Mental status examination (examination ).pptx

Mental status examination
Dr Maja Đurović

Mental status - definition
 The mental status examination (MSE) is the psychiatric equivalent of the physical
examination in the rest of medicine.
 The mental status examination is the part of the clinical assessment that describes
the sum total of the examiner's observations and impressions of the psychiatric
patient at the time of the interview.
 Whereas the patient's history remains stable, the patient's mental status can
change from day to day or hour to hour.
 The mental status examination is the description of the patient's appearance,
speech, actions, and thoughts during the interview.

Mental status - definition
 Even when a patient is mute, incoherent, or refuses to answer questions, the
clinician can obtain a wealth of information through careful observation.
 The MSE gives the clinician a snapshot of the patient's mental status at the time of
the interview and is useful for subsequent visits to compare and monitor changes
over time
 Most of the informations does not require direct questioning, and the information
gathered from observation may give the clinician a different dataset than patient
responses
 Direct questioning augments and rounds out the MSE

Outline for the Mental Status Examination:
1. Appearance
2. Overt behavior
3. Attitude
4. Speech
5. Mood and affect
6. Thinking (Form and Content)
7. Perceptions
8. Sensorium
a)Alertness
b)Orientation (person, place, time)
c)Concentration
d)Memory (immediate, recent, long term)
e)Calculations
f) Fund of knowledge
g)Abstract reasoning
9. Insight
10. Judgment

Appearance
 In this category, the psychiatrist describes the patient's appearance and overall
physical impression, as reflected by posture, poise, clothing, and grooming, hair,
and nails.
 Items to be noted include what the patient is wearing, including body jewelry, and
whether it is appropriate for the context.
 Signs of anxiety are noted: moist hands, perspiring forehead, tense posture, wide
eyes.
 Common terms used to describe appearance are healthy, sickly, poised, old
looking, young looking, disheveled, childlike, and bizarre.

Appearance
 Does the patient appear to be his or her stated age, younger or older?
 A physical appearance older than the patient’s stated age may suggest depression
or long-term substance abuse.
 A more youthful appearance may be restored as the patient recovers.

Appearance
 Patients with schizophrenia, for example, may sometimes appear poorly groomed
or even dirty.
 Patients with major depression can be negligent about their dress and grooming,
withdrawal and stooped posture
 Patients with mania may wear odd or unusual clothing, incongruously inbrightly
coloured

Appearance
 Sunglasses worn indoors may suggest paranoia.
 A puffy face and red palms are suggestive, but not diagnostic, of alcohol
abuse/dependence.
 We can register pinpoint pupils in narcotic addiction.
 Self-neglect suggests alcoholism, drug addiction, dementia, or schizophrenia

Attitude Toward Examiner
 The patient's attitude toward the examiner can be described as:
1. cooperative, 10. apathetic,
2. friendly, 11. hostile,
3. attentive, 12. ingratiating,
4. interested, 13. evasive.
5. frank,
6. seductive,
7. defensive,
8. contemptuous,
9. perplexed,

 Patients who are paranoid are often suspicious, guarded, or hostile.
 Patients with somatization disorder sometimes try to flatter interviewers by
comparing them favorably with previous doctors; they are often dramatic, friendly
— sometimes seductive.
 During manic episodes, patients may crack jokes and occasionally are quite funny
— when they are not irritable or obnoxious.
 Sociopathic patients may seem like con men — and sometimes are.

 The description of a patient's behavior includes a general statement about whether
he or she is exhibiting acute distress and then a more specific statement about the
patient's approach to the interview.
 Appropriateness is an important factor to consider in the interpretation of the
observation. If a patient is brought involuntarily for examination, it may be
appropriate, certainly understandable, that he or she is somewhat uncooperative,
especially at the beginning of the interview.

Speech Characteristics
 This part of the report describes the physical characteristics of speech.
 Speech can be described in terms of its quantity, rate of production, and quality.
 Elements considered include:
1. fluency,
2. amount,
3. rate,
4. tone,
5. volume.

 Fluency can refer to whether the patient has full command of the English language as
well as potentially more subtle fluency issues such as stuttering, word finding
difficulties, or para phasic errors. (A Spanish-speaking patient with an interpreter would
be considered not fluent in English, but an attempt should be made to establish
whether he or she is fluent in Spanish.)
 The evaluation of the amount of speech refers to whether it is normal, increased, or
decreased.
 Decreased amounts of speech may suggest several different things ranging from
anxiety or disinterest to thought blocking or psychosis.
 Increased amounts of speech often (but not always) are suggestive of mania or
hypomania. A related element is the speed or rate of speech. Is it slowed or rapid
(pressured)?
 Finally, speech can be evaluated for its tone and volume. Descriptive terms for these
elements include irritable, anxious, dysphoric, loud, quiet, timid, angry, or childlike.
Depressive patient talks slow, manic patients talks rapidly.

 The patient may be described as talkative, garrulous, voluble, taciturn,
unspontaneous, or normally responsive to cues from the interviewer.
 Speech can be rapid or slow, pressured, hesitant, emotional, dramatic,
monotonous, loud, whispered, slurred, staccato, or mumbled. Speech impairments,
such as stuttering, are included in this section.
 Any unusual rhythms (termed dysprosody) or accent should be noted.
 The patient's speech may be spontaneous.

Overt Behavior and Psychomotor Activity
 Here is described both the quantitative and qualitative aspects of the patient's motor
behavior.
 Motor activity may be described as normal, slowed (bradykinesia), or agitated
(hyperkinesia). This can give clues to diagnoses (e.g., depression vs. mania) as well as
confounding neurological or medical issues.
 Included are mannerisms, tics, gestures, twitches, stereotyped behavior, echopraxia,
hyperactivity, agitation, combativeness, flexibility, rigidity, gait, and agility.
 Describe restlessness, wringing of hands, pacing, and other physical manifestations.
 Note psychomotor retardation or generalized slowing of body movements.
 Describe any aimless, purposeless activity.

 Neuroleptic medications may produce a restlessness called ‘‘akathisia,’’ in which the
patient cannot sit still and feels compelled to walk.
 Neuroleptics also may produce Parkinson-type symptoms, including tremor and an
expressionless face.
 Neuroleptics are given so commonly that it is often impossible to determine
whether abnormal movements are drug induced or are catatonic symptoms.
 Pacing and handwringing may be expressions of depression and psychomotor
retardation too.
 Joviality and volubility may portray mania. Patients are overactive, restless and
moving rapidly with stimulant (cocaine) abuse and in mania.

 Schizophrenia also may involve psychomotor disturbances such as mannerisms,
posturing, stereotypical movements, and negativism (doing the opposite of what is
requested).
 Also seen is echopraxia, in which movements of another person are imitated
 In catalepsy awkward positions are maintained for long periods without apparent
discomfort.
 Some patients say nothing. Called ‘‘mutism’’ this behavior may be seen in schizophrenia,
depression, delirium/dementia, and drug intoxication.
 Tremors we can see with anxiety or as medication side effect (lithium).
 Eye contact is normally made during the interview. Minimal eye contact is common in
schizophrenia.
 Scanning of environment we can often see in paranoid states.

Mood and Affect
 Mood is defined as a pervasive and sustained emotion that colors the person's
perception of the world.
 Mood refers to what the patient says about his internal emotional state:
‘‘I am sad,’’ ‘‘I am happy,’’ and ‘‘I am angry’’…
 Statements about the patient's mood should include depth, intensity, duration, and
fluctuations.
 Common adjectives used to describe mood include depressed, despairing, irritable,
anxious, angry, expansive, euphoric, empty, guilty, hopeless, futile, frightened, and
perplexed.
 Mood can be labile fluctuating or alternating rapidly between extremes (e.g.,
laughing loudly and expansively one moment, tearful and despairing the next).

Mood and Affect
 Affect can be defined as the patient's present emotional responsiveness, inferred
from the patient's facial expression, including the amount and the range of expressive
behavior.
 Affect is often described with the following elements:
1. quality,
2. quantity,
3. range,
4. appropriateness and
5. congruence.

Mood and Affect
 Terms used to describe the quality (or tone) of a patient's affect include dysphoric,
happy, euthymic, irritable, angry, agitated, tearful, sobbing, and flat.
 Quantity of affect is a measure of its intensity.
 Affect can be described as within normal range, constricted, blunted, or flat.
 In the normal range of affect can be variation in facial expression, tone of voice,
use of hands, and body movements.

Mood and Affect
 Affect may or may not be congruent with mood (for example, if a person smiles
happily while telling of people trying to poison her, the affect would be described
as inappropriate)
 When affect is constricted, the range and intensity of expression are reduced.
 Sometimes patients with hysteria have an inappropriate affect in that they describe
excruciating pain and other extreme distress with the same indifference or good
cheer with which they would describe a morning of shopping. (The French call this
la belle indiffe ´rence.)

Mood and Affect
 Affect is sometimes referred to as ‘‘flat,’’ meaning that the usual fine modulation in
facial expression is absent. Patients with schizophrenia sometimes have a flat affect,
but so do patients taking neuroleptic medications, and depressed patients may
show little change of expression while speaking.
 ‘‘Flat affect’’ is probably the most overused and misused term in the psychiatric
examination. It should only be used if the affect is extremely ‘‘flat’’ or ‘‘blunted.’’
Inappropriate and flat affects are especially associated with schizophrenia. To
diagnose flat affect, virtually no signs of affective expression should be present; the
patient's voice should be monotonous and the face should be immobile.
Appropriateness of affect refers to how the affect correlates to the setting.

Mood and Affect
 A patient who is laughing at a solemn moment of a funeral service is described as
having inappropriate affect.
 Delusional patients who are describing a delusion of persecution should be angry
or frightened about the experiences they believe are happening to them.
 Anger or fear in this context is an appropriate expression.
 Psychiatrists use the term inappropriate affect for a quality of response found in
some schizophrenia patients, in which the patient's affect is incongruent with what
the patient is saying (e.g., flattened affect when speaking about murderous
impulses).

Perception
 Perceptual disturbances, such as hallucinations, illusions, depersonalization and
derealization can be experienced in reference to the self or the environment.
 Hallucinations are perceptions in the absence of stimuli to account for them.
 Auditory hallucinations are the hallucinations most frequently encountered in the
psychiatric setting.
 Other hallucinations can include visual, tactile, olfactory, and gustatory

Perception
 In the North American culture, nonauditory hallucinations are often clues that there
is a neurological, medical, or substance withdrawal issue rather than a primary
psychiatric issue.
 In other cultures, visual hallucinations have been reported to be the most common
form of hallucinations in schizophrenia.
 Olfactory hallutionations are common in temporal lobe epilepsy.

Perception
 The interviewer should make a distinction between a true hallucination and a
misperception of stimuli (illusion). Hearing the wind rustle through the trees
outside one's bedroom and thinking a name is being called is an illusion
 The circumstances of the occurrence of any hallucinatory experience are important;
hypnagogic hallucinations (occurring as a person falls asleep) and hypnopompic
hallucinations (occurring as a person awakens) have much less serious significance
than other types of hallucinations and may be normal phenomena. At times
patients without psychosis may hear their name called or see flashes or shadows
out of the corners of their eyes.

Perception
 Hallucinations can also occur in particular times of stress for individual patients.
 Formication, the feeling of bugs crawling on or under the skin, is seen in cocainism,
and also in delirium tremens.
 Depersonalization is a feeling that one is not oneself or that something has
changed.
 Derealization is a feeling that one's environment has changed in some strange way
that is difficult to describe.

Perception
 Examples of questions used to elicit the experience of hallucinations include the
following:
• Have you ever heard voices or other sounds that no one else could hear or when
no one else was around?
• Have you experienced any strange sensations in your body that others do not
seem to see?

Thought Content and Mental Trends
 Тhought can be divided into:
1. thought process (or form) and
2. thought content.
 Thought process refers to the way in which a person puts together ideas and
associations, the form in which a person thinks.
 Process or form of thought can be logical and coherent or completely illogical and even
incomprehensible.
 Thought content is essentially what thoughts are occurring to the patient. This is
inferred by what the patient spontaneously expresses, as well as responses to specific
questions aimed at eliciting particular pathology.
 Some patients may perseverate or ruminate on specific content or thoughts. They may
focus on material that is considered obsessive or compulsive.

Thought Process (Form of Thinking)
 Thought process differs from thought content in that it does not describe what the
person is thinking but rather how the thoughts are formulated, organized, and
expressed.
 A patient can have normal thought process with significantly delusional thought
content.
 Conversely, there may be generally normal thought content but significantly impaired
thought process. Normal thought process is typically described as linear, organized, and
goal directed.
 The patient may have either an overabundance or a poverty of ideas.
 There may be rapid thinking, which, if carried to the extreme, is called a flight of ideas.
 A patient may exhibit slow or hesitant thinking.

 Formal Thought Disorders
Circumstantiality - Overinclusion of trivial or irrelevant details that impede the
sense of to the point. Circumstantiality indicates the loss of capacity for goal
-directed thinking; in the process of explaining an idea, the patient brings in
many irrelevant details and parenthetical comments but eventually does get
back to the original point.
Older people may be circumstantial. They return to the subject but only after
providing excessive detail.

Patients with somatization disorder or borderline personality disorder can be
almost maddenly circumstantiall (providing excessive detail of little clinical
importance) while at the same time being quite vague (lacking
specific information being sought);
When severe, this ‘‘nonpsychotic thought disorder’’ pattern can be mistaken
for the tangentiality of formal thought disorder observed in patients with psychosis.

Clang associations - Thoughts are associated by the sound of words rather
than by their meaning (e.g., through rhyming or assonance).
Derailment (Synonymous with loose associations) - A breakdown in both the
logical connection ideas and the overall sense of goal-directedness.
The words make sentences, but the sentences do not make sense.
This disturbance point to schizophrenia.

Flight of ideas - A succession of multiple associations so that thoughts seem
to move abruptly from idea to idea, but all ideas are logically connected.
Flight of ideas are often (but not invariably) expressed through rapid,
speech.
Pressure of speech and flight of ideas are seen in mania and in drug intoxication.
The patient with pressured speech seems to be compelled to talk.
Loose thoughts or associations differ from circumstantial and tangential thoughts in
that with loose thoughts it is difficult or impossible to see the connections between the
sequential content.

Neologism - The invention of new words or phrases or condensed combination of
several words that is not a true word and is not readily understandable, although
sometimes the intended meaning or partial meaning may be apparent.
Word salad is speech characterized by confused, and often repetitious,
language with no apparent meaning or relationship attached to it
Perseveration - Repetition of out of context of words, phrases, or ideas.
The perseverative patient will repeatedly come back to the same topic despite the
interviewer's attempts to change the subject.

Tangentiality - a disturbance in which the patient loses the thread of the
conversation, pursues divergent thoughts stimulated by various external or internal
irrelevant stimuli, and never returns to the original point.
As response to a question, the patient gives a reply that is appropriate to the
general topic without actually answering the question.
Patients with schizophrenia are often tangential.

Example: Doctor: “Have you had any trouble sleeping lately?” Patient: “I
usually sleep in my bed, but now I'm sleeping on the sofa.”
Typically the examiner can follow a circumstantial train of thought, seeing
connections between the sequential statements.
Tangential thought process may at first appear similar, but the patient
never returns to the original point or question.

Thought blocking - A sudden disruption of thought or a break in the flow of
ideas.
Тhe patient may indicate an inability to recall what was being said or intended to be said.
Thought blocking refers to a disordered thought process in which the patient appears to
be unable to complete a thought.
The patient may stop midsentence or midthought and leave the interviewer waiting for
the completion.
When asked about this, patients will often remark that they don't know what happened
and may not remember what was being discussed.

Thought Content
 Disturbances in content of thought include:
1. delusions,
2. preoccupations (which may involve the patient's illness),
3. obsessions
4. compulsions
5. phobias, plans, intentions, recurrent ideas about suicide or homicide

Thought Content
 Obsessional thoughts are unwelcome and repetitive thoughts that intrude into the
patient's consciousness.
They are generally ego alien and resisted by the patient
 Compulsions are repetitive, ritualized behaviors that patients feel compelled to perform
to avoid an increase in anxiety or some dreaded outcome.
 What can we ask the patient:
“Do you have ideas that are intrusive and repetitive?”
“Are there things you do over and over, in a repetitive manner?”
“Are there things you must do in a particular way or order?”
“If you do not do them that way, must you repeat them?”
“Do you know why you do things that way?”),

Thought Content
 Delusions - a major category of disturbances of thought content.
 Delusions are fixed, false beliefs out of keeping with the patient's cultural
background (delusions are not shared by others)
 Delusions may be mood congruent ( thoughts that are in keeping with a depressed
or elated mood, e.g., a depressed patient thinks he is dying or an elated patient
thinks she is the Virgin Mary) or mood incongruent (e.g., an elated patient thinks
he has a brain tumor).
 Delusions can be bizarre and may involve beliefs about external control.
 Non bizarre delusions refer to thought content that is not true but is not out of the
realm of possibility

Thought Content
 Common delusions include grandiose, erotomanic, jealous, somatic, guilty, nihilistic
and persecutory.
 Examples of ideas of reference include a person's belief that the television or radio
is speaking to or about him or her.
 Examples of ideas of influence are beliefs about another person or force controlling
some aspect of one's behavior.

Thought Content
 Questions that can be helpful with delusions include:
• "Do you ever feel like someone is following you or out to get you?"
• "Do you feel like the TV or radio has a special message for you?“
• “ Do you feel people want to harm you?”
• “Do you have special powers?”
• “Is anyone trying to influence you?”
• “Are there thoughts that you can't get out of your mind?”
• “ Can people read your mind?”

Thought Content
 An affirmative answer to the latter question indicates an "idea of reference."
 Paranoia can be closely related to delusional material and can range from "soft"
paranoia, such as general suspiciousness, to more severe forms that impact daily
functioning.
 Questions that elicit paranoia can include asking about the patient worrying about
cameras, microphones, or the government.

Thought Content
 Suicidality and homicidality fall under the category of thought content.
 Simply asking if someone is suicidal or homicidal is not adequate. One must get a
sense of ideation, intent, plan, and preparation.
 Although completed suicide is extremely difficult to accurately predict, there are
identified risk factors, and these can be used in conjunction with an evaluation of
the patient's intent and plan for acting on thoughts of suicide

Sensorium and Cognition
 The sensorium and cognition portion of the mental status examination seeks to assess
brain function, including:
1. alertness,
2. orientation,
3. concentration,
4. memory (both short and long term),
5. calculation,
6. fund of knowledge,
7. abstract reasoning,
8. insight and
9. judgment.

Consciousness
 Disturbances of consciousness usually indicate organic brain impairment. Clouding
of consciousness is an overall reduced awareness of the environment. A patient
may be unable to sustain attention to environmental stimuli or to maintain goal-
directed thinking or behavior.
 Clouding or obtunding of consciousness is frequently not a fixed mental state. A
patient typically exhibits fluctuations in the level of awareness of the surrounding
environment.
 The patient who has an altered state of consciousness often shows some
impairment of orientation as well, although the reverse is not necessarily true.
 Some terms used to describe the patient's level of consciousness are clouding,
somnolence, stupor, coma, lethargy, or alert.

Orientation and Memory
 Disorders of orientation are traditionally separated according to time, place, and
person. Any impairment usually appears in this order (i.e., sense of time is impaired
before sense of place); similarly, as the patient improves, the impairment clears in
the reverse order.
 The psychiatrist must determine whether a patient can give the approximate date
and time of day. In addition, if hospitalized, does the patient know how long he or
she has been there? Does the patient seem to be oriented to the present?
 In questions about orientation to place, patients should be able to state the name
and the location of the hospital correctly and to behave as though they know where
they are.
 In assessing orientation for person, the psychiatrist asks patients whether they know
the names of the people around them and whether they understand their roles in
relationship to them. Do they know who the examiner is? Only in the most severe
instances do patients not know who they themselves are.

Memory
 Memory functions have traditionally been divided into four areas:
1. remote memory,
2. recent past memory,
3. recent memory and
4. immediate retention and recall.
 Recent memory can be checked by asking patients about their appetite and then
about what they had for breakfast or for dinner the previous evening. Patients can
be asked at this point if they recall the interviewer's name.
 Asking patients to repeat six digits forward and then backward is a test of
immediate retention.

Memory
 Remote memory can be tested by asking patients for information about their
childhood that can be verified later.
 Asking patients to recall important news events from the past few months checks
recent past memory.
 Often in cognitive disorders, recent or short-term memory is impaired first, and
remote or long-term memory is impaired later.
 If there is impairment, what efforts are made to cope with it or to conceal it? Is
denial, confabulation, or circumstantiality used to conceal a deficit?

Memory
 Reactions to the loss of memory can give important clues to underlying disorders
and coping mechanisms. For instance, a patient who appears to have memory
impairment but, in fact, is depressed is more likely to be concerned about memory
loss than is someone with memory loss secondary to dementia.
 The clinician must also determine whether a catastrophic reaction is present
(anxious crying when unable to remember). Confabulation (unconsciously making
up false answers when memory is impaired) is most closely associated with
cognitive disorders

Concentration and Attention
 A patient's concentration can be impaired for many reasons: a cognitive disorder,
anxiety, depression and internal stimuli, such as auditory hallucinations.
 Subtracting serial 7s from 100 is a simple task that requires intact concentration
and cognitive capacities. Could the patient subtract 7 from 100 and keep
subtracting 7s? If the patient could not subtract 7s, could 3s be subtracted? Were
easier tasks accomplished: 4 × 9, 5 × 4?
 The examiner must always assess whether anxiety, some disturbance of mood or
consciousness, or a learning deficit (dyscalculia) is responsible for the difficulty.
 Attention is assessed by calculations or by asking the patient to spell the word
world (or others) backward. The patient can also be asked to name five things that
start with a particular letter.

Reading and Writing
 The psychiatrist should ask the patient to read a sentence.
 Patient should also be asked to write a simple but complete sentence.

Visuospatial Ability
 The patient should be asked to copy a figure, such as a clock face or interlocking
pentagons

Abstract Thought
 Abstract thinking is the ability to deal with concepts.
 Patients can have disturbances in the manner in which they conceptualize or
handle ideas.
 Can the patient explain similarities, such as those between an apple and a pear or
between truth and beauty? Are the meanings of simple proverbs, such as “A rolling
stone gathers no moss,” understood?
 Answers can be concrete (giving specific examples to illustrate the meaning) or
overly abstract (giving too generalized an explanation).
 In a catastrophic reaction, brain-damaged patients become extremely emotional
and cannot think abstractly.

Information and Intelligence
 The patient's intelligence is related to vocabulary and general fund of knowledge
(e.g., the distance from New York to Paris, presidents of the United States).
 The patient's educational level (both formal and self-education) and socioeconomic
status must be taken into account.
 Handling difficult or sophisticated concepts can reflect intelligence, even in the
absence of formal education or an extensive fund of information.
 If a possible cognitive impairment is suspected, does the patient have trouble with
mental tasks, such as counting the change from 10 KM after a purchase of 6.37
KM?

Impulsivity
 An assessment of impulse control is critical in ascertaining the patient's awareness
of socially appropriate behavior and is a measure of the patient's potential danger
to self and others.
 Patients may be unable to control impulses secondary to cognitive and psychotic
disorders or because of chronic characterological defects, as observed in the
personality disorders.
 Impulse control can be estimated from information in the patient's recent history
and from behavior observed during the interview.

Questions Used to Test
Cognitive Functions in the
Sensorium Section of the
Mental Status Examination

Cognitive Functions
Alertness  Observation

Cognitive Functions
 Orientation  What is your name?
 Who am I?
 What place is this?
 Where is it located?
 What city are we in?

Cognitive Functions
 Concentration  Starting at 100, count backward by 7
(or 3).
 Say the letters of the alphabet
backward starting with Z.
 Name the months of the year
backward starting with December

Cognitive Functions
 Immediate memory
 Recent memory
 Long term memory
 Repeat these numbers after me: 1, 4, 9,
2, 5.
 What did you have for breakfast? What
were you doing before we started
talking this morning? I want you to
remember these three things: a yellow
pencil, a cocker spaniel, and Cincinnati.
After a few minutes I'll ask you to
repeat them
 What was your address when you were
in the third grade? Who was your
teacher? What did you do during the
summer between high school and
college?

Cognitive Functions
 Calculations  If you buy something that costs $3.75
and you pay with a $5 bill, how much
change should you et?
What is the cost of three
organges if a dozen oranges cost
$4.00?

Cognitive Functions
 Fund of knowledge  What is the distance between New
York and Los Angeles?
 What body of water lies between
South America and Africa?

Cognitive Functions
 Abstract reasoning  Which one does not belong in this
group: a pair of scissors, a canary,
and a spider? Why?
 How are an apple and an orange
alike?

Judgment and Insight
 Judgment - During the course of history taking, the psychiatrist should be able to
assess many aspects of the patient's capability for social judgment.
 Does the patient understand the likely outcome of his or her behavior, and is he
or she influenced by this understanding?
 Can the patient predict what he or she would do in imaginary situations (e.g.,
smelling smoke in a crowded movie theater)?

Insight
 Insight is a patient's degree of awareness and understanding about being ill.
 A summary of six levels of insight follows:
1. Complete denial of illness
2. Slight awareness of being sick and needing help, but denying it at the same time
3. Awareness of being sick but blaming it on others, on external factors, or on organic
factors
4. Awareness that illness is caused by something unknown in the patient
5. Intellectual insight: admission that the patient is ill and that symptoms or failures in social
adjustment are caused by the patient's own particular irrational feelings or disturbances
without applying this knowledge to future experiences
6. True emotional insight: emotional awareness of the motives and feelings within
the patient and the important persons in his or her life, which can lead to
basic changes in behavior.

Common Questions for Psycihatric History and Mental Status
Topic Questions Comments and Clinical Hints
General
appearance
Introduce yourself and direct patient to take a seat. In the
hospital, bring your chair to bedside; do not sit on the
bed.
Unkempt and disheveled in cognitive disorder, pinpoint pupils in
narcotic addiction, withdrawal and stooped posture in depression.
Motoric behavior
Have you been more active than usual? Less active? You
may ask about obvious mannerisms, such as, "I notice
that your hand still shakes, can you tell me about that?"
Stay aware of smells, such as alcohol ism/ketoacidosis.
Fixed posturing, odd behavior in schizophrenia.
Hyperactive with stimulant (cocaine) abuse and
in mania. Psychomotor retardation in depression;
tremors with anxiety or medication side effect
(lithium). Eye contact is normally made during the
interview. Minimal eye contact in schizophrenia.
Scanning of environment in paranoid states.
Attitude during
interview
You may comment about attitude: "You seem irritated
about something; is that an accurate observation?"
Suspiciousness in paranoia; seductive in hysteria;
apathetic in conversion disorder (/a belle
indifference); punning (witzelsucht) in frontal lobe
syndromes.
Mood
How do you feel? How are your spirits? Do you have
thoughts that life is not worth living or that you want to
harm yourself? Do you have plans to take your own life?
Do you want to die? Has there been a change in your
sleep habits?
Suicidal ideas in 25 percent of depressives; elation
in mania. Early morning awakening in depression;
decreased need for sleep in mania.

Common Questions for Psychiatric History and Mental Status
Affect
Observe nonverbal signs of emotion, body
movements, facies, rhythm of voice (prosody).
Laughing when talking about sad subjects, such as
death, is inappropriate.
Changes in affect usual with schizophrenia: loss of
prosody in cognitive disorder, catatonia. Do not
confuse medication adverse effect with flat affect.
Speech
Ask patient to say "Methodist Episcopalian" to test
for dysarthria.
Manic patients show pressured speech; paucity of
speech in depression; uneven or slurred speech in
cognitive disorders.
Perceptual
disorders
Do you ever see things or hear voices? Do you
have
strange experiences as you fall asleep or upon
awakening? Has the world changed in any way?
Do you have strange smells?
Visual hallucinations suggest schizophrenia. Tactile
hallucinations suggest cocainism, delirium tremens
(DTs). Olfactory hallucinations common in temporal
lobe epilepsy.
Thought content
Do you feel people want to harm you? Do you
have special powers? Is anyone trying to influence
you? Do you have strange body sensations? Are
there thoughts that you can't get out of your
mind? Do you think about the end of the world?
Can people read your mind? Do you ever feel the
TV is talking to you? Ask about fantasies and
dreams.
Are delusions congruent with mood (grandiose
delusions with elated mood) or incongruent? Mood
incongruent delusions point to schizophrenia.
Illusions are common in delirium. Thought insertion is
characteristic of schizophrenia.

Thought process
Ask meaning of proverbs to test abstraction, such as,
"People in glass houses should not throw stones.“
Concrete answer is, "Glass breaks." Abstract answers
deal with universal themes or moral issues. Ask
similarity between bird and butterfly (both alive), bread
and cake (both food).
Loose associations point to schizophrenia; flight of ideas
to mania; inability to abstract to schizophrenia, brain
damage.
Sensorium
What place is this? What is today's date? Do you
know who I am?
Delirium or dementia shows clouded or wandering
sensorium. Orientation to person remains intact
longer than orientation to time or place.
Remote memory
(long-term
memory)
Where were you born? Where did you go to school?
Date of marriage? Birthdays of children? What
were last week's newspaper headlines?
Patients with dementia of the Alzheimer's type retain
remote memory longer than recent memory. Gaps
in memory may be localized or filled in with
confabulatory details. Hypermnesia is seen in
paranoid personality.
Immediate memory
(very short-term
memory)
Ask patient to repeat six digits forward, then
backward (normal responses). Ask patient to try to
remember three nonrelated items; test patient after 5
minutes
Loss of memory occurs with cognitive, dissociative, or
conversion disorder. Anxiety can impair immediate
retention and recent memory. Anterograde memory
loss (amnesia) occurs after taking certain drugs, such
as benzodiazepines. Retrograde memory loss occurs
after head trauma.

Concentration and
calculation
Ask patient to count from 1 to 20 rapidly; do simple
calculations (2 x 4, 4 x 9); do serial 7 test (i.e., subtract
7 from 1 00 and keep subtracting 7). How many
nickels in $1 .35?
Rule out medical cause for any defects vs. anxiety or
depression (pseudodementia). Make tests congruent
with educational level of patient.
Information and
intelligence
Distance from New York City to Los Angeles. Name
some vegetables. What is the largest river in the
United States?
Check educational level to results. Rule out mental
retardation, borderline intellectual functioning.
Judgment
What is the thing to do if you find an envelope in the
street that is sealed, stamped, and addressed?
Impaired in brain disease, schizophrenia, borderline
intellectual functioning, intoxication.
Insight level
Do you think you have a problem? Do you need
treatment? What are your plans for the future?
Impaired in delirium, dementia, frontal lobe syndrome,
psychosis, borderline intellectual functioning.

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