The mental state examination 320
Putting it all together: clinical vignettes 325
OSCE example 1: Assessing suicidal risk 327
OSCE example 2: Assessing delirium 328
Integrated examination sequence for the psychiatric assessment 328
320 • The patient with mental disorder
death) or incriminating (illicit drug misuse, other crime, homicidal
ideas). For interviews undertaken in non-clinical settings such as
police stations or prisons, or for the provision of court reports,
the latter is obviously especially pertinent, and it is important to
be clear with the patients about any limits to confidentiality in
Try to develop rapport early in the interview, if possible, and to
consolidate it before raising a sensitive topic, although sometimes
you must cover such material without delay. It is particularly
important to ask about suicidal thoughts.
Adapt your approach to a patient who is mute, agitated, hostile or
otherwise uncooperative during the interview, by relying more on
observation and collateral information. The safety of the patient,
other patients and staff is paramount, so your initial assessment
of an agitated or hostile patient may be only partial.
The mental state examination (MSE) is a systematic evaluation
of the patient’s mental condition at the time of interview. The
aim is to establish signs of mental disorder that, taken with the
history, enable you to make, suggest or exclude a diagnosis.
While making your specific enquiries, you need to observe,
evaluate and draw inferences in the light of the history. This is
daunting, but with good teaching, practice and experience you
The MSE incorporates elements of the history, observation
of the patient, specific questions exploring various mental
phenomena and short tests of cognitive function. Like the history,
its focus is determined by the potential diagnoses. For example,
detailed cognitive assessment in an elderly patient presenting
with confusion is crucial; similarly, you should carefully evaluate
mood and suicidal thoughts when the presenting problem is
Think of this as a written account of a still photograph, prepared
for someone who cannot see it. Observe:
• general elements such as attire and signs of self-neglect
• tattoos and scars (especially any that suggest recent or
• evidence of substance misuse (such as injection tracks
from intravenous drug use; spider naevi and jaundice from
• possibly relevant physical disease (such as exophthalmos
Think of this as a written account of a video, observing such
• cooperation, rapport, eye contact
• social behaviour (such as aggression, disinhibition, fearful
• apparent responses to possible hallucinations or
Mental disorders are very common, frequently coexist with physical
disorders and cause much mortality and morbidity. Psychiatric
assessment is therefore a required skill for all clinicians. It consists
of four elements: the history, mental state examination, selective
physical examination and collateral information. Each element can
be expanded considerably, so the assessment must be adapted
to its purpose. Is it a quick screening of a patient presenting
with other problems, a confirmation of a suspected diagnosis
or a comprehensive review for a second opinion?
The distinction between symptoms and signs is less clear in
psychiatry than in the rest of medicine. The psychiatric interview,
which covers both, has several purposes: to obtain a history of
symptoms, to assess the present mental state for signs, and to
establish rapport that will facilitate further management.
A comprehensive history covers a range of areas (Box 16.1), but
the nature of the presenting problem and/or the referral question,
and the setting in which the history is being taken, will determine
the degree of detail needed for each. When seeing someone in
the accident and emergency department with a first episode of
psychosis, the focus is on symptoms, recent changes of function,
family history and drug use; when interviewing someone in an
outpatient clinic with a possible personality disorder, assessment
concentrates instead on their personal history, which is essentially
a systematised biography (Box 16.2).
Some subjects require particular skill. The common theme is
reluctance to disclose, which can arise because the information
is private, and disclosure is potentially embarrassing (such as
sexual dysfunction, gender identity), distressing (major traumatic
experiences, such as rape, childhood sexual abuse, witnessing a
16.1 Content of a psychiatric history
• History of presenting symptom(s)
• Systematic enquiry into other relevant problems and symptoms
• Past medical/psychiatric history
• Prescribed and non-prescribed medication
• Substance use: illegal drugs, alcohol, tobacco, caffeine
• Family history (including psychiatric disorders)
The mental state examination • 321
any aspect of life, and at interview appear downcast, withdrawn
and tearful, with little brightening even when talking about their
Pervasive disturbance of mood is the most important
feature of depression, mania and anxiety, but mood changes
commonly occur in other mental disorders such as schizophrenia
and dementia. You might ask patients ‘How has your mood
been lately?’, ‘Have you noticed any change in your emotions
recently?’ and ‘Do you still enjoy things that normally give you
pleasure?’ Abnormalities of mood include a problematic pervasive
mood, an abnormal range of affect, abnormal reactivity and
inappropriateness or incongruity. Some terms relating to mood
Some patients prompt affective responses in the interviewer,
via the process of countertransference. The elated gaiety of some
hypomanic patients can be infectious, as can the hopeless gloom
of some people with depression. Recognising these responses in
yourself can be helpful in understanding how the patient relates
As with speech, this is a not an assessment of what the patient
is thinking about, but how they think about it. Assess it by
observing how thoughts appear to be linked together, and the
speed and directness with which the train of thought moves,
considering rate, flow, sequencing and abstraction. Some terms
relating to thought form are defined in Box 16.6.
Thinking may appear speeded up, as in hypomania, or
slowed down, as in profound depression. The flow of subjects
• over-activity (agitation, pacing, compulsive hand washing)
• under-activity (stupor, motor retardation)
• abnormal activity (posturing, involuntary movements,
This is not a description of what the patient says (that is, content),
but of how they say it (form). Assess:
• articulation (such as stammering, dysarthria)
• quantity (mutism, garrulousness)
• volume (whispering, shouting)
• tone and quality (accent, emotionality)
• fluency (staccato, monotonous)
• abnormal language (neologisms, dysphasia, clanging,
Mood is the patient’s pervasive emotional state, while affect is the
observable expression of their emotions, which is more variable
over time. Think of mood as the emotional climate and affect
as the weather. Both have elements of subjective experience
(that is, how the patient feels, according to their own report and
your specific questions) and how the patient appears to feel,
according to your own objective observation. So a depressed
patient might describe feeling sad, hopeless and unable to enjoy
Agitation A combination of psychic anxiety and excessive,
Compulsion A stereotyped action that the patient cannot
Disinhibition Loss of control over normal social behaviour
Motor retardation Decreased motor activity, usually a combination
Posturing The maintenance of bizarre gait or limb positions
Clang associations Thoughts connected by their similar sound
Echolalia Senseless repetition of the interviewer’s words
Mutism Absence of speech without impaired
Neologism An invented word, or a new meaning for an
Pressure of speech Rapid, excessive, continuous speech (due to
Word salad A meaningless string of words, often with loss
Blunting Loss of normal emotional sensitivity to experiences
An extreme emotional and behavioural over-reaction
Flattening Loss of the range of normal emotional responses
Incongruity A mismatch between the emotional expression and
Lability Superficial, rapidly changing and poorly controlled
16.6 Thought form: definitions
Circumstantiality Trivia and digressions impairing the flow but
Concrete thinking Inability to think abstractly
Flights of ideas Rapid shifts from one idea to another,
Logical sequence of ideas impaired. Subtypes
include knight’s-move thinking, derailment,
thought blocking and, in its extreme form,
Perseveration Inability to shift from one idea to the next
Pressure of thought Increased rate and quantity of thoughts
322 • The patient with mental disorder
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
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