Mental Status

Examination (MSE)
Where counting
backwards isn’t just for
rockets.

SOMYA JAIN
Table of Contents

Appearance Judgment and Insight

Behavior
Orientation
Speech
Mood and Affect

Consciousness Thought

Memory and Speech

Attention
Abstract Thinking
Introduction

The Mental Status Examination is a structured tool and

process that allows you to observe and assess a patient's
current mental state. It can also be helpful to use as part of
a working diagnosis
[
and identifies possible areas for
intervention. MSEs are usually incorporated into every
mental health assessment and clinical contact

3
Mnemoic

The mnemonic ASEPTIC can be used to remember the components

of the Mental Status Examination.

A - Appearance/Behaviour
S - Speech
E - Emotion[ (Mood and Affect)
P - Perception (Auditory/Visual Hallucinations)
T - Thought Content (Suicidal/Homicidal Ideation) and Process
I - Insight and Judgement
C - Cognition 4
 Appearance and
Behavior
Observation of
appearance and non-
verbal communication
 Appearance and Behavior
* Have they dressed appropriately for the season,
setting and occasion?
* Did they choose clothes that reflect their mood?
(Bright/dark/dull) Has the patient stopped
* Are their clothes clean and in wearable condition? looking after themselves
* Do their clothes have any emblems or logo's recently? Do they need
which may indicate substance misuse? (E.g. help/prompting with
Cannabis leaf on the T-Shirt / Alcohol branding on personal hygiene?
clothing etc.).
Grooming and
Clothing type: * Is their posture closed, self hygiene
slouched or open? Is there
any sign of postural
instability?
5
Posture
 Appearance and Behavior

If the patient is
Gait
cooperative, hostile, Brisk gait – Fast and energetic walking, often seen
open, secretive, evasive, in active individuals.
suspicious, apathetic, Slow gait – Reduced speed of walking, commonly
easily distracted,
due to age, weakness, or neurological issues.
focused, or defensive
Hesitant gait – Difficulty initiating steps, often
seen in Parkinson’s disease or anxiety-related
Attitude Towards
Examiner conditions.
Propulsive gait – Forward-leaning, hurried walking,
typically associated with Parkinson’s disease.
Shuffling gait – Dragging or sliding feet with
reduced step height, commonly seen in Parkinson’s
disease and elderly individuals. 5
 Appearance and Behavior
Eye Contact
Observe the patient’s facial
expression (e.g. relaxed, fearful, Observe the patient’s level of eye
angry, disengaged). Note if they contact and note if this appears
respond appropriately (e.g. reduced or intense and staring
becoming tearful when discussing
difficult topics vs laughing
Observe for any evidence of psychomotor
incongruously).
abnormalities:
Facial Expression Psychomotor retardation: associated with a
paucity of movement and delayed responses to
questions.
Restlessness: the patient may continuously fidget,
pace and refuse to sit still.
5
Psycho-motor Activity
Appearance and Behavior
Eye contact, mannerisms, tics, activity level, psychomotor retardation/activation.
Akathisia: Inner restlessness with inability to stay still.
Automatism: Spontaneous verbal or motor behavior without patient
awareness.
Catatonia: Extreme motor inactivity or hyperactivity.
Choreoathetosis: Involuntary combination of chorea (irregular migrating
contractions) and athetosis (twisting/writhing).
Dystonia: Twisting/repetitive movement or abnormal fixed posturing.
Tremor: Unintentional, rhythmic, oscillatory movement.
Speech
Assessed by observing
and listening to
patient’s spontaneous
speech
 Speech
Rate: Pressured > Rapid > Regular > Slowed
Pressured speech: Rapid, frenzied speech driven by an internal
sense of urgency.
Rhythm:
Prosody – The rhythm, intonation, and stress patterns in speech
that convey emotion and meaning.
Cadence – The natural flow and rhythm of speech, including its
speed and variation.
Latency – The delay or pause before responding in
conversation, often indicative of cognitive or emotional factors.
Spontaneity – The ability to engage in unplanned, natural small 4
talk without hesitation.
 Speech
Articulation:
Dysarthria – Slurred or unclear speech due to muscle
weakness or neurological impairment.
Stuttering – Disruptions in speech flow, including
repetitions, prolongations, or blocks.
Accent/Dialect – Variations in pronunciation, vocabulary,
and grammar based on regional or cultural background.
Tone – The emotional quality or attitude conveyed
through voice inflection.
Volume/Modulation – The control of loudness and
softness in speech for clarity and expression. 4
 Speech
Quantity
Talkative – Speaks frequently and at length in
conversations.
Spontaneous – Initiates speech naturally without
prompting or hesitation.
Expansive – Overly elaborate or excessive speech, often
seen in mania.
Paucity – Noticeably reduced speech output with minimal
elaboration.
Poverty – Severe reduction in speech content, with brief
or empty responses, often seen in schizophrenia. 4
 Speech
Route
Circumstantial speech – Overly detailed and indirect but
eventually reaches the point (seen in obsessive traits, anxiety).
Tangential speech – Deviates from the topic and never returns
to the original point (common in mania).
Flight of ideas – Rapid, loosely connected thoughts with
frequent topic shifts (common in mania).
Derailment (Loose associations) – Speech that jumps between
unrelated topics without logical connection (seen in
schizophrenia).
Perseveration – Repetitive speech or returning to the same 4
topic despite attempts to change (seen in autism, brain injury).
Speech
Clanging – Speech driven by sound associations (rhyming,
punning) rather than meaning (seen in mania, schizophrenia).
Echolalia – Repetition of another person’s words or phrases
(seen in autism, catatonia).
Neologisms – Inventing new words or using words in
unconventional ways (seen in schizophrenia).
Word salad – Disorganized, incoherent speech with no logical
connection (seen in severe psychosis).
Mutism – Complete absence of speech, despite the ability to
speak (seen in catatonia, severe depression).
4
Speech
Logorrhea – Excessive, incoherent talking, often seen in mania
or neurological disorders.
Paraphasia – Substituting incorrect words or sounds in speech
(seen in aphasia, neurological conditions).
Coprolalia – Involuntary use of obscene or inappropriate
language (seen in Tourette’s syndrome)

4
Thought
Thought can be
described in terms of
form, content and
possession.
 Thought

Goal-directed/logical: Linear progression of thought without

veering from subject at hand.
Circumstantial: Inability to answer a question without giving
excessive, unnecessary detail. Does eventually return to the original
point.
Tangential: Wandering
[ from the topic and never returning to it or
providing the information requested.
Loosening of associations: Incoherent slippage of ideas further and
further from point of discussion.
4
 Thought

Flight of ideas: Rapid shift from one topic to another.

Perseveration: Repetition of a particular response (e.g., word or
phrase), regardless of the absence or cessation of a stimulus.
Thought blocking: Abrupt cessation of speech without explanation
in the middle of a sentence
Possession of Thought
[ refers to disturbances in the control of one's
thoughts, often seen in psychotic disorders like schizophrenia.
1. Thought Broadcasting – The belief that one's thoughts are being
transmitted or heard by others (e.g., "Everyone around me can
hear what I’m thinking"). 4
 Thought
2. Thought Insertion – The belief that thoughts are being placed into
one's mind by an external force (e.g., "These ideas are not mine;
someone is putting them in my head").
3. Thought Withdrawal – The belief that one's thoughts are being
removed or stolen by an external force (e.g., "I had a thought, but it was
taken away before I could say it").
[
Obsessions: Recurrent and persistent thoughts, impulses or images
that are intrusive and cause marked anxiety or distress.
Compulsions: Repetitive behaviours (e.g. washing, ordering, checking,
hoarding) or mental acts (e.g. praying, counting, repeating words
silently) that the person feels compelled to perform in response to 4
obsessive thoughts.
 Thought

Preoccupation / Worry: Perseverative cognition that tends to be

anchored around the sustained processing of uncertainty.
Rumination: Sustained processing of negative material.
Repetitive and passive thinking that dominates attention. A
tendency to continue to think about something bad, harmful, or
[
unhopeful for a long time. Prolonged processing of self-referent
material is due to an impairment in the ability to disengage one's
attention

4
 Thought

Poverty of thought: A global reduction in the quantity of thought.

Overabundance of thought: A global increase in the quantity of
thought.
Delusions: Fixed, false beliefs that do not change even when
presented with evidence counter to them, and are outside of
cultural, societal or
[ religious norms.
● Somatic delusion: Delusion that one’s bodily function, sensation
or appearance is abnormal.
● Delusion of grandeur: Delusion of possessing superior qualities
such as fame, wealth or supernatural powers. 4
 Thought

● Paranoid delusion: Delusion of mistreatment, usually persecution

(e.g., being spoken about behind one’s back, “people are out to get
me”).
● Delusion of thought insertion: Delusion where one believes one's
thoughts to be externally placed from an outside party.
● Delusion of thought
[ control: Delusion where one believes one is
being controlled by an outside party or parties, and self-control is
lost.
● Delusion of reference: Delusion where an otherwise insignificant
event is misconstrued as having special significance specifically to 4
oneself.
 Thought

● Delusion of thought broadcasting: Delusion where one's thoughts

are made known to everyone in the outside world.
● Erotomanic delusion: Delusion where one believes that
prominent figures or superstars are in love with or in a relationship
with oneself, when that is not the case in reality.
● Nihilistic delusion:
[ Delusion where one believes that nothing is
real. This is in contrast to derealization or depersonalization, which
have more to do with an altered reality, not the lack of it.

4
Differences

Obsession Over-valued Ideas Delusions

Intrusive, distressing, and Strongly held beliefs that are Firmly held false beliefs despite
unwanted thoughts. amplified and defended. evidence to the contrary.
Ego-dystonic (felt as Ego-syntonic (consistent with Ego-syntonic (strongly
senseless and intrusive). one's beliefs and personality). believed, even if irrational).
Person tries to resist or Person amplifies, defends, and Person is completely
suppress them acts on them. convinced and does not
Not influenced by culture May align with cultural or question them.
Common in OCD personal experiences. Out of sync with cultural or
Found in conditions like educational background.
anorexia nervosa, jealousy, Seen in delusional disorders
hypochondriasis, and body (e.g., persecutory, grandiose,7
dysmorphic disorder. jealous type).
Perception
Organisation,
identification and
interpretation of
sensory information to
understand the world
around us.
 Perception

Depersonalization: Loss of all sense of identity, wherein one's

thoughts and feelings are no longer felt to be one's own.
Derealization: A change in the perception or experience of the
external world to where it feels unrealistic.
Illusion: A misinterpretation of existing stimuli.
Hallucination: A perception
[ perceived in the absence of any
existing stimuli.
Hypnagogic hallucination: A hallucination experienced before
falling asleep.
Hypnopompic hallucination: A hallucination experienced upon 4
waking up from sleep.
Perception
Auditory hallucinations – Hearing voices, sounds, or noises without
external stimuli (common in schizophrenia).
Visual hallucinations – Seeing people, shapes, or lights that aren’t
present (seen in delirium, substance use).
Tactile hallucinations – Feeling sensations like crawling, tingling, or
electric shocks on the skin (seen in withdrawal, psychosis).
Olfactory hallucinations
[ – Smelling odors that have no real source
(seen in temporal lobe epilepsy, schizophrenia).
Gustatory hallucinations – Experiencing unusual tastes, often
unpleasant (seen in epilepsy, migraines).
Somatic hallucinations – Feeling internal bodily sensations that are 4
not real (e.g., organs moving, foreign objects inside).
Mood and Affect
Mood is the climate
whilst affect is the
current weather
Mood vs Affect

Mood represents a Affect represents an

patient’s immediately
predominant expressed and
subjective internal observed emotion
state at any one time (e.g. the patient’s
as described by facial expression or
them. overall demeanour).
Mood is what the Affect is what you
patient tells you observe
9
 Mood

A patient’s mood can be explored by asking questions such as:

“How are you feeling?”
“What is your current mood?”
“Have you been feeling low/depressed/anxious lately?”
Subjective (As reported by the patient and observed by the examiner):
Ask the patient[ to describe how they are feeling and if they are
experiencing any biological symptoms as a result of their mood-for
example, insomnia or appetite.
Make sure you note their exact words and verbatim. Example
questions to encourage a subjective answer:
 Mood
Objective (How we observe and describe their mood):
Elated, dysthymic, euthymic, apathetic, blunted, depression
(mild/moderate/severe), irritability, anxious?
Does their mood change throughout the meeting?
What is the constancy of mood?
Examples of mood state
[

Low mood Anxious

Angry Enraged
Euphoric Guilty
Apathetic
 Affect

Intensity: Normal, blunted, flat?

Heightened: associated with mania and some personality disorders.
Blunted or flat: associated with schizophrenia, depression and post-
traumatic stress disorder.
Fluctuation: Labile- easily altered?
Labile affect: characterised
[ by exaggerated changes in emotion
which may or may not relate to external triggers. Patients typically
feel like they have no control over their emotions.
Fixed affect: the patient’s affect remains the same throughout the
interview, regardless of the topic.
 Affect

Quality: Sad, agitated, hostile?

Congruence: Congruent / incongruent
Note if the patient’s affect appears in keeping with the content of
their thoughts (known as congruency). A patient sharing distressing
thoughts whilst demonstrating a flat affect or laughing would be
described as showing
[ incongruent affect. Incongruent affect is
typically associated with schizophrenia.
Range: Restricted, expansive, normal?
Restricted affect: the patient’s affect changes slightly throughout the
interview, but doesn’t demonstrate the normal range of emotional
expression that would be expected.
Orientation
Person's awareness of
themselves and their
surroundings
Orientation

Consider the level of consciousness by assessing their orientation.

Can the patient accurately answer the time, their date of birth, their
age, and the place they currently are at?
Is there an awareness of the current setting?
"What is your full name?" "How would you describe the situation we're
[
in?".
What was their score?
Repeat if necessary.
 Orientation

Types of Orientation:
Person – Awareness of self (e.g., name, age, personal details).
Place – Awareness of location (e.g., hospital, home, city).
Time – Awareness of time-related details (e.g., date, day of the
week, year, season).
[
Situation (or Event) – Awareness of the current circumstances
(e.g., why they are in the hospital or being assessed).
Consciousness
The level of
consciousness refers
to the state of
wakefulness of the
patient ct is the
current weather
Affect Levels of Consciousness

Alert – Fully awake, responsive, and aware of surroundings.

Lethargic – Drowsy but responsive; can be aroused with verbal
stimuli.
Obtunded – Significant reduction in alertness; slow responses and
drowsiness; requires repeated stimulation to maintain attention.
Stuporous – Only[ responds to strong, painful stimuli; minimal
awareness of surroundings.
Comatose – No response to stimuli; unconscious and unresponsive.
Memory
Person’s ability to
retain and recall
information
Memory

Immediate Memory (Registration) – The ability to recall information

just presented (e.g., repeating a sequence of numbers or words).
Recent Memory (Short-term Memory) – The ability to recall events
from minutes to hours ago (e.g., recalling three words after 5
minutes).
Remote Memory [ (Long-term Memory) – The ability to recall past
events from years ago (e.g., childhood events, historical facts).
Attention
Ability to focus and
sustain mental effort
on a task
Attention
Digit Span – Asking the patient to repeat a sequence of numbers forward
and backward.
Serial Sevens – Asking the patient to subtract 7 from 100 and continue
subtracting (100, 93, 86, 79…).
Spelling Backward – Asking the patient to spell a word (e.g., "WORLD")
backward.
Months of the Year in Reverse Order – Checking for sustained focus and
processing speed.
Abstract
Thinking
Ability to understand
concepts that are not
concrete, think
metaphorically,
recognize patterns, and
apply logical reasoning
Abstract Thinking
Proverb Interpretation:
The patient is asked to interpret common proverbs.
Example: "What does ‘A rolling stone gathers no moss’ mean?"
Responses:
Abstract (normal): "A person who keeps moving won’t establish roots."
Concrete (impaired): "Stones don’t collect moss if they keep rolling."
Abstract Thinking
Similarities Test:
The patient is asked how two things are alike.
Examples:
"How are an apple and an orange alike?"
Abstract (normal): "They are both fruits."
Concrete (impaired): "They are both round."
"How are a train and a bicycle alike?"
Abstract: "Both are modes of transportation."
Concrete: "Both have wheels."
Abstract Thinking
Differences Test
This assesses the ability to contrast two objects or concepts beyond their basic
physical characteristics.
Example Question: "What is the difference between a river and a lake?"
Abstract Response: "A river flows, while a lake is stationary; rivers usually
connect to larger bodies of water."
Concrete Response: "A river is long, and a lake is round."
Judgement and
Insight
Problem-solving ability
and understanding of
the disorder
 Social Judgment
Refers to a person's ability to behave appropriately in social situations and
understand societal norms.
Observing behavior during the interview (e.g., does the patient act
appropriately?).
Asking about past social interactions (e.g., relationships, conflicts, legal
issues).
Examples of Impairment:
Inappropriate behavior (e.g., making inappropriate comments, violating
personal space).
Socially unacceptable actions (e.g., aggression, impulsivity).
Seen in conditions like antisocial personality disorder, frontal lobe damage,
and schizophrenia.
 Personal Judgment

Refers to the ability to make reasonable decisions in one's own life, considering
consequences and personal well-being.
"What would you do if you ran out of your medication?"
"How would you handle a situation where someone offers you an illegal drug?"
Examples of Impairment:
Poor financial decisions (e.g., giving away money recklessly).
Engaging in risky behaviors (e.g., substance abuse, unsafe sex).
Often seen in bipolar mania, dementia, and substance use disorders.
 Test Judgment

The ability to solve hypothetical problems logically and make reasoned decisions
in structured tasks.
"What would you do if you found a stamped and addressed envelope on the
ground?"
"What should you do if you see a fire in a crowded building?"
Examples of Impairment:
Giving illogical or unrealistic responses.
Responses suggesting a lack of understanding of consequences.
Seen in intellectual disabilities, psychosis, and severe neurocognitive
disorders.
 Insight

Insight, in a mental state examination context, refers to the ability of a patient to

understand that they have a mental health problem and that what they’re
experiencing is abnormal. Several mental health conditions can result in patients
losing insight into their problem.
Some examples of questions which can be used to assess insight include:
“What do you think the cause of the problem is?”
“Do you think you have a problem at the moment?”
“Do you feel you need help with your problem?”
 Levels of Insight

Six levels of insight have been described:

1. Complete denial of illness
2. Slight awareness of being sick and needing help, but denying at the same
time
3. Aware of being sick but blaming it on others, or external factors like physical
illness
4. Awareness that illness is caused by something unknown
5. Intellectual insight: awareness that there is a mental illness without applying
this knowledge to future experiences
6. Emotional insight: emotional awareness into the feelings and illness and
ability to modify behaviour accordingly.
The End
Thank You for Listening