How to assess mental status of patients

Mental state examination is a very important part of clinical assessment in a psychiatric patient. Most of the time, it is the only method available to diagnose the psychiatric disorder which the patient is suffering from. Therefore, it is a very important part of the clinical management of a psychiatric patient. The examination is designed to assess the patents appearance, mood and affect, speech, thought process, thought content, insight, judgment, impulsivity and reliability.

The examination should be taken at a quite and non-threatening environment for the patient. The place should be arranged to secure the patient’s privacy. There should not be any object that can be used as weapon. Start the examination by recording the time and date.

1) Appearance -The examination starts the moment you see the patient. First, the patient identification information such as age, sex, and race are recorded. Then, details about the patient’s appearance such as nutritional status, whether the patient is thin, obese, or wasted, is recorded. It is said that most of the patient with mania are obese, and those with schizophrenia are thin. Make a note regarding the general hygiene and clothing of the patient. Depressed patients often neglect themselves and have poor hygiene. Patients with mania tend to wear bright colours and a lot of jewelries. The patient’s posture, eye contact relationship with the doctor is also important to record. If the patient is avoiding your eye contact note whether he is staring at something (ceiling, floor) or scanning the room.

2) Mood - The mood of the patient is what the patient generally feels in most of the days. Ask the patient “How do you fell most of the days?” If the patient is unable to give a straight answer such as ‘depressed, ‘anxious’ etc, then you have to ask further questions to know what he really feels.

3) Affect - They say that mood is like the climate and the affect is like the weather. Affect of a person can be described as expansive, euthymic, constricted, blunted, and flat. Euthymic affect is normal. When the patient’s affect appears to be limited, it is called constricted. The affect is said to be blunted when it shows minimal variation.

4) Speech - The quality, quantity, rate and volume of the speech is assessed during the interview. The quality of speech is assessed by the loudness of the voice. If the patient is answering in one or two words the quantity of the speech is reduced. How fast they talk is also important. Patients with mania usually talk a lot at a fast rate. Patients suffering from depression talk slowly and tend to answer in one word.

5) Thought Process - There are different types of thought processes. They are looseness of ideas, flight of ideas, pressure of thoughts, word salad, thought blocking etc. The thought process of a patient is understood by carefully listening to the patient. Listen carefully how the patient answers when he/she is given a question. If the patient changes topics vary rapidly, it is called flight of ideas. At first it may look like that there is no association. But, there is a hidden association. Pressure of thought is when the patient continues to talk without any pause. It may appear that there are a lot in the patient’s mind, but he/she is trying to let them all out at once. Word salad is when there is no association between the things the patient says. This is seen in schizophrenic patients. Thought blocking is also seen in schizophrenic patients. The patient suddenly stops talking as if he has totally forgotten what he was saying. There are moany other terms to describe the patient’s thought process. Some of them are racing, tangential, circumstantial, neologism, clanging, and punning.

6) Thought content - Thought content describes whether the patient is having any hallucinations, delusions, obsessions and compulsions, phobias, suicidal or homicidal ideas, cognition, consciousness, orientation, concentration, attention, memory, knowledge and intelligence.

 To know whether the patient is having auditory hallucinations, ask the patient whether he is hearing voices when there is no one around. If he says ‘yes’ investigate further to know what the voices say. What do you hear? Do the voices command you to do various things? This is very important in diagnosis of schizophrenia. To know whether there is visual hallucinations; ask him/her whether he/she sees things that others can not. Also ask whether there is any abnormal smell, taste or sensation that he is experiencing.

Patients can present with several kinds of delusions such as grandiose, religious, persecutory, erotomanic, etc. Patients can also have delusions of thought insertion, thought withdrawal or delusions of reference. Most of these are associated with schizophrenia. To find out whether the patient has above delusions, ask him whether he has any special powers (grandiose delusions), whether any one is trying to harm him (persecutory), whether some one is putting or withdrawing thoughts from his mind?

7) Insight - Insight is very important part of the mental status. Ask the following questions to know he has insight or not. “Do you know that you have an illness?” “Do you know that there is treatment?” “Are you willing to take treatment?

8) Judgment - The judgment can be assessed by the history as well as by asking hypothetical questions.

9) Impulsivity - Ask the patient about his/her hobbies.  

10) Reliability - During the interview, try to get an idea about how reliable the patient is.

A correct and comprehensive mental state examination is very important in psychiatric practice. It can be diagnostic as well as therapeutic. Building a good doctor patient relationship during mental state examination would be very helpful in management of the patient in the future.