At a glance #
The examination begins when you meet the person and continues throughout the interview. Assess appearance and interaction, motor activity, speech, mood and affect, thought process and content, perception, cognition, insight and judgement. Setting, fatigue, pain, medication, intoxication, language, hearing, vision and rapport can change what you observe.
| Component | Main question |
|---|---|
| Psychiatric history | What has happened over time, and in what context? |
| Mental status examination | What is observed, reported and demonstrated during this encounter? |
| Physical examination | What physical findings contribute to understanding the presentation? |
| Cognitive screening | How does the person perform on a suitable standardized assessment? |
| Formulation | How can the available evidence be understood, and what remains uncertain? |
| Decision-making capacity assessment | Can the person make this particular decision under the applicable legal framework? |
Conducting and recording the examination #
Introduce your role, explain the purpose, and establish the preferred language and communication needs. Arrange an interpreter when needed. Begin with ordinary conversation, then use focused questions to clarify gaps.
- Separate what was observed, what the person reported, and what was tested.
- Write ‘not assessed’ or ‘assessment limited by…’ when information is unavailable. Silence or non-participation does not establish normality.
- Describe behaviour concretely. ‘Stood and paced repeatedly’ is more informative than an unexplained ‘agitated’ label.
- Use brief representative speech examples when thought or language abnormalities matter.
- Consider culture, disability, neurodivergence, education, literacy and the circumstances of the encounter.
Appearance, behaviour and rapport #
Observe grooming, clothing, posture, facial expression, visible injury or discomfort, and ability to attend to personal care. Describe clinically relevant changes without moral judgement. Compare with usual functioning where possible.
Assess spontaneous engagement, guardedness, distress, withdrawal, disinhibition, irritability and understanding of the interview. Rapport reflects the interaction between two people; it is not solely a patient characteristic.
Limited eye contact does not establish dishonesty. Clothing, makeup, body shape and a clinician’s aesthetic preferences cannot establish personality or diagnosis. Describe the observation rather than assigning an unsupported cause.
Psychomotor activity and abnormal movements #
Observe the amount, speed, initiation and pattern of movement. Slowing may involve delayed responses, reduced gestures and slow movement. Increased activity may involve pacing, fidgeting or difficulty remaining seated.
Distinguish observed movement from subjective experience. Akathisia involves an uncomfortable urge to move; visible restlessness alone is insufficient. Ask, ‘Do you feel an inner restlessness or a need to keep moving?’
- Describe tremor, tics, repetitive movements, stiffness, reduced facial movement, sustained postures and involuntary oral or limb movements.
- Establish onset, medication exposure, discomfort, suppressibility and functional effect.
- Catatonic phenomena may include reduced responsiveness or movement, mutism, sustained postures, negativism, echolalia, echopraxia, stereotyped activity and excitement.
- A non-speaking person may still hear and understand. Observations should prompt competent assessment rather than an automatic diagnosis.
Speech and language #
Describe spontaneity, quantity, response latency, rate, volume, articulation, prosody and interruptibility. Separate these from the organization of thought.
| Finding | Description | What to clarify |
|---|---|---|
| Pressured speech | Driven, excessive speech that is difficult to interrupt | Change from baseline; concurrent mood and activity |
| Poverty of speech | Little spontaneous speech or very brief replies | Language barriers, anxiety, fatigue, motor or cognitive difficulty |
| Poverty of content | Many words convey little substantive information | Examples of vagueness or repetitive empty phrases |
| Dysarthria | Impaired articulation of speech sounds | Neurological, medication or intoxication context |
| Aphasia | Impaired language production or comprehension | Naming, repetition and comprehension, rather than assuming thought disorder |
| Mutism | Absence of spoken response | Arousal, hearing, language, distress, motor phenomena and alternative communication |
Ask for a description of a familiar activity or recent event. If language impairment is suspected, examine comprehension, naming, repetition, reading and writing using suitable tasks. Do not assume intellectual impairment from unfamiliar or difficult-to-understand answers.
Mood and affect #
Ask, ‘How have you felt emotionally?’ and ‘How would you describe your mood today?’ Clarify duration, variability, triggers and change from usual. History establishes the longitudinal pattern; the MSE records the present state.
- Quality: anxious, sad, irritable, elevated or another observed quality.
- Range: breadth of emotional expression.
- Intensity: degree of expression.
- Reactivity: change in response to topics or events.
- Stability: relatively steady or rapidly changing expression.
- Congruence: relationship to reported mood and the content discussed.
| Term | Practical description |
|---|---|
| Restricted | A narrower variety of emotional expressions |
| Blunted | Markedly reduced expressive intensity |
| Flat | Little or no observable emotional expression |
| Labile | Rapid changes in emotional expression |
| Incongruent | Expression appears discordant with the reported mood or topic |
These terms describe observable expression, not proof that a person has no feelings. Culture, nervous laughter, trauma responses, medication and neurological conditions can affect expression.
Thought stream and form #
Thought process concerns how ideas develop and connect. Infer it from sufficient speech, taking account of language and attention. Document a short example before applying a technical label.
| Phenomenon | Defining feature |
|---|---|
| Circumstantiality | Excessive related detail; eventually reaches the answer |
| Tangentiality | Moves away from the question without reaching the answer |
| Derailment | Successive ideas have weak or unclear connections |
| Flight of ideas | Rapid shifts with traceable superficial connections, such as sound or external cues |
| Thought blocking | Abrupt interruption in the train of thought |
| Perseveration | Repeats an earlier response despite a changed question or task |
| Incoherence | Speech becomes difficult to understand because organization breaks down |
| Clang associations | Word choice follows sound rather than meaning |
Thought content: beliefs and intrusive experiences #
Explore concerns, preoccupations, guilt, hopelessness, fears, obsessional experiences, unusual beliefs and thoughts of harm. Start openly: ‘What has been occupying your mind most?’ Then clarify specific experiences without suggesting an answer.
| Concept | What to establish |
|---|---|
| Delusion | A firmly maintained belief in a pathological context, not adequately explained by cultural setting. Explore conviction, openness to alternatives, preoccupation, related experiences and consequences. |
| Overvalued idea | A dominant idea that differs from a delusion in conviction and its relationship to understandable concerns. Boundaries can be difficult to establish. |
| Obsession | A recurrent intrusive thought, image or urge. Distress, unwantedness, resistance and insight can vary. |
| Compulsion | A repetitive action or mental act performed in response to an obsession or rigid rules. It may be entirely internal. |
An unusual or apparently implausible belief is not automatically a delusion. Explore cultural meaning, context, evidence and the person’s experience. An intrusive thought’s content does not, on its own, establish the person’s intention.
Thought ownership, agency and thoughts of harm #
Clarify thought insertion, withdrawal, broadcasting and externally controlled actions in the person’s own words. ‘People can tell what I think from my face’ differs from experiencing thoughts as directly accessible to others. An unwanted thought still experienced as one’s own differs from a thought experienced as inserted by another agency.
Ask directly and compassionately about self-harm, wishes to die, suicidal thoughts, intentions, preparations, access to means, recent behaviour, harm to others and immediate support needs. Explore meaning and circumstances rather than assigning motives.
Perception and self-experience #
| Experience | Description | Synthetic example |
|---|---|---|
| Illusion | Misinterpretation of an actual stimulus | A coat in dim light is briefly perceived as a standing person |
| Hallucination | A sensory experience without an adequate corresponding stimulus | A distinct voice is heard when no corresponding speaker or sound source is present |
| Sensory distortion | Changed qualities of a real perception | An actual object appears unusually small or distorted |
| Intrusive image | A mental image distinguished from a current sensory event | A distressing picture is recognized as an image in the mind |
Explore modality, onset, frequency, duration, vividness, location, context, controllability, insight, distress and effects on behaviour. Experiences around sleep, bereavement, sensory impairment, substances and physical or neurological illness require context.
Location inside the head or preserved insight does not, alone, exclude a hallucination. Prefer a precise description to an unexplained ‘pseudohallucination’ label.
Depersonalisation concerns detachment or unreality about oneself. Derealisation concerns the surroundings. Clarify whether this is an ‘as if’ experience or a firmly held belief that reality has literally changed.
Consciousness, orientation and attention #
Describe alertness, drowsiness, responsiveness and fluctuation. Quiet withdrawal and slowing can occur in hypoactive delirium; agitation is not required. New acute changes in attention, cognition, perception or behaviour require prompt clinical assessment.
Ask respectfully about person, place, time and situation. Record exact errors rather than merely ‘disoriented’. Full orientation does not exclude delirium or other cognitive difficulties.
Poor performance can reflect hearing, comprehension, education, anxiety, fatigue or reduced arousal. Establish that the instructions were understood before interpreting the result.
Memory and higher cognition #
Separate registration, delayed recall, recent events and remote autobiographical memory. Confirm that information was heard and registered before interpreting later failure to recall it. Compare spontaneous recall with properly administered cues or recognition tasks when indicated.
Verify recent events with collateral information where appropriate. Inconsistent recall is not automatically deliberate deception. Explore language, executive function, abstraction, calculation, visuospatial skills and praxis when relevant.
Insight and judgement #
Explore understanding of difficulties, perceived causes, effects on life and preferences for help. Ask, ‘How do you understand what has been happening?’ and ‘What kind of help would make sense to you?’ Record dimensions rather than only ‘present’ or ‘absent’.
Disagreement with treatment does not automatically establish absent insight. Assess judgement using actual recent decisions and their context: describe the behaviour, understanding of consequences and uncertainty.
Synthetic documentation examples #
These original synthetic examples illustrate descriptive documentation. Neither establishes a diagnosis or declares a person safe. Document the examination actually performed, including its limitations.