Mental status examination

Department of Psychiatry
All India Institute of Medical
Sciences, Patna
 Symptoms and signs
There are few ‘signs’ in psychiatry in medical sense (apart from
the motor abnormalities of catatonia), with most diagnostic
information coming from the history and observations of the
patient’s appearance and behavior.
So ‘signs’ in psychiatry are less clear, and two different uses are
encountered.
First, it may refer to a feature noted by the observer rather
than something spoken by the patient (e.g. a patient who
appears to be responding to a hallucination).
Second, it may refer to a group of symptoms that the observer
interprets in aggregation as a sign of a particular disorder. In
practice, a clear distinction between the two are not present.

-adi
 Information is started from the initial contact of the
patient till the end of interview.
Includes Observation and interviewing.
MSE is not only cross sectional but may span over a
time. Useful for diagnosis, treatment and monitor of
response to treatment.
The following presentation of MSE is an outline for
documentation but it is important to note that the
information is gathered from first contact till
completion of the interview.

-adi
 Important Points
• Gender
• Education
• Occupational background
• Social background

-adi
 Language of interview and use of interpreter
1. General appearance
2. Attitude
3. Motor behavior
4. Speech
5. Mood and Affect
6. Thought
7. Perceptual Disorders
8. Other phenomenon and other psychotic phenomenon
9. Cognitive functions
10. Judgment
11. Insight

-adi
 General physical appearance
Estimate of age
Body build
Dress
Hygiene
Grooming
Touch with surrounding
Eye contact
Facial expression and posture.

-adi
 GAB (General Appearance and Behaviour)
• Depression- A middle aged patient appearing to be of stated
age entered into interviewer room accompanied by his wife.
The patient walked with the slow but steady gait and
appeared to be in touch with surrounding. The patient did
not greet the examiner and sat on chair when asked to do so.
He was wearing unclean and un-ironed shirt and trouser and
appeared not to have taken bath or shaved in the last few
days. While sitting in the chair, the patient kept his head bent
forward with drooping shoulder and kept his arms close to his
body. The patient kept a dull face and appeared distressed
with vertical and horizontal furrows in the forehead. The
patient avoided eye contact with the examiner and kept
looking downward toward the floor. The patient was generally
cooperative and answered most of questions put to him but
would not elaborate much in his replies and on occasions tears
would roll out of his eyes while talking.
-adi
 • Mania- A young female with average built and nutrition came
into the interview room with a normal gait accompanied by
her mother. Her gait was normal and she appeared to be in
touch with surrounding. She greeted the examiner and sat on
the chair when asked to do so. She was dressed in a neat and
clean T-shirt and Jeans and was over groomed for the
occasion. The patient appeared relaxed & comfortable and
was co-operative throughout the interview. She adequately
answered all the questions asked but would be extremely
talkative and would elaborate all her answers more than
what was required. She appeared to be very jovial and would
burst into laughter at times and again during the interview.
• ETEC – M/S

-adi
 Co-operative
Uncooperative
Evasive
Guarded
Manner of relation (relaxed, tense, overfamiliarity,
aggressive, withdrawn)
Rapport.

-adi
 Inactive
Hyperactive
Catatonic features
Hallucinatory behavior
Involuntary movements
(Tremor, Dystonia, Dyskinesia, Chorea, Athetosis)

-adi
 Speech-
• Reaction Time
• Rate/vol/tone – Increased/ decreased/
Normal
• Spontaneous/relevant/coherent/goal
directed
• Productivity – Increased/ decreased/ Normal

-adi
 Observe both verbal and non verbal behavior-
• Mood- Subjective
• Objective- Quality of Affect,
Appropriateness, Range, Reactivity,
Communicability

-adi
 • Form – loosening of Association, Derailment, Neologism
• Flow – Pressure of speech, Flight of ideas, retardation of
thought, circumstantiality, thought block
• Possession – Obsession, Thought Alienation (Thought
insertion, withdrawal, broadcasting)
• Content- Worry, phobia, somatic symptoms, reference,
persecution, grandiosity, hypochondriasis.
• ( Distinguish between idea, overvalued idea and delusion)
• Delusion- primary or secondary, systematized / un
systematized, Mood congruent / Incongruent.

-adi
 Thought
• Form – circumstantiality
• Flow – NAD
• Possession – NAD
• Content – Asked about herself/ When asked about people knowing her
“Jab ghar se baahar nikalti hoon to lagta hai ki log mujhe dekh rahe hain,
sab log mujhe jaante hain, meri taraf dekh kar smile karte hain. Aisa lagta
hai ki sab log mujh se baat karma chhahte hain. Abhi kuchh din pahle mein
bank gayi thi wahan jaise hi mein andar gayi sab log mujhe hi dekhne lage
aur mujhe ajeeb sa lagne laga. Mummy ne kaha ki aisa nahin hai par mera
dil nahin mana aur mein waapas aa gayi. Pehle yeh sab achha lagta tha par
ab bahut problem hoti hai. Ghar se baahar nikalne ka bhi man nahin karta.
Ghar mein bhi aisa lagta hai sab log mujhe dekh rahe hain, mera saari
dunia mein live telecast ho raha hai. Pata nahin kaise par shaayad Inke ke
haath mein koi Camera hoga jisse sab jagah telecast ho jata hai. Is se bhi
problem hoti hai, apne hi ghar mein jaise nazarband ho gaye hoon. Kapde
badalne ke liye bhi light band karni padti hai warna who bhi telecast ho
jayega.”
-adi
 Perception
• Illusion
• Autoscopy
• Distinguish between mental imagery, Pseudo-hallucination
and hallucinations.

-adi
 Perception
• “Mere aaspas mujhe koi mehsoos hota hai. Kissi ko bhi dikhai
nahin deta, mujhe bhi nahin, par mujhe us ke hone ka pata lag
jata hai. Kabhi bolta bhi nahin hai par mujhe touch or pinch
karta rahta hai jis se lal nishan pad jate hain. Pehle mujhe lagta
tha ki yeh IB ke hi aadmi hain par ab aisa nahin lagta. Pehle
mein us se baatien bhi karti thi par ab mera man nahin karta
aur mein us ki taraf dhyan nahin deti par who phir bhi mere
paas hi khada rahta hai”

-adi
 Attention & Concentration
• Asses clinical behavior
• Serial Subtraction Test: 100-7, 50-3
• Months / Days backwards
• DST- First give an example( in monotonous tone, with a gap
of 1 sec between different digits, not of telephone numbers,
not in sequence)
• Finger\ tapping test

Impression: Patient attention was aroused and sustained

-adi
 Orientation
• Time – Patient was able to tell the current date (27th), day
(Friday) and approximate time of the day.
• Place- – Patient was able to tell the name of city(PNBE),
building(aiims) and floor(First )
• Person- Patient was able to identify doctor and the
attendant
• Sense of passage of time.

Impression: Patient was fully oriented

-adi
 Memory
• Immediate – Digit forward/ digit backwards.
Verbal immediate recall- Patient was able to correctly repeat 3 words
immediately and after a period of 5 minutes. E.g.Ram, kitab, ghar.
• Recent- Recall of items/ events in last 1 / 2 days.
Object test with 5 unrelated objects.
Verbal Story
Patient was able to tell correctly about the breakfast he had in the morning
and people he met on the day before. This information was corroborated by
the attendant.
• Remote- Personal events
Memory of skills
Topographical memory.
Patient was able to tell the name of the school he went to, year of his and his
sibling’s marriage
Impression: Intact immediate, recent and remote memory

-adi
 Abstract ability

• Clinical Behavior
• Test of Similarities – Ask for at least 2 similarities in 2 different
objects. Repeat 3 times.
• Proverbs- Ask for proverbs from the patient or the informants.
And then ask the meaning.
If no proverb said, ask the commonly prevalent ones.
Ask 3 proverbs.

-adi
 • General fund of information
– how many months are there in a year
– Why do people have lungs
– How many seasons are there in a year
– Garmiyon mein gahre rang ke kapde kyo
nahin pahne chahiye
– Jung kaise lagta hai
– Ramayan kisne kisne likhi thi

-adi
 • Arithmetic Calculation
– Addition – simple-Rs 7+9, complex- Rs 14+17
– Subs traction-simple -17-9, complex- 43-38
– Multiplication-Simple- 2x8, 7x9, complex- 21x5,
– Division- 9/3, 56/8, complex- 128/8

• Comprehension- sweater problem, umbrella problem

IMP: Intelligence appears to be average

-adi
 Judgment
– Personal- Patient wished to complete the
treatment and go back to his previous job and take
care of the family
– Social
– Test
• Letter problem- dak-khane mein post kar dunga
• Fire problem- fire brigade ko phone karunga aur usne
aane tak paani se aag bujhane ki koshish karunga
• Accident problem- doctor ke paas le kar jaunga
Inference: Judgment is intact

-adi
 Insight –
insight refers to awareness of morbid change in oneself and a
correct attitude to this change, including, in appropriate cases, a
realization that it signifies a mental disorder.
Insight has to be assessed against the background of knowledge and
beliefs about psychiatric disorder— it is not the same as
complete agreement with the views of the doctor.
Influenced by cultural and cognitive factors.
Lack of insight was said to be a feature that distinguishes between
psychosis and neurosis, this distinction is no longer thought to be
reliable or useful.
The ‘lack of insight’ in psychosis is better conceptualized in terms of
‘impaired reality testing’ or ‘reality distortion’.

-adi
 Insight is not simply present or absent. It has several facets, each
being a matter of degree.
Oxford-
● Is the patient aware of phenomena that others have observed
(e.g. that he is unusually active and elated)?
● If so, does he recognize the phenomena as abnormal (rather than,
for example, maintaining that his unusual activity and
cheerfulness are due to normal high spirits)?
● If so, does he consider that the phenomena are caused by mental
illness (as opposed to, say, a physical illness or poison
administered by enemies)?
● If so, does he think that he needs treatment?

-adi
 Insight (Synopsis/ CTP) – 1 to 5
• 1/5- Pt would not acknowledge any illness
• 2/5- Ambivalence
• 3/5- Acknowledge mental illness, but due to
external factor
• 4/5- Acknowledge mental illness with
treatment modality
• 5/5- Improvement in functioning
Mujhe lagta hai ki yeh ek mansik bimari hai
jiske liye mujhe ilaj ki aavakshyakta hai= ?
-adi
 • In discussions of psychotherapy, insight has a
different meaning from general psychiatry.
• In psychotherapy, insight is the capacity to
understand one’s own motives and to be
aware of previously unconscious aspects of
mental activity.
• Intellectual insight - sometimes used to
denote the capacity to formulate this
understanding.
• Emotional insight -refers to the capacity to
feel and respond to the understanding.

-adi
 • Rapport- Spontaneous, conscious feeling of harmonious
responsiveness that promotes the development of a
constructive therapeutic relationship.
– Alliance, Comfort, Expertise, Guidance, Insight, Trust

• Empathy- Intellectual and emotional awareness, and

understanding of another person state of mind by putting
oneself in the position of other, but at the same time
maintaining ones own perspective

• PMA- Motor component of psychic activity evident through

speech and behavior

-adi
 • Affect- Pattern of observable behavior that is the expression of
subjectively experienced feeling state

• Mood- Pervasive and sustained feeling tone that is experienced

internally and that influences virtually all aspects of person’s
behavior and perception.

• Appropriateness- Expressed affect is in harmony with the

accompanying idea, thought or speech.

• Range- Extent of variability of affect during the interview

-adi
 • Thought- Goal directed flow of ideas, symbols and
association, initiated by a problem and task, and leading
toward a reality oriented conclusion, and follows a logical
sequence
– Form- It is the way in which a person puts together ideas and
associations.
– Flow- Uninterrupted sequence of thoughts in which one or
more associations arise from each preceding thought.
– Content- What the person is actually thinking and it includes
ideas, beliefs, obsessions and preoccupations

• Perception- Conscious awareness of elements in the

environment, by the mental processing of sensory stimuli

-adi
 • Cognition- Process of obtaining, processing, organizing,
retaining and using information available
• Orientation- State of awareness of oneself and one’s
surrounding in terms of time, place and person
• Attention- Ability of an individual to focus on a specific
stimulus, without being distracted by other extraneous
or internal stimuli
• Concentration- It is the ability to maintain attention to
a specific stimulus for an extended period of time

-adi
 • Memory- It is the general term for a mental
process which helps a person to store information
for later recall
• Immediate memory- It is the ability to recall
registered information after an interval of few
seconds
• Recent memory- It is the ability to register new
information and retrieve that information after a
period of min, hrs or days.
• Remote memory- Refers to recall of facts or
events that occurred in the distant past

-adi
 • Intelligence- It is the ability to think logically, act rationally and deal
effectively with the environment and the situation

• Abstraction- It is the thinking characterized by the ability to grasp

the essentials of a whole, to break a whole into its parts and to
discern common properties

• Judgment- Mental act of comparing and evaluating choices, within

the framework of given set of values, for the purpose of deciding a
course of action

• Insight- Conscious awareness and understanding of one’s own

psychological state, and symptoms of maladaptive behavior, and
need for treatment

-adi
 THANK YOU
-adi