Appearance

Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height,
weight, and manner of dress and grooming. Colorful or bizarre clothing might suggest mania, while
unkempt, dirty clothes might suggest schizophrenia or depression. If the patient appears much older than
his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories
of a particular subculture, body modifications, or clothing not typical of the patient's gender, might give
clues to personality. Observations of physical appearance might include the physical features of alcoholism
or drug abuse, such as signs of malnutrition, nicotine stains, dental erosion, a rash around the mouth from
inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor
which might suggest poor personal hygiene due to extreme self-neglect, or alcohol intoxication. Gelder,
Mayou & Geddes (2005) tells us to look out for weight loss. This could signify a depressive disorder,
physical illness, anorexia nervosa or chronic anxiety

Physically unkempt, unclean, Clothing disheveled, dirty, Clothing atypical, unusual, bizarre, Unusual
physical characteristics

Attitude

Attitude, also known as rapport, refers to the patient's approach to the interview process and the interaction
with the examiner. The patient's attitude may be described for example as cooperative, uncooperative,
hostile, guarded, suspicious or regressed. The most subjective element of the mental status examination,
attitude depends on the interview situation, the skill and behaviour of the clinician, and the pre-existing
relationship between the clinician and the patient. However, attitude is important for the clinician's
evaluation of the quality of information obtained during the assessment

Slumped, tense, Rigid, Atypical, inappropriate

Behavior

Abnormalities of behavior, also called abnormalities of activity, include observations of specific abnormal
movements, as well as more general observations of the patient's level of activity and arousal, and
observations of the patient's eye contact and gait. Abnormal movements, for example choreiform, athetoid
or choreoathetoid movements may indicate a neurological disorder. A tremor or dystonia may indicate a
neurological condition or the side effects of antipsychotic medication. The patient may have tics
(involuntary but quasi-purposeful movements or vocalizations) which may be a symptom of Tourette's
syndrome. There are a range of abnormalities of movement which are typical of catatonia, such as
echopraxia, catalepsy, waxy flexibility and paratonia (or gegenhalten). Stereotypies (repetitive purposeless
movements such a rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal
movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or autism. More
global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as
psychomotor agitation or hyperactivity) which might reflect mania or delirium. An inability to sit still
might represent akathisia, a side effect of antipsychotic medication. Similarly a global decrease in arousal
and movement (described as psychomotor retardation, akinesia or stupor) might indicate depression or a
medical condition such as Parkinson's disease, dementia or delirium. The examiner would also comment on
eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations),
and the quality of eye contact (which can provide clues to the patient's emotional state). Lack of eye contact
may suggest autism

Anxiety, fear, apprehension, Depression, sadness, Depression, sadness, Anger, hostility, Decreased
variability of expression, Bizarreness, inappropriateness, Domineering, Submissive, overly compliant,
Provocative, Suspicious, Uncooperative, Inappropriate to thought content, Increased lability of affect,
Blunted, absent, unvarying
Mood and affect

The distinction between mood and affect in the MSE is subject to some disagreement. For example
Trzepacz and Baker (1993) describe affect as "the external and dynamic manifestations of a person's
internal emotional state" and mood as "a person's predominant internal state at any one time", whereas
Sims (1995) refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or
disposition". This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a
current subjective state as described by the patient, and affect as the examiner's inferences of the quality of
the patient's emotional state based on objective observation.

Mood is described using the patient's own words, and can also be described in summary terms such as
neutral, euthymic, dysphoric, euphoric, angry, anxious or apathetic. Alexithymic individuals may be unable
to describe their subjective mood state. An individual who is unable to experience any pleasure may be
suffering from anhedonia.

Affect is described by labelling the apparent emotion conveyed by the person's nonverbal behavior
(anxious, sad etc.), and also by using the parameters of appropriateness, intensity, range, reactivity and
mobility. Affect may be described as appropriate or inappropriate to the current situation, and as congruent
or incongruent with their thought content. For example, someone who shows a bland affect when
describing a very distressing experience would be described as showing incongruent affect, which might
suggest schizophrenia. The intensity of the affect may be described as normal, blunted, exaggerated, flat,
heightened or overly dramatic. A flat or blunted affect is associated with schizophrenia, depression or post-
traumatic stress disorder; heightened affect might suggest mania, and an overly dramatic or exaggerated
affect might suggest certain personality disorders. Mobility refers to the extent to which affect changes
during the interview: the affect may be described as mobile, constricted, fixed, immobile or labile. The
person may show a full range of affect, in other words a wide range of emotional expression during the
assessment, or may be described as having restricted affect. The affect may also be described as reactive, in
other words changing flexibly and appropriately with the flow of conversation, or as unreactive. A bland
lack of concern for one's disability may be described as showing belle indifférence, a feature of conversion
disorder, which is historically termed "hysteria" in older texts

Euphoria, elation, Anger, hostility, Fear, anxiety, apprehension, Depression, sadness

Speech

The patient's speech is assessed by observing the patient's spontaneous speech, and also by using structured
tests of specific language functions. This heading is concerned with the production of speech rather than the
content of speech, which is addressed under thought form and thought content (see below). When
observing the patient's spontaneous speech, the interviewer will note and comment on paralinguistic
features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate,
spontaneity and latency of speech. A structured assessment of speech includes an assessment of expressive
language by asking the patient to name objects, repeat short sentences, or produce as many words as
possible from a certain category in a set time. Simple language tests form part of the mini-mental state
examination. In practice, the structured assessment of receptive and expressive language is often reported
under Cognition (see below).

Language assessment will allow the recognition of medical conditions presenting with aphonia or
dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific
language disorders such as stuttering, cluttering or mutism. People with autism or Asperger syndrome may
have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another
person's words) and palilalia (repetition of the subject's own words) can be heard with patients with autism,
schizophrenia or Alzheimer's disease. A person with schizophrenia might use neologisms, which are made-
up words which have a specific meaning to the person using them. Speech assessment also contributes to
assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech;
on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow,
quiet and hesitant manner

Increased, loud, Decreased, slowed, Atypical quality, slurring, stammer

Thought process

Thought process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of
thought. Thought process cannot be directly observed but can only be described by the patient, or inferred
from a patient's speech. Regarding the tempo of thought, some people may experience flight of ideas, when
their thoughts are so rapid that their speech seems incoherent, although a careful observer can discern a
chain of poetic associations in the patient's speech. Alternatively an individual may be described as having
retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of
thought is a global reduction in the quantity of thought and thought perseveration refers to a pattern where a
person keeps returning to the same limited set of ideas. A pattern of interruption or disorganization of
thought processes is broadly referred to as formal thought disorder, and might be described more
specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of
thought, or knight's move thinking. Thought may be described as circumstantial when a patient includes a
great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Flight
of ideas is typical of mania. Conversely, patients with depression may have retarded or inhibited thinking.
Poverty of thought is one of the negative symptoms of schizophrenia, and might also be a feature of severe
depression or dementia. A patient with dementia might also experience thought perseveration. Formal
thought disorder is a common feature of schizophrenia. Circumstantial thinking might be observed in
anxiety disorders or certain kinds of personality disorders
Associational disturbance, Thought flow decreased, slowed, Thought flow increased

Thought content

A description of thought content would describe a patient's delusions, overvalued ideas, obsessions,
phobias and preoccupations. Abnormalities of thought content are established by exploring individual's
thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions
associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's
control, and the degree of belief or conviction associated with the thoughts.

A delusion can be defined as "a false, unshakeable idea or belief which is out of keeping with the patient's
educational, cultural and social background ... held with extraordinary conviction and subjective certainty",
and is a core feature of psychotic disorders. The patient's delusions may be described as persecutory or
paranoid delusions, delusions of reference, grandiose delusions, erotomanic delusions, delusional jealousy
or delusional misidentification. Delusions may be described as mood-congruent (the delusional content in
keeping with the mood), typical of manic or depressive psychoses, or mood-incongruent (delusional
content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or
passivity experiences (in which the individual has the experience of the mind or body being under the
influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of
this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic
passivity. Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said
to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and
nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses.

An overvalued idea is a false belief that is held with conviction but not with delusional intensity.
Hypochondriasis is an overvalued idea that one is suffering from an illness, dysmorphophobia is an
overvalued idea that a part of one's body is abnormal, and people with anorexia nervosa may have an
overvalued idea of being overweight.

An obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's
volition", but unlike passivity experiences described above, they are not experienced as imposed from
outside the patient's mind. Obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or
obsessive ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive
worries about whether they have made the wrong decision, or forgotten to do something, for example turn
off the gas or lock the house. In obsessive-compulsive disorder, the individual experiences obsessions with
or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their
wishes).

A phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a
delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain
situations and will usually be reported by the patient rather than being observed by the clinician in the
assessment interview.

Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the
person's mind. Clinically significant preoccupations would include thoughts of suicide, homicidal thoughts,
suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example
that one is unloved or a failure), or the cognitive distortions of anxiety and depression. The MSE
contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought
content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal
thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end
his or her life.

Obsessions, Compulsions, Phobias, Derealization/depersonalization, Suicidal ideation, Homicidal ideation,

Perceptions

A perception in this context is any sensory experience, and the three broad types of perceptual disturbance
are hallucinations, pseudohallucinations and illusions. A hallucination is defined as a sensory perception in
the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by
the subject as real). An illusion is defined as a false sensory perception in the presence of an external
stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject.
A pseudohallucination is experienced in internal or subjective space (for example as "voices in my head")
and is regarded as akin to fantasy. Other sensory abnormalities include a distortion of the patient's sense of
time, for example déjà vu, or a distortion of the sense of self (depersonalization) or sense of reality
(derealization).

Hallucinations can occur in any of the five senses, although auditory and visual hallucinations are
encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations.
Auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the
patient) and hearing one's thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the
Schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations
(voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of
psychotic depression or schizophrenia. Visual hallucinations are generally suggestive of organic conditions
such as epilepsy, drug intoxication or drug withdrawal. Many of the visual effects of hallucinogenic drugs
are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of
sensory experiences, and are not experienced as existing in objective reality. Auditory pseudohallucinations
are suggestive of dissociative disorders. Déjà vu, derealization and depersonalization are associated with
temporal lobe epilepsy and dissociative disorders.
Illusions, Auditory hallucinations, Visual hallucinations

Cognition

This section of the MSE covers the patient's level of alertness, orientation, attention, memory, visuospatial
functioning, language functions and executive functions. Unlike other sections of the MSE, use is made of
structured tests in addition to unstructured observation. Alertness is a global observation of level of
consciousness i.e. awareness of, and responsiveness to the environment, and this might be described as
alert, clouded, drowsy, or stuporose. Orientation is assessed by asking the patient where he or she is (for
example what building, town and state) and what time it is (time, day, date). Attention and concentration
are assessed by the serial sevens test (or alternatively by spelling a five-letter word backwards), and by
testing digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-
term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term
memory (recollection of well known historical or geographical facts). Visuospatial functioning can be
assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room.
Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's
spontaneous speech and response to instructions. Executive functioning can be screened for by asking the
"similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g.
"list as many words as you can starting with the letter F, in one minute"). The mini-mental state
examination is a simple structured cognitive assessment which is in widespread use as a component of the
MSE.

Mild impairment of attention and concentration may occur in any mental illness where people are anxious
and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to
indicate a gross disturbance of brain functioning such as delirium, dementia or intoxication. Specific
language abnormalities may be associated with pathology in Wernicke's area or Broca's area of the brain. In
Korsakoff's syndrome there is dramatic memory impairment with relative preservation of other cognitive
functions. Visuospatial or constructional abnormalities here may be associated with parietal lobe pathology,
and abnormalities in executive functioning tests may indicate frontal lobe pathology. This kind of brief
cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed
using formal neuropsychological testing.

The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is
suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-stone"). The
posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists
and ankles. The parietal lobe can be assessed by the person's ability to identify objects by touch alone and
with eyes closed. A cerebellar disorder may be present if the person cannot stand with arms extended, feet
touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches
for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again.
Pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by
the presence of characteristic involuntary movements. A lesion in the posterior fossa can be detected by
asking the patient to roll his or her eyes upwards (Perinaud's sign). Focal neurological signs such as these
might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head
injuries, tumors or other brain disorders.

Impaired level of consciousness, Impaired attention span/concentration, Impaired abstract thinking,

Insight

The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory
account of the problem, and understanding of the treatment options. In this context, insight can be said to
have three components: recognition that one has a mental illness, compliance with treatment, and the ability
to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a
continuum, the clinician should not describe it as simply present or absent, but should report the patient's
explanatory account descriptively.

Impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment
planning and in assessing the capacity to consent to treatment.[54]

Difficulty in acknowledging the presence of psychological problems, Mostly blames others or

Judgment

Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. Traditionally,
the MSE included the use of standard hypothetical questions such as "what would you do if you found a
stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how
the patient has responded or would respond to real-life challenges and contingencies. Assessment would
take into account the individual's executive system capacity in terms of impulsiveness, social cognition,
self-awareness and planning ability.

Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting
the frontal lobe of the brain. If a person's judgment is impaired due to mental illness, there might be
implications for the person's safety or the safety of others

Impaired ability to manage daily living activities. Impaired ability to make reasonable like decisions

Memory

Impaired immediate recall, Impaired recent memory, Impaired remote memory

Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects
of disorder or disability:

• Axis I: Clinical disorders, including major mental disorders, and learning disorders
• Axis II: Personality disorders and intellectual disabilities (although developmental disorders, such
as Autism, were coded on Axis II in the previous edition, these disorders are now included on
Axis I)
• Axis III: Acute medical conditions and physical disorders
• Axis IV: Psychosocial and environmental factors contributing to the disorder
 • Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and
teens under the age of 18

Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism
spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia.

Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid
personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality
disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder,
dependent personality disorder, obsessive-compulsive personality disorder, and intellectual disabilities.

Common Axis III disorders include brain injuries and other medical/physical disorders which may
aggravate existing diseases or present symptoms similar to other disorders

The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used by mental health
clinicians and physicians to subjectively rate the social, occupational, and psychological functioning of
adults, e.g., how well or adaptively one is meeting various problems-in-living

91 - 100 Superior functioning in a wide range of activities, life's problems never seem to get out of
hand, is sought out by others because of his or her many positive qualities. No symptoms.
81 - 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all
areas, interested and involved in a wide range of activities, socially effective, generally satisfied
with life, no more than everyday problems or concerns (e.g., an occasional argument with family
members).
71 - 80 If symptoms are present, they are transient and expectable reactions to psychosocial
stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in
social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
61 - 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in
social, occupational, or school functioning (e.g., occasional truancy, or theft within the
household), but generally functioning pretty well, has some meaningful interpersonal
relationships.
51 - 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks)
OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts
with peers or co-workers).
41 - 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting)
OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable
to keep a job).
31 - 40 Some impairment in reality testing or communication (e.g., speech is at times illogical,
obscure, or irrelevant) OR major impairment in several areas, such as work or school, family
relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is
unable to work; child frequently beats up younger children, is defiant at home, and is failing at
school).
21 - 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment,
in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal
preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home,
or friends)
11 - 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of
death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal
hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or
mute).
1 - 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent
inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of
death.