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MSE
Mental Status Exam
| Term | Definition |
|---|---|
| Aloof | disengaged, lack of connection with others |
| Avoidant | disengaged due to anxiety and desire to escape/avoid contact |
| Contempt | passive aggressive style of relating to others, rolling eyes, imitating tone, mocking |
| Defensive | reacting to the input of others in a hostile manner, feels threatened and under attack |
| Dismissive | reacting to the input of others by disregarding/rejecting, think they know better |
| Oppositional/Defiant | intentional power struggles/arguments (particularly with authority), ignoring, baiting |
| Guarded | overly careful about sharing information with others, lack of trust, secretive, closed off, little self disclosure |
| Hypervigilant | excessive attention to external environment/stimuli due to heightened fear and anxiety (trauma) |
| Suggestible | easily influenced, uncritical acceptance and compliance with another person's ideas |
| Eye contact | Good Poor Fixed |
| Psychomotor Activity | Fidgeting, agitated, balling up fists, slow, odd mannerisms, gestures, coordination, compulsions |
| Movements | tremor, abnormal moves, gait |
| Behavior | Manner of relating to others eagerness to please defiant overfamiliar expression |
| Descriptors of presentation | Cooperative, focused, uncooperative, aggressive, cooperative, guarded, hostile, impatient, indifferent, ingratiating, intense, manipulative, negativistic, open, passive, seductive, suspicious, secretive, evasive, distracted, apathetic, defensive. |
| Ego Dystonic | Individual does not consider their behavior to be consistent with their core self/personality |
| Ego Syntonic | Individual considers their behavior to be consistent with self, externalizing blame to others for problem behavior |
| Conceited | Arrogant, self-important, proud, egocentric, hides deeper feelings of inadequacy/anxiety |
| Grandiose/Expansive | belief that they can accomplish anything, even outrageous tasks, ego inflation (mania) |
| Intropunitive | Turning anger inward, punishing self for unwanted events even if not at fault, self derision (depression) |
| Splitting | Dichotomous/all or nothing thinking, black or white, good or bad (borderline) |
| Catastrophizing | dramatically predicting that the worst event will happen, faulty logic (depression, histrionic) |
| Speech - Verbal Communication (descriptors) | Rate, Rhythm/Fluency, Volume/Tone, Content, Amount, Spontaneity/Talkative, Language ability |
| Speech rate | Fast, Slow, Normal, Pressured |
| Speech Rhythm/Fluency | Clear, Slurred, Hesitant, Good articulation, Appropriately placed inflections, Aphasic |
| Speech Volume/Tone | Loud, Soft, Monotone, Weak, Strong |
| Speech Spontaneity/Talkative | Expansive, Paucity, Poverty, Mute |
| Regular Rate and Rhythm of Speech | Controlled, even paced, cadenced, can interact/exchange/dialogue with another person |
| Pressured Speech | Accelerated, uncontrollable, excessive talking, rapid rate/rhythm, difficult to understand, individual feels like they cannot talk fast enough to get everything out |
| Laconic Speech | Terse, brief responses provided without elaboration, poverty of speech, one word answers, bare minimum, no unprompted info given |
| Disorganized Speech | Unintelligible, disconnected speech (dementia, delirium, schizophrenia, substance misuse) |
| Coprolalia (speech) | Involuntary use of vulgar/obscene language, found in Tourette's syndrome. Can also include sounds/tics such as grunts, 'hmmm', 'grr', shhh', 'ah', 'huh', etc. |
| Echolalia (speech) | Mirroring or repeating the speech of another person. Repeating back the question vs. answering the question (autism) |
| Mood | Main emotional state that the client expresses to you about how they are feeling over days/weeks. |
| Euthymic | Normal/typical mood, happy, upbeat |
| Dysphoric/Depressed | Down, "blue" mood decreased energy, irritability (common to depression, anxiety, bipolar disorder) |
| Euphoric/Elated | Increased energy, "on top of the world", "up", or amped. (common with mania, bipolar disorder) |
| Labile | Unstable, quickly changing mood, unpredictable, impulsive. (common in bipolar disorder) |
| Anhedonia | Withdrawal from regular and pleasurable activities, lack of interest in same |
| Vegetative symptoms | dysregulations in brain chemistry. appetite and sleep changes are most evident (common in depression) |
| Affect Type | normal (euthymic), depressed/irritable/angry/hostile (dysphoric), elevated/elated (euphoric), sad, indifferent, detached, anxious, animated |
| Affect Range | Normal/typical (broad/full) vs Constricted, restricted, labile |
| Affect Intensity | Normal, blunted, flat, hyper-energized |
| Reactivity (affect) | dulled range of expression (blunted, flat) associated with depression, brain injury, trauma |
| Congruency (affect) | Does affect match mood? Authentic, genuine, integrated |
| Incongruent (affect) | inappropriate, inauthentic, superficial |
| Affect | The observable emotional state: Stability, range, appropriateness, intensity, mood. |
| Thought process | The rate of thoughts, how they flow and are connected, stream, and speed. |
| Normal thought process | includes logical, coherent, linear, tight, direct and goal directed vs disordered |
| Abnormal/Disordered thought process | loose associations, are not clear, organized or coherent (ex. tangential, flight of ideas, word salad, thought blocking) |
| Clang associations | Combining unrelated words/phrases because they have similar sounds |
| Perservation | Repetition of words, phrases, ideas |
| Neologism | |
| Thought blocking | Thoughts interrupted |
| Circumstantial | provide unnecessary detail in thought and speech but eventually get to the point |
| Tangential | irrelevant, digressive, oblique speech, move from thought to thought that relate in some way but never get to the point |
| Loose Associations | Illogical shifting between unrelated topics. Little or vague connections like "going down the rabbit hole" |
| Flight of Ideas | moving quickly from one idea to another, similar to mania. multiple thoughts occurring, often in list form, have a pressured quality. |
| Word Salad | Nonsensical, randomly spoken words. |
| Distractible | Focus can shift quickly to the external environment. This awareness interrupts the present dialogue (anxiety, ADHD) |
| Rumination | Preoccupation with a single idea or theme. Similar to perseveration (anxiety, OCD, delusional thoughts) |
| Preoccupied | Inattentive to the external environment, internally focused, seems to be in deep thought (depression, psychosis, schizoid) |
| Racing thoughts | Multiple thoughts occurring in a seamless fashion, frequently in order/list form, with pressured quality (anxiety, mania, bipolar) |
| Latent | Prolonged period of time between a thought and its actual verbal expression (anxiety, depression, schizophrenia) |
| Thought Content | Refers to themes that occupy the clients thoughts and perceptual disturbances |
| Ideas of reference | misinterpretation of incidents and events in the outside world having direct personal reference to the client |
| Delusions | Fixed, false beliefs firmly held in spite of contradictory evidence (persecutory, somatic, control, grandiose, erotomanic, reference, bizarre) |
| Preoccupations | suicidal or homicidal ideation (SI or HI), compulsions, obsessions, perseverations |
| Phobias | fears |
| Perceptions | Disturbances include illusions, altered bodily experiences (depersonalization, derealization), hallucinations (auditory, visual, olfactory, tactile), deja vu, flashbacks. |
| Illusions | misinterpretations of environment, perceptual distortions |
| Depersonalization | sensation of unreality concerning oneself or parts of self |
| Derealization | feelings that the outer environment feels unreal |
| Hallucinations | false sensory perceptions that are not experienced by others (auditory, visual, tactile, olfactory) |
| Dissociation | altered consciousness, trance-like state, disconnected from emotions, often associated with painful emotional content/trauma |
| Regression | return to a child-like state. individual is unconscious and unaware of their regression |
| Psychomotor Retardation | decreased activity, slow responses, sluggish (depression, brain injury) |
| Catatonic | severe immobility (schizophrenia) |
| Apathetic | laissez-faire attitude, indifference, accompanied by dulled emotional tone and slow motor activity |
| Restless/Hyperactive | difficult to sit still, needs to be in constant movement (anxiety, add/adhd, trauma) |
| Agitated | severe irritation and/or anxiety, adrenaline response, preparation for some kind of action, pacing, hyperventilation |
| Stereotypy | continuous mechanical repetition of speech or physical activity, such as rocking back and forth, or flapping hands (autism, psychosis) |
| Memory - Normal (Intact) | Appropriate short/long term recall, normal, typical |
| Anterograde Amnesia | memory loss for events after the onset of amnesia (brain injury, dementia, substance misuse) |
| Retrograde Amnesia | memory loss for events before the onset of amnesia (brain injury, dementia, substance misuse) |
| Recent memory assessment | What is your name? What did you eat for your last meal? What time was your appointment today? |
| Immediate memory assessment | Repeat then Recall of 3 unrelated words (Apple, Table, Penny) ask after 5 minutes |
| Serial Sevens (or 2's) | To assess attention, concentration, and calculation. |
| Long term memory assessment | What is your Social Security Number? What year did you graduate from high school? What was the make of your first car? |
| Insight | Awareness of one's own illness and/or situation, of the world around them Rate: Full/Intact, Partial, Limited, Poor understanding of Illness Help Seeking vs Help Rejecting What brought you here today? What do you think is the problem? |
| Judgment | the ability to anticipate the consequences of one's behavior and make decisions to safeguard well being and that of others Good/Intact, Adequate, Fair, Poor |
Created by:
akimball80
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