MSE | John Sommers-Flanagan

Rita Wood Surfing

Affect is how you look to me.

Affect involves me (an outsider) judging your internal emotional state (as it looks from the outside). Whew.

Mood is how you feel to you.

Mood is inherently subjective and limited by your vocabulary, previous experiences, and inclination or disinclination toward feeling your feelings.

Independently, neither affect nor mood makes for a perfect assessment. But let’s be honest, there’s no such thing as a free lunch, and there’s no such thing as a perfect assessment. Even in elegant combination, affect and mood only provide us with limited information about a client’s emotional life.

Our information is limited and always falls short of truth because, not only is there always that pesky standard error of measurement, also, emotion is, by definition, phenomenologically subjective and elusive. Emotion, especially in the form of affect or mood, is a particularly fragile and quirky entrepreneur of physiology and cascading neurochemical caveats. Nothing and everything is or isn’t as it seems.

As an interviewer, even a simple emotional observation may be perceived as critical or inaccurate or offensive in ways we can only imagine. Saying, “You seem angry” might be experienced as critical or inaccurate and inspire the affect you’re watching and the mood your client is experiencing to hide, like Jonah, inside the belly of a whale.

Oddly, on another day with the same client, your emotional reflection—whether accurate or inaccurate—might facilitate emotional clarity; affect and mood may re-unite, and your client will experience insight and deepening emotional awareness.

As a clinician, despite your efforts to be a detached, objective observer, you might experience a parallel emotional process. Not only could your understanding of your client deepen, but ironically, because emotional lives resist isolation, you might experience your own emotional epiphany.

Rest assured, as with all emotional epiphanies—including our constitutionally guaranteed inevitable and unenviable pursuit of happiness—you’ll soon find yourself staring at your emotional epiphany through your rear view mirror.

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Just for fun, below I’ve included a link to a brief clip of me doing a mental status examination with a young man named Carl. A longer version of my interview with Carl is available with the 6^th edition of Clinical Interviewing. https://www.youtube.com/watch?v=1lu50uciF5Y

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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Tag Archives: MSE

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