psychiatry case presentation, mental status examination,

1. MENTAL STATUS
EXAMINATION
Psy. Vijay Lal vijayan
Consultant Clinical Psychologist
Dept. of Psychiatry
Pushpagiri Medical College

2. Contents
• Introduction
• General appearance and behavior
• Psychomotor activity
• Speech
• Thought
• Mood
• Perception
• Cognitive functions
• Conclusion

3. Introduction
• It is a tool that covers how the patient is feeling and thinking at the
moment as he or she responds to the specific questions asked by the
examiner.
• It is functionally equivalent to physical examination in other areas of
medicine.
• It is a systematic collection of the observations and reported mental
experiences that gives a picture of the patients current mental status.

4. General appearance and behavior:
• Give a good observational description.
• General appearance and grooming: Kempt/ un kempt, body build,
hygiene
• Awareness of surroundings: In touch with or with out surroundings,
• Co- operative/not
• Rapport – could be established/very easily established and
overfamiliar/difficult to establish – guarded/hostile
• Eye to eye contact – maintained/fleeting/hyper
vigilance/avoids/downcast
• Any observed repetitive motor movements –
tics/mannerisms/stereotypies/motor perseveration/catatonic signs

5. Psychomotor activity
• Note if the Psychomotor activity is increased, decreased or normal
• Increase in goal directed activity/retardation
• Agitation
• Hand gestures while conversation
• Hyperactivity

6. Speech
• Spontaneous / only in response to questions
• Amount – little / excessive
• Tone (loudness) – high / low
• Tempo (rate or speed) – fast / slow
• Volume (amount) of speech. Estimate words per minute –
verbose/pressure of speech/decreased
• Reaction time – increased / decreased
• Prosody ( emotional intonations of speech) – maintained or not
• Relevant and coherent

7. Thought
• Form: (Organisation and expression of thought)
Presence of formal thought disorder
• Stream:(Flow and continuity of thought process)
Flight of ideas, retardation of thinking, circumstantially,
perseveration, thought blocking
• Possessions: Ownership of thought
Self :Obsessions and compulsions, imagery, impulses and phobias.
External Agency : thought alienation,withdrawal, insertion and
broadcasting.

8. Content of thought
• Delusions
• Overvalued ideas
• Depressive cognitions
• Worries and Preoccupations
• Suicidal ideas and death wishes.

9. Delusion
• Detailed description of the phenomenon.
• Single or multiple
• Bizzare/Non – Bizzare
• Fleeting or fixed
• Systematized or poorly systematized
• Mood congruent or not
• Acting out
• Type of delusion (Grandiose,persecutory, nihilistic etc.)

10. Mood
• Assess subjective report and objective evaluation
• Assess both longitudinal (mood) & cross sectional (affect)
• Quality of emotion – happiness / sadness
• Intensity of emotional expression – flat / blunt / normal
• Range of affective responses – full / restricted
• Mobility & reactivity – change of emotions in relation to the
environmental factors
• Diurnal variations
• Congruity in relation to the thought process
• Appropriateness in relation to the situations

11. Perception
Modalities - vision, hearing, smell, taste, pain and deep sensations vestibular
sensations and sense of presence.
• Detailed description of Hallucination
• Auditory h. – Verbal / non verbal
• Continuous / intermittent
• Single voice / multiple voices
• Familiar voice / unfamiliar voice
• First person / sec. Person / third person
• Pleasant / unpleasant
• If unpleasant – commanding / abusive / threatening
• Whether mood congruent

12. • Distinguish hallucinations from imagery and pseudo-hallucinations.
Other perceptual disturbances, include
• Illusions
• Heightened perception
• Dulled perception
• Depersonalization
• Derealization

13. Orientation
• TIME : Approximately what time of the day is it ?
Is it morning / evening / afternoon / night ?
What is the date & day is today ?
• PLACE: What place is this ?
• PERSON:Tested by asking identity of the pt.
Inquire about the identity of the patients relatives and
family members.

14. Attention and Concentration
1. Digit span test
5-7-3 4-1-7
5-3-8-7 6-1-5-8
1-6-4-9-5 2-9-7-6-3
3-4-1-7-9-6 6-1-5-8-3-9
7-2-5-9-4-8-3 4-7-1-5-3-8-6
2. Serial subtraction
3. Days or months forward to backward

15. Memory
a) Immediate : tested by digit span test
b) Recent :
1) Address Test.
2) Asking the patient to recall events in the last 24 hours
e.g., details of the time and amount in a meal, visitors to the hospital
from an inpatient. Responses given by the patient should be noted of
any cross-checked from reliable source.
c) Remote : Information on life events.

16. Intelligence
Includes : General information, comprehension, arithmetic and
vocabulary.
• General information: information relevant to the patients literacy age
or occupation may be asked
In literate a) Name of Prime Minister b) 5 river, cities or states c)
Capitals of countries d) Current events (major)
For illiterates: a) Seasons b) Crops of fruits growing particular seasons
c) Prices of food grains or food items d) Prices of land

17. Intelligence(cont..)
• Comprehension
1. What will you do when you feel cold?
2. What will you do if it rains when you start to work?
3. What will you do when you miss the bus when you are on a journey?
• Arithmetic

18. Abstraction
• Similarities
Orange - Banana (fruits)
Dog - Lion (animals)
• Differences
Stone - Potato (not edible - edible/hard-soft)
TV- Radio (audio-visual-audio)
• Proverbs
1) Slow and steady wins the race.
2) A barking dog never bites.

19. Judgement
• Personal : Inquiries about the patients future plans.
• Social : observing behaviour in social situations.
• Test :
1. Fire problem: If the house in which you are catches fire, what is
the first thing you will do?
2. Letter problem: If when you are walking on the roadside you see a
stamped and sealed envelope with an address on it which someone
had dropped, what will you do?

20. Insight
GRADE 1 Complete denial of illness.
GRADE 2 Slight Awareness of being ill but denying it at the same
time.
GRADE 3 Awareness of being sick but blaming it on others ,
external factors, or medical or unknown organic
factors.
GRADE 4 Awareness that illness is due to something unknown in
the patient.
GRADE 5 Intellectual insight : Admission of illness & recognition
that symptoms or failure in social adjustment are due
to irrational feelings/disturbances, without applying
that knowledge to future experiences.

21. Diagnostic Formulation
• Index patient, Mr/Ms/ Mrs X, Age, sex, married/single, education,
occupation, religion, hailing from rural or urban place belongs to socio-
economic(LSES, MSES, USES), nuclear or joint family presenting with chief
complaints of (complaints in chronological order), with past history of
(medical or psychiatric), family history, personal history, with premorbid
personality suggestive of,
• On MSE findings- only positive findings which are supported to final
diagnosis
• Eg… general appearance, unkempt, untidy, non co-operative, incesed
psychomotor activity, speech soft, relevant, coherent, decresed reaction
time and productivity, affect- cheerful at time inappropriate, present
delusion of infidelity and persecution, impaired social and personal
judgment, Insight- Grade I.
• Diagnosis:

22. Diagnostic Clusters under ICD-10
F00-09 Organic including symptomatic, mental dis
F10-19 Mental & Behavioral dis. Due to psychoactive
substance use
F20-29 Schizophrenia, schizotypal & delusional dis.
F30-39 Mood (Affective) disorders
F40-49 Neurotic-stress related & Somatoform dis.
F50-59 Behavioral syndromes associated with physiological
disturbances & physical factors
F60-69 Dis. of adult personality & behavior
F70-79 Mental retardation
F80-89 Disorders of psychological development
F90-98 Behavioral & emotional dis. with onset usually occurring in
childhood and adolescence

23. Conclusion
• MSE is a tool that provides a picture of the patients current mental
status which include evaluating different aspects including cognitive
functions.
• Performing a detailed MSE is significant in determining how we can
manage as well as monitoring treatment response of the patient .

24. References
1.Comprehensive casework schedule , Dept. of Psychiatry, Pushpagiri
Institute of Medical Sciences and Research Centre, Thiruvalla.
2. NIMHANS Pro-forma for Case Taking.
3.Kaplan & Sadock’s Comprehensive Textbook of Psychiatry 10th
Edition.

25. Thank You!