The mental state examination (MSE) forms a cornerstone of a clinical evaluation in a variety of settings, including psychiatry, neurology, and medicine. It can also be an important part of an evaluation in a medical-legal setting. Like a physical or elementary neurological examination, the MSE tends to follow a standard approach, although the content and depth of the examination may vary, depending on what discipline is doing the examination and for what reason. This article reviews the general principals of the MSE in a medical-legal context, and how the MSE may be important to the expert witness consultant. The MSE can be divided into two sections: the psychiatric and cognitive state exams. In some clinical settings, one or the other is focused on, although assessment of both are appropriate in most clinical and forensic settings, where mental state may play a role in the legal question being asked. The examination assesses current state, and does not reflect past symptoms, functions, or behaviors. However, it may be very important to compare a current exam with previous exams for changes. Aspects of the examination occur throughout the meeting with the client or subject of the exam, such as behavior, speech (reflecting his or her thinking), and presentation.
The psychiatric ‘phase’ of the examination assesses the person’s current mental state with regards to psychiatric and behavioral symptoms, which may underlie a psychiatric disorder. The following components are assessed in this phase of the exam:
1- Presentation: how the person presents him or herself is important, with regards to dress and hygiene. Poor self care may reflect acute psychiatric symptoms, poor self-awareness, or even an intentional effort to present poorly. Behavioral appropriateness is also important to assess – is the person’s behavior appropriate to the setting? Depending on the legal situation, behavior of an elderly person during an assessment of testamentary capacity may be dramatically different from a psychiatric assessment of an incarcerated defendant. Motor behavior (assessing movement abnormalities) may also provide data about an underlying neurological or psychiatric condition.
2- Level of wakefulness and awareness is assessed, as someone who is either hyper-alert or has diminished arousal may be impaired on other parts of the examination, which in turn may make the examination at that time invalid. Examples of impaired arousal include delirium or over-sedation due to medication.
3- Thought content, as reflected by what the person is reporting or answering, reveals important data about his or her thinking and whether the content seems ‘normal’ or reflects some type of pathology. Thought content may be superficial, as may be found in a dementia, overly-detailed, unusual, or bizarre, as may reflect different psychiatric disorders, or have an atypical clinical pattern, reflecting possible malingering.
4- Thought process, again demonstrated by speech and communication, reflects how the person is thinking. Disturbances in thought processing can reflect a variety of psychiatric or neurological conditions. Examples include an increased rate of thinking in a manic mood state, interruptions in thinking in psychosis or in a partial seizure, or an unusual, atypical clinical picture, which may again be consistent with malingering.
5- Sensory Input/Perception: this category assesses unusual or pathological symptoms found in a variety of conditions. Sensory input involves auditory, visual, olfactory, somatosensory and gustatory. Examples of disturbances include hallucinations, which are perceptions of internally-driven stimuli and which not real, and sensory misperceptions of external, real stimuli. Hallucinations can be in different modalities and may be due to various psychiatric and neurological disorders, such as psychotic illness, seizures, or specific medication or drug use. Misperceptions of stimuli may occur also in a variety of conditions, including people with cognitive impairment and poor eyesight or hearing.
6- Assessment of target symptoms and safety includes assessing mood state and associated symptoms, which may be consistent with a mood or anxiety disorder. In some evaluations, this assessment becomes part of a ‘review of symptoms or systems’ done separate from a MSE. Assessment of safety issues can include thoughts, plans, and intent regarding harm to ones self or others (or property). In addition, an assessment of impulsivity is important. A risk assessment reviews both intentional thoughts or plans of harm, and behaviors where unintentional injury or death may occur. Examples include suicidal thinking in a severe depression, high risk behaviors in mania, and impaired thinking and behavior in dementia (the latter can include higher risk situations such as dementia and driving).
The ‘cognitive’ phase of the MSE evaluates mental processes such as attention, memory, language, etc. As in the above ‘psychiatric’ phase of the exam, the depth and detail of the cognitive exam may be dictated by concerns about specific cognitive impairments, and a cognitively intact individual may not require an in-depth cognitive evaluation. Despite the detail of this evaluation, specific ‘spheres’ of functioning should be assessed, which, like the psychiatric exam, may provide important information related to a specific legal question or issue. The following components are assessed in this phase of the exam:
1- Attention: this sphere may be divided into simple and complex attention. Simple attention is the ability to focus on a specific task for a limited time. A test of simple attention is the digit span, where a series of digits are given with increasing number, and the person recites them forwards and backwards. Complex attention is the ability to sustain attention over a prolonged time, shift between two different sets of stimuli, and selectively focus on more relevant stimuli and filter out competing but less relevant stimuli. There are several tests of complex attention, such as being able to shift between numbers and letters (having the person recite 1-A-2-B-3-C., etc.), serial subtraction (subtracting 7s starting with 100), and naming the months of the year backwards. People having significant problems in the area of attention (like in impaired awareness) may also do poorly in other areas of cognitive testing, and a more detailed exam may be deferred.
2- Language: an important sphere of functioning and fundamental to communication. To some degree this area is assessed throughout a meeting, but formal testing includes assessing fluency and grammar, comprehension, repetition, naming, reading, and writing.
3- Memory: another important area, which can be affected by a variety of conditions. There are numerous levels or divisions in memory, including verbal and non-verbal. Tests of memory functioning include giving the person new material to learn, to assess registration and immediate recall, short-term recall (reviewing the new material after a delay, and asking about orienting items such as date and place), and long-term recall (such as biographical and historical information). Visual memory can also be tested as part of the memory assessment.
4- Visuospatial and Constructional Abilities are assessed in part by copying drawings. Some tests assess various functions, an example being a clock drawing where the person is asked to draw a clock face, put in the numbers and set the hands at a specific time. This task assesses visuospatial, planning, and memory functions.
5- Higher-order Executive Functioning: this concept relates to overriding cognitive managerial functioning to one’s self and the interactions one has with the external world. Functions include planning, reasoning, foresight, initiation, continuation, and inhibition of tasks and behaviors, monitoring and altering behaviors, decision making, and problem solving. This area is more difficult to test in an examination, and in part is assessed by getting a history of how a person is functioning at home, work, school, with others, etc. Various tests which can provide some information in this area include fund of information (asking closed ended questions with known answers), proverb interpretation, and assessing similarities/differences in items. Additionally during the exam, the person can be assessed for ability to weigh options, make decisions, make plans, display ability to inhibit tendencies, reason through complex material, display flexibility in thinking, etc. There is a definitional and practical relationship between some of these functions and the concept of ‘competency’.
The above examinations provide clinical information which may be related to or support specific medical-legal questions or issues. Examples include impact of psychiatric symptoms and behaviors on an alleged criminal activity, whether the psychiatric examination supports a person being civilly ‘committable’ to a psychiatric hospital setting, or whether focal cognitive deficits may negatively affect decision-making and competency in treatment or legal settings. Formal evaluations through psychological and neuropsychological testing provide additional data which may support the above clinical evaluations.
About the author:
Jacob C. Holzer M.D.
Following service in the US Air Force, Dr. Holzer completed undergraduate, medical school, and internal medicine internship in the Boston area, followed by psychiatry residency at Yale University. He completed two fellowships, in psychoparhamcology research at Yale and clinical neuropsychiatry/behavioral neurology at the Beth Israel Hospital/Harvard. Since completing training, Dr. Holzer has provided direct clinical care in several areas, including neuropsychiatry and medical psychiatry, psychopharmacology, and forensic psychiatry, and has worked with various patient populations, including co-morbid medical/neurological conditions, traumatic brain injury, chronic psychiatric conditions, mood and anxiety disorders, and geriatric patients, He has been involved in law and psychiatry and legal medicine for approximately 20 years, in both consultation with courts and attorneys, the private business sector and companies, and government agencies, and in academic settings involving research, teaching, writing, and formal presentations, in various law and psychiatry topics. He has also been involved in committees and presentations at law and psychiatry organizations and conferences in the US and abroad. He is ABPN board certified in general and forensic psychiatry, and has been certified as a Designated Forensic Professional in Massachusetts. He is on the staff at McLean Hospital and Massachusetts General Hospital, and on the faculty at Harvard Medical School.
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