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Mental Status Exam

Heidi Combs, MD

What it is it?

• The Mental Status Exam (MSE)
is the psychological equivalent
of a physical exam that
describes the mental state and
behaviors of the person being
seen. It includes both objective
observations of the clinician
and subjective descriptions
given by the patient.

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

• To properly assess the MSE
information about the patients
history is needed including
education, cultural and social

• It is important to ascertain what
is normal for the patient. For
example some people always
speak fast!

Components of the
Mental Status Exam
• Appearance
• Behavior
• Speech
• Mood
• Affect
• Thought process
• Thought content
• Cognition
• Insight/Judgment

Appearance: What do
you see?
• Build, posture, dress, grooming,

prominent physical

• Level of alertness: Somnolent,

• Emotional facial expression
• Attitude toward the examiner:

Cooperative, uncooperative



• Eye contact: ex. poor, good,

• Psychomotor activity: ex.
retardation or agitation i.e..
hand wringing

• Movements: tremor, abnormal
movements i.e.. sterotypies,


• Rate: increased/pressured,
decreased/monosyllabic, latency

• Rhythm: articulation, prosody,
dysarthria, monotone, slurred

• Volume: loud, soft, mute
• Content: fluent, loquacious, paucity,



• The prevalent emotional state
the patient tells you they feel

• Often placed in quotes since it
is what the patient tells you

• Examples “Fantastic, elated,
depressed, anxious, sad, angry,
irritable, good”


• The emotional state we observe
• Type: euthymic (normal mood),

dysphoric (depressed, irritable, angry),
euphoric (elevated, elated) anxious

• Range: full (normal) vs. restricted,
blunted or flat, labile

• Congruency: does it match the mood-
(mood congruent vs. mood incongruent)

• Stability: stable vs. labile

Thought Process

• Describes the rate of thoughts, how
they flow and are connected.

• Normal: tight, logical and linear,
coherent and goal directed

• Abnormal: associations are not
clear, organized, coherent. Examples
include circumstantial, tangential,
loose, flight of ideas, word salad,
clanging, thought blocking.

Thought Process:
• Circumstantial: provide

unnecessary detail but
eventually get to the point

• Tangential: Move from thought
to thought that relate in some
way but never get to the point

• Loose: Illogical shifting
between unrelated topics


• Flight of ideas: Quickly moving
from one idea to another- see
with mania

• Thought blocking: thoughts are

• Perseveration: Repetition of
words, phrases or ideas

• Word Salad: Randomly spoken

Thought Content

• Refers to the themes that
occupy the patients thoughts
and perceptual disturbances

• Examples include
preoccupations, illusions, ideas
of reference, hallucinations,
depersonalization, delusions

Thought Content:
• Preoccupations: Suicidal or

homicidal ideation (SI or HI),
perseverations, obsessions or

• Illusions: Misinterpretations of

• Ideas of Reference (IOR):
Misinterpretation of incidents and
events in the outside world having
direct personal reference to the

• Hallucinations: False sensory
perceptions. Can be auditory (AH),
visual (VH), tactile or olfactory

• Derealization: Feelings the outer
environment feels unreal

• Depersonalization: Sensation of
unreality concerning oneself or parts
of oneself

• Delusions: Fixed, false beliefs firmly held in
spite of contradictory evidence
• 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

• Somatic: patient has a physical defect
• Reference: unrelated events apply to them
• Persecutory: others are trying to cause harm


• Level of consciousness
• Attention and concentration:

the ability to focus, sustain and
appropriately shift mental

• Memory: immediate, short and
long term

• Abstraction: proverb


Folstein Mini-Mental
State Exam
• 30 item screening tool
• Useful for documenting serial

cognitive changes an cognitive

• Document not only the total
score but what items were
missed on the MMSE


• Insight: awareness of one’s own
illness and/or situation

• Judgment: the ability to
anticipate the consequences of
one’s behavior and make
decisions to safeguard your well
being and that of others

Sample initial MSE of a
patient with depression
and psychotic features
• Appearance: Disheveled,

somnolent, slouched down in
chair, uncooperative

• Behavior: psychomotor
retarded, poor eye contact

• Speech: moderate latency, soft,
slow with paucity of content

• Mood: ”really down“
• Affect: blunted, mood congruent

MSE continued

• Thought Process: linear and
goal directed with paucity of

• Thought Content: +SI, +AH,
+paranoia, -VH, -IOR, -HI

• Cognition: Alert, focused,
MMSE:24- missed recall of 2
objects, 2 orientation questions,
2 on serial sevens

• Insight: fair
• Judgment: poor


• By the end of a standard psychiatric
interview most of the information for
the MSE has been gathered.

• The MSE provides information for
diagnosis and assessment of
disorder and response to treatment
over time.

• Remember to include both what your
hear and what you see!

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