Scroll below or search in the bar for "Mental Status Exam: Behavioral Aspects" to see the first part of these posts. MSEs include an evaluation of both behavioral aspects and cognitive aspects. Today's post will include the second component of cognitive aspects. Come back on Friday for a question related to this topic!
Cognitive Aspects of an MSEÂ
Whereas observation alone can be used to obtain information about behavioral variables, to collect data about cognitive functioning you must also actively question the client to elicit the material you need.
- Thought Content: Similar to flow of thought, thought content is reflected in the content of a client’s speech. Examples of abnormal thought content include delusions and morbid preoccupations. Depending on the nature of the abnormal thought content, diagnostic possibilities include a primary psychosis, depressive or bipolar disorder, mental disorder due to another medical condition, or substance/medication-induced mental disorder. Mood-congruent delusions, for example, are associated with a mood disorder, while mood-incongruent delusions are more typical of schizophrenia.
- Perception: Perception refers to the accuracy of a client’s five senses (sight, hearing, touch, smell, and taste) or her ability to correctly perceive external stimuli and her own internal processes. Examples of abnormal perceptions include illusions (misperceptions of actual stimuli) and hallucinations (perceptions in the absence of actual stimuli). Hallucinations can involve any of the five senses and may be associated with a primary psychosis, mental disorder due to another medical condition, or substance/medication-induced mental disorder. Auditory hallucinations are the most common type among people with schizophrenia, while visual hallucinations are commonly reported by people withdrawing from alcohol who are experiencing delirium tremens. A depressive or bipolar I disorder can also include hallucinations in some cases.
This MSE category also includes anxiety symptoms (e.g., excessive, uncontrollable worry neither directed at nor caused by anything specific the client can identify), phobias, obsessions and compulsions, and thoughts of violence (including suicidal ideation).
- Consciousness and Cognition: Consciousness and cognition consist of the ability to absorb, process, and communicate information.
Attention and concentration: “Attention” refers to the ability to focus on a current task or topic, while “concentration” is the ability to focus over a sustained period of time. Both abilities require a client to filter out irrelevant stimuli. You can get a sense of a client’s attention span and ability to concentrate by observing her behavior during the entire interview.Â
Orientation: Orientation refers to an accurate awareness of the following: (a) person (e.g., you ask the client, “who are you,” “what’s your name,” “are you married?”); (b) place (e.g., “where are you,” “where do you live?”); (c) time (e.g., “how old are you,” “what day is today?”); (d) situation (e.g., “who am I,” “why are you here?”); (e) familiar objects (e.g., you point to common objects and ask the client to identify them); and (f) other people (e.g., “what’s your mother’s name?”).Â
Language: This MSE category evaluates comprehension, fluency, naming of items, repetition, reading, and writing. These language aspects can be partially assessed based on how the client responds to conversation in the interview. They can also be evaluated by means of simple screening tests (e.g., you ask the client to repeat a simple phrase, instruct the client to perform a complex behavior involving a sequence of steps, or ask the client to read or write one or two sentences).
Memory: Memory consists of three types: immediate (within 5 or 10 seconds), short-term, and long-term. Immediate and short-term memory can be evaluated by asking the client to repeat a short list of items immediately (immediate memory) and then after five minutes have passed (short-term memory). To test long-term memory, you can evaluate the client’s ability to organize information needed to relate her life history.Â
Cultural information: This area is concerned with the client’s remote memory (long-term memory for things that happened years ago) and general intelligence or intellectual functioning. To test these functions, you can ask a series of questions such as, “name the five most recent presidents,” “name the vice president,” and “name five large cities.” Poor intellectual functioning despite a good educational background can sometimes indicate a neurological problem. As with attention and concentration, however, it’s important to consider a client’s age, education level, culture, and degree of depression and anxiety when assessing performance in this area.
Abstract thinking: Abstract thinking includes the ability to extract a principle from a specific example. Common ways of assessing abstract thinking include asking a client to interpret some familiar proverbs (e.g., “people in glass houses shouldn’t throw stones”) or explain the similarities and differences between specific objects (e.g., “How are an apple and an orange alike?”). When evaluating this function, it’s important to recognize that abstract thinking depends much more on cultural background, intelligence, and education than mental health. Additionally, proverbs and their interpretations vary across cultures, and clients from some cultural backgrounds may be unfamiliar with the proverbs presented to them.
- Insight and Judgment: To evaluate a client’s insight (i.e., ideas about her problem and life situation), you can ask a series of questions such as, “do you think you are impaired” and  “what strengths do you have?” Insight can be either complete, partial, or nonexistent, and  tends to diminish during episodes of illness and improve during periods of remission. Poor insight is associated with neurocognitive disorders, severe depression, psychotic disorders, and mania.
As noted earlier, judgment (or common sense) refers to the ability to decide on an appropriate course of action to achieve realistic goals and has a significant influence on decision-making and problem-solving ability. To assess judgment directly, you can ask questions such as, “what do you expect from treatment,” “what are your plans for the future,” or “you find a stamped, addressed envelope on the sidewalk, what would you do?” Frequent poor judgment can be associated with a manic episode.