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The Mental Status Exam is the basis for understanding the client's presentation and beginning to conceptualize their functioning into a diagnosis.
At first all this might seem overwhelming and time consuming, but really it's not that bad to do. It can generally be done in a few minutes when you need to do specific things, and the vast majority of this you can get from interviewing and simply watching the client carefully.
Presenting Appearance including sex, chronological and apparent age, ethnicity, apparent height and weight (average, stocky, healthy, petite), any physical deformities (hearing impaired, injured and bandaged right hand)
Basic Grooming and Hygiene, dress and whether it was appropriate attire for the weather, for a doctor's interview, accessories like glasses or a cane
Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), work speed, any noteworthy mannerisms or gestures
Manner and Approach
Interpersonal Characteristics and Approach to Evaluation (oppositional/resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness)
Behavioral Approach (distant, indifferent, unconcerned, evasive, negative, irritable, depressive, anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert, agitated, lethargic, needed minor/considerable reinforcement and soothing)
Speech (normal rate and volume, pressured, slow, accent, enunciation quality, loud, quiet, impoverished)
Eye Contact (makes, avoids, seems hesitant to make eye contact)
Expressive Language (no problems expressing self, circumstantial and tangential responses, anomia, difficulties finding words, misuse of words in a low-vocabulary-skills way, misuse of words in a bizarre-thinking-processes way, echolalia or perseveration, mumbling)
Note if English is not primary language here and comment on their command of the language
Receptive Language (normal, able to comprehend questions, difficulty understanding questions)
Recall and Memory
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*could explain recent and past events in their personal history
recalls three words (e.g., Cadillac, zebra, and purple) immediately after two rehearsals, and then again five minutes later (five minutes is how long it takes for information to move from short-term to long term memory). If they can't, you can prompt them (e.g., Was the first one a kind of tree, color, or car? A car, OK was it a Camero, Continental, or Cadillac?)
recalls your name after 30 minutes
Orientation, Alertness, and Thought Processes
Orientation (person, place, time, presidents, your name)
Alertness (sleepy, alert, tired for working late, dull and uninterested, highly distractible)
Coherence (responses were coherent and easy to understand, simplistic and concrete, lacking in necessary detail, overly detailed and difficult to follow)
Concentration and Attention (based on Digit Span and attention to your questions, serial 7's or 3's in which they count backwards from 100 to 50 by 7s or 3s, naming the days of the week or months of the year in reverse order, spelling the word "world", their own last name, or the ABC's backwards)
Thought Processes (could/could not recall the plot of a favorite movie or book logically, difficult to understand line of reasoning, showed loose associations, confabulations, flight of ideas, ideas of reference, illogical thinking, grandiosity, magical thinking, obsessions, perseveration, delusions, reports of experiences of depersonalization)
Hallucinations and Delusions (presence, absence, denied visual but admitted olfactory and auditory, denied but showed signs of them during testing, denied except for times associated with the use of substances, denied while taking medications)
Judgment and Insight (based on explanations of what they did, what happened, and if they expected the outcome, good, poor, fair, strong)
Intellectual Ability (roughly average, above average, or below average based on answers to questions like "name last four presidents," "who is the governor of the state," "what is the capitol of the state," "what direction does the sun set," etc
These are based on proverbs and sayings ("What do people mean when they say
"), similarities ("How are a ______ and a ______ alike? Different?"), and giving both definitions for word ("What are two different meanings for the word 'right,' 'bit,' and 'left'?")
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Some proverbs and sayings are:
A rolling stone gathers no moss, In the land of the blind, the one-eyed person is king, All that glitters is not gold, Don't count your chicken before they hatch, Don't put all your eggs in one basket, Strike while the iron is hot, Rome wasn't built in a day, When the cat's away the mice will play, A stitch in time saves nine, You can dress a monkey in silk but it's still a monkey ("Aunque la mona se vista in seda
What would I mean if I said I were feeling blue? seeing red? I had a chip on my shoulder? or was hot under the collar?
You can also use Absurdities ("What's wrong or doesn't make sense in the following sentence?") and use sayings like "Bills ears were so big, he had to pull his sweaters on over his feet" or "A man was in two auto accidents. The first one killed him, but the second time he got well very quickly."
Mood and Affect
Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry). Think of the climate in an area.
Affect or how they felt a a given moment (comments can include range of emotions like broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation and facial expressions, pessimistic, optimistic) as well as inappropriate signs (began dancing in the office, verbally threatened examiner, cried while discussing recent happy event and unable to explain why). Think of the weather, which varies slightly from day to day.
Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)
Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such)
Suicidal and Homicidal Ideation (ideation but no plan or intent, clear/unclear plan but no intent, ideation coupled with clear plan and intent to carry it out)
Risk for Violence (fair, low, high, uncertain, effected by substance use)
Response to Failure on Test Items (unaware, frustrated, anxious, obsessed, unaffected)
Impulsivity (low medium, high, effected by substance use)
Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it)
Defense Mechanisms observed (may not have seen any, but if did, note them and the behaviors that indicated this)
I also note in this section any special considerations that were taken into account during testing, such as the testing room was noisy, I read to the client and took answers by dictation, audiotaped versions of tests were used)
Some screening questions I ask to explore other areas include:
How are you sleeping? Do you have trouble falling asleep, staying asleep, waking up? How is your energy level though the day; do you have enough energy to get things done? How is your appetite? How do you feel most days? (Depression) Note: Some antidepressants work best with clients who have trouble falling asleep, while others work best with those who can't stay asleep or wake up. This may be very helpful to others to document.
Are there things that worry you a lot? Have you ever felt an intense fear or worry that something bad would happen to you? Are there specific things that frighten you? (Anxiety)
Do you ever feel the need to do something over and over until it's perfect? Are there certain things you sometimes feel compelled to do over and over? Are there ever thoughts that you just can't get out of your head? (Compulsions and Obsessions)
Have you ever felt someone was reading you mind or making you think things? Have you eve felt your mind was playing tricks on you? Have you ever had a dream that was so intense and real, your weren't sure if you were asleep or awake? (Delusions and Hallucinations)
Do you think your eating habit are unusual? What is your weight now? What is the most and least you've weighed? Are you concerned about your weight? (Eating Disorders)
Do you ever find yourself suddenly doing something before you have really had a chance to think about it? Do you ever do things you had decided not to do, and don't know why? Does money "burn a hole in your pocket"? (Impulsivity)
Have you ever had so much energy you couldn't sit still? That you didn't need to sleep for days at a time? (Mania)
When you enter a building or get on a bus, does everyone turn to look and watch you. Do you think someone is out to get or harm you, or is plotting against you? Have you ever done something unusual, and thought someone might have drugged you to make you do it?