Psychiatry Interview

and
Mental Status Examination
Edore Onigu-Otite, MD
Child and Adolescent Psychiatry; Addiction Psychiatry
Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences
Associate Course Director, Behavioral Sciences Foundations Course,
Baylor College of Medicine,
Houston, TX
Disclosures
• None
Objectives
1. Compare / contrast components of a psychiatric history with
histories gathered in other medical settings.

2. Apply terminology to describe mental status

3. Summarize the components of the cognitive assessments

(such as MMSE) including recalling what domains are
assessed by particular questions
Outline

1. Psychiatry Interview
2. Mental Status Examination
3. Cognitive Assessment
The Mental vs Physical Exam
A Psychiatry history or examination:

• Differs from other histories/exams in the amount

of developmental and social history elicited
(evaluation of psychological and social aspects of
illness model)

• Patient is usually allowed to give a more narrative

account of their history; fewer close-ended
questions are used
Psychiatry Work Up

The goal is to obtain relevant information

(biological, psychological, social factors)
that influence a person’s mental/emotional
well-being, make observations, and come
up with an assessment and treatment
plan.
 Psychiatric Workup
• Identifying Data • Substance Use History
• Chief Complaint • Family Psych History
• HPI • Social History
• Past Psych History • Review of Systems
• Past Medical History • Mental Status Exam
• Medications • Assessment
• Allergies • Treatment Plan
 Psychiatric Interview: ID, CC, HPI, PPH

• Past Psych History:

• ID: Age, Race, Gender, • Illness history, treatment history
Informants, Referral source • Hospitalizations
• Suicide attempts, self harm
• Medication hx
• CC: “In patient’s own words”
• Therapy hx

• HPI: • Past Medical History

• Current symptoms • Special attention to: Seizures, LOC,
head injury
• Symptom screening
• Current stressors • Current Medications
• Allergies
Psychiatric Interview: FPH and SH
• Family Psychiatric History
• Mood disorders, Anxiety disorders,
Schizophrenia/Psychotic illness, Suicides

• Social History
• Birth and Development
• Living situation
• Current relationships, Marital status, Children
• Schooling, Employment
• Abuse and Neglect
• Legal, Military
Psychiatric Interview: ROS
• Psych ROS • HEENT
• Mood • CVS
• Anxiety • Resp
• Psychosis
• GI
• Substance Use History • CNS
• By substance: age at
first use, route of use, • Endocrine
heaviest use, current • Genitourinary
use, symptoms of
dependence or • Musculoskeletal
withdrawal, • Skin/Integumentary
treatment history
General Interview Tips

• Ask open ended questions (initially)

• Allow patient talk freely with as little interruption as is
feasible
• Pay attention to what is volunteered
• Pay attention to what is omitted / not said
• Go back and pick up missed items at the end
• Try to mimic a conversation not an interrogation
• At the end, ask if there is anything else important you
should know
Psychiatry Interview

By the end of your psychiatry interview,

you would have obtained most of the
information needed for the mental status
examination
 Mental Status Examination

The Mental Status Examination is a structured way of

observing, describing, and documenting a patient’s
mental state at a given point in time.
Mental Status Exam (MSE)

• MSE is the psychological equivalent of a physical exam

• Describes the mental state and behaviors of the patient

• Includes:
• Objective observations made by the clinician
• Subjective descriptions given by the patient
Why do we need the MSE?
• Provides information for:
• Diagnosis
• Assessment of disorder
• Response to treatment

• Provides a snap-shot at a point in time

• Allows documentation of change in a person’s

mental status (the next provider can tell if the
patient’s mental status has changed within a given
time without previously seeing the patient)
 How do we do the MSE?

• Observing
• Asking
• Listening
• Documenting

MSE begins the minute you come into contact with the patient
Mental Status Examination

Appearanc
Affect
e

Thought Cognition
MSE: Appearance

• General Appearance
• Demeanor
• Behavior
• Motor
• Speech
MSE: General Appearance

• Age
• Build
• Posture
• Prominent physical abnormalities
• Dress
• Grooming
MSE: Motor Activity
• Psychomotor activity
• Calm
• Decreased - Retardation (slow),
• Increased - Fast - agitation, pacing, Restless - squirming in seat,
feet-tapping, hand wringing,
• Movements
• Gait
• Abnormal movements – tics, tremors, akathisia, movement
disorders, stereotypies
• Unusual postures
MSE: Behavior
• Demeanor: Interaction / Attitude toward the examiner:
• Cooperative, uncooperative
• Open
• Withdrawn
• Guarded
• Eye contact: good, poor, avoidant, piercing
• Conversation: Spontaneous or non-spontaneous
 MSE: Speech
Rhythm is the
sense of • Rate: increased (pressured), decreased (e.g. monosyllabic)
movement in
speech, • Latency: Increased, decreased
shown by • Volume: loud, soft, mute
alternating
stressed and • Content: fluent, loquacious, paucity, impoverished
unstressed
elements and • Rhythm: articulation, monotone, prosody, dysarthria,
by the timing slurred
and quantity
of syllables.
 MSE: Affect

Affect is the
experience of
feeling or
emotion.
Mood
Affect
Affect is a key
part of the (What
(What
patient
you observe)
tells you)
process of an
organism's
interaction
with stimuli.
 MSE: Mood

• Often placed in “Quotes”

Mood is the
prevalent
emotional • Examples:
state the • SUPER-HAPPY!, GREAT! WOOHOO!!!
patient
experiences
- Elevated (Expansive, Euphoric, Grandiose)
(subjective) • Good, normal, happy, okay, neutral - Normal (Euthymic)
which is often • Down, sad, depressed, hopeless - Depressed / Dysphoric mood
observed by • Worried, fearful, afraid - Anxious mood
others
(objective) • Angry, Mad, Upset – Anger / Irritable mood
 MSE: The Affect
• Affect is the emotional state we observe
• Types of Affect:
Affect: Things
to look for: • Neutral, Happy, Content, Sad, Depressed, Angry, Bizarre
1.Type
• Range
2.Range • Full (normal) vs. restricted (blunted or flat)
3.Stability • Flat – lacks response
4.Congruency
• Congruency: affect does it match the mood
• Mood congruent vs. mood incongruent
• Stability: stable vs. labile (frequently changing)
 MSE: Thoughts

Content Process
What
you How you
think think it
about
 MSE: Thought Process

• Normal: coherent (well-linked)

Thought • Linear, Goal-directed, Coherent
Process
• Logical: flow with reason
describes the
rate of
thoughts, how • Abnormal: associations are not clear, organized, coherent
they flow and • Non-linear: Circumstantial, tangential, loosening of association
are • Not clearly logical/linked: Flight of ideas, word salad, clanging
connected.
• No/poverty of thought: Thought blocking
 Thought Process: Speed

Normal Flow of Thoughts

Paucity / Poverty of Thoughts
Racing Thoughts
 Thought Process: Destination

Linear, Coherent, Goal-directed

Incoherent
(Point A to Point B)
(Disorganized)
 Thought Process
Direction Off the main highway
• Circumstantial:
B • Provides unnecessary detail but eventually get to the
point
• Taking detours but getting to the destination
• Tangential:
• Moves from thought to thought that relate in some way
A but never get to the point
• Taking detours and never quite getting to the destination
• Perseverative:
• Repetition of words, phrases or ideas
• Takes and stays on same roundabout over and over again
and doesn’t get off
 Thought Process:
Connections Between Thoughts

• Logical
• Thoughts are reasonably
connected
Thought Process: Train of Thought

• Logical
• Thoughts connected

• Loosening of Association
• Illogical shifting between unrelated
topics
• Taking detours from detours

• Flight of Ideas
• Quickly moving from one idea or train
of thought to the next and the next
(mania)
Thought Process: Lack of Thought

• Thought blocking:
thoughts are
interrupted
• (Cricket sounds)
 Interactive Section
Role Play - Thought Process

• Doctor Asks: When did you get to class today?

WHAT TO DO
• Patient Answers:
1. Pair up 1. Circumstantial
2. Pick a role (patient or doctor)
2. Tangential
3. Act the thought process
4. Switch roles

Note:
Circumstantial - Arrives at answer/destination
Tangential - Does NOT arrive at answer/destination
What are they thinking? = Thought Content

• Refers to the themes that occupy

the patient's thoughts and
perceptual disturbances
Thought Content

• Perceptual Disturbances
• Preoccupations
• Delusions
• Ideas of Reference
Thought Content: Perceptual Disturbances

• Illusions: Misperception of a true sensory input

• Derealization: Feeling the outer environment feels

unreal

• Depersonalization: Sensation of unreality concerning

oneself or parts of oneself
Thought Content: Hallucinations

Hallucinations: Perceiving a stimulus in the

absence of external sensory stimulus

• Auditory (AH)
• Visual (VH)
• Tactile
• Olfactory
• Gustatory
Thought Content: Preoccupations

Preoccupations:
• Suicidal
• Homicidal
• Obsessions

Ideas of Reference
• Misinterpretation of incidents and events in the outside world
having direct personal reference to the patient
 Thought Content: Delusions
Delusions: Fixed, false beliefs firmly held in spite of contradictory evidence
Delusions:
Fixed, false
beliefs firmly
• Control: outside forces are controlling actions
held in spite of • Erotomanic: a person, usually of higher status, is in love with the
contradictory patient
evidence and • Grandiose: inflated sense of self-worth, power or wealth
are out of
harmony with • Somatic: patient has a physical defect
the patients • Reference: unrelated events apply to them
social,
• Persecutory: others are trying to cause harm
cultural, and
religious • Paranoia: characterized by systematized delusions usually related to an
background organization
 MSE - Cognition
• Alertness
Cognition is
the mental • Level of consciousness
action or
process of • Orientation
acquiring • Attention and concentration
knowledge
and • Memory: immediate, short and long term
understanding
through
thought, In addition, the Mini Mental State Exam (Folstein)
experience,
and the gives a score/numerical measure of cognitive
senses. functioning
 Knowledge and Estimate of Intellectual
Functioning
Judgment: the
• Knowledge
ability to • Estimate of Intellectual Functioning
anticipate the
• Abstraction:
consequences
• Similarities and difference
of one’s
behavior and • Proverb interpretation
make • Insight: awareness of one’s own illness and/or situation
decisions to
safeguard • Judgment:
your well • Adequate
being and that
of others
• Lacking (Poor)
• Suspect
 Sample MSE - 34y/o male
with Depression with Psychotic Features
GENERAL: THOUGHT:
• Appearance: Disheveled, somnolent, • Thought Process: Goal-directed, Logical
slouched down in chair, uncooperative • Thought Content: Wishes to be dead (SI+), Hears
• Behavior: psychomotor retarded, poor eye whispering voices (AH+), Sees shadows (VH+). No HI,
contact no paranoia, no obsessions, no delusions
• Speech: moderate latency, soft, slow with COGNITION:
paucity of content • Alert and Oriented x3
• Attention and Concentration: Impaired (“woldr”)
MOOD & AFFECT:
• Memory: Impaired (recalled only 1 of 3 items)
• Mood: “Really down“
• Knowledge fund: Good
• Affect: depressed, blunted, mood congruent,
stable • Est. of Intellectual Functioning: Average
• Insight: Good; Judgement: Adequate
 By the end of your MSE, you would have collected
most of the information needed to have a good
Psychiatry Interview
sense of your patient’s symptoms and functioning.
Mental Status Examination

For more detailed / specific assessment of

cognitive functioning within clinic settings, we use
additional tests.
Folstein’s MMSE Components
• Orientation:
• “What is the year? Season? Date? Day? Month?”
• “Where are we now? State? County? Town/city? Type of
building? Floor?”
• Memory – recall 3 items
• Attention – serial 7’s or world backwards
• Ability to translate thought to writing – “Make up and write
a sentence about anything.”
• Copy Design
• Scoring - 26 or > out of 30 = normal (college educated)
 MMSE Alternatives
• MOCA = Montreal Cognitive Assessment
• Introduced in 1996
Psychiatry Interview
• More sensitive to mild cognitive impairment

Mental Status Examination

• Mini-Cog

Cognitive
Assessment • ACE-R = Addenbrookes Cognitive Examination
Revised
 Psych Interview & MSE

https://www.youtube.com/watch?v=-qp2nIQ8BFA
 MSE of Craig
(from available information)
APPEARANCE: THOUGHT:

MOOD & AFFECT: COGNITION:

 Summary
• Psychiatry Interview and Examination includes objective and subjective
information and observations
• MSE is the psychological equivalent of a physical exam
• MSE is a structured way of observing and describing a patient’s
psychological function at a given point in time.
• MSE documents a patient’s mental status at the time of the
examination
• MSE has 4 main domains: (General, Affect, Thought, Cognition)
• MMSE (Folstein’s) is a brief exam for detecting cognitive problems
Questions?
Thank you