clients. In fact, if a research study were conducted on diagnoses or symptoms commonly associated with unshaven-ness, it might show a small correlation with depressive symptoms, partly because poor hygiene can be a feature of some depressive disorders. However, in the absence of additional confirming evidence, an unshaven client is just an unshaven client. And when it comes to social adaptation, I should note that I know many young men (as well as a variety of movie stars) who consider the unshaven look as either desirable, sexy, or both. This could lead to an equally likely hypothesis that an unshaven client is particularly cool or has an especially high level of social adaptation.

In your own MSE work I encourage you to adopt the following three guidelines to help you avoid what might be called the overconfident clinician syndrome:

  1. When you spot a single symptom or client feature of particular interest, you should begin the scientific mindedness process.
  2. Remember that hypotheses are hypotheses and not conclusions; this is why hypotheses require additional supporting evidence.
  3. Don’t make wild inferential leaps without first consulting with colleagues and/or supervisors; it’s often easier to become overconfident and subsequently make inappropriate judgments when working in isolation.

Keep these preceding guidelines in minds as you conduct mental status examinations. You can find my DVD with a clip of a mental status exam at: http://www.amazon.com/Clinical-Interviewing-Skills-John-Sommers-Flanagan/dp/1118390121

Two Sample Mental Status Examination Reports

The following two fictional reports are samples for those individuals learning to conduct Mental Status Examinations and write MSE reports. They’re from the forthcoming 5th edition of Clinical Interviewing.

If you’d like to see a short video-clip MSE example, you can go to: http://www.youtube.com/watch?v=1lu50uciF5Y

Mental Status Examination Reports

A good report is brief, clear, concise, and addresses the areas below:

1.  Appearance

2.  Behavior/psychomotor activity

3.  Attitude toward examiner (interviewer)

4.  Affect and mood

5.  Speech and thought

6.  Perceptual disturbances

7.  Orientation and consciousness

8.  Memory and intelligence

9.  Reliability, judgment, and insight

The following reports are provided as samples.

Mental Status Report 1

Gary Sparrow, a 48-year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner. 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”). His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and 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 performance. He reported auditory hallucinations (God had told him to quit his job and become a professional golfer) and was preoccupied with his athletic and sexual accomplishments. 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 exhibited poor judgment. Insight was absent.

Mental Status Report 2

Ms. Rosa Jackson, a 67-year-old African American female, was evaluated during routine rounds at the Cedar Springs Nursing Home. She was about 5’ tall, wore a floral print summer dress, held tight to a matching purse, and appeared approximately her stated age. Her grooming was adequate and she was cooperative with the examination. She reported her mood as “desperate” because she had recently misplaced her glasses. Her affect was characterized by intermittent anxiety, generally associated with having misplaced items or with difficulty answering the examiner’s questions. Her speech was slow, halting, and soft. She repeatedly became concerned with her personal items, clothing, and general appearance, wondering where her scarf “ran off to” and occasionally inquiring as to whether her appearance was acceptable (e.g., “Do I look okay? You know, I have lots of visitors coming by later.”). Ms. Jackson was oriented to person and place, but indicated the date as January 9, 1981 (today is July 8, 2009). She was unable to calculate serial sevens and after recalling zero of three items, became briefly anxious and concerned, stating “Oh my, I guess you pulled another one over me, didn’t you, sonny?” She quickly recovered her pleasant style, stating “And you’re such a gem for coming to visit me again.” Her proverb interpretations were concrete. Judgment, reliability, and insight were significantly impaired.

The latest edition (4th edition, updated) of Clinical Interviewing also includes a DVD with me (John) demonstrating a mental status examination. You can check our and/or purchase the whole DVD at: http://www.wiley.com/WileyCDA/Section/id-302475.html?query=John+Sommers-Flanagan

If you’re interested in having me come to your organization to provide a workshop or keynote on this or on a related topic, please email me at johnsf44@gmail.com.