A mental state examination is used to assess patients presenting with mental health symptoms and disorders. It is equivalent to performing an abdominal examination for a patient with abdominal pain. It offers a structure for assessing and documenting the essential features of a mental health presentation.
The examination involves observing, assessing and commenting on:
- Appearance and behaviour
- Speech
- Mood and affect
- Thought
- Perception
- Cognition
- Insight
- Judgement
A risk assessment typically follows a mental state examination, giving an estimate of the risk of self-harm, suicide and harm to others.
The features listed below describe typical exam findings in patients with depression, mania and schizophrenia. In reality, patients vary tremendously. For example, depressed patients may appear and sound normal despite having a very low mood and suicidal intentions.
Appearance and Behaviour
Depressed patients may show signs of poor self-care, with poor hygiene and old clothes. There may be self-harm scars. They may have weight loss or weight gain. They may have slow movements and speech (psychomotor retardation), reduced eye contact, downward gaze and a stooped posture. Alternatively, they may be fidgety and restless (psychomotor agitation). They may be tearful during the consultation
Manic patients may be dressed in bright colours, extravagant outfits, or inappropriate outfits. Alternatively, they may be dressed chaotically and appear disheveled. Their behaviour is hyperactive, energetic, talkative, and overly familiar. They may display disinhibition and sexually inappropriate behaviour. Eye contact may be intense. They may have psychomotor agitation and appear fidgety and restless.
Patients with schizophrenia may be unkempt, dressed inappropriately for the environment or show signs of self-neglect. They may behave agitated, suspicious or aggressive. Alternatively, they may be withdrawn, quiet and blank. Catatonia may be present, with the patient holding unusual postures, performing odd actions, repeating sounds or words, or remaining blank and unresponsive.
Extrapyramidal side-effects from antipsychotic drugs may be observed, including:
- Akathisia (psychomotor restlessness, with an inability to stay still)
- Dystonia (abnormal muscle tone, leading to abnormal postures)
- Pseudo-parkinsonism (tremor and rigidity, similar to Parkinson’s disease)
- Tardive dyskinesia (abnormal movements, particularly affecting the face)
Speech
Depressed patients may have slow, quiet, soft and monotone speech. They may have “poverty of speech” (alogia).
Manic patients have characteristically pressured speech, which is fast, unrelenting, and impossible to interrupt. It is typically loud and confident.
Patients with schizophrenia may have poverty of speech (alogia) or poverty of content (speech without meaning). Due to thought disorder, their speech may be incoherent and impossible to understand. They may use invented words (neologisms). Thought blocking can cause sudden interruptions to the flow of thoughts and speech. Word salad refers to when speech contains a completely random jumble of words and phrases with no meaning.
Mood and Affect
Euthymia refers to a normal and neutral mood, not low or elevated.
Depressed patients have a low mood. They may describe their mood using many terms, such as sad, depressed, numb, flat, hopeless, empty, miserable or terrible. Blunted affect refers to a reduced emotional range (the ability to experience positive and negative emotions).
Manic patients have an elevated mood. This may be described as euphoric, elated or excited. They can also be irritable and have a labile mood (their mood quickly flips from elevated to angry or depressed).
Patients with schizophrenia may display affective flattening (reduced emotional reactions), anhedonia (lack of interest in activities) and avolition (lack of motivation). Their mood may seem odd or incongruent (e.g., appearing happy when describing upsetting events).
Thought
Depressed patients have negative thoughts, such as thoughts of guilt, hopelessness, worthlessness, self-harm and suicide, which they may ruminate on. They may have poverty of ideas, with reduced production of thoughts.
Manic patients often have thoughts of increased self-worth, self-confidence, optimism and grandiose plans. The typical feature is flight of ideas, which refers to rapidly flowing thoughts that jump quickly from one idea to another. There is generally some understandable connection to the flow of ideas. Grandiose delusions (e.g., that they have special powers or special importance) may be present.
Patients with schizophrenia may have delusions (beliefs that are strongly held and clearly untrue) and thought disorder (disorganised thoughts causing abnormal speech and behaviour). This makes the things they say difficult or impossible to follow and understand. Specific examples include:
- Somatic passivity (believing that an external entity is controlling their sensations and actions)
- Thought insertion or thought withdrawal (believing that an external entity is inserting or removing their thoughts)
- Thought broadcasting (believing that others are overhearing their thoughts)
- Persecutory delusions (a false belief that a person or group is going to harm them)
- Ideas of reference (a false belief that unconnected events or details in the world directly relate to them)
- Preoccupations (being focused and absorbed with one thought without being able to move to the next)
- Loosening of associations (no logical association linking one thought to the next)
- Knight’s move thinking (jumping from one thought to another without a logical association or flow)
- Tangentiality (goes off on a tangent from the original topic without returning to that topic)
Perception
Hallucinations (hearing or seeing things that are not real) are abnormal perceptions. These may be found in:
- Psychotic depression
- Mania with psychosis
- Schizophrenia (particularly a voice narrating the person’s actions)
A delusional perception (seen in schizophrenia and psychosis) occurs when the patient experiences an ordinary and unremarkable perception (e.g., a cat crossing the road) that triggers a sudden, often self-related delusion (e.g., “and I knew I would be meeting the aliens on behalf of humanity”).
Cognition
Depressed patients often experience cognitive symptoms like poor concentration, slow thoughts, impaired memory and difficulty learning new things.
Manic patients do not typically have significant cognitive impairment, although their ideas are of lower quality and often disorganised. Cognitive impairment may be difficult to assess accurately, as the patient is easily distracted, excitable, and irritable.
Patients with schizophrenia often have some degree of cognitive impairment (e.g., difficulty with attention and memory), although it may be difficult to assess formally. They are usually oriented to person, place and time unless their delusions affect these details. Significant cognitive impairment or disorientation may suggest an alternative diagnosis (e.g., delirium).
Insight and Judgement
Depressed patients generally have insight into their low mood. They may not realise the severity of their depression. Sometimes, patients may present with other symptoms (e.g., worsening physical symptoms or memory impairment) without realising they are caused by depression. Judgment may be impaired, for example, in a hopeless patient who sees no solution to their problems and no chance of improvement.
Manic patients typically lack insight and have poor judgement. Their poor judgement often leads to issues such as gambling, sexually inappropriate behaviour, excessive spending, aggression and criminal acts.
Patients with schizophrenia typically lack insight and have impaired judgment.
Last updated June 2024
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