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
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