What Are the Components of a Mental Status

Exam?
In general, the components of a mental status exam include descriptions of the following:

 Appearance
 General behavior
 Speech and language
 Emotions
 Thought and perception
 Cognition
The exam may also include cognitive testing, depending on a client’s needs.

Why Are Mental Status Exams Important?

In combination with family and personal histories, the mental status exam forms the foundation for a psychiatric
diagnosis.Clinicians can also use mental status exams for the following reasons:

 To determine if certain issues are improving or getting worse

 To identify areas that need attention from a specialist
 To offer a snapshot of a client at a specific point in time and provide that information to another provider

When Are Mental Status Exams Performed?

Mental status exams are often performed during the first one or two sessions with a client as part of the initial
assessment and when reassessing their symptoms. It should be performed in person and not over the phone due to its visual
elements. Mental status exams are especially useful in helping clinicians differentiate between various psychiatric and
neurological disorders.
Typically, these exams are used for patients who have chronic, severe, or acute symptoms. A mental status exam aims to
capture dysfunction, though you can still use them to confirm ordinary function for clients.
As a behavioral health professional, you may choose to complete regular mental status exams to identify progress or on an
as-needed basis throughout the treatment process. Completing a mental status exam at the end of treatment can highlight
the differences in a client's presentation and illustrate their growth.

Who Uses Mental Status Exams?

Although mental status exams have been an assessment tool mainly used in clinical psychology, psychiatry, and social work
to examine patients with an altered mental status or evolving impairment of cognition, counselors and therapists can also use
this type of exam as an informal way to gain information about a client’s cognitive and behavioral functioning. The
counselor's findings can help them diagnose and treat a mental health disorder. Mental status exams also provide an
excellent source of documentation to support a diagnosis.

How Do I Write a Mental Status Exam?

In private practice, you have the flexibility to create the sections you want to include in your mental status exam. When you
are writing your mental status exam, review the typical sections, and identify which ones you believe will be useful to
document during your intake assessments with clients. Keep in mind that some sections may be more or less relevant for
specific clients.
To determine which portions to include in your mental status exam, consider your current clients. Would this apply to at least
half of them? If so, it will likely be useful for you. If not, maybe you don't need to include it every time, and you can add it
whenever necessary. You may also want to have an "other" section for topics that may come up during a mental status exam
but do not fit in already established sections.

Mental Status Exam Checklist

To help you use a mental status exam as an assessment tool, we've created a cheat sheet. The following checklist is meant
to be easy to read, so you can use it as a quick reference. Although you can customize a mental status exam to suit each
client, you’ll generally want to focus on the categories in this checklist:

1. Appearance
Appearance includes your observations of how a client looks initially and throughout the assessment. A client's appearance
gives you an idea of their functioning level, their history, and symptoms they're experiencing. Always look for signs of self-
neglect and note anything unusual.

Hygiene and Grooming

Would you describe your client's hygiene and grooming as:
  Clean
 Neat
 Shaven
 Body odor
 Disheveled
Dress
Is your client's clothing:

 Casual
 Immaculate
 Neat
 Business
 Fashionable
 Bizarre
 Inappropriate
 Dirty
 Stained
 Ragged
Makeup
Is your client's makeup:

 Appropriate
 Garish
 Bizarre
 No makeup
Distinguishing Features
Does your client have any distinguishing features, such as:

 Tattoos
 Piercings
 Scars
Apparent Age
Does your client appear:

 Older than their stated age

 Younger than their stated age
Habitus
Is your client's habitus:

 Normal
 Underweight
 Overweight
 Obese
Facial Expressions
Does your client appear:

 Calm
 Sad
 Anxious
 Disgusted
 Angry
 Perplexed

2. General Behavior
Describe how your client moves and behaves physically during the assessment. Always note if they are being hostile,
uncooperative or have inappropriate impulses.

Eye Contact
Isyour client's eye contact:

 Appropriate
 Decreased
 Heightened
 Avoidant
Motor Activity
Does your client display:

 Normal activity
 Decreased activity
 Restlessness
 Tension
 Agitation
Gait
Does your client:

 Seem unsteady
 Limp
 Shuffle
 Use a cane, crutches or another device
Orofacial Dyskinesia
Does your client display unusual movements in the jaw, face or tongue, such as:

 Grimacing
 Tongue writhing
 Lip smacking
 Lip pursing
 Chewing
Cooperativeness and Attitude
Doesyour client exhibit an appropriate level of cooperation, or are they:

 Evasive
 Guarded
 Playful
 Ingratiating
 Passive
 Sullen
 Withdrawn
 Manipulative
 Demanding
 Hostile
 Overly friendly
 Relaxed
 Open
 Shy
 Candid
 Suspicious
Movements
Does your client display any unusual or repetitive movements, such as:
  Tics
 Twitches
 Tremor
 Mannerisms
 Stereotypies
 Posturing

3. Speech and Language

Consider how your client speaks and uses language. The amount a client speaks and how they talk can indicate a mental
health issue such as depression or anxiety or a neurocognitive disorder.

General
Does your client speak clearly or have an:

 Accent
 Stutter
 Lisp
Rate
Is your client's rate of speech:

 Normal
 Slow
 Fast
 Delayed onset
Rhythm
Is your client's speech:

 Articulate
 Slurred
 Monotone
 Dysarthric
Volume
Is your client's speech:

 Soft
 Loud
 Mute
Content
Is your client:

 Loquacious
 Fluent
 Impoverished

4. Emotions
Try to determine your client's emotional state by asking them how they feel and observing their facial expressions and body
language.

Mood
Does your client say they feel:

 Depressed
 Sad
 Angry
 Irritable
 Good
 Fantastic
Affect
Does your client seem to be:

 Euthymic
 Depressed
 Irritable
 Angry
 Elated
 Euphoric
 Anxious
Range
Is your client's affect range:

 Broad: The client shows a normal range of emotions.

 Restricted: Theclient seems limited in expressing emotions.
 Flat: The client does not show any change in mood.
 Labile: The client's mood changes rapidly.
 Anhedonic: The client seems incapable of a pleasurable response.
Congruency
Is your client's affect:

 Congruent to their mood

 Incongruent to their mood

5. Thought and Perception

Consider how your client's thoughts flow and connect and whether your client has a normal, linear thought process or if they
go off-topic or make disorganized associations. Also, listen to what your client focuses on and find out if they're experiencing
hallucinations. Always note hallucinations or the presence of delusions, and take appropriate action if a client expresses
plans to carry out suicidal or homicidal ideation.

Thought Process
Would you describe your client's thought process as:

 Goal-directed: The client answers your questions and does not move onto other related topics.
 Impoverished: The client displays slow thinking and does not share many ideas.
 Rapid: The client expresses racing thoughts and rapid thinking.
 Illogical: The client does not make sense when they speak.
 Incoherent: The client's speech is disorganized, and there is no meaning to what they're saying.
 Distractible: The client cannot stay focused.
 Blocking: The client's thoughts are interrupted.
 Circumstantial: The client provides unnecessary detail but gets to the point eventually.
 Perseverative: The client shows a repetition of words, ideas or phrases.
 Tangential: The client moves from one related thought to the next but never reaches the point.
 Loose: The client shifts illogically between unrelated topics.
 Flight of ideas: The client quickly jumps from one idea to the next.
 Word salad: The client speaks words randomly.
Thought Content
Do your client's thoughts consist of:

 Suicidal ideation
 Homicidal ideation
 Grandiose, somatic, paranoid or other delusions
 Distortions
 Obsessions
 Worries
 Compulsions
 Phobias
  Ruminations
Perception
Is your client experiencing:

 No hallucinations
 Auditory hallucinations
 Visual hallucinations
 Tactile hallucinations
 Olfactory hallucinations
 Illusions
 Derealization, or feeling detached from the surroundings
 Depersonalization, or feeling separated from him- or herself

6. Cognition
When evaluating a client's cognition, clinicians commonly assess the person's alertness or level of consciousness,
orientation, attention, concentration and memory. If your client shows symptoms of a neurocognitive disorder, consider using
additional tools such as the Mini-Mental State Examination or the Montreal Cognitive Assessment.

Alertness
Is your client:

 Alert
 Lethargic
 Obtunded
 In a stupor
 Comatose
Orientation
Does your client know:

 Their name
 Their current location
 The date
 The time
Memory
To test your client's memory, you might ask them to do the following:

 Repeat three words immediately and again in five minutes.

 Sign their name while answering unrelated questions.
 Tell you their birthday, where they were born and their parents' names.
Does your client display:

 No impairment
 Short-term impairment
 Long-term impairment
Attention
Does your client's attention seem:

 Normal
 Distracted
Insight
Describe your client's insight or their awareness of their situation or condition. Start by answering the following questions:

 How well does your client understand the reasons for their behavior?
 How well does your client appreciate how they contribute to a problem?
 Does your client recognize or acknowledge the severity of an issue?
 What do they perceive is the best way to address a problem?
Is your client's insight:

 Good
 Fair
 Poor
Judgment
Consider if your client anticipates the consequences of their behavior and makes decisions to safeguard their well-being and
that of others. Is their judgment:

 Good
 Fair
 Poor
Impulse Control
Does your client show:

 Normal impulse control

 Impaired impulse control
Motivation
Would you describe your client's motivation level as:

 Good
 Fair
 Poor
Reliability
Consider your client's reliability and accuracy as they share details about their situation. Do you consider your client to be:

 Reliable
 Unreliable

7. Environment
If part of your mental status exam includes assessing the client's living environment, you may want to describe their
surroundings. Ask yourself the following:

 Have they made odd decisions, such as blocking doors or windows with furniture?
 Are there unusual decorations or wires that lead nowhere?
 Are they using any household objects inappropriately?
 Is their home extremely cluttered or dirty?
 Do they collect junk or garbage?