MENTAL STATUS EXAMINATION

(MSE)
• The mental status examination describes the
sum total of the examiner’s observations and
impressions of the psychiatric patient at the
time of the interview.
• Whereas the patient's history remains stable,
the patient's mental status can change from
day to day or hour to hour.
• Even when a patient is mute, is incoherent, or
refuses to answer questions, the psychiatrist/
clinical psychologist/ counsellor can obtain a
wealth of information through careful
observation.
 Definition
• It is a standardized format in which the
clinician records the psychiatric signs and
symptoms present at the time of interview.
 Purpose
• The purpose is to evaluate quantitatively and
qualitatively , a range of mental functions and
behaviors at a specific point in time.
• The aim of the MSE is to elicit the client’s current
psychopathology- no historical details
• It collects both objective and subjective
information:
• Objective:- what you observe about the client
during interview
• APPEARANCE, BEHAVIOUR, SPEECH, COGNITION
and MOOD-affect
• Subjective :- the client’s current psychological
symptoms
• MOOD, THOUGHTS, PERCEPTION AND INSIGHT
 Points of MSE
• GENERAL APPEARANCE
• BEHAVIOUR
• PSYCHOMOTOR ACTIVITY
• SPEECH (LANGUAGE)
• MOOD & AFFECT (EMOTIONS)
• THOUGHT & PERCEPTION
• COGNITIVE FUNCTIONING
• JUDGMENT
• INSIGHT
 1. General appearance and beahviour
• Facial expression:- anxiety, pleasure, confidence , blunted,
pleasant.
• Posture :- stooped, stiff, guarded, normal
• Mannerisms:- stereotype, negativism, tics, normal
• Eye to eye contact:- build easily or not built or built with difficulty.
• Consciousness :- conscious or drowsy or unconscious
• Behaviour (social behaviour):- overfriendly, disinhibited (frank) ,
restless, aggressive , normal, seductive , Cooperative-
uncooperative , suspicious, evasive.
(attitude toward examiner)
• Dressing and situation- well dressed/ appropriate (to season and
situation)/ neat and tidy/ untidy- dirty
• Physical features:- look older/ younger that his or her stated age/
underweight/ overweight/ physical deformity
 2- psychomotor activity
• Increased/ decreased, compulsive (agitation),
stereotype,echoprexia
 Motor activity
• Psychomotor activity :- retardation / agitation
• Movement :- tremor (drug side effects). Abnormal
movements i.e. stereotypes, gait,
• Apparent restlessness, lip smacking, tongue protrusion,
drug side affects.
• Difficulty in initiation of movement or slow , stiff
movement – parkinsonism
• Waxy flexibility:- client’s movement having the feeling
of a plastic resistance e.g. in catatonic schizophrenia
• Negativism:- client resist attempts to move him and
does opposite to what is asked . A sign of catatonia
 3. Speech
• Rate :- normal, very slow, rapid, pressure of speech (word
more than 250 per minute)
• Flow:- spontaneous, hesitant, slurring, stuttering, speaks
only on question, muttering , mute.
• Volume:- audible/non audible, excessive loud, abnormally
soft.
• Amount :- normal, abundant (more than adequate ) ,
scanty (small in quantity)
• Tone:- normal, fluctuations, Monotonous (unchanging
tone)
• Coherence :- coherent –incoherent (unconnected )
• Relevance :- relevant –irrelevant
 Disorders of speech
• Aphonia :- fails to produce any volume of sound e.g. in laryngeal or
vocal cord disorder. If despite this he/she is able to cough normally,
probably hysterical
• Slow speech:- may be a feature of psychomotor retardation.
• Fast speech :- normal anxiety but may indicate Mania or schizophrenia
• Pressure of speech :- rapid speech that is increased in amount and
difficulty to interrupt. Seen in Mania.
• Poverty of speech:- restriction in amount of speech, replies may be
monosyllabic
• Poverty of content of speech :- speech is adequate in amount but
covers little information due to vagueness, emptiness, stereotyped
phrases.
• Echolalia:- repetition of sentence just uttered by the examiner
• Palilalia:- repetition of only last uttered word or phrase said by the
examiner. (Parkinson disease)
 Mood
• Mood is defined as a pervasive and sustained emotion that colors
the person's perception of the world.
• Usually means patient’s self reported mood
• Does the patient remark voluntarily about feelings or whether it is
necessary to ask the patient how he or she feels?
• Statements about the patient's mood should include depth,
Intensity, duration, and fluctuations.
• Common adjectives used to describe mood include depressed,
Despairing (lose of hope), irritable, anxious, angry, euphoric, guilty,
hopeless, frightened,
• Mood can be labile, fluctuating or alternating rapidly between
extremes (e.g., laughing loudly and expansively one moment, tearful
and despairing the next).
 Affect
• client's present emotional responsiveness, inferred from the patient's facial
expression, including the amount and the range of expressive behavior.
• Quality: Dysphoric in depression, Euthymic (normal) or Elevated/Euphoric in
mania, Flat in Schizophrenia or labile (all over the place), or irritable
• Congruency: Affect may or may not be congruent with mood.
• Range: Affect can be described as within normal range, constricted, blunted,
or flat.
• In the normal range of affect can be variation in facial expression, tone of
voice, use of hands, and body movements.
• When affect is constricted, the range and intensity of expression are
reduced.
• In blunted affect, emotional expression is further reduced.
• To diagnose flat affect, virtually no signs of affective expression should be
present; the patient's voice should be monotonous and the face should be
immobile. Note the patient's difficulty in initiating, sustaining, or
terminating an emotional response.
• Type :- depressed/ sad/ anxious/ euphoric/
angry
• Range :- full range. Labile/ flattened/blunted
• Appropriateness to content and congruence
with stated mood
 4-thought
• A. form though/ formal thought disorder – (not understandable/ normal/
circumstantiality/ tangentially / neologism/ word salad/ perseveration
(organic disorder / brain injury) / ambivalence)
• Stream of thought / flow of thought:- (pressure of speech, flight of ideas,
thought retardation/ mutism/ aphnoia/ thought block/ clang association)
• Content of thought :-
• A) delusion:- specify type and give example- persecutory/ delusion of
reference/ delusion of influence or passivity/hypochondracal delusion/
delusions of grandeur/ nihilistic – dereailization/ depersonalization/
delusions of infidelity.
• B) obsession
• C) phobia
• D) preoccupation
• E fantasy – creative or dreaming
 Thought process
• Describes the rate of thoughts, how they flow and are connected
• 1. stream of thought :- quote from the client
• A) productivity:- abnormalities seen are
1. Overabundance of ideas . E.g. mania
2. Paucity :- depression
3. Light of ideas :- in flight of ideas there are rapid shift in the frame
of reference and there associations are incoherent . e.g. Mania
4. rapid thinking
5. Slow thinking or hesitant . E.g. depression and rare condition of
mania stupor
6. Spontaneous or only when questioned
B. Continuity of thought :- abnormalities seen
are
1. Circumstantial :- when thinking proceeds
slowly with many unnecessary detail but
eventually get to the point. Goal is never
completely lost. It can occur in context of
learning disability and in individual with
obsessional personality traits , schizophrenia,
dementia and anxiety disorders.
2. Tangential :- move from thought to thought
that relate in some way but never get to the
point. E.g. in psychosis and dementia .
• Thought blocking :- sudden arrest of the train
of thought , leaving a blank, than entirely a
new thought may begin. May be seen in
exhausted or very anxious state. When clearly
present , it highly suggests schizophrenia.
• Perseveration :- inappropriate repetition of
words or phrases. It is common in generalized
& local disorders of brain. When present
provide strong support for such a diagnosis.
Also seen in OCD & psychosis.
• Thought possession/alienation : abnormalities
seen are
• 1. thought Echo:- Hearing one’s own thought
being spoken aloud.
• Thought insertion :- other person or forces are
implanting thoughts in a person’s mind.
• Thought withdrawal:- other person or forces are
removing thoughts from a person’s mind.
• Thought broadcasting :- one’s own thoughts
experienced as being transmitted to another
person or agency.
• All are feature of schizophrenia
• Formal thought disorder –abnormalities seen are
• 1. loosening of association :- illogical shifting between
unrelated topics. It is a hallmark feature of
schizophrenia.
• 2Derailment :- gradual or sudden deviation in train of
thought without blocking
• 3. word salad :- extreme version of loosening od
association in which changes in topics are so extreme
and the associations so loose that the resulting speech
is completely incoherent.
• 4. stereotypes:- constant repetition of a phrase (or
behavior ) in many different setting, irrespective of
context.
• 5.Verbigeration :- disappearance of understandable
speech replaced by strings of incoherent utterance.
• 6. metonyms: are word approximation e.g.
paper skate for pen.
• 7.Clang association : words are chosen or
repeated based on similar sounds , instead
semantic meaning : seen in Menia
• 8. Neologism :- if refers to the new word
formation by the client or ordinary word that
are used in new way . Seen in schizophrenia.
• THOUGHT CONTENT
• Refers to the themes that occupy the patients
thoughts and perceptual disturbances .
• Abnormalities seen are-
• 1. overvalued ideas:- this is a thought, which
because of associated feeling tone, take
precedence over all other ideas and maintains
this precedence permanently or for a long
period of time. It tend to be less fixed than
delusions and tend to have some degree of
basis n reality.
• Delusions :- false, firm (fixed), unshakable belief
that is out of keeping with the client's social,
cultural and educational background. E.g.
 control :- outside forces are controlling actions
 Erotomaina :- a person, usually of higher status ,
is in love with the client.
 Grandiose :- inflated sense of self –worth, power
or wealth.
 Somatic:- client has physical defect.
 Reference :- unrelated events apply to them
 Persecutory :- other are trying to cause harm
• 3. preoccupations
 About illness
 Obsessions (repetitive preoccupation with a thought,
acknowledged by the client to be irrational) or compulsions
(repetitive acts based on obsession)
 Phobia (persistent and irrational fear of delineated aspects of
nonhuman objects or environment)
 Plans, intentions or recurrent ideas about suicide, homicide.
 Hypochondriacally symptoms ( excessive fear and anxiety of having
a serious diseases)
 Specific antisocial urges or impulse
 Ideas of references :- the incorrect idea that words and actions of
others refer to oneself or the projection of causes of one’s own
imaginary difficulties upon someone else.
 How ideas begin?
 Content and meaning client attribute to them.
 APPEARANCE
• DEMOGRAPHICS :- Gender, apparent age, racial
origin
• PHYSIQUE, HAIR and MAKE-UP:- E.G. mania
clients- bright/oddly assorted clothes
• CLEANLINESS:- look for signs of self –neglect e.g.
dirty, unkempt. Stained or crumpled clothing.
• WEIGHT LOSS:- consider bio-psycho-social cause
for example:- cancer vs anorexia vs financial
difficulties
 BEHAVIOUR
• RAPPORT:-
• Attitude :- relaxed/ co-operative/ suspicious/ guarded/ pre-
occupied/ over familiar
• Eye contact:- avoidant / appropriate/intense
• PSYCHOMOTOR ACTIVITY:- agitation vs retardation
• MOVEMENT DISORDERS:-
• Tics= irregular repeated movements, in a group of muscles e.g
sideways head.
• Choreiform movements:- co-ordinated , brief, involuntary
movement e.g grimacing
• Dystonia:- painful muscle spasm which may lead to contortions
• Sign of impending violence:- restlessness/ sweating/ clenched fists/
pointing fingers/ raised voice
• Intruding onto the interviewer’s personal space.
 SPEECH
• Physical characteristics only- content comes under “
thoughts”
• QUANTITY:-
• Pressure of speech:- rapid, can’t get a word in’. Lengthy
speech- typical of mania
• Poverty of speech :- minimal responses e.g. yes/ no- typical
of depression
• QUALITY:-
• volume :- loud (mania), or quiet (depression)
• Tone and fluency
• Spontaneity :- prompt response (mania) and slow response
(intoxicated/ depression)
 MOOD (or AFFECT)
• Chang In Mood = commonest symptoms of a psychiatric
disorder.
• Should Be Documented both subjectively and objectively .
• Subjective mood
• Ask the client “ how are you feeling in yourself”
• Document their response without alternation- record any
other details in Hx
• Objective mood :- nature of mood during examination , if
no mood is noted= “euthymic”
• Constancy of mood-:- does mood change during the
interview?
• Congruity of mood :- is the client’s mood appropriate to
context?
 thoughts
• Deduce what the client is thinking using :
verbal , written and behaviour clues.
• Abnormalities can occur in a 3 different
aspects of thought: stream, form, and
content ..
Aspect of thought Description Abnormalities

Stream The amount and PRESSURE OF THOUGHT-unusually rapid,

speed of abundant/ varied thoughts
thoughts POVERTY OF THOUGHT- Unusually slow,
few or unvaried thoughts
BLOCKED OF THOUGHTS- Abrupt and
complete emptying of the mind.
Form The way in FLIGHT OF IDEAS:- One train of thoughts is
which thoughts not completed before another begins,
are linked ideas may be linked by ;
Rhyme (aka ;”clang association”)
together
Puns- words which sound similar e.g. mail
and male.
Distraction- by something in room/
surroundings
LOSSENING ASSOCIATIONS:- complete lack
of logical connections in a sequence of
thought , not even by above links. Also
know as ;” knights move” thinking
PRESERVATION:- Persistent inappropriate
repetition of the same sequence of though
e.g. same answer for every varied
question,
Content What ideas Preoccupation :- recurring thoughts that can be put
the thoughts out of the mind at will, but result in distress and /or
contain disability.
MORBID THOUGHTS:- hopelessness, suicidality and
suicidal intention. Don’t be afraid to ask about self
harm or suicide.
DELUSIONS:-a fixed false belief, unaffected by
rational argument and unsupported by cultural or
educational background
OBSESSIONS:- Recurring and persistent thoughts. The
patient recognizes them as senseless products of
their own mind , but cannot get rid the them.
COMPULSIONS:- actual actions secondary to
obsessions
 PERCEPTIONS
• Perception = becoming aware of what is presented to
the body through the 5 senses. There are four
perception abnormalities.
• 1. Change in perception intensity:- e.g. colors brighter
to a client with mania.
• 2. change in perception quality :- e.g. flowers smelling
acrid to a patient with schizophrenia.
• 3. ILLUSIONS= a misperception of a real stimulus.
• More likely to occur in the presence of : sensory
impairments/inattention/ impaired consciousness/
emotional arousal
• Ask: “have you seen anything unusual?”
• 4. HALLUCINATIONS= a perception
experienced in the absence of a real stimulus.
Ask sensitively / “ when their nerves are
upset. Same people have unusual
experiences…”
 COGNITIONS
• There is 6 aspects to assess when assessing higher
cortical functions :-
• 1. consciousness= an awareness of self and
environment . States includes:
• Clouding of consciousness:- a state of drowsiness, with
incomplete reaction to stimuli and impaired :
attention; concentration; memory and thinking.
• Stupor- state in which the client is : mute, immobile
and unresponsive. However they may appear
conscious as eyes are open and follow objects
• Confusion –muddled thinking , can be : acute
(delirium) or chronic (DEMENTIA)
• 2. Orientation =awareness of person, place and
time –who are you/ where are you etc…
• 3. Attention :- ability to focus on the matter in
hand –serial sevens (100-7=93 etc…) and
• Concentration= ability to sustain focus –can also
be assessed by serial sevens
• 4. memory :- assess immediate, recent and long
term memory.
• Immediate:- digit span test, ask client to repeat a
series of digit straight after you
• Recent:- remember 3 random objects or an
address , recall 5 mins later.
• Long –term:- recall personal events or well –
known public events.
• 5. language :- assess the client’s ability to :
name common objects ; follow written and
verbal instruction and write in sentences.
• 6. visio-spatial functioning: ask the client to
draw an old fashioned clock, showing 14.50
 INSIGHT
• Insight = the extent to which the client’s view of their
illness is congruent to that of their healthcare
professional :- usually assessed as : good/ moderate /
poor.
• Assessment of insight is important in order to :
determine the likelihood od client co-operation with
treatment and aid efforts to change client’s health
beliefs to improve prognosis.
• Should consider whether the client is :
• AWARE their thoughts/ behaviour are abnormal and
treatment is required.
• According that the abnormalities are as a result of a
mental health illness and that subsequent professional
recommendation should be followed.