What are the aspects of patient thought content in a Mental Status Examination (MSE)?

Updated: Sep 24, 2020
  • Author: Jeffrey S Forrest, MD; Chief Editor: David Bienenfeld, MD  more...
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Aspects of thought content are as follows:

  • Obsession and compulsions: Ask the following questions to determine if a patient has any obsessions or compulsions. "Are you afraid of dirt?" "Do you wash your hands often or count things over and over?" "Do you perform specific acts to reduce certain thoughts?" Signs of ritualistic type behaviors should be explored further to determine the severity of the obsession or compulsion.

  • Phobias: Determine if patients have any fears that cause them to avoid certain situations. The following are some possible questions to ask. "Do you have any fears, including fear of animals, needles, heights, snakes, public speaking, or crowds?"

  • Suicidal ideation or intent: Inquiring about suicidal ideation at each visit is always important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent. "Do you have any thoughts of wanting to harm or kill yourself?" "Do you have any thoughts that you would be better off dead?" If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views suicide to determine if a suicidal gesture or act is ego-syntonic or ego-dystonic. Next, determine if the patient will contract for safety. For homicidal ideation, make similar inquiries.

  • Homicidal ideation or intent: Inquiring about homicidal ideation or intent during each patient interview also is important. Ask the following types of questions to help determine homicidal ideation or intent. "Do you have any thoughts of wanting to hurt anyone?" "Do you have any feelings or thoughts that you wish someone were dead?" If the reply to one of these questions is positive, ask the patient if he or she has any specific plans to injure someone and how he or she plans to control these feelings if they occur again.

  • Sensorium and cognition: Perform the Folstein Mini-Mental State Examination.

  • Language: Spontaneous speech may be noted. Repetition ("no, Ifs, ands, or buts") should be considered.

  • Comprehension: Provide a simple instruction to patient, such as “fold this paper in half” or "squeeze my fingers."

  • Consciousness: Levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness. If patients exhibit decreased levels of consciousness note the stimulus required to arouse the patient.

  • Orientation: To elicit responses concerning orientation, ask the patient questions, as follows. "What is your full name?" (ie, person). "Do you know where you are?" (ie, place). "What is the month, date, year, day of the week, and time?" (ie, time). "Do you know why you are here?" (ie, situation).

  • Concentration and attention: Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as "serial 7s." If a patient’s academic abilities are prohibitive or impeding, a clinician may ask for them to recite the months of the year backwards instead. Next, ask the patient to spell the word "world" forward and backward. Document the patient's reaction times to particular questions because this may provide valuable information in the overall evaluation.

  • Reading and writing: Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, "Close your eyes."). This part of the MSE evaluates the patient's ability to sequence.

  • Visuospatial ability: Have the patient draw interlocking pentagons in order to determine constructional apraxia. Have the patient "use imaginary scissors" to evaluate motor activity.

  • Memory: To evaluate a patient's memory, have them respond to the following prompts. "What was the name of your first grade teacher?" (ie, for remote memory). "What did you eat for dinner last night?" (ie, for recent memory). "Repeat these 3 words: 'pen,' 'chair,' 'flag.' " (ie, for immediate recall). Tell the patient to remember these words. Then, after 5 minutes, have the patient repeat the words. Orientation represents recent memory.

  • Abstract thought: Assess the patient's ability to determine similarities. Ask the patient how 2 items are alike. For example, an apple and an orange (good response is "fruit"; poor response is "round"), a fly and a tree (good response is "alive"; poor response is "nothing"), or a train and a car (good response is "modes of transportation"). Assess the patient's ability to understand proverbs. Ask the patient the meaning of certain proverbial phrases. Examples include the following. "A bird in the hand is worth 2 in the bush" (good response is "be grateful for what you already have"; poor response is "one bird in the hand"). "Don't cry over spilled milk" (good response is "don't get upset over the little things"; poor response is "spilling milk is bad").

  • General fund of knowledge: Test the patient's knowledge by asking a question such as, "How many nickels are in $1.15?" or asking the patient to list the last 5 presidents of the United States or to list 5 major US cities. Obviously, a higher number of correct answers is better; however, the interviewer always should take into consideration the patient's educational background and other training in evaluating answers and assigning scores.

  • Intelligence: Based on the information provided by the patient throughout the interview, estimate the patient's intelligence quotient (ie, below average, average, above average).

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