The Mental Status

Examination &
Psychiatric Symptoms
K.M. Kanyata
LMMU - Lecturer
Introduction
 The mental state examination (MSE) is a structured
way of observing and describing a patient’s current
state of mind, under the domains of appearance,
attitude, behaviour, mood, affect, speech, thought
process, thought content, perception, cognition, insight
and judgement.
Introduction cont’d…
 The purpose of the MSE is to obtain a comprehensive
cross-sectional description of the patient’s mental state,
which when combined with the biographical and
historical information of the psychiatric history, allows
the clinician to make an accurate diagnosis and
formulation.
 Below is a framework that demonstrates the type of
information that the mental state examination hopes to
gather.
Appearance
 The appearance of the patient may provide some clues
as to their lifestyle, current mental state and ability to
care for themselves.
 Observe the patient’s general appearance:
 Distinguishing features: these may include scars (e.g.
self-harm), tattoos and signs of intravenous drug use.
 Weight: note if they appear significantly underweight or
overweight.
 Stigmata of disease: note any stigmata of disease (e.g.
jaundice).
Appearance cont’d..
 Personal hygiene: this can provide insight into the
patient’s current ability to care for themselves.
 Clothing: note if this is appropriate for the
weather/circumstances and if the clothes have been put
on correctly.
 Objects: look around to see if the patient has brought
any objects with them and note what they are.
Behaviour
 A patient’s behaviours may provide insights into their
current mental state.
 Engagement and rapport
 Note if the patient appears engaged in the consultation
and if you are able to develop a rapport with them.
 Note if they appear distracted or if they appear to be
engaging with hallucinations (e.g. replying to auditory
hallucinations in schizophrenia).
Behaviour cont’d..
 Eye contact
 Observe the patient’s level of eye contact and note if this
appears reduced or excessive.
 Facial expression
 Observe the patient’s facial expression (e.g. relaxed,
angry, disengaged).
 Body language
 Observe the patient’s body language which may appear
threatening (e.g. standing up close to you) or withdrawn
(e.g. curled up or hands covering their face).
 Note any evidence of exaggerated gesticulation or
unusual mannerisms.
Psychomotor activity
 Observe for any evidence
of psychomotor abnormalities:
 Psychomotor retardation: associated with a paucity
of movement and delayed responses to questions.
 Restlessness: the patient may continuously fidget,
pace and refuse to sit still.
Psychomotor activity cont’d..
 Abnormal movements or postures
 Note any abnormal movements or postures:
 Involuntary movements
 Tremors
 Tics
 Lip-smacking
 Akathisias
 Rocking
 Waxy flexibilitus
Speech
 Assess the patient’s speech to identify abnormalities
which may indicate underlying mental health issues.
 Abnormalities of speech include the following:
A. Mutism: an inability to speak that is caused by a
structural or motor dysfunction of the vocal apparatus or
that is the result of an individual's unwillingness to speak.
B. Echolalia: the involuntary repetition of another person's
speech
C. Neologisms: the creation and use of new words that are
only understood by the speaker (e.g., Pepsidiction = Pepsi
+ addiction, Spritependency = Sprite + dependency)
Speech cont’d..
D. Word salad: incoherent thinking expressed as a
sequence of words without a logical connection

 Example: “They’re destroying too many cattle and oil

just to make soap. If we need soap when you can jump
into a pool of water, and then when you go to buy your
gasoline, my folks always thought they should get pop
but the best thing to get is motor oil and money.”
Speech cont’d..
 Rate of speech
 Pay attention to the patient’s rate of speech:
 Pressure of speech: a tendency to speak rapidly,
motivated by an urgency that may not be apparent to
the listener (often a manifestation of thought
abnormalities such as flight of ideas, which is described
later in this presentation).
 Slow speech: may occur due to psychomotor
retardation which is typically associated with major
depression.
Speech cont’d..
 Quantity of speech
 Note the quantity of the patient’s speech:
 Minimal or absent speech: associated with depression.
 Excessive speech: associated with mania and schizophrenia.
 Tone of speech
 Note the tone of the patient’s speech:
 Monotonous speech: associated with conditions such as
depression, schizophrenia and autism.
 Tremulous speech: associated with anxiety.
Speech cont’d..
 Volume of speech
 Note the volume of the patient’s speech.
 Fluency and rhythm of speech
 Note the fluency and rhythm of the patient’s speech
for abnormalities:
 Stammering or stuttering
 Slurred speech: may occur in major depression due to
psychomotor retardation.
Mood and affect
 Mood and affect both relate to emotion, however, they
are fundamentally different.
 Affect represents
an immediately expressed and observed emotion (
e.g. the patient’s facial expression or overall
demeanour).
 Mood represents a patient’s predominant subjective
internal state at any one time as described by them.
 Affect is what you observe and mood is what the
patient tells you.
Mood and affect cont’d..
 Mood
A patient’s mood can be explored by
asking questions such as:
 “How are you feeling?”
 “What is your current mood?”
 “Have you been feeling low/depressed/anxious lately?”
Mood and affect cont’d..
 Examples of mood states
 Low mood
 Anxious
 Angry
 Enraged
 Euphoric
 Guilty
 Apathetic
Mood and affect cont’d..
Affect
 To assess affect you need to observe the
patient’s facial expressions and overall demeanour.
 Apparent emotion
 Observe the apparent emotion reflected by the
patient’s affect, examples may include:
 Sadness
 Anger
 Hostility
 Euphoria
Mood and affect cont’d..
 Range and mobility of affect
 Range and mobility of affect refer to the variability observed
in the patient’s affect during the assessment. Abnormalities
may include:
 Fixed affect: the patient’s affect remains the same
throughout the interview, regardless of the topic.
 Restricted affect: the patient’s affect changes slightly
throughout the interview, but doesn’t demonstrate the normal
range of emotional expression that would be expected.
 Labile affect: characterised by exaggerated changes in
emotion which may or may not relate to external triggers.
 Patients typically feel like they have no control over their
emotions.
Mood and affect cont’d..
 Intensity of affect
 A patient’s intensity of affect may be described as:
 Heightened: associated with mania and some
personality disorders.
 Blunted or flat: associated with schizophrenia,
depression and post-traumatic stress disorder.
Mood and affect cont’d..
 Congruency of affect
 Note if the patient’s affect appears in keeping with the
content of their thoughts (known as congruency).
A patient sharing distressing thoughts whilst
demonstrating a flat affect or laughing would be
described as showing incongruent affect.
 Incongruent affect is typically associated with
schizophrenia.
Thought
 Thought can be described in terms
of form, content and possession.
 Thought form
 Thought form refers to the processing and organisation of thoughts.
 Speed of thoughts
 Patient’s may demonstrate abnormally fast (i.e. racing) or abnormally
slow thought processing.
 Flow and coherence of thoughts
 In healthy individuals, thoughts flow at a steady pace and in a logical
order. However, in several mental health conditions, the flow and
coherence of thoughts can become distorted.
Thought cont’d..
 Abnormalities of thought flow and coherence include:
 Flight of ideas: moving rapidly from one topic to
another with no apparent connection between the
topics.
 Circumstantial thoughts: these are thoughts which
include lots of irrelevant and unnecessary details. (e.g.
When a patient is asked where they are from, they
describe their favourite hometown diners before
answering your question).
Thought cont’d..
 Tangential thoughts: digressions from the main
conversation subject, introducing thoughts that seem
unrelated, oblique, and irrelevant.
 (e.g. When asked about their medical history, the
patient describes the hospitals they have stayed in
without mentioning their medical conditions).
Thought cont’d..
 Flight of ideas: there is an accelerated tempo of
speech often referred to as ‘pressure of speech’.
 This is also commonly accompanied by arbitrary shifting
from one topic to the other.
 (e.g. When asked how they are feeling, the patient
delivers a 10-minute monologue on different topics
using rapid, intangible speech)
Thought cont’d..
 Thought blocking: sudden cessation of thought,
typically mid-sentence, with the patient being unable to
recover what was previously said.
 Perseveration: refers to the repetition of a particular
response (such as a word, phrase or gesture) despite
the absence/removal of the stimulus (e.g. a patient is
asked what their name is and they then continue to
repeat their name as the answer to all further
questions).
 Neologisms: words a patient has made-up which are
unintelligible to another person.
Thought cont’d..
 Thought content
 Abnormalities of thought content can include:
 Delusions: a firm, fixed belief based on inadequate
grounds, not amenable to a rational argument or
evidence to the contrary and not in sync with regional
and cultural norms.
 These may include persecutory delusions, in which the
patient erroneously believes another individual or group
is trying to harm them or
Types of delusions
 Persecutory delusions: The patient believes that they are
being cheated on, conspired against, or harassed.
 Ideas of reference: in which the individual incorrectly
believes specific events relate to the. (e.g., an individual
might feel that a television reporter is talking about them).
 Paranoid delusions: The patient has an exaggerated
distrust of others and is suspicious of their motives.
 Delusions of grandeur or grandiosity: The patient
insists that they have special powers or importance (e.g., a
patient saying they can read minds, they are very wealth,
most intelligent etc).
Types of delusions cont’d..
 Erotomania delusions: The patient believes that other
individuals are in love with them (e.g., a patient claiming a
famous actress is sending them love letters).
 Delusions of Jealousy: The patient believes their partner is
unfaithful without justification.
 Somatic delusions: The patient believes there is
something abnormal about their body function or appearance
(e.g., an individual might feel like they are missing a hand).
 Religious delusions: The patient believes they have divine
powers, receive messages from God, or that they actually are
God.
 Delusions of guilty: The patient believes that they have
wronged someone and/or are responsible for something bad.
Thought cont’d..
 Obsessions: thoughts, images or impulses that occur
repeatedly and feel out of the person’s control.
 The patient is aware these obsessions are irrational, but the
thoughts continue to enter their head.
 Compulsions: repetitive behaviours that the patient feels
compelled to perform despite recognising the irrationality of
the behaviour.
 Overvalued ideas: a solitary, abnormal belief that is neither
delusional nor obsessional in nature, but which is
preoccupying to the extent of dominating the sufferer’s life
(e.g. the perception of being overweight in a patient with
anorexia nervosa).2
 Suicide thoghts/Homicidal/violent thoughts
Thought cont’d..
 Some examples of questions which can be used to screen for
thought content abnormalities include:
 “What’s been on your mind recently?”
 “Are you worried about anything?”
 “Do you sometimes have thoughts that others tell you are
false?”
 “Do you have any beliefs that aren’t shared by others you
know?”
 “Do you ever feel that people are out to do you harm?”
 “Do you ever feel that specific events in the world are related
to you in some way?”
Thought cont’d..
 “Are there any thoughts you have a hard time getting
out of your head?”
 “Do you sometimes feel the need to perform certain
behaviours repetitively, despite understanding these are
irrational?”
 “Do you ever think about ending your life?”
 “Have you ever felt your life was not worth living?”
 “Have you ever attempted to end your life?”
 “Do you ever think about harming others?”
Thought possession
 Abnormalities of thought possession include:
 Thought insertion: a belief that thoughts can be
inserted into the patient’s mind.
 Thought withdrawal: a belief that thoughts can be
removed from the patient’s mind.
 Thought broadcasting: a belief that others can hear
the patient’s thoughts.
Thought possession
 Some examples of questions which can be used
to screen for thought possession
abnormalities include:
 “Do you think people can put ideas in your head,
without your control?”
 “Have you ever felt like people have removed memories
or thoughts from your mind?”
 “Do you ever feel like others can hear what you’re
thinking?”
Perception
 Perception involves the organisation, identification and
interpretation of sensory information to understand the
world around us. Abnormalities of perception are a
feature of several mental health conditions.
 Abnormalities of perception include:
 Hallucinations: a sensory perception without any
external stimulation of the relevant sense that the
patient believes is real (e.g. the patient hears voices but
no sound is present).
Perception cont’d..
 Pseudo-hallucinations: the same as a hallucination
but the patient is aware that it is not real.
 Illusions: the misinterpretation of an external stimulus
(e.g. mistaking a shadow for a person).
 Depersonalisation: the patient feels that they are no
longer their ‘true’ self and are someone different or
strange.
 Derealisation: a sense that the world around them is
not a true reality.
Perception cont’d..
 Some examples of questions which can be used
to screen for perceptual abnormalities include:
 “Do you ever see, hear, smell, feel or taste things that
are not really there?”
 “Did you think this was real at the time?”
 “Do you still believe it was real?”
 “Do you ever feel like you’ve changed or that you don’t
recognise the person you currently are?”
 “Do you ever feel like the world around you isn’t real?”
 Cognition
 Cognition refers to “the mental action or process of acquiring
knowledge and understanding through thought, experience, and
the senses”. Cognition can be impaired as a result of mental health
conditions and their treatments.
 Throughout the process of performing a mental state examination,
you will develop a vague idea of the patient’s cognitive
performance including:
 whether they are orientated in time, place and person
 what their attention span and concentration levels are like
 what their short-term, medium-term and long-term memory is like
 A formal assessment of cognition can be achieved through a
variety of different validated clinical tests including-Mini Mental
State Examination
Insight and judgement
 Insight, in a mental state examination context, refers to the
ability of a patient to understand that they have a mental
health problem and that what they’re experiencing is
abnormal.
 Several mental health conditions can result in patients losing
insight into their problem.
 Some examples of questions which can be used to assess
insight include:
 “What do you think the cause of the problem is?”
 “Do you think you have a problem at the moment?”
 “Do you feel you need help with your problem?”
Judgement
 Judgement refers to the ability to make considered decisions or
come to a sensible conclusion when presented with information.
 Judgement can become impaired in several mental health
conditions leading to poor decision making.
 You may get some idea of the patient’s judgement abilities as
you move through the mental state examination, but you can
also specifically assess judgement by presenting the patient a
scenario such as:
 “What would you do if you could smell smoke in your house?”
 Sensible judgement in this situation would involve leaving the
house immediately wherever possible and calling the fire
department.
 A patient with impaired judgement may suggest ignoring it.
 The end
Thank you for your attention