COLLEGE OF NURSING BJGMC,PUNE.
MENTAL HEALTH NURSING
MENTAL STATUS EXAMINATION FORMAT
A.GENERAL APPEARANCE AND BEHAVIOR:
1. Appearance:
Looking one's age/looks older/younger than his/her
age/underweight/overweight/physical deformity
2. Facial expression: Anxious blunted/pleasant/fearful
3. Level of grooming: Normal/shabbily dressed/overdressed/idiosyncratically
dressed
4. Level of cleanliness: Adequate inadequate/overtly clean
5. Level of consciousness Fully conscious and
alert/drowsy/stuporous/comatosed
6. Mode of entry: Came willingly/persuaded/brought using physical force
7. behaviour: Normal/over friendly/preoccupied/aggressive Co-operativeness:
Normal/more than so/less than so
8. Eye-to-eye contact: Maintained/difficult/not maintained
9. Psycho-motor activity: Normal/increased/decreased
10.rapport: Spontaneous/difficult/not established.
11.Gesturing Normal/exaggerated/odd
12.Posturing: Normal posture/catatonic posture/stooped/stiff/guarded
13.Other movements: Normal/stereotype/tremors/extra pyramidal
symptoms/abnormal involuntary movements
14.Other catatonic phenomena: Automatic obedience/negativism/excessive
co-operation/waxy flexibility/ echopraxia/echolalia.
PRANAV SARGULE 1
15.Conversion and dissociative signs: Pseudo seizures/possession states/any
other
16.Compulsive acts or rituals or habits (for example nail biting):
17.Hallucinatory behavior: Smiling or crying without reason/muttering or
talking to self, odd gesturing.
B. SPEECH
1. Initiation: Spontaneous/speaks when spoken to/minimal/mute
2. Reaction time (time taken to answer the question):
Normal/delayed/shortened/difficult to assess Rate: Normal/słow/rapid
3. Productivity: Monosyllabic/elaborate replies/pressured
4. Volume: Normal/Increased (loud)/decreased (soft) Tone: Normal
variation/high pitch/low pitch/monotonous
5. Relevance: Fully relevant/sometimes off target/irrelevant (answer the
question appropriately) Stream:
Normal/circumstantial/tangential/blocking/verbigeration/stereotypies
verbal/flight of ideas/ clang associations (flow and rhythm of speech)
6. Coherence: Fully coherent/loosening of associations (in coherent)
7. Others: Echolalia/perseveration/neologism
8. Sample of speech (in response to open-ended questions, verbatim in 2 or 3
sentences)
C. MOOD AND AFFECT:
1. Subjective:
PRANAV SARGULE 2
2. Objective:
3. Predominant mood state:
Irritable/labile/blunted/anxious/fearful/panic/aggressive/cheerful/depressed
4. Appropriate: (relevance to situation and thought congruent)/inappropriate:
D. THOUGHT
1. Stream (flow of thought): Normal/racy thoughts (pressure of
thought)/retarded thinking (poverty of thoughts)/ unclear thinking/flights of
idea/class association/mutism.
Form (formal thought disorder): Normal/ not
understandable/circumstantiality/ tangentiality/ neologism/word
salad/ambivalence/perseveration (specify with a sample of speech)
2. Content:
Delusion : (Specify and give example) persecutory delusion / delusion of
reference/delusion of influence/passivity/hypochondracal delusion/delusionof
grandeur/nihilistic delusion/delusion of infidelity/delusion of control/bizarre
delusion.
3. Thought alienation phenomena:Thought insertion/thought
withdrawal/thought broadcasting
4. Obsessional /compulsive phenomena:
Thoughts/images/ruminations/doubts/impulsive rituals
5. Phobias (irrational fears):
6. Any preoccupations:
E. PERCEPTION
1. Illusions:
PRANAV SARGULE 3
2. Hallucinations (Specify type and give example):
Auditory/visual/olfactory/Gustatory/Tactile
3. Somatic passivity:
4. Déjà vu jamais vu:
5. Depersonalization/derealization:
F. COGNITIVE FUNCTION (NEUROPSYCHIATRIC ASSESSMENT)
1. Consciousness: Conscious/cloudy/comatosed
2. Orientation:
Time: Appropriate time/day/night/date/day/month/year
Place: Kind of place/area/city
Person: Self/close associates/hospital staff
3. Attention: Normally aroused/aroused with difficulty
Digit forward
Digit backward
4. Concentration: Normally sustained/sustained with difficulty/distractible
100-7
40-3
20-1
Names of months (backwards)
Names of weekdays (backwards)
5. Memory:
Immediate (same test as for attention):
Recent: (recent happenings last meal, visitors, etc.)
Verbal recall: 3 unrelated objects
5 unrelated objects/imaginary address
PRANAV SARGULE 4
6. Remote:
Personal events:
Impersonal events:
Illness-related events:
7. Intelligence:
General fund of information:
Arithmetic ability: Mental arithmetic/written sums
8. Abstraction:
Normal/concrete
Interpretation of proverbs (give a proverb and ask the inner meaning, eg.
feathers of a bird flock together/rolling stones gather no mass):
Similarities between paired objects:
Dissimilarities between paired objects:
9. Judgment:
Personal (future plans): intact/impaired
Social(perception of the society): intact/impaired
Test (present a situation and ask their response to the situation):
intact/impaired
G. INSIGHT:
Insight is rated on a 6 point scale from 1 to 6:
1. Complete denial of illness
2. Slight awareness being sick
3. Awareness of being sick attributed to external or physical factor
4. Awareness of being sick but due to something unknown in himself
PRANAV SARGULE 5
5. Intellectual insight
6. True emotional insight.
DIAGNOSTIC FORMULATION:
PRANAV SARGULE 6
