The main difference between them is that delusions either
lack a cultural basis for the belief or have been derived from
abnormal psychological processes.
These are usually beliefs of great personal significance. They
fall short of being full delusions but are abnormal because of
their effects on a person’s behaviour or wellbeing. For example,
in anorexia nervosa, people may still believe they are fat when
they are seriously underweight – and then respond to their belief
rather than their weight, by further starving themselves.
These beliefs also matter greatly to the person, resulting in
powerful emotions and important behavioural consequences;
they are always of clinical significance. They are classified by
• of thought interference (broadcasting, insertion and
Bizarre delusions are easy to recognise, but not all delusions
are weird ideas: a man convinced that his partner is unfaithful
may or may not be deluded. Even if a partner were unfaithful,
it would still amount to a delusional jealousy if the belief were
held without evidence or for some unaccountable reason, such
as finding a dead bird in the garden.
may be understandable but unusually rapid, as in the flight of
ideas that characterises hypomania, or unduly ‘single track’ and
perseverative, as in some cases of dementia. Sometimes thinking
appears to be very circumstantial, and the patient hard to pin
down, even when asked simple questions.
More severe disruption of the train of thought is termed
loosening of associations or formal thought disorder, in which
the patient moves from subject to subject via abrupt changes of
direction that the interviewer cannot follow. This is a core feature
of schizophrenia. Concrete thinking, in the sense of difficulty
handling abstract concepts, is a common feature of dementia,
and can be assessed by asking the patients to explain the
It may help to illustrate your assessment with verbatim examples
from the interview, chosen to illustrate the patient’s manner of
Thought content refers to the main themes and subjects occupying
the patient’s mind. It will become apparent when taking the history
but may need to be explored further via specific enquiries. It
may broadly be divided into preoccupations, ruminations and
abnormal beliefs. These are defined in Boxes 16.7 and 16.8.
Preoccupations occur in both normal and abnormal mood states.
Sadly dwelling on the loss of a loved one is entirely normal in
bereavement; persisting disproportionate guilty gloom about the
state of the world may be a symptom of depression.
These are preoccupations that are in themselves abnormal –
and therefore symptoms of mental disorder – by reason of
repetition (as in obsessional disorders) or groundlessness (as
These beliefs fall into two categories: those that are not diagnostic
of mental illness (such as overvalued ideas, superstitions and
magical thinking) and those that invariably signify mental illness
16.7 Thought content: definitions
Hypochondriasis Unjustified belief in suffering from a particular
disease in spite of appropriate examination and
Morbid thinking Depressive ideas, e.g. themes of guilt, burden,
unworthiness, failure, blame, death, suicide
Phobia A senseless avoidance of a situation, object or
activity stemming from a belief that has caused
Preoccupation Beliefs that are not inherently abnormal but which
have come to dominate the patient’s thinking
Ruminations Repetitive, intrusive, senseless thoughts or
Obsessions Ruminations that persist despite resistance
16.8 Abnormal beliefs: definitions
Delusion An abnormal belief, held with total conviction, which
is maintained in spite of proof or logical argument to
the contrary and is not shared by others from the
A delusion that arises fully formed from the false
interpretation of a real perception, e.g. a traffic light
turning green confirms that aliens have landed on
An irrational belief that certain actions and outcomes
are linked, often culturally determined by folklore or
custom, e.g. fingers crossed for good luck
Beliefs that are held, valued, expressed and acted
on beyond the norm for the culture to which the
The belief that the patient’s thoughts are heard by
The belief that thoughts are being placed in the
The belief that thoughts are being removed from the
The mental state examination • 323
when going to sleep (hypnagogic) or waking up (hypnopompic).
Hallucinations are categorised according to their sensory modality
as auditory, visual, olfactory, gustatory or tactile.
Any form of hallucination can occur in any severe mental
disorder. The most common are auditory and visual hallucinations,
the former associated with schizophrenia and the latter with
delirium. Some auditory hallucinations are characteristic of
schizophrenia, such as voices discussing the patient in the
third person or giving a running commentary on the person’s
activities (‘Now he’s opening the kitchen cupboard’). Ask, for
example, ‘Do you ever hear voices when nobody is talking?’
Pseudohallucinations are common. The key distinction from
a true hallucination is that they occur within the patient, rather
than arising externally. They have an ‘as if’ quality and lack the
vividness and reality of true hallucinations. Consequently, the
affected person is not usually distressed by them, and does
not normally feel the need to respond, as often happens with
If the history and observation suggest a cognitive deficit, it must
be evaluated by standard tests. History, observation, MSE and
rating scales (see later) are then used together to diagnose and
distinguish between the ‘3Ds’ (dementia, delirium and depression),
which are common in the elderly and in hospital inpatients.
Core cognitive functions include:
Mental disorders are rarely associated with a reduced (or clouded)
level of consciousness, such as drowsiness, stupor or coma.
The exception is delirium (which is both a physical and a mental
disorder), where it is common.
This is a key aspect of cognitive function, being particularly
sensitive to impairment. Disorientation is the hallmark of
the ‘organic mental state’ found in delirium and dementia.
Abnormalities may be evident during the interview but some
patients are adept at hiding them in social interactions. Check
the patient’s orientation to time, place and person by evaluating
their knowledge of the current time and date, recognition of
where they are, and identification of familiar people.
Memory function is divided into three elements:
• Registration is tested by asking the patient to repeat after
you the names of three unrelated objects (apple, table,
penny); any mistake is significant. Alternatively, in the digit
span test, ask the patient to repeat after you a sequence
of random single digit numbers. Make sure you speak
slowly and clearly. A person with normal function can
• Short-term memory (where short-term is defined as a
matter of minutes) is tested by giving the patient some
Delusions can sometimes be understood as the patient’s way
of trying to make sense of their experience, while the content of
the delusions often gives a clue that may help type the underlying
illness: for example, delusions of guilt suggest severe depression,
whereas grandiose delusions typify mania.
Some delusions are characteristic of schizophrenia. They
include a delusional perception (or primary delusion) and ‘passivity
phenomena’: namely, the belief that thoughts, feelings or acts
are no longer controlled by a person’s own free will.
People normally distinguish between their inner and outer worlds
with ease: we know what is real, what reality feels like, and what
resides in our ‘mind’s eye’ or ‘mind’s ear’. In mental illness this
distinction can become disrupted, so that normal perceptions
become unfamiliar, while abnormal perceptions seem real.
Abnormal perceptions are assessed via the history and specific
enquiries, backed up by observation. They fall into several
categories, defined in Box 16.9.
Perceptions may be altered (as in sensory distortions or illusions)
or false (as in hallucinations and pseudohallucinations). In a third
category, what is altered is not a perception in a specific sensory
modality but a general sense of disconnection and unreality
in oneself (depersonalisation), the world (derealisation) or both.
People find depersonalisation and derealisation intensely
unpleasant but hard to describe. They may occur in association
with severe tiredness or intense anxiety but can also arise in most
types of mental illness. Ask, for example, ‘Have you ever felt that
you were not real or that the world around you wasn’t real?’
With altered perceptions there is a real external object but its
subjective perception has been distorted. Sensory distortions,
such as unpleasant amplification of light (photophobia) or sound
(hyperacusis), can occur in physical diseases, but are also
common in anxiety states and drug intoxication or withdrawal.
Diminution of perceptions, including pain, can occur in depression
Illusions, in which, for example, a bedside locker is misperceived
as a threatening animal, commonly occur among people with
established impairment of vision or hearing. They are also found
in predisposed patients who are subjected to sensory deprivation,
notably after dark in a patient with clouding of consciousness.
They are suggestive of an organic illness such as delirium,
dementia or alcohol withdrawal.
True hallucinations arise without external stimuli. They usually
indicate severe mental illness, although they can occur naturally
Depersonalisation A subjective experience of feeling unreal
Derealisation A subjective experience that the surrounding
Hallucination A false perception arising without a valid
stimulus from the external world
Illusion A false perception that is an understandable
misinterpretation of a real stimulus in the
Pseudohallucination A false perception that is perceived as part
324 • The patient with mental disorder
be neither overstated nor ignored. Any others at risk are most
likely to be family or, less commonly, specific individuals (such
as celebrities in cases of stalking) or members of specific groups
(defined by age, ethnicity, occupation and so on). Sometimes the
risk applies non-specifically to strangers, or to anyone preventing
the patient from achieving their goals.
There may be direct risk to life and limb (as in suicide, self-harm
or violence to others), or it may be an indirect risk, either to health
(through refusal of treatment for physical or mental illness) or
welfare (through inability to provide basic care – food, warmth,
shelter, hygiene – for oneself or one’s dependents). The risk may
be imminent, as in a patient actively attempting self-harm, or
remote, as in a patient refusing prophylactic medical treatment.
Direct risks tend to be imminent and indirect risks remote, although
this is not always so. A patient declining renal dialysis because
their depression makes them feel unworthy is at imminent but
indirect risk of death. Finally, the likelihood of the risk may range
from near certainty to hypothetical possibility.
A risk assessment should readily distinguish between cases
where there is an imminent, direct and near-certain risk to the
patient’s life (such as a man actively trying to throw himself from
the window to escape delusional persecutors), and those where
any risks apply to the welfare of other people, at some point
in the future, and amount to possibilities (such as a depressed
woman who may be neglecting her frail elderly father). The former
case calls for urgent intervention, probably via mental health
legislation; the latter requires engagement over time, preferably
While all psychiatric evaluations require some assessment of
risk, it should be considered in depth whenever the presentation
includes acts or threats of self-harm or reports of command
hallucinations, the past history includes self-harm or violent
behaviour, the social circumstances show a recent, significant
loss, or the mental disorder is strongly associated with risk (as
Assessing suicidality is the element of risk assessment that is
most often needed. If a patient presents after an act of self-harm
or overdose, the questions arise naturally (‘What did you want
to happen when you took the tablets? Did you expect to die?
Is that what you wanted? How do you feel about that now? Do
you still feel you’d be better off dead? Have you had thoughts
about doing anything else to harm yourself?’).
In other circumstances the subject will need to be introduced,
but do not fear that you may be putting ideas in the patient’s
mind (‘You’ve told me how bad you have been feeling. Have
you ever felt life is not worth living? Have you had any thoughts
about ending your life? How close have you come? What has
stopped you acting on those thoughts so far?’).
Assessing capacity is a skill required of all doctors and should not
be delegated to psychiatrists. The legal elements vary between
jurisdictions but there are key clinical principles in common.
The first is the presumption of capacity: clinicians should treat
patients as retaining capacity until it is proven that they have lost
it. Secondly, capacity is decision-specific: patients may not be
able to understand the risks and benefits of complex medical
treatment options, while retaining the ability to decide whether
or not to enter a nursing home. Thirdly, residual capacity should
be maximised: if a patient’s ability to understand is impaired by
sensory deficits or language barriers, these should be corrected
new information; once this has registered, check retention
after 5 minutes, with a distracting task in between. Do the
same with the names of three objects; any error is
significant. Alternatively, use a six-item name and address
(in the format: Mr David Green, 25 Sharp Street, Durham).
More than one error indicates impairment.
• Long-term memory is assessed mainly from the personal
history. Gaps and mistakes are often obvious but some
patients may confabulate (that is, fill in the gaps with
plausible but unconsciously fabricated facts), so check the
account with a family member or other informant if
possible. Confabulation is a core feature of Korsakoff’s
syndrome, a complication of chronic alcoholism. Failing
long-term memory is characteristic of dementia, although
this store of knowledge can be remarkably intact in the
presence of severe impairment of other cognitive functions.
Impaired attention and concentration
These occur in many mental disorders and are not diagnostic.
Impaired attention is observed as increased distractibility, with
the patient responding inappropriately to intrusive internal events
(memories, obsessions, anxious ruminations) or to extraneous
stimuli, which may be either real (a noise outside the room) or
unreal (auditory hallucinations).
Concentration is the patient’s ability to persist with a mental
task. It is tested by using simple, repetitive sequences, such as
asking the patient to repeat the months of the year or days of
the week in reverse, or to do the ‘serial 7s’ test, in which 7 is
subtracted from 100, then from 93, then 86 and so on. Note
the finishing point, the number of errors and the time taken.
This is estimated clinically from a combination of the history
of educational attainment and occupations, and the evidence
provided at interview of vocabulary, general knowledge, abstract
thought, foresight and understanding. If in doubt as to whether
the patient has a learning disability, or if there is a discrepancy
between the history and presentation, a psychologist should
Insight is the degree to which a patient agrees that they are
ill. It can be broken down into the recognition that abnormal
mental experiences are in fact abnormal, agreement that these
abnormalities amount to a mental illness, and acceptance of the
need for treatment. Insight matters, since a lack of it often leads
to non-adherence, and sometimes to the need for compulsory
detention. You might ask ‘Do you think anything is wrong with
you’ or ‘If you are ill, what do you think needs to happen to
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