Clinician's View RE-EXAMINA nON OF THE CLINICAL MENTAL STATUS EXAMINAnON * MORTON
Several years of teaching and practismg psychiatric evaluation has convinced me of the need to re-evaluate the formal teaching of the "mental status examination" as currently taught to budding physicians and psychiatrists. The psychiatric examiner must, of course, draw conclusions about the mental state of patients, but the value of many of the "specific tests" of mental function is debatable. I refer to such "tests" as digit span, tests of abstracting ability, estimates of judgement, intelligence and insight, and serial seven subtraction. There are at least four concerns about them. 1. We do not practise what we preach and teach. Experienced clinicians do not perform these tests often. 2. We do not use them because we know intuitively that while the mental status examination is supposed to be the psychiatric equivalent of a physical examination in medicine, there is no evidence to support this assumption. 3. Detailed mental status examinations are too often performed at the expense of careful, directed listening to the patient as he talks in a natural conversation. The main aim of history-taking remains to "listen with the third ear". It may not be possible to teach that skill, but it behooves us to emphasize the importance of acquiring it. 4. Since medical records are increasingly coming under the scrutiny of various legal and quasi-legal bodies, the need to expunge from these records data which are vulnerable to attack becomes more pressing.
S.
RAPP, M.D.l
I became alerted to the fact that most people seem aware of the uselessness of formal mental status testing during the course of another study, in which I performed digit span tests on seven lithiumcontrolled outpatients, who had been hospitalized in the past. I was curious to compare the outpatient achievement with the inpatient scores, but found that in five cases the examining physician had not bothered to perform the test, even in cases that were otherwise well documented. It is hard to escape the inference that most physicians are aware that the digit span is so unreliable that it is not worth recording. In point offact, most people seem unaware of what digit span tests are even supposed to measure. Turning from these "hard data" to reports of a more anecdotal nature, let us consider some other features of the formal mental status examination. a) The Test for Judgement
The patient is asked what he would do if he found a stamped, addressed, sealed envelope in the street. In our experience, all patients respond by saying they would mail it, except in two kinds of cases: 1) Where cortical function is so impaired that the patient cannot comprehend the question, in which case disturbed function is obvious during history-taking. 2) Where the patient, in a lapse of candor, admits he would open the envelope in search of valuables. Where such "standard" questions are virtually always answered in the same way, it cannot be said that they differentiate one group of patients from another; why then,
"Manuscript received February 1979. 'Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Staff Psychiatrist, Sunnybrook Medical Centre, Toronto. Can. J. Psychiatry Vol. 24 (1979)
773
774
CANADIAN JOURNAL OF PSYCHIATRY
use them at all? Some students do create original questions (for example, "What would you do if your car's tire went flat on the highway?"), but since the student has no standard accepted "correct" answers, the answer given by the patient will be evaluated strictly in terms of what the examiner thinks is the appropriate thing to do, destroying any semblance of objectivity. b) The "Similarities Test" for Abstracting
Ability What do an apple and an orange have in common? A poem and a statue? A dog and a tree? These three typical noun-pairs are said to describe ascending orders of difficulty in finding common features. The "best" answers are "fruit", "works of art" and "living things", respectively. But how would one judge an examinee who said that a dog and a tree were similar because they both had a bark? Is he creative or psychotic? Again, the answer will be found in the history. Recently we found an amusing specific example in which the harder a student made this test, the better the patient performed. The examinee was asked the similarity between an orange and an apple, and responded that they were both round (not very good). He was then asked the similarity between an apple and a basketball, and in response to this "harder" question, again said "round"; if the test results were taken literally, the patient improved as the questions got harder. One might argue that the single result must be considered "along with other corroborating data from the examination", but this is merely a euphemism for admitting that the test was not necessary in the first place; the patient's concrete thinking was known to the examiner before the test was administered.
c) The "Proverbs Test" of Abstracting
Ability
Here we deal with familiar glass houses being constantly shattered by
Vol. 24, No.8
(possibly moss-laden) rolling stones, to say nothing of messy hand-held birds. Where examiner and examinee share the same culture, this test may give information. However, the problem is that these homilies are simply ceasing to exist in the parlance of both the examiners and the younger patients. Vocabulary and usage have changed dramatically in a few short years. The "Rolling Stones" is a rock music group. One student was discovered, in fact, who was merrily administering the Proverbs Test under the impression that the concrete answer was the correct one! Here language and culture were barriers, but the fact that English is a second language to large numbers of Canadian doctors cannot be dealt with by pretending it does not exist. d) Tests for Intelligence
Intelligence is such a wide-range phenomenon that no conclusions about it can be derived from asking a few questions. Yet that is precisely what is done (and what is worse, recorded) on charts every day. Most estimates of intelligence probably derive from vocabulary usage, which in fact probably is the least unreliable single indicator of intelligence. If this must be done, could the examiner at least mention a few of the words used appropriately during conversation which suggested to him that intelligence was high (or average, or low)? And if he did this, would he then have to resort to less valid specific tests? e) Tests for Insight
"Insight" is usually a measure of the extent to which the patient's bias about the nature of his problem correlates with the bias of the examiner. The term "intellectual insight" is often found, implying the existence of non-intellectual insight. The term "emotional insight" is frequently used without anyone being able to explain what it means. It would often appear to mean that the frustrated examiner cannot tolerate the
December, 1979
CLINICAL
M ENTAL STATUS
ambiguities inherent in a psychiatric examination. f) Memory for Objects (or Free Recall
Test) There is no doubt that patients with organic brain syndrome will have deficits in the performance of free recall. However, so will patients suffering distractibility due to other causes. Since virtually all other tests given are useless, it is difficult to justify the use of this test alone, it having no differentiating value,
Discussion, Recommendations and Conclusions The reliability and validity of most tests discussed above is non-existent. The onus is on the proponent of a diagnostic tool to prove its utility. There is no onus on the critic of such a tool to disprove its usefulness where no prior proof of utility exists. I believe this to be the current state of affairs. This does not rule out attempts to test the reliability and validity of mental status test questions, and that is the first recommendation emanating from this essay. Until that is done, it is recommended that structured questions be used only where the history itself reveals contradictory data about the mental status. And when tests are done, they should at least be done in some standardized way, so that the stimulus question put to the patient on his first examination will be as close as possible to that put to him later on. This gives some semblance of reliability, ifnot validity. A clinical teaching unit should have a typewritten mental status questionnaire for use, to ensure that the questions asked are uniform. Where doubt exists about the severity of a depression, the existence of organicity or of thought disorder, psychological testing
775
EXAMINATION
by a competent psychometrist is preferable. The psychiatric teaching curriculum should include a guide about exactly which tests to administer, while also leaving some room for the judgement of the psychometrist. The teaching of the psychiatric anamnesis should then give much more emphasis to what can be learned by simply talking with, and listening to, the patient. Formal testing as now taught is useless in diagnosis, a humiliation to many patients, and an embarrassment to the profession. Summary The traditional "mental status examination", as taught in medical school, is critically reviewed. The disparity between what is practised and what is preached, is outlined. Specific tests alleged to give information about mental function are discussed, and their clinical utility is found to be debatable. It is concluded that the reliability and validity of the mental status examination would be well worth testing. Alternatively, more use should be made of standarized tests which are now in the hands of clinical psychologists. Resume On revoit d'une maniere critique "l'examen de I'etat mental" traditionnel, tel qu'enseigne en medecine, en soulignant la disparite entre l'enseignement et la pratique. On discute des tests specifiques soidisant fournissant des informations sur Ie fonctionnement mental et on estime leur utilite clinique discutable. On conclut qu'il faudrait tester la fiabilite et la validite de l'examen de l'etat mental. Une alternative serait d'utiliser plus abondamment les tests standardises employes par les psychologues cliniciens.
Several years of teaching and practismg psychiatric evaluation has convinced me of the need to re-evaluate the formal teaching of the "mental status examination" as currently taught to budding physicians and psychiatrists. The psychiatric examiner must, of course, draw conclusions about the mental state of patients, but the value of many of the "specific tests" of mental function is debatable. I refer to such "tests" as digit span, tests of abstracting ability, estimates of judgement, intelligence and insight, and serial seven subtraction. There are at least four concerns about them. 1. We do not practise what we preach and teach. Experienced clinicians do not perform these tests often. 2. We do not use them because we know intuitively that while the mental status examination is supposed to be the psychiatric equivalent of a physical examination in medicine, there is no evidence to support this assumption. 3. Detailed mental status examinations are too often performed at the expense of careful, directed listening to the patient as he talks in a natural conversation. The main aim of history-taking remains to "listen with the third ear". It may not be possible to teach that skill, but it behooves us to emphasize the importance of acquiring it. 4. Since medical records are increasingly coming under the scrutiny of various legal and quasi-legal bodies, the need to expunge from these records data which are vulnerable to attack becomes more pressing.
S.
RAPP, M.D.l
I became alerted to the fact that most people seem aware of the uselessness of formal mental status testing during the course of another study, in which I performed digit span tests on seven lithiumcontrolled outpatients, who had been hospitalized in the past. I was curious to compare the outpatient achievement with the inpatient scores, but found that in five cases the examining physician had not bothered to perform the test, even in cases that were otherwise well documented. It is hard to escape the inference that most physicians are aware that the digit span is so unreliable that it is not worth recording. In point offact, most people seem unaware of what digit span tests are even supposed to measure. Turning from these "hard data" to reports of a more anecdotal nature, let us consider some other features of the formal mental status examination. a) The Test for Judgement
The patient is asked what he would do if he found a stamped, addressed, sealed envelope in the street. In our experience, all patients respond by saying they would mail it, except in two kinds of cases: 1) Where cortical function is so impaired that the patient cannot comprehend the question, in which case disturbed function is obvious during history-taking. 2) Where the patient, in a lapse of candor, admits he would open the envelope in search of valuables. Where such "standard" questions are virtually always answered in the same way, it cannot be said that they differentiate one group of patients from another; why then,
"Manuscript received February 1979. 'Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Staff Psychiatrist, Sunnybrook Medical Centre, Toronto. Can. J. Psychiatry Vol. 24 (1979)
773
774
CANADIAN JOURNAL OF PSYCHIATRY
use them at all? Some students do create original questions (for example, "What would you do if your car's tire went flat on the highway?"), but since the student has no standard accepted "correct" answers, the answer given by the patient will be evaluated strictly in terms of what the examiner thinks is the appropriate thing to do, destroying any semblance of objectivity. b) The "Similarities Test" for Abstracting
Ability What do an apple and an orange have in common? A poem and a statue? A dog and a tree? These three typical noun-pairs are said to describe ascending orders of difficulty in finding common features. The "best" answers are "fruit", "works of art" and "living things", respectively. But how would one judge an examinee who said that a dog and a tree were similar because they both had a bark? Is he creative or psychotic? Again, the answer will be found in the history. Recently we found an amusing specific example in which the harder a student made this test, the better the patient performed. The examinee was asked the similarity between an orange and an apple, and responded that they were both round (not very good). He was then asked the similarity between an apple and a basketball, and in response to this "harder" question, again said "round"; if the test results were taken literally, the patient improved as the questions got harder. One might argue that the single result must be considered "along with other corroborating data from the examination", but this is merely a euphemism for admitting that the test was not necessary in the first place; the patient's concrete thinking was known to the examiner before the test was administered.
c) The "Proverbs Test" of Abstracting
Ability
Here we deal with familiar glass houses being constantly shattered by
Vol. 24, No.8
(possibly moss-laden) rolling stones, to say nothing of messy hand-held birds. Where examiner and examinee share the same culture, this test may give information. However, the problem is that these homilies are simply ceasing to exist in the parlance of both the examiners and the younger patients. Vocabulary and usage have changed dramatically in a few short years. The "Rolling Stones" is a rock music group. One student was discovered, in fact, who was merrily administering the Proverbs Test under the impression that the concrete answer was the correct one! Here language and culture were barriers, but the fact that English is a second language to large numbers of Canadian doctors cannot be dealt with by pretending it does not exist. d) Tests for Intelligence
Intelligence is such a wide-range phenomenon that no conclusions about it can be derived from asking a few questions. Yet that is precisely what is done (and what is worse, recorded) on charts every day. Most estimates of intelligence probably derive from vocabulary usage, which in fact probably is the least unreliable single indicator of intelligence. If this must be done, could the examiner at least mention a few of the words used appropriately during conversation which suggested to him that intelligence was high (or average, or low)? And if he did this, would he then have to resort to less valid specific tests? e) Tests for Insight
"Insight" is usually a measure of the extent to which the patient's bias about the nature of his problem correlates with the bias of the examiner. The term "intellectual insight" is often found, implying the existence of non-intellectual insight. The term "emotional insight" is frequently used without anyone being able to explain what it means. It would often appear to mean that the frustrated examiner cannot tolerate the
December, 1979
CLINICAL
M ENTAL STATUS
ambiguities inherent in a psychiatric examination. f) Memory for Objects (or Free Recall
Test) There is no doubt that patients with organic brain syndrome will have deficits in the performance of free recall. However, so will patients suffering distractibility due to other causes. Since virtually all other tests given are useless, it is difficult to justify the use of this test alone, it having no differentiating value,
Discussion, Recommendations and Conclusions The reliability and validity of most tests discussed above is non-existent. The onus is on the proponent of a diagnostic tool to prove its utility. There is no onus on the critic of such a tool to disprove its usefulness where no prior proof of utility exists. I believe this to be the current state of affairs. This does not rule out attempts to test the reliability and validity of mental status test questions, and that is the first recommendation emanating from this essay. Until that is done, it is recommended that structured questions be used only where the history itself reveals contradictory data about the mental status. And when tests are done, they should at least be done in some standardized way, so that the stimulus question put to the patient on his first examination will be as close as possible to that put to him later on. This gives some semblance of reliability, ifnot validity. A clinical teaching unit should have a typewritten mental status questionnaire for use, to ensure that the questions asked are uniform. Where doubt exists about the severity of a depression, the existence of organicity or of thought disorder, psychological testing
775
EXAMINATION
by a competent psychometrist is preferable. The psychiatric teaching curriculum should include a guide about exactly which tests to administer, while also leaving some room for the judgement of the psychometrist. The teaching of the psychiatric anamnesis should then give much more emphasis to what can be learned by simply talking with, and listening to, the patient. Formal testing as now taught is useless in diagnosis, a humiliation to many patients, and an embarrassment to the profession. Summary The traditional "mental status examination", as taught in medical school, is critically reviewed. The disparity between what is practised and what is preached, is outlined. Specific tests alleged to give information about mental function are discussed, and their clinical utility is found to be debatable. It is concluded that the reliability and validity of the mental status examination would be well worth testing. Alternatively, more use should be made of standarized tests which are now in the hands of clinical psychologists. Resume On revoit d'une maniere critique "l'examen de I'etat mental" traditionnel, tel qu'enseigne en medecine, en soulignant la disparite entre l'enseignement et la pratique. On discute des tests specifiques soidisant fournissant des informations sur Ie fonctionnement mental et on estime leur utilite clinique discutable. On conclut qu'il faudrait tester la fiabilite et la validite de l'examen de l'etat mental. Une alternative serait d'utiliser plus abondamment les tests standardises employes par les psychologues cliniciens.
