Which aspects of the mental status exam refer to data about how thoughts connect to one another?

The mental state examination (MSE) is a structured way of observing and describing a patient’s current state of mind, under the domains of appearance, attitude, behaviour, mood, affect, speech, thought process, thought content, perception, cognition, insight and judgement.

The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient’s mental state, which when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation. Below is a framework that demonstrates the type of information that the mental state examination hopes to gather.

Download the mental state examination (MSE) PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our depression history taking guide.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Ask the patient if they’d be happy to talk with you about their current issues.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Appearance

The appearance of the patient may provide some clues as to their lifestyle, current mental state and ability to care for themselves.

Observe the patient’s general appearance:

• Distinguishing features: these may include scars (e.g. self-harm), tattoos and signs of intravenous drug use.
• Weight: note if they appear significantly underweight or overweight.
• Stigmata of disease: note any stigmata of disease (e.g. jaundice).
• Personal hygiene: this can provide insight into the patient’s current ability to care for themselves.
• Clothing: note if this is appropriate for the weather/circumstances and if the clothes have been put on correctly.
• Objects: look around to see if the patient has brought any objects with them and note what they are.

Behaviour

A patient’s behaviours may provide insights into their current mental state.

Engagement and rapport

Note if the patient appears engaged in the consultation and if you are able to develop a rapport with them.

Note if they appear distracted or if they appear to be engaging with hallucinations (e.g. replying to auditory hallucinations in schizophrenia).

Eye contact

Observe the patient’s level of eye contact and note if this appears reduced or excessive.

Facial expression

Observe the patient’s facial expression (e.g. relaxed, angry, disengaged).

Body language

Observe the patient’s body language which may appear threatening (e.g. standing up close to you) or withdrawn (e.g. curled up or hands covering their face).

Note any evidence of exaggerated gesticulation or unusual mannerisms.

Psychomotor activity

Observe for any evidence of psychomotor abnormalities:

• 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.

Abnormal movements or postures

Note any abnormal movements or postures:

• Involuntary movements
• Tremors
• Tics
• Lip-smacking
• Akathisias
• Rocking

Speech

Assess the patient’s speech to identify abnormalities which may indicate underlying mental health issues.

Rate of speech

Pay attention to the patient’s rate of speech:

• Pressure of speech: a tendency to speak rapidly, motivated by an urgency that may not be apparent to the listener (often a manifestation of thought abnormalities such as flight of ideas, which is described later in the article).
• Slow speech: may occur due to psychomotor retardation which is typically associated with major depression.

Quantity of speech

Note the quantity of the patient’s speech:

• Minimal or absent speech: associated with depression.
• Excessive speech: associated with mania and schizophrenia.

Tone of speech

Note the tone of the patient’s speech:

• Monotonous speech: associated with conditions such as depression, schizophrenia and autism.
• Tremulous speech: associated with anxiety.

Volume of speech

Note the volume of the patient’s speech.

Fluency and rhythm of speech

Note the fluency and rhythm of the patient’s speech for abnormalities:

• Stammering or stuttering
• Slurred speech: may occur in major depression due to psychomotor retardation.

Mood and affect

Mood and affect both relate to emotion, however, they are fundamentally different.

Affect represents an immediately expressed and observed emotion (e.g. the patient’s facial expression or overall demeanour).

Mood represents a patient’s predominant subjective internal state at any one time as described by them.

Affect is what you observe and mood is what the patient tells you.

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?”

Examples of mood states

• Low mood
• Anxious
• Angry
• Enraged
• Euphoric
• Guilty
• Apathetic

Affect

To assess affect you need to observe the patient’s facial expressions and overall demeanour.

Apparent emotion

Observe the apparent emotion reflected by the patient’s affect, examples may include:

• Sadness
• Anger
• Hostility
• Euphoria

Range and mobility of affect

Range and mobility of affect refer to the variability observed in the patient’s affect during the assessment. Abnormalities may include:

• Fixed affect: the patient’s affect remains the same throughout the interview, regardless of the topic.
• 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.
• 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.

Intensity of affect

A patient’s intensity of affect may be described as:

• Heightened: associated with mania and some personality disorders.
• Blunted or flat: associated with schizophrenia, depression and post-traumatic stress disorder.

Congruency of affect

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.

Thought

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

Thought form

Thought form refers to the processing and organisation of thoughts.

Speed of thoughts

Patient’s may demonstrate abnormally fast (i.e. racing) or abnormally slow thought processing.

Flow and coherence of thoughts

In healthy individuals, thoughts flow at a steady pace and in a logical order. However, in several mental health conditions, the flow and coherence of thoughts can become distorted.

Abnormalities of thought flow and coherence include:

• Loose associations: moving rapidly from one topic to another with no apparent connection between the topics.
• Circumstantial thoughts: these are thoughts which include lots of irrelevant and unnecessary details.
• Tangential thoughts: digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.
• Flight of ideas: there is an accelerated tempo of speech often referred to as ‘pressure of speech’. In addition to the increased rate of delivery, the language employed is characterised by a wealth of associations, many of which seem to be evoked by more or less accidental connections… the excited speech wanders off the point following the arbitrary connections, and the coherent progression of ideas tends to become obscured.1
• Thought blocking: sudden cessation of thought, typically mid-sentence, with the patient being unable to recover what was previously said.
• Perseveration: refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is and they then continue to repeat their name as the answer to all further questions).
• Neologisms: words a patient has made-up which are unintelligible to another person.

Thought content

Abnormalities of thought content can include:

• Delusions: a firm, fixed belief based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms. These may include persecutory delusions, in which the patient erroneously believes another individual or group is trying to harm them or ideas of reference, in which the individual incorrectly believes specific events relate to them.
• Obsessions: thoughts, images or impulses that occur repeatedly and feel out of the person’s control. The patient is aware these obsessions are irrational, but the thoughts continue to enter their head.
• Compulsions: repetitive behaviours that the patient feels compelled to perform despite recognising the irrationality of the behaviour.
• Overvalued ideas: a solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life (e.g. the perception of being overweight in a patient with anorexia nervosa).2
• Suicidal thoughts
• Homicidal/violent thoughts

Some examples of questions which can be used to screen for thought content abnormalities include:

• “What’s been on your mind recently?”
• “Are you worried about anything?”
• “Do you sometimes have thoughts that others tell you are false?”
• “Do you have any beliefs that aren’t shared by others you know?”
• “Do you ever feel that people are out to do you harm?”
• “Do you ever feel that specific events in the world are related to you in some way?”
• “Are there any thoughts you have a hard time getting out of your head?”
• “Do you sometimes feel the need to perform certain behaviours repetitively, despite understanding these are irrational?”
• “Do you ever think about ending your life?”
• “Have you ever felt your life was not worth living?”
• “Have you ever attempted to end your life?”
• “Do you ever think about harming others?”

Thought possession

Abnormalities of thought possession include:

• Thought insertion: a belief that thoughts can be inserted into the patient’s mind.
• Thought withdrawal: a belief that thoughts can be removed from the patient’s mind.
• Thought broadcasting: a belief that others can hear the patient’s thoughts.

Some examples of questions which can be used to screen for thought possession abnormalities include:

• “Do you think people can put ideas in your head, without your control?”
• “Have you ever felt like people have removed memories or thoughts from your mind?”
• “Do you ever feel like others can hear what you’re thinking?”

Perception

Perception involves the organisation, identification and interpretation of sensory information to understand the world around us. Abnormalities of perception are a feature of several mental health conditions.

Abnormalities of perception include:

• Hallucinations: a sensory perception without any external stimulation of the relevant sense that the patient believes is real (e.g. the patient hears voices but no sound is present).
• Pseudo-hallucinations: the same as a hallucination but the patient is aware that it is not real.
• Illusions: the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).
• Depersonalisation: the patient feels that they are no longer their ‘true’ self and are someone different or strange.
• Derealisation: a sense that the world around them is not a true reality.

Some examples of questions which can be used to screen for perceptual abnormalities include:

• “Do you ever see, hear, smell, feel or taste things that are not really there?”
• “Did you think this was real at the time?”
• “Do you still believe it was real?”
• “Do you ever feel like you’ve changed or that you don’t recognise the person you currently are?”
• “Do you ever feel like the world around you isn’t real?”

Cognition

Cognition refers to “the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses”. Cognition can be impaired as a result of mental health conditions and their treatments.

Throughout the process of performing a mental state examination, you will develop a vague idea of the patient’s cognitive performance including:

• whether they are orientated in time, place and person
• what their attention span and concentration levels are like
• what their short-term memory is like

A formal assessment of cognition can be achieved through a variety of different validated clinical tests including:

• Mini-mental state exam (MMSE)
• Abbreviated mental test score (AMTS)
• Addenbrooke’s cognitive examination III (ACE-III)

Insight and judgement

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?”

Judgement

Judgement refers to the ability to make considered decisions or come to a sensible conclusion when presented with information. Judgement can become impaired in several mental health conditions leading to poor decision making.

You may get some idea of the patient’s judgement abilities as you move through the mental state examination, but you can also specifically assess judgement by presenting the patient a scenario such as:

• “What would you do if you could smell smoke in your house?”

Sensible judgement in this situation would involve leaving the house immediately wherever possible and calling the fire department. A patient with impaired judgement may suggest ignoring it.

Closing the consultation

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

References

1. Murray, R., Hill, P., & McGuffin, P. (Eds.). (1997). The essentials of postgraduate psychiatry. Cambridge University Press.
2. P.J. Mckenna. Disorders with overvalued ideas. Published in December 1984. Available from: [LINK].

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