The mental status exam (MSE) is a process that delivers information about the patient’s current mental state. The examination is conducted primarily through observations and interviewing that is used to verify the available historical data. Thus, it serves as a validation technique. It is important to understand that the results of an MSE can, and often do, contradict the findings of a biopsychosocial assessment that is usually based on historical data and may not represent the latest changes in the client’s mental state.
The goal of an MSE is the review of psychiatric functions and is usually conducted informally despite the existence of a number of standardized formats (Wiger, 2012). The information is gathered throughout the session and targets specific components such as language, appearance, the level of activity, cognition, mood, and judgment. The physical appearance in combination with respective historical information could indicate or confirm an existence of a disorder or point to the important area of inquiry. However, it is important to remember that such data alone is insufficient for making a definitive conclusion and requires careful verification.
The abnormal activity level is usually indicative of the existence of psychological concerns and should be reported whereas the absence of deviations can be omitted from the report. The clarity of speech can be used as a criterion for determining the mental status, where the disrupted sentence structure and improper grammar usage point to the possibility of cognitive, neurological, or psychotic dysfunction. The lack of congruence between affect and mood reflects the inconsistencies in the client’s emotional state and suggests the existence of a psychopathology (Wiger, 2012). Finally, cognition is a combination of factors such as attention span, orientation, memory, and concentration which collectively determine the mental state of the client.
Reference
Wiger, D. E. (2012). The mental status exam. In D. E. Wiger, The psychotherapy documentation primer (3rd. ed.) (pp. 81-94). Hoboken, NJ: John Wiley & Sons.