The Mental Status Exam (MSE) provides a snapshot of a patient’s current emotional and cognitive functioning at the time of the assessment. It systematically covers various domains, including appearance, speech, thought processes, and perception. ‘Mood’ is a core component of this assessment, representing the patient’s sustained, internal emotional experience, rather than a fleeting reaction. The accurate documentation of mood is therefore a necessary step in formulating a clinical impression.
Understanding the Difference Between Mood and Affect
The terms mood and affect carry distinct meanings within the MSE framework. Mood refers to the patient’s pervasive and sustained internal emotional state, which they report subjectively to the clinician. Clinicians cannot directly observe mood; they must rely on the patient’s own description of their feelings, which typically lasts for hours, days, or weeks. Affect, in contrast, is the observable, external expression of emotion that the clinician interprets during the interview, involving facial expression, vocal tone, and body language. The relationship between reported mood and observed affect is significant; for example, a patient may report a depressed mood but display a restricted or flat affect.
Eliciting the Patient’s Subjective Emotional State
Because mood is an internal experience, it is assessed primarily through direct, open-ended questioning rather than simple observation. Clinicians will often begin with broad questions like, “How have your spirits been lately?” or “What is your mood right now?”. These questions encourage the patient to describe their emotional atmosphere in their own words, providing the most authentic representation of their subjective experience. A precise assessment requires documenting the duration, intensity, and any fluctuation of the reported feeling, such as a patient reporting feeling “empty” for two weeks. To ensure the integrity of the clinical record, the patient’s exact words should be captured verbatim, often enclosed in quotation marks, preventing misinterpretation of the subjective report.
Standard Terminology for Documenting Mood
The subjective emotional state is formally documented using standardized clinical terminology for clarity and consistency across records. The term Euthymic describes a mood that is within the normal, non-depressed, and non-elevated range. A mood described as sad, unhappy, or low is documented using terms such as Dysphoric or depressed. When a patient reports a mood of extreme happiness or an exaggerated sense of well-being, it is documented as Elevated or Euphoric. An emotional state characterized by easy annoyance and quick temper is formally noted as Irritable, and a mood that shifts quickly or alternates rapidly between emotional extremes is described as Labile.