P.G.I.M.E.R - DEPTT.

OF PSYCHIATRY
Mental Status Examination:-

 Mental status examination in psychiatry is equivalent to physical

examination of medicine. MSE gives idea of cross sectional /current
state of mind or mental state of a person. It is covered under following
headings--

1. General Appearance and Behaviour

2. Speech

3. Mood and Affect

4. Thought

5. Perception

6. Cognition (Higher Mental Functions)

7. Insight

8. Judgement
General appearance and behavior-

 It gives idea about the physique, body build [Asthenic-lean and thin, Pyknic-
fatty and Athletic- well developed body , bones, muscles]
 Physical appearance [apparent age, state of physical health, hygiene, self-care i.e.
cleanliness of hair, cloths, body, concern about appearance], grooming [overly
groomed/poorly groomed], dressing (adequate, appropriate, any peculiarities),
facies (non-verbal expression of mood visible on face), whether patient is
comfortable/uncomfortable
 Attitude towards examiner-
Cooperation/guardedness/evasiveness/hostility/combativeness/ haughtiness,
attentiveness,
 Appears interested/disinterested/apathetic
 Perplexity- [है रान / परे शान सा चेहरा]- confused / indifferent looking face
 Comprehension - Intact/impaired (partially/fully)
 Gait [चाल/चलने का ढं ग ]and posture- Normal or abnormal (way of sitting,
standing, walking, how patient is lying on bed)
 Motor activity- Increased/decreased, any over excitement/stupor[akinesis (not
able to move) and mutism (unable to speak)], abnormal involuntary movements
(AIMs) such as tics, tremors, akathisia, restlessness
Catatonic signs (mannerisms, stereotypies, posturing [voluntarily maintaining
abnormal posture specially against gravity for prolonged period of time], waxy
flexibility, negativism, ambitendency [inability to decide for or against same
activity/behaviour example-brings hand for shaking with examiner at same time
takes back]), conversion and dissociative signs (pseudo seizures, possession
state), social withdrawal, autism, compulsive acts, rituals or habits (for example,
nail biting, counting via fingers etc]

 Social manner and non-verbal behaviour- Increased, decreased, or

inappropriate behaviour, eye to eye contact (gaze aversion, staring vacantly,
staring at the examiner, hesitant (shy) eye contact, or normal eye contact).

 Rapport- It is a conscious feeling of accord [तालमेल/सहमतत], sympathy, trust and

mutual responsiveness between the patient & therapist so can it be established
with the patient easily, with difficulty, with efforts or not established should be
mentioned.

 Hallucinatory Behaviour- Smiling or crying without reason, muttering [अपने

आप में बड-बडबडाना] or talking to self [अकेले अकेले बातें करना] (non-social speech),
odd gesturing in response to auditory or visual hallucinations

Speech
 Speech can be examined under the following headings:

 Rate and quantity of speech- Whether speech is present or absent (mutism), if

present, whether it is spontaneous, non spontaneous, whether productivity
[उत्पादकता] is increased [ज्यादा बाते करना] or decreased [एकदम कम बातें करना]
 Rate[speed] is rapid or slow (along with its appropriateness to situation-
example speaking slowly/politely with HOD/Elders is normal), pressure of
speech [very fast speech difficult to interpret] or poverty of speech [speaks very
limited words]

 Volume and tone of speech- Increased/decreased (its appropriateness ,

example- speaking with junior in loud volume on his/her mistake is not
abnormal), Low/high/normal pitch

 Flow and rhythm of speech- Smooth/hesitant, blocking (sudden pause while

speaking), dysprosody, Stuttering/Stammering/Cluttering.
Circumstantiality [in response to a question patient give very unnecessary trivial
details before actually answering the question]
Tangentiality [in response to a question patient gives answer which is relevant
to the general topic without actually answering the questions ex- Q How was
your sleep last night? A- Before I used to sleep in bed, now I m sleeping in floor
(general topic is sleep], verbigeration, stereotypies (verbal), flight of ideas
[patient shift from one topic to another very fast sometimes there is connection
in between the topics], clang associations [speech is associated with sound of
words/rhyming rather than by its meaning- Ex- I m in JAIL, because I m FAIL,
Not easy to get BAIL--so jail, fail, bail etc.], neologism

Mood and Affect

 Mood [मन] is the sustained/constant emotional feeling tone which is
experienced internally (lasts for some length of time) and affects the person’s
behaviour and perception from outside world.
 Affect [चेहरे के हाव भाव]- is the outward objective expression of the feeling
tone/internal emotions on the face during interview which is assessed by
psychiatrist.

The mood and affect both are similarly described under quality, range (of
emotional changes displayed over time), depth or intensity of affect (normal,
increased or blunted) and appropriateness of affect (in relation to thought and
surrounding environment).
Mood and affect are assessed subjectively (‘how do you feel whole day’/पुरे ददन
आपका मन कैसा रहता है ) as well as objectively by looking at face and described
as general warmth, euphoria, elation, exaltation and/or ecstasy (seen in severe
mania) in mania; anxious and restless in anxiety and depression; sad, irritable,
angry and/or despaired in depression; and shallow, blunted, indifferent,
restricted [narrow in range], inappropriate/ appropriate to situations and/or
labile in bipolar / schizophrenia. Anhedonia may occur in both schizophrenia
and depression.
Thought

 Normal thinking is a goal directed flow of ideas, symbols and

associations initiated by a problem or a task, characterised by rational
connections between successive ideas or thoughts, and leading towards a
reality oriented conclusion. Therefore, thought process that is not goal-
directed, or not logical, or does not lead to a realistic solution to the
problem at hand, is not considered normal. Thought is assessed (by the
content of speech) under the four headings of stream, form, content and
possession of thought.

 Stream [flow] of thought- It is divided in two parts thought TEMPO

(speed) and CONTINUITY of thought-

Disorder in thought tempo are- flight of ideas, prolixity, poverty of

content of speech, circumstantiality

Defect in ‘continuity’ of thought- Perseveration [persistent and

inappropriate repetition of same thought or verbal response- Ex- Q. What
is your name- xyz, Q where do you live -xyz, Q. What do you do? - xyz]
and thought block [sudden interruption/brake in train/continuity of
thought]

 Form of thought [it means- how thoughts are forming/thought

process]- Disorder of form is assessed by checking whether -
loosening of associations/association disturbance/derailment [Example-
Normal form- I joined Psychiatry to study doctor of medicine, Disorder in
Form- I study to medicine doctor Psychiatry of (means - AB CD
becomes CADB)], tangentiality, circumstantiality, neologism
  Content of thought- Delusions (false, unshakable beliefs it may be
primary or secondary ) or Over-valued ideas
delusions/ ideas of persecution, reference, grandeur, love, jealousy
(infidelity), guilt, nihilism, poverty, somatic (hypochondriacal)
symptoms, hopelessness, helplessness, worthlessness, and suicidal
ideation.

 Possession of thought- Some times person loses control on their own

thinking and have either- personal possession of thought i.e. obsessions
means - patients thinking is under control of their own thought (recurrent,
irrational, intrusive, ego-dystonic) or other outside agency is controlling
thinking of patient (thought insertion/withdrawal/broadcasting)-thought-
alienation

Perception/Perceptual disturbance

Perception means process by which information which we are receiving via our
5 sensory organs are meaningfully arranged and decoded/interpreted by our
brain by comparing it with our previous experiences. Perception is assessed
under the following headings:

 Hallucinations-A hallucination is a perception experienced in the

absence of any outside external stimulus. The hallucinations can be in the
auditory, visual, olfactory, gustatory or tactile domains.

It should be further enquired what was heard, how many voices were
heard, in which part of the day, male or female voices, how interpreted
and whether these are second person or third person hallucinations (i.e.
whether the voices were addressing the patient or were discussing him in
third person); also enquire about command (imperative) hallucinations
(which give commands to the person). Enquire whether the hallucinations
occurred during wakefulness, or were they hypnogogic (occurring while
going to sleep) and/or hypnopompic (occurring while getting up from
sleep) hallucinations.
 Illusions- misinterpretation of normal stimuli like seeing rope as snake in
dark room
  Depersonalisation/derealisation- disorder in perception of a person’s
environment and own self [patient feel they are seeing their bodies from
out-side]
 Somatic passivity phenomenon- Somatic passivity 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.

Cognition (Neuropsychiatric) Assessment

It is the assessment of the cognitive or higher mental functions. Any disturbance

of cognitive functions commonly points to the presence of an organic
psychiatric disorder.
 Consciousness- The intensity of stimulation needed to arouse the
patient will demonstrate the level of alertness, for example, by calling patient’s
name in a normal voice, calling in a loud voice, light touch on the arm, vigorous
shaking of the arm, or painful stimulus.

Grade the level of consciousness: conscious/ confusion/

somnolence/clouding/delirium/stupor/coma. Any disturbance in the level of
consciousness should ideally be rated on Glasgow Coma Scale, where a
numeric value is given to the best response in each of the three categories (eye
opening, verbal, motor).

 Orientation- Whether the patient is well oriented to time (test by

asking the time, date, day, month, year, season, and the time spent in hospital),
place (test by asking the present location, building, city, and country) and
person (test by asking his own name, and whether he can identify people around
him and their role in that environment). Disorientation in time usually precedes
disorientation in place and person.
 Attention- It is check by asking the patient to repeat digits forwards and
backwards (digit span test; digit forward and backward test), one at a time (for
example, patient may be able to repeat 5 digits forward and 3 digits backwards).
Start with two digit numbers increasing gradually up to eight digit numbers or
till failure occurs on three consecutive occasions.

 Concentration [ability of patient to focus/ maintain sustained attention]-

Ask the patient to subtract serial sevens from hundred (100-7 test), or serial
threes from fifty (50-3 test), or to count backwards from 20 to 1, or enumerate
the names of the months (or days of the week) in the reverse order. Note down
the answers and the time taken to perform the tests.
 Memory- a. Immediate Retention and Recall (IR and R)- Use the digit span test
to assess the immediate memory; digit forwards and digit backwards subtests
(also used for testing attention; are described under attention).

b. Recent Memory- Ask how did the patient come to the hospital; what he ate
for dinner the day before or for breakfast the same morning. Give an address to
be memorised and ask it to be recalled 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 other relevant questions from the person’s past. Check for any
amnesia (anterograde/ retrograde), or confabulation, if present.

 Intelligence and fund of knowledge-

Intelligence is defined as ability to think logically, act rationally, and deal
effectively with environment. Ask about general information, keeping in mind
the patient’s educational and social background, his experiences and interests,
for example, ask about the current and the past prime ministers, sarpanch of
village and presidents of India, the capital of India, and how the wall/tea is
made [complete procedure]
Test for reading and writing; Use simple tests of calculation, like 5 + 9=?
3x7=?

Abstract thinking
 Abstraction means the concept which cannot be seen and touched it can
only be understand/conceptualized. The methods used are:

a. Proverb interpretation: The meaning of simple proverbs (usually three)

should be asked.
‘’जैसी करनी वैसी भरनी” का क्या मतलब होता है ?
“बन्दर क्या जाने अदरक का स्वाद”
“चोर की दाढ़ी में ततनका”

b. Similarity testing (and also the differences-usually 3) between familiar

objects should be asked, such as: table/ chair; banana/orange; dog/lion[both
are animals-Abstract answer]; bus/car [Abstract answer- both are means of
transportation - this means of transportation is a concept which can only be
understand; Concrete answer (focusing on external features)- both have 4
wheels, staring, seat for sitting]. The answers may be concrete or abstract.
 Insight

 Insight is the degree of awareness and understanding that the patient has
about his/her illness.[मरीज़ मानता है की नहीीं की उसे कोई मानससक बबमारी
है ]. Insight is rated on a 6-point scale from one to six.

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 experiences.
6. True Emotional Insight: It is different from intellectual insight in that
the awareness leads to significant basic changes in the future behaviour

Judgement

 Judgement is the ability of the person to take sound/correct decisions and

act effectively on them ‘or’ ability to assess a situation correctly and act
appropriately within that situation. It has 2 parts social and test
judgement.

i. Social judgement is observed during the hospital stay and during the
interview session. It includes an evaluation of ‘personal judgement’.

ii. Test judgement is assessed by asking the patient what he/she would do
in certain test situations such as-
what he/she will do ‘when they see a house on fire’ [यदद आपके आँखों के
सामने ककसी के घर पे आग लग जाएगी तब आप क्या करोगे ], or
‘a sealed, stamped, addressed envelope lying on a street’. or
‘यदद आपको ककसी का पसस, पते और पैसे के साथ रोड पर पड़ा हुआ समले तो
आप क्या करोगे?’
Judgement is rated as Good/Intact/Normal or Poor/ Impaired/Abnormal