The Mental Status Examination (MSE) is an evaluation of a client’s current overall functioning with emphasis on his or her cognitive and emotional functioning. The MSE is a structured observational system of the client’s behavior, emotions, and thoughts. The MSE is often confused with the Folstein Mini-Mental State Examination, which is a standardized screen for dementia. The MSE has several components, which generally cover the client’s appearance, behavior, and attitude toward the examination, speech, affect and mood, thought process and content, sensory perception, and general cognitive functioning. Different clinicians use slightly different categories, but the goal of each approach is the same—to provide a clear and comprehensive description of a client’s overall functioning.
Appearance includes a description of the client’s body, movements, dress, and overall grooming. Speech includes a description of the client’s rate and volume of speech as well as ability to articulate. Affect and mood includes both a statement of the client’s self-report of feelings and the clinician’s impressions of the stability, appropriateness, and range of the client’s affect. A description of the client’s thought process and content refers to the coherence of the client’s thoughts and the presence of any dangerous or psychotic ideas. A sensory assessment includes vision and hearing problems and the presence of any illusions or hallucinations. Assessment of overall cognitive functioning includes the client’s estimated intelligence, alertness, attention and concentration, memory, insight, and judgment.
The psychosocial history and the MSE provide the clinician with information about both the client’s past and present functioning and provides the information needed to form a complete picture of the client’s current condition. The MSE can be completed in a narrative or a checklist format. MSE checklists for children, adolescents, and adults allow the clinician to gather rich data in a thorough and efficient manner. Two examples of MSE checklists are Schinka’s Mental Status Checklist for Adults and Dougherty and Schinka’s Mental Status Checklist for Children. Choosing an MSE designed for children is particularly helpful because it adapts the general areas of observation to a child’s developmental level.
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- Zuckerman, E. (2000). The clinician’s thesaurus. New York: Guilford Press.