1. MENTAL STATUS EXAMINATION
Dr. Vijit Jaiswal
Junior Resident
Deptt. of Psychiatry

2. WHAT IS IT?
 The Mental Status Exam (MSE) is the
psychological equivalent of a physical exam that
describes the mental state and behavior of the
person being seen. It includes both objective
observations of the clinician and subjective
descriptions given by the patient.

3. WHY DO WE DO THEM?
 The MSE provides information for diagnosis
and assessment of disorder and response to
treatment.
A Mental Status Exam provides a snap shot at
a point in time
 If another provider sees your patient it allows
them to determine if the patients status has
changed without previously seeing the patient

4. CONTINUED…
 To properly assess the MSE, information about
the patients history is needed including
education, cultural and social factors
 It is important to ascertain what is normal for
the patient. For example some people always
speak fast!

5. COMPONENTS OF THE MENTAL
STATUS EXAMINATION
 Appearance and Behavior
 Motor activity
 Speech
 Mood
 Affect
 Thought process
 Thought content
 Perceptual disturbances
 Cognition
 Abstract thinking
 Insight
 Judgment

6. APPEARANCE AND BEHAVIOR:WHAT DO
YOU SEE?
 Stated age, younger/older
 Build, posture, dress, grooming, prominent physical
abnormalities
 Level of alertness: Somnolent, alert
 Emotional facial expression
 Attitude toward the examiner: Cooperative,
attentive,interested,frank,seductive,defensive,hostile,playfull,
evasive or guarded
 Eye contact: ex. poor, good, piercing
 Rapport: measure of the quality of interaction b/w the patient
and examiner. Described in actual characteristics of the
interaction and changes throughout the interview.

7. Examples:
General self neglect- chronic schizophrenia, dementia, alcohol/drug
de-addiction.
Bright/ Colorful clothes- Mania
Stooped posture,hunched,leaning forward- Depression
Sitting on the edge of the seat, gripping the arms of the chair- Anxiety
Facial Expression:
Sad face with downward corners of the mouth, flattened expressions
and vertical furrowing of brows suggest “Depression”
Horizontal furrowing of the brows with wide eyes,sweating and
dilated pupils suggest “Anxiety”
Expressionless face, mask like face suggest“Parkinsonism”
Grave’s disease is characterized by exophthalmos
Eye contact:
Reduced in Depression,Unsettled in Autistic disorder or social
Anxiety, may appear staring in Parkinsonism/Drug side effects.

8. MOTOR ACTIVITY
 Psychomotor activity: ex. retardation or agitation
 Movements: tremor( Drug side effects), abnormal movements i.e..
Stereotypes, gait ,freedom of movement
 Apparent restlessness , lip smacking , tongue protrusion- Drug Side
effects
 Difficulty in initiation of movement or slow, stiff movement-
Parkinsonism
 Waxy Flexibility: patient’s movement having the feeling of a plastic
resistance e.g. in catatonic schizophrenia
 Negativism: patient resist attempts to move him and does opposite to
what is asked. A sign of Catatonia.

9. Speech
Rate: normal, very slow, rapid, pressure of speech
Flow: spontaneous, hesitant, slurring, stuttering, speaks
only on question, muttering, mute
Volume: audible, excessive loud, abnormally soft
Amount: Normal, abundant, scanty
Tone: normal fluctuations, monotonous
Coherence: coherent, incoherent
Relevance: relevant, irrelevant

10. Disorders of Speech:-
Aphonia: fails to produce any vol. 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 difficult 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.

11. MOOD
 A pervasive and sustained emotion that color the patient’s
perception of the world subjectively experienced and
reported by the patient.
 Often placed in quotes since it is what the patient tells you.
e.g. “Fantastic, elated, depressed, anxious, sad, angry,
irritable, good”
 Necessary to ask in mood- Depth
Intensity
Duration
Fluctuation

12. AFFECT
 The expression of emotions expressed by the patient and
observed by the others.It varies over the time in response
to changing emotions.
 Type: euthymic (normal mood), dysphoric (depressed,
irritable, angry), euphoric (elevated, elated), anxious
 Range: full (normal) vs. restricted(reduced in range and
intensity), blunted(Severe reduction in intensity of
externalized feeling tone) or flat(no sign of affective
expression,monotonous voice,immobile face);
labile(repeated, rapid and abrupt variability in affective
expression)
 Congruency: does it match the mood-(mood congruent
vs. mood incongruent)
 Stability: stable vs. labile
 Appropriateness: appropriate to situation or not
appropriate to situation.

13. THOUGHT PROCESS
 Describes the rate of thoughts, how they flow and
are connected.
1. Stream of thought : Quote from the patient
a).Productivity – abnormalities seen are
1.Overabundance of idea. e.g. Mania
2.Paucity. e.g. depression
3.Flight of Ideas;- In FOI there are rapid shifts 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 manic stupor
5.Spontaneous or only when questioned

14. b). Continuity of thoughts – 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

15. 3. Thought blocking: Sudden arrest of the train of thought,
leaving a blank, then entirely a new thought may begin.
May be seen in exhausted or very anxious state. When
clearly present, it highly suggests Schizophrenia.
4. 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.

16. Thought Possession/alienation : abnormalities seen are
1. Thought Echo : Hearing one’s own thought being spoken
aloud
2.Thought Insertion: Other person or forces are implanting
thoughts in a person’s mind
3. Thought Withdrawal: Other person or forces are removing
thoughts from a person’s mind
4. Thought Broadcasting: One’s own thoughts experienced
as being transmitted to another person or agency
 All are features of Schizophrenia.

17. Formal thought disorder - abnormalities seen are
1. Loosening of association: Illogical shifting between
unrelated topics. It is a hallmark feature of
Schizophrenia.
2. Derailment : Gradual or sudden deviation in train of
thought without blocking.
3. Word Salad: Extreme version of LOA 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 settings, irrespective of
context.
3. Verbigeration: Disappearance of understandable
speech replaced by strings of incoherent utterance

18. .
4. Metonyms: are word approximation e.g. paper skate for
pen
5. Clang association: words are chosen or repeated based on
similar sounds, instead of semantic meaning.
Seen in mania
6. Neologism : It refers to the new word formation by the
patient or ordinary word that are used in new way.
Seen in Schizophrenia.

19. THOUGHT CONTENT
 Refers to the themes that occupy the patient’s
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 in reality.
(McKenna, 1984).

20. 2. Delusions: False, firm (fixed), unshakable belief that is
out of keeping with the patient’s social, cultural, and
educational background. E.g.
Control: outside forces are controlling actions
Erotomanic: a person, usually of higher status, is in
love with the patient
Grandiose: inflated sense of self-worth, power or
wealth
Somatic: patient has a physical defect
Reference: unrelated events apply to them
Persecutory: others are trying to cause harm

21. Richard & Richard, 2010, provided the following
distinction b/w delusion and overvalued ideas –
1. Delusional individuals are less likely to identify what
might modify their belief, less preoccupied and less
concerned about others’ reactions than those with
overvalued ideas.
2. Delusions are less plausible and their onset less likely
to appear reasonable.
3. Delusions are more likely to have abrupt onset and
overvalued ideas have gradual onset.
4. Conviction and insight were similar in both groups.
5. Belief , conviction and insight may be an inadequate
basis for separating delusion from overvalued ideas.
Abrupt onset, implausible content, and relative
indifference to the opinions of others may be better
distinguishing feature.

22. CONTINUED....
3. Preoccupations
 About illness
 Obsessions(repetitive preoccupation with a thought,
acknowledged by the patient to be irrational) or
compulsions(repetitive acts based on obsession)
 Phobias(persistent and irrational fear of delineated aspects
of nonhuman object or environment)
 Plans, intentions or recurrent ideas about suicide, homicide
 Hypochondriacal symptoms(excessive fear and anxiety of
having a serious disease)
 Specific antisocial urges or impulse
4. Ideas of reference: 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 patient attribute to them.

23. Perceptions:
Process of transferring physical stimulation
into psychological information i.e. mental
process by which sensory stimuli are brought
to awareness.

24. PERCEPTUAL DISTURBANCES
 Hallucinations: A false perception which is not a sensory
distortion or a misinterpretation, but which occurs at the
same time as real perception.
 Can be auditory (AH), visual (VH), tactile or
olfactory,hypnogogic or hypnopompic hallucinations
 Illusion : Misinterpretation of stimuli arising from an
external object.
types:- 1.Visual(m.c.)- Delirium
2.Complete – Due to inattention e.g. misreading in
newspaper or missing misprints
3.Affect Illusion- arise in context of particular
mood state
4.Pareidolia- vivid illusion without any effort by
the patient.

25. o Derealization: Feelings the outer environment feels
unreal and detached from environment
o Depersonalization: Sensation of unreality concerning
oneself or parts of oneself (detached from self)
o Distinction b/w illusion and Functional hallucination-
Although both occur in response to an environmental
stimulus but in a functional hallucination both the
stimulus and the hallucination are perceived by the
patient simultaneously and can be identified as
separate and not as a transformation of the stimulus,
this contrast with the illusion in which the stimulus
from the environment changes but forms an essential
and integral part of the new perception.

26.  COGNITION:-
Sensorium: State of functioning of special senses
alertness : awareness of the environment, attention span,
clouding of consciousness, fluctuation in level of awareness,
somnolence, stupor, lethargy, fugue state, coma
orientation:
time: day or approximate day and time, time spent in
hospital
place: where he or she is ?
person: name of the person with whom patient is in
contact
Disorders:- disorientation for time and place signifies organic
brain disorders like dementia, delirium, acute
confusional state, partial seizure, brain tumors and
intoxication
disorientation for personal identity is rare and is
associated with psychogenic or post-ictal fugue states,
other dissociative disorders and agnosia.It may occur in panic
attacks, PTSD and acute Psychotic state

27. concentration and calculations:
digit repetition test: repeat digit at a rate of one per
second, like
3-7 ; 7-4-9 ; 8-5-2-7 ; 2-9-6-8-3 ; 5-7-2-9-4-6
a patient of av. Intelligence can repeat 5 to 7 digits
without difficulty
serial subtractions like 100-7=?-7=?-7=?-7=?-7=?-7
tasks like 5 multiplied by 4=?
whether anxiety or some disturbance of mood or
concentration seems to be responsible for difficulty

28.  Memory: It is a process whereby what is experienced or
learned is established as a record in C.N.S.(registration);
where it persist with a variable degree of Performance
(repetition) and can be recollected or retrieved from storage
at will(recall).
Impairment
Effort made to cope with impairment i.e confabulation,
denial, catastrophic reaction, circumstantialities used to
conceal deficit
 Whether registration, retention or recollection is impaired
 Types :-
1. Immediate retention and recall: ability to repeat six
figures after examiner dictate them- first forward
then backward then after a few minutes’ interruption

29. 2.Recent past memory: past few months
3. Recent memory: past few days or breakfast, lunch
or dinner
4. Remote memory: childhood datas, important events
known to have occurred when patient was younger or
free of illness, personal matters, neutral materials
5. Working memory : Immediate + recent memory

30. Fund of knowledge
• level of formal education
• counting and calculations
• general knowledge; questions should have relevance
to the patient’s educational and cultural background.
• Intellectual capacity

31.  Abstract thinking
• Manner in which patient conceptualizes or handles his/
her ideas.
 To test we may ask
1. Similarities and differences b/w similar looking
objects (e.g., between apple and pears)
2.meaning of simple proverbs(e.g., where there is a will,
there is a way)
Answer may be concrete( giving specific examples to
illustrate the meaning) or overtly abstract(giving
generalized explanation); appropriate

32.  Insight : Degree of awareness and understanding
the patient has that he/she is ill
Grades :-.
1. complete denial of illness
2. slight awareness of being ill but denying it at the
same time
3. awareness of being sick but blaming it on others,
external factors, or medical or unknown organic
factors
4. Awareness that illness is due to something unknown
in the patient
5. Intellectual insight : admission of illness and
recognition that symptoms or failure in social
adjustment are due to irrational feelings or
disturbances, without applying that knowledge
to future experiences.

33. 6.True emotional insight : emotional awareness of
motives and feeling within and of the underlying
symptoms; whether the awareness leads to changes
in personality and future behavior; openness to new
ideas and concept about self and important people
in patient’s life.

34.  Judgment
 Social judgment: subtle manifestations of behavior
that are harmful to the patients and contrary to acce-
- ptable behavior in the culture; whether the patient the
likely outcome of personal behavior and is influenced
by that understanding
 Test judgment: the patient's prediction of what he or
she would do in imaginary situations; for instance,
what patient would do with a stamped, own or neigh-
-bour’s house on fire, addressed letter found on street .
 Personal Judgment: Ability for sufficiently realistic
future plan in the context of education, job or life situation
 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 concern for the person’s safety or the safety of others

35.  Bibliography
1.C.T.P.
2.Synopsis of Psychiatry
3.Fish’s clinical psychopathology

36. THANK YOU