Elizabeth Price
 · LMFT, LCSW

Mental Status Exam: Behavioral Aspects

Most MSEs include an evaluation of both behavioral aspects and cognitive aspects. Behavioral aspects are described below. Come back Friday for a question related to this topic, and come back next week for the cognitive aspects of MSEs.  

A mental status exam (MSE) is used to evaluate a client’s current mental functioning. As a social worker, you may see clients who have an undiagnosed mental illness, neurological condition, or neurocognitive disorder (e.g., dementia). Understanding how to use a mental status exam enables you to recognize key symptoms and refer clients for needed psychiatric evaluations and evaluations of medical problems that affect psychological functioning (especially neurological evaluations). In conjunction with other data, information collected from an MSE may also be used to formulate an appropriate clinical diagnosis.

To conduct an MSE, you observe a client’s behavior in an informal, systematic way, noting the presence of cognitive, emotional, and behavioral problems. For example, you note the presence of unusual behavior or answers that suggest a mental disorder. You then use your observations to make preliminary decisions about which areas of the client’s functioning should be assessed in more detail and, sometimes, more formally. A common practice is to make mental status observations during the course of the interview and then change to direct questioning near the end of the interview to elicit additional information needed for the MSE.

Behavioral Aspects: Behavioral functions are evaluated through direct observation of the client’s speech and nonverbal behavior during an interview (i.e., you observe certain cues and interpret them as expressions of the client’s present functioning).

General Appearance and Behavior: The client’s appearance and behavior should be evaluated in light of what is generally expected for a person of the client’s age, race, sex, socioeconomic status, cultural background, etc.

Physical characteristics

Communication barriers

Alertness/level of consciousness 

Dress and hygiene

Movement and activity

Facial expression

Speech behavior

Attitude toward the clinician

Mood and Affect: “Mood” refers to a relatively sustained and pervasive emotional state  (e.g., anxious, depressed). “Affect” is more variable and reactive than mood. It consists of the expression of emotion or feelings displayed to others through facial expressions, hand   gestures, voice tone, and other emotional signs such as laughter or tears. 

Lability or reactivity: 

(a) A client may exhibit a mild restriction in the range or intensity of display of her feelings. This is referred to as restricted or constricted affect. 

(b) A client may have labile affect (i.e., her affect may be unstable and constantly changing).

 (c) Conversely, a client may display a significantly reduced variation of mood or affect. As noted earlier in this chapter, the term affective flattening  (or  blunting)  is  used  to describe an extremely limited affective range or lack of response to environmental stimuli. Flat affect is associated with schizophrenia and is also found in severe depression and certain neurological conditions. 

(d) Bland affect, in which nothing seems to affect the client, is associated with a major neurocognitive disorder (i.e., dementia).

Appropriateness: Do the client’s mood and affect match the current situation and the content of her thought? When a person’s mood or affect is significantly inappropriate, this can be a sign of schizophrenia.

Flow of Thought: Flow of thought is reflected in a client’s flow of speech (i.e., the client’s speech is presumed to reflect her thought).

Association: (a) Is the client’s speech spontaneous or does it occur only in response to questions? (b) Is there flight of ideas? Clients with mania often display flight of ideas, along with pressured speech. (c) Is there tangential speech (answers that seem unrelated to questions)? Are there loose associations? Both tangentiality and loose associations are associated with psychosis (often schizophrenia) but may also be found in mania. (d) Incoherent and rambling speech is often associated with a thought disorder, but may also be a sign of alcohol or other drug intoxication. A client who displays these symptoms must be screened for alcohol and other drug use.

Rate and rhythm of speech: (a) Is there pressured speech? This includes rapid speech that is difficult to interrupt and instances in which a client responds extremely quickly to questions (sometimes even before a question is fully asked). Pressured speech is associated with mania; some individuals with mania report that their words can’t keep up with their thoughts. (b) Alternatively, a client may take far longer than normal to respond to questions, have long pauses between sentences, speak extremely slowly, and/or provide very brief answers. This is part of psychomotor retardation and is associated with severe depression. (c) Other speech cues that may be present include circumstantial speech (speech that contains excessive extraneous material in addition to the principal message) and stuttering.

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