Mental Status Examination (MSE) Assessment
The Mental Status Examination (MSE) is a structured, systematic assessment of a patient's behavioral and cognitive functioning that serves as the psychiatric equivalent of the physical examination, providing essential data for diagnosis and treatment planning of psychiatric and neurological conditions. 1
Components of the MSE
The MSE follows a standardized structure that evaluates multiple domains of mental functioning. Based on current guidelines, the comprehensive MSE includes:
1. Appearance and Behavior
- General appearance (grooming, dress, hygiene)
- Level of consciousness
- Psychomotor activity (agitation, retardation)
- Attitude toward examiner (cooperative, guarded, hostile)
- Eye contact and posture
2. Speech
- Rate, rhythm, volume
- Fluency and prosody
- Spontaneity and quantity
3. Thought Process
- Logic and coherence
- Flow of associations
- Flight of ideas or thought blocking
- Tangentiality or circumstantiality
4. Thought Content
- Delusions
- Obsessions
- Phobias
- Suicidal or homicidal ideation
5. Perception
- Hallucinations (auditory, visual, tactile)
- Illusions
- Depersonalization/derealization
6. Mood and Affect
- Patient's subjective emotional state (mood)
- Observed emotional expression (affect)
- Range, appropriateness, and stability of affect
7. Cognition
- Orientation (person, place, time)
- Attention and concentration
- Memory (immediate, recent, remote)
- Abstract thinking
- Visuospatial ability
- Executive functioning
8. Insight and Judgment
- Awareness of illness
- Understanding of consequences
- Decision-making capacity
Standardized Assessment Tools
Several validated tools can be incorporated into the MSE for more objective cognitive assessment:
- Mini-Mental State Examination (MMSE): A widely used 30-point cognitive screening tool that assesses orientation, attention, recall, and language 2
- Montreal Cognitive Assessment (MoCA): More sensitive than MMSE for detecting mild cognitive impairment 2, 3
- Mini-Cog: Brief 2-3 minute screening tool assessing short-term memory and visuospatial/executive function 3
- Memory Impairment Screen (MIS): Focuses on memory assessment 2, 3
- St. Louis University Mental Status (SLUMS) Examination: Alternative to MMSE without copyright restrictions 2
Clinical Applications
The MSE is indicated in various clinical scenarios:
- Psychiatric complaints
- Behavioral abnormalities
- Head injuries
- Drug ingestions/intoxication
- Altered mental status
- Cognitive decline
- Neurological disorders
Most emergency physicians complete the MSE in less than five minutes, focusing on level of consciousness, orientation, spontaneous speech, and behavioral observation 4.
Documentation Approach
The most effective documentation approach follows an organized framework such as:
- ABC-STAMPS: Appearance, Behavior, Cooperation; Speech, Thought process and content, Affect, Mood, Perceptions, Suicidality 1
Common Pitfalls and Considerations
- Educational bias: Performance on cognitive tests like MoCA can be affected by educational level 3
- Cultural/language differences: May require modified assessment approaches 3
- Incomplete assessment: Failing to assess all domains can lead to missed diagnoses
- Overreliance on screening tools: Tools like MMSE should supplement, not replace, clinical judgment 2
- Lack of collateral information: Informant reports significantly improve assessment accuracy 3
Enhancing MSE Reliability
To improve MSE reliability:
- Use standardized terminology when documenting findings
- Combine cognitive tests with functional screens and informant reports 3
- Consider comprehensive neuropsychological evaluation for complex cases 3
- Perform serial assessments to track changes over time 3
The MSE requires practice to master but is an essential skill for all clinicians who evaluate patients with potential psychiatric or cognitive disorders 5.