MENTAL STATUS

EXAMINATION
Introduction
Known as Mental status examination in
USA
Mental state examination in the rest of the
world
Abbreviated as MSE
Should not be confused with the Mini-
Mental State Examination (MMSE), which
is a brief neuro -psychological screening
test for dementia.
General physical examination (GPE) is a
must in every patient
Physical disease causing psychiatric
symptoms or accidentally co-existent or
caused by psychiatric condition or
treatment can be detected by GPE
MSE is a part of Case History
MSE at a glance
An important part of the clinical assessment
process in psychiatric practice
Also considered as a part of the
comprehensive physical examination
performed by physicians and nurses
A structured way of observing and describing
a patient's current state of mind
Under the domains of appearance, attitude,
behavior, mood and affect, speech, thought
process, thought content, perception,
cognition, insight and judgement
Minor variations in the subdivision of the MSE and
the sequence and names of MSE domains.
Data is collected through a combination of direct
and indirect means, (unstructured observation,
focused questions, psychological tests, etc)
Core skill of psychiatrists, psychologists, physician
assistants, nurse practitioners and other qualified
mental health personnel.
Key part of the initial psychiatric assessment in an
out-patient or psychiatric hospital setting .
A systematic collection of data based on
observation of the patient's behavior while the
patient is in the clinician's view during the
interview.
Information obtained in the MSE is used, together
with the biographical and social information of the
psychiatric history, to generate a diagnosis, a
psychiatric formulation and a treatment plan.
A standardized format in which the clinician
records the psychiatric signs and symptoms
present at the time of the interview
The Theory
Derives from an approach to psychiatry known as
descriptive psychopathology or descriptive
phenomenology
Which developed from the work of the philosopher and
psychiatrist Karl
Jaspers Jaspers' perspective assumed that the only
way to comprehend a patient's experience is through
his or her own description (through an approach of
empathic and non-theoretical enquiry)
In practice, MSE is a blend of empathic, descriptive
set of objective descriptions of a psychiatric patient
and empirical clinical observation
The purpose
To obtain a comprehensive cross-sectional
description of the patient's mental state
To get information on the patient's insight,
judgment, and capacity for abstract reasoning
To obtain evidence of symptoms and signs of
mental disorders, including danger to self and
others, that are present at the time of the interview
To make an accurate diagnosis and formulation,
which are required for coherent treatment planning
To inform decisions about treatment strategy and
the choice of an appropriate treatment setting
Major Domains
MSE should describe all areas/domains of
mental functioning such as;
General appearance and Behavior,
Speech, Mood and Affect, Thought process,
Perceptions, Cognition (Higher Mental
functions), Insight, Judgment
Emphasis shall be given to some areas
according to clinical impressions arise from
the history (mood and affect in depression,
cognitive functions in delirium and dementia)
1.General appearance and
Behavior
A rich deal of information can be elicited
Important to remember patients socio-
cultural background and personality
More emphasis in the examination of an
un co-operative patient
1.1. General Appearance
Physique and body habitus (build)
Physical appearance (height, weight and
appearance)
Looks comfortable/uncomfortable
Physical health
Grooming, hygiene, self care
Dressing (adequate/appropriate/peculiarities)
Facies (non-verbal expression of mood)
Effeminate / masculine
1.2. Attitude towards Examiner
Co-operation/guardedness/evasiveness/
hostility/combativeness/haughtiness
Attentiveness
Appears interested/disinterested/apathetic
Ingratiating behavior
Perplexity
1.3. Comprehension
Intact/impaired (partially/fully)
1.4. Gait and Posture
Normal/abnormal (way of sitting, standing,
walking, lying )
1.5. Motor activity
Increased/decreased
Excitement/stupor
Abnormal involuntary movements (AIMs)
such as tics, tremors, akathisia
Restlessness/ill at ease
Catatonic signs (mannerisms, steriotypies ,
posturing, waxy flexibility, negativism,
ambitendency , automatic obedience, stupor,
echopraxia , psychological pillow, forced
grasping,
Conversion and dissociative signs ( pseudo
seizures , possession states)
Social withdrawal, Autism
Compulsive acts, rituals or habits (nail biting,
etc)
Reaction time
1.6. Social manner and non-verbal
behavior
Increased/decreased/inappropriate
behavior
Eye contact (gaze aversion, staring
vacantly, staring at the examiner, hesitant
eye contact, normal eye contact )
1.7. Rapport
Whether a working and empathetic
relationship can be established with the
patient
1.8. Hallucinatory behavior
Smiling /crying without reason
Muttering or talking to self (non-social
speech)
Odd gesturing in response to auditory or
visual hallucinations
2 . Speech
2.1. Rate and quantity
Speech Present or absent ( mutism )
If present, whether spontaneous
Productivity increased/decreased
Rate is rapid/slow/appropriate
Pressure of speech/poverty of speech
2.2.Volume and tone
Increased/ decreased/appropriate
Low/high/normal pitch
2.3. Flow and rhythm
Smooth/hesitant
Blocking (sudden)
Dysprosody ,
suffering/stammering/cluttering, any
accent
Circumstantiality, tangentiality
Verbigeration , steriotypies (verbal)
Flight of ideas, clang associations
Mood and Affect :

3.1 Mood
Is the pervasive feeling tone which is
sustained (last for some length of time) and
colors the total experience of the person
Described as general warmth/ euphoria/
elation/ exaltation and/ or ecstasy in mania,
anxious/ restless in anxiety and depression,
sad/ irritable/angry and/or despaired in
depression,
shallow/blunted/indifferent/restricted/inapprop
riate and or labile in schizophrenia
Anhedonia may occur on both schizophrenia
and depression
Quality of mood - assessed subjectively
how do you feel? , and objectively by
examination
Stability of mood over a period of time
Reactivity of mood variation in mood with
stimuli
Persistence of mood length of time the
mood lasts
3.2. Affect
Is the outward objective expression of the
immediate, cross sectional experience of
emotion at a given time
Quality of affect
Range of affect - of emotional changes
displayed over time
Depth / intensity of affect normal /
increased / blunted
Appropriateness of affect in relation to
thought and surrounding environment
4. Thought
Normal thinking is goal directed flow of
ideas, symbols and associations initiated by a
problem/task, characterized by rational
connections between successive
ideas/thoughts, leading towards a reality
oriented conclusion
Thought process considered not normal
when not goal-directed/ not logical/ does
not lead to realistic solution to the problem at
hand

In traditional clinical examination, thought
is assessed by the content of speech-
under 4 headings- stream, form, content,
and possession of thought
Due to widespread disagreement
regarding the sub-division now assessed
under 2 headings stream and form ,
content
4.1. Stream and form
Stream of thought overlaps with
examination of speech
Spontaneity
Productivity
Flight of ideas
Prolixity
Poverty of content of speech
Thought block
Continuity of Thought is assessed as
follows: Whether the thought processes are
relevant to the questions asked
Any loosening of associations
Tangentiality
Circumstantiality
Illogical thinking
Perseveration
Verbigeration
4.2. Content
Preoccupations
Obsessions recurrent/irrational/intrusive/ego-
dystonic /ego-alien ideas
Content of phobias irrational fears
Delusion (false/unshakable beliefs ) or over-valued
ideas; ideas of persecution, reference, grandeur, love,
jealousy(infidelity), guilt, nihilism, poverty, somatic(
hypochondriacal )symptoms, hopelessness,
worthlessness, suicidal ideation
Schneiderian first rank symptoms(SFRS) - delusions
of control, thought insertion, thought withdrawal,
thought broadcasting
Presence of neologisms
5. Perception
Is the process of being aware of a sensory
experience and being able to recognize it
by comparing it with previous experience
5.1. Hallucinations
Is a perception experienced in the absence of an
external stimulus.
Can be auditory, visual, olfactory, gustatory, tactile
domains
Auditory hallucinations are common types in non-
organic psychiatric disorders
Clarify - Elementary(only sounds are heard) /
complex(voices heard)
Experienced like a true perception and seems to
come from an external objective space(from
outside the ears in case of auditory hallucination)
Pseudo hallucination - does not appear to
be a true perception or comes from a
subjective internal space(inside the
persons own head in the case of auditory
hallucination)
What was heard/how many voices were
heard/in which part of the day/male or
female voices/how interpreted
Whether these are second person or third
person hallucinations (the voices were
addressing the patient/discussing him in
third person)
Command(imperative)Hallucinations
give commands to the person
Occurred during wakefulness
Were they hypnagogic (while going to
sleep) and/or hypnopompic (while getting
up from sleep)
5.2. Illusions and misinterpretations
Visual / auditory / or in other sensory fields
Occur in clear circumstances or not
Any steps taken to check the reality of
distorted perceptions
5.3. De personalization / de
realization
Are abnormalities in the perception of a
persons reality
Described as as if phenomena
5.4. Somatic passivity phenomenon
Is the presence of strange sensations
described by the patient as being imposed
on the body by some external agency,
with the patient being a passive recipient
One of the Schneiders first rank
symptoms(SFRS)
5.5. Others
Autoscopy
Abnormal vestibular sensations
Sense of presence
6. Cognition (Neuropsychiatric)
Assessment
Assessment Higher mental functions
An important part of MSE
Disturbance of cognitive functions points
to the presence of an organic psychiatric
disorder
Folsteins mini mental state examination
(MMSE) is used for a systematic clinical
examination of higher mental functions
6.1. Consciousness
The intensity of stimulation needed to arouse the
patient should be indicated to demonstrate the level of
alertness
By calling a patients name in a normal voice/ in a loud
voice, light touch on the arm, vigorous shaking of the
arm or painful stimulus
Grade the level consciousness ; conscious/ confusion/
somnolence/ clouding/delirium/stupor/coma
Disturbance in the level of consciousness be rated on
Glasgow Coma Scale, where numeric value is given to
the best response in 3 categories eye opening,
verbal, motor
6.2. Orientation
Whether well oriented to time ask the time,
date, day, month, year, season, the time
spent in hospital
Place ask the present location, building,
city, country
Person ask his own name, whether
identifies people around him and their role in
that setting
Disorientation in time precedes disorientation
in place and person
6.3. Attention
Check, attention easily aroused and
sustained
Ask to repeat digits forwards and backwards
(digit span test, digit forward and backward
test)
One at a time ( may be able to repeat 5 digits
forward and 3 digits backward)
Start with 2 digit numbers increasing
gradually up to 8 digits or till failure occurs on
3 consecutive occasions
6.4. Concentration
Can the patient concentrate / easily
distractible
Ask to subtract serial sevens from hundred
(100-7 test), or serial threes from fifty (50-
3 test), or to count backwards from 20, or
enumerate the names of the months(or
days of the week) in the reverse order
Note the answers and time taken to
perform the tests
6.5. Memory
a). Immediate Retention and Recall (IR and
R)
Use Digit Span Test to assess the
immediate memory; digit forward and digit
backward subtests (also used for testing
Attention)
b). Recent memory
Ask how did the patient come to the room/hospital;
what he ate for dinner the day before or for breakfast
the same morning
Give an address to be memorized and ask to recall 15
minutes later or at the end of the interview
c). Remote memory
Ask for the date and place of marriage, name and
birthdays of children, any relevant questions from the
persons past
Note any amnesia( anterograde / retrograde), or
confabulation
6.6. Intelligence
Is the ability to think logically, act rationally,
and deal effectively with environment
Keep in mind, patients educational and
social background, experiences and interests
Can ask about the current and past prime
ministers, presidents of India, the capital of
India, and the same of various states
Test for reading and writing
Simple tests of calculation
6.7. Abstract thinking
Characterized by the ability to :
a).Assume a mental set voluntarily
b).Shift voluntarily from one aspect of situation
to another
c).Keep in mind simultaneously the various
aspects of a situation
d).Grasp the essentials of a whole (situation
or concept)
e).To break a Whole into its parts
f).Abstract Thinking Tests assesses Patients
concept formation

1.Proverb Testing the meaning of simple proverbs ,
usually 3
2. Similarities(and differences) between familiar objects,
such as table/chair, banana/orange, dog/lion, eye/ear
3. Answers may be overly concrete or abstract
4. Appropriateness of answers is judged
5. Concretization of responses or inappropriate answers
may occur in schizophrenia
7. Insight
Is the degree of awareness and
understanding that the patient has,
regarding his illness
Ask the patients attitude towards his
present state ; whether there is illness or
not;
If yes , What kind of illness(physical
psychiatric or both)
Any treatment needed ; hope for recovery
Cause of the illness
Depending on response , insight
is rated on a 6 point scale:
1. Complete denial of illness
2. Slight awareness of being sick and needing help, but
denying it at the same time
3. Awareness of being sick, but it is attributed to external
or physical factors
4. Awareness of being sick, due to something unknown in
self
5. Intellectual Insight : awareness of being ill and that the
symptoms/failures in social adjustment are due to own
particular irrational feelings/thoughts; yet does not
apply this knowledge to the current/future experience
6. True Emotional Insight ; It is different from intellectual
insight in that the awareness leads to significant basic
changes in the future behavior
8.Judgement
Is the ability to assess a situation correctly
and act appropriately within that situation
Both social and test judgement are
assessed
1. Social judgement
Observed during hospital stay and the
interview session
Includes an evaluation of personal
judgement
2. Test judgement
Assessed by asking, what would he do in
certain test situations a house on fire , a
man lying on the road , a sealed ,
stamped, addressed envelope lying on a
street
Judgement is rated as Good/Intact/Normal
or Poor/Impaired/Abnormal
Investigations

After the detailed history and examination,
investigations - laboratory tests, diagnostic
standardized interviews, family interviews,
and/or psychological tests - are carried out
based on the diagnostic and aetiological
possibilities.