JOURNAL TRANSCRIPT

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BEAT THE BOARDS! MENTAL STATUS EXAM ITEMS American Physician Institute for Advanced Professional Studies LLC 877-225-8384

GENERAL APPEARANCE • Alertness: normal, decreased, increased • Arousal: normal, decreased, increased • Distractibility: normal, increased • Apparent Age: as stated, younger, older • Sex: male/female/transgender • Race / Ethnicity: African American, Caucasian, Hispanic, Middle Eastern, etc. • Habitus/Build: normal, overweight /obese, underweight, emaciated, thin, muscular • Stature: normal, short, petite, tall • Grooming/hygiene: good, immaculate, adequate, poor, disheveled/unkempt, neglected • Dress: Appropriate or inappropriate (for particular setting and/or weather), casual, formal, stylish, mismatched items • Make-Up: None, appropriate, garish, bizarre • Tattoos /Piercings: present, absent FACE • • • • • • • • • •

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Hair: normal appearance, uncombed, alopecia, evidence of trichotillomania Dentition: good, poor hygiene, missing teeth, evidence of dentures Eyes: normal, eyeglasses, exophthalmus, strabismus, nystagmus, ptosis Pupils: normal/reactive to light and accommodation; dilated (mydriatic) or constricted (myotic) Facial Asymmetries: none, on left, on right, on forehead, on lower face Facial Dyskinesias: blepharospasm, grimacing, jaw thrusts, lip smacking/puckering, chewing/sucking, tongue protrusion/writhing Facial Tics: absent, present Dystonia: absent, present Parkinsonian: flat affect, drooling, decreased blink Dysmorphisms: microcephaly, macrocephaly, ears, webbed neck, prominent epicanthal folds, short palpebral fissures, hypertelorism, short nose/ low bridge, indistinct philtrum, large tongue, micrognathia, macrognathia Facial Expression: appropriate, sad, anxious, angry, contemptuous, disgusted, perplexed

BODY • Skin: normal, puffy, spider angiomas, hemangiomas, café au lait spots, neurofibromata, bruises, cancer-like growths (Kaposi, basal cell, squamous cell) • Scars: none, needle tracks, skin popping, self-cutting, burns, surgical, from fights/accidents • Trunk/Extremities: scoliosis, lordosis, limb abnormalities, arthritis, amputation • Other Medical: smoker's cough, SOB, goiter, clubbing, tobacco-stained fingers, pregnant • Aids: cane, walker, wheel chair, hearing aid, prosthesis ENGAGEMENT WITH INTERVIEWER/“interpersonal style” • Eye contact: appropriate, heightened (vigilant), avoidant, decreased, fleeting, intense/unwavering, sporadic, poor, downcast eyes, none • Cooperation: appropriate, congenial, engaging, open, candid, guarded, evasive, suspicious, challenging, withdrawn, distant, annoyed, irritable, hostile, shy, relaxed, cautious, defensive, resistant • Adherence to social conventions: shakes hands, greets appropriately, salutes (military bearing)

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Reliability: good, contradictory, unreliable, unknowledgeable Transference: intimidating, dismissive, critical, entitled, suspicious, seductive/flirtatious, adoring, helpless/waif-like Interviewer's Countertransference: intimidated, angry, withholding, over-identifying, solicitous, overwhelmed, grandiose

MOTOR • Motor Activity Level: normal, hyperactive (goal-directed), agitated (non-goal-directed), hypoactive  Dyskinesias: Where: _________, ballismus (large, violent movements), hemiballismus (confined to one side), athetoid (slow writhing-like, sinusoidal movements), choreiform (rapid, jerky movements) • Other Movements: tics (sudden spasmodic movement), stereotypies (ritualistic, repetitive movement or utterance, like rocking, finger-flicking, hand waving), mannerisms (distinctive manner of moving or speaking, like gesticulating while speaking), tremors (resting, intention), dystonias • Catatonia: waxy flexibility/catalepsy (immobility with unresponsiveness), echopraxia (mimicking gestures), echolalia (repeating words), automatic obedience, negativism (doing the opposite of command) • Gait: cerebellar ataxic gait (appears drunk, wide-based), magnetic gait (feet appear magnetically stuck to floor, lifted as against magnetic attachment), Parkinsonian (festinating gait: small accelerating steps, often on tiptoe, with forward center of gravity), paralytic (weakness evident on one side), antalgic (gait used to avoid pain in weight bearing structures), spastic (scissor-like with stiff legs close together) SPEECH (must comment on rate, rhythm, volume, tone, prosody and spontaneity) Clear, coherent, pressured(fast), soft-spoken, stuttering, includes profanity, impoverished, monotone, mumbled, animated/excited, slurred, difficulty word finding, spontaneous, confabulatory, impressionistic (with little detail), poorly articulated • Expression: spontaneous, fluent, nonfluent, ungrammatical • Comprehension: normal, reduced • Speech form: normal, dysarthric, delayed onset, loud, soft, fast, slow, decreased prosody, monotone • Paraphasias: none, auditory (sounds similar), syntactical (means similar) EMOTIONS • Mood (self-report, in quotes):” “; euthymic (normal), anxious, depressed, elated/euphoric, calm, irritated, alexithymic, dysphoric • Affect quality: happy, sad, desperate, worried, anxious, angry, irritable, euphoric, expansive, detached, dysphoric (sad, angry, or anxious) • Affect Range/Intensity: normal, expansive, decreasing intensity of affect: restricted, constricted, blunted, flat • Affect Fixity/Lability: normal, volatile/labile, rapid, extreme, brief swings of emotion followed by a quick return to normal • Affect Congruency: congruent or incongruent to topic and/or to mood

THOUGHT FORM/PROCESS  Coherence: Are the patient’s thoughts organized well enough that they make sense to the listener?  Logic: Are the conclusions reached logical (based on sound or flawed logic?)  Goal Directedness: Does the patient get to the point in a direct manner? Or is he/she circumstantial or tangential, etc.? (see below)  Associations: How well connected are the thoughts? Disordered associations include blocking, loose associations, flight of ideas, etc. (see below) o Definition of formal thought disorder: pattern of interruption or disorganization of thought o Disturbance in thought form: poverty of thought (reduced thought), mutism (refusal to speak), incoherence, word salad (mixture of words and phrases lacking comprehensive meaning or coherence), thought blocking (sudden interruption of thought or speech), clanging, punning, neologisms (new words formed to express ideas), echolalia (meaningless repetition of words) o Disturbance in connection between thoughts: overinclusive, perseverative (remaining or returning to limited set of topics), pressured ( talking quickly such that interruption is difficult), circumstantial (adding irrelevant detail but reaching goal), tangential (moving from related thought to related thought but not reaching goal), loose associations (illogical shifting to unrelated topics), flight of ideas (skipping from one topic to another in fragmented, rapid fashion)), derailing (loss of train of thought following thought blocking) THOUGHT CONTENT (actual statements, themes, and beliefs presented by the patient) 

Perceptions – False perceptions include: o Hallucinations (false sensory perceptions without external stimuli): i.e., auditory (running commentary, arguing, derogatory, commanding of suicide/self-injury or of homicide or violence) , visual, olfactory, gustatory, tactile, kinesthetic) o Illusions (misinterpretation of actual sensory stimuli) o Depersonalization (feelings of unreality or strangeness concerning one’s self) o Derealization (feeling that the external world is foreign or strange) o Distortion of body image (erroneous self-assessment that one’s physique is flawed)

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Delusions – Fixed, false beliefs. Examples include: somatic, persecutory, jealousy, erotomanic, of grandeur, nihilistic, Fregoli's (disguised persecutor), Capgras (loved one replaced by imposter), etc. Ideas of reference or delusions of control are also part of this category.

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If present, include: o Thought broadcasting (feeling that one’s thought are being “put out there” for all to see/hear) o Thought insertion (others can place thoughts into one’s mind) o Thought withdrawal (feeling others can remove thoughts from them)

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Thought content also includes: o Overvalued ideas (differs from delusions in that the belief is less firmly held, is less bizarre, and is not systematized) o Obsession themes o Phobias o Ruminations/worries

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Additional components of thought: o Insight: Perception of illness; understanding of presence, nature, cause, and significance of any mental or emotional problem; clarify if in denial or if recognizes there is a problem but projects blame. o Judgment – This is the ability to make good decisions concerning the appropriate thing to do in various situations. o Motivation o Impulse control: estimate of patient’s ability to control their actions (and thinking about them prior to acting on them). Evident throughout the interview (i.e., swearing or attacking the interviewer) or from past history (i.e., overt sexual behavior, fights, and/or substance use)

Note: Dangerousness/Risk: should always be a part of MSE; include suicidal and/or homicidal ideation, being as specific as possible with past attempts, current intent and/or plan; include if victim of abuse/neglect or if perpetrator of abuse or neglect COGNITIVE TEST SCORING • Orientation (Sensorium): □ place □ time □ person □ situation • 3-Word Repeat: □ 3 □ 2 □ 1 □ 0 • 5-Min Recall: □ 3 □ 2 □ 1 □ 0 • 3-Step Command: □ 3 □ 2 □ 1 □ 0 • Serial #: □ 5 □ 4 □ 3 □ 2 □ 1 □ 0 • DLROW: □ 5 □ 4 □ 3 □ 2 □ 1 □ 0 • Intersecting Pentagons: □ 2 □ 1 □ 0 • Proverb interpretation: abstract, concrete, idiosyncratic • Similarities/differences: abstract, concrete, idiosyncratic PSYCHOLOGICAL DEFENSES • Mature Defenses o Humor: appropriate use of humor to reframe viewpoint and decrease catastrophizing o Sublimation: impulses directed to socially useful projects o Altruism: vicarious gratification o Suppression: conscious deferment • Neurotic Defenses o Isolation: splitting off of unacceptable affects from the idea that accompanies it, e.g., speaking of traumatic events with a neutral affect o Displacement: an affect shifted from one object (person) to another, e.g., kicking the dog when you're mad at the boss o Reaction formation: transforming an unacceptable impulse into its opposite, e.g., showering a person you hate with kindness o Denial: an unconscious repression of unacceptable impulses, emotions, desires, and instincts • Immature Defenses o Regression: a return to earlier modes of acting or feeling, e.g., becoming very needy and helpless when under stress o Somatization: transforming unacknowledged needs (e.g., dependence) into physical symptoms as a way to have needs met without acknowledging them

o Acting Out: avoiding unacceptable affects or impulses by engaging in a flurry of diversionary activity o Blocking: a temporary stopping of thoughts or feelings as a protection against them 

Narcissistic Defenses o Projection: shifting unacceptable impulses into outside persons, institutions, etc, e.g., projecting rage at others and feeling threatened by the projected affect o Projective identification: Unacceptable feelings or impulses are projected onto another person who is then “made” to feel that they are his own, e.g., a patient treats the psychiatrist as incompetent. The psychiatrist accordingly begins to feel and act incompetently o Splitting (primitive idealization and denigration): an inability to see people or situations in shades of gray; people or situations are seen as all good or all bad o Distortion: reality is distorted to meet the person’s emotional needs

COGNITIVE DISTORTIONS • All-Or-Nothing Thinking: Seeing things in categories of all-good or all-bad. Performance that is less than perfect is interpreted as a complete failure. • Overgeneralizing: Generalizing a single negative event into a larger never-ending pattern of defeat. • Negative mental filter: Dwelling on negative details to the exclusion of positive aspects, even when the positive aspects are more prominent. • Disqualifying the positive: Rejecting positive experiences by insisting they "don't count." For instance, handling an interpersonal challenge effectively and maturely but concluding that it was "just luck." • Jumping to conclusions: Interpreting events negatively even though there is little evidence to support the negative assessment. • Mind reading: Believing that others hold a negative view of you without confirming this belief or entertaining alternate explanations. For example, thinking your boss is angry with you because he didn't say "Hi." His behavior in fact may have been unrelated to you, perhaps related to preoccupation with financial problems. • The Fortuneteller Error: Predicting the future in a negative way as if it were preordained to turn out badly. • Catastrophizing: Exaggerating the importance of negative events until they are seen as overwhelming. This increases a person's sense of helplessness and hopelessness. • Emotional Reasoning: Believing that your negative emotions reflect the state of the world. For instance, when depressed, believing that the world is "going to hell in a hand basket." • Essentializing: Seeing setbacks as a reflection of your core self. Rather than thinking, "I made a mistake," you think, "I'm a loser." This distortion also occurs when assessing others. For instance, if someone forgets your name, concluding, "He's such a self-centered and shallow guy." • Personalizing: Believing yourself to be the cause of external negative events, even though it is unlikely you are responsible for them. For instance, when your parents argue, concluding that it's your fault. This distortion is particularly common among people raised or living with an abusive parent or spouse or with a substance abuser.