Mental Status Examination

Question 1

ASEPTIC

Answer 1

A : Appearance and Behaviour
S : Speech
E : Emotion ( Mood and Affect )
P : Perception
T : Thoughts ( Thoughts process and thought content )
I : Insight and Judgement
C : Cognition ( Orientation, Memory, Concentration, General Knowledge and Abstract Reasoning )

Question 2

Appearance and Behaviour

Answer 2

• Describes the prominent physical features of an individual
• Highlights his / her unique aspects
• Basic physical characteristics/ Demographics

1. Age
2. Height
3. Build
4. Race
5. Gender
6. Clothes

Question 3

Appearance ( observed )

Answer 3

1. Dressing
   ( type and apprioprateness )
   ( lifestyle, ability to self care, thought disorganized )
2. Grooming : Hair, makeup, nails
3. Hygiene : good or poor? unkempt or dishevelled
4. BMI : appetite
5. Prominent physical abnormalities : scars ( e.g. over the wrist) , tattoos
6. Gait : shuffling, rigid ( toy soldier )
   - medication side-effects, substance abuse
7. postures : tense

Question 4

Behaviour ( Observed )

Answer 4

• Eye contact: poor, good, piercing…
• Facial expression: hostile
• Attitude
• Cooperative, open, guarded, friendly, seductive,
hostile, suspicious, apathetic, easily distracted,
defensive, etc.

• Psychomotor activity:
• normal, reduced, excessive? i.e.
retardation/agitation/ hand wringing/ pacing/
ability to follow commands

• Movements: abnormal movements, e.g. tremors/
stereotypies
• Abnormal behaviours: MTH, TTH, STH, Social
withdrawn

Question 5

Clinical examples

appearance and behaviour

Answer 5

• People with psychosis such as schizophrenia
may be poorly groomed or dressed in bizarre
manner

• Depressed person may show decreased
psychomotor activity

• Swollen neck may be evidence of
hypothyroidism and perspiration may be
evidence of hyperthyroidism- both of which can
have mental status findings

• Confused behavior can point to cognitive
deficits

Question 6

Speech ( observed )

Answer 6

• Rate: normal, slow, fast, pressured
• Tone of Voice: normal, monotonous, tremulous
• Fluency and Rhythm: normal, slurred, clear, hesitant, with
appropriately placed inflections, with good articulation
• Volume: normal, loud, soft, whispered, yelling, inaudible
• Quantity: spontaneous (normally responsive to cues),
talkative, poverty, repetitive, expansive

Question 7

Emotion ( Mood )

Answer 7

It’s patient’s words describing his/her sustained internal emotional state.

• How do we assess ?
• ask pt questions:
• “How are you feeling?”
• “What is your current mood?”
• place pt’s responds in quotes:
• “ I’m happy” “Good” “Happy” “Sad”
• How do rate the mood?
• rate on a scale (1-10)

Question 8

Emotion ( Affect )

Answer 8

An observed expression of inner feeling

• Appropriateness to situation/congruence with mood

• mood congruent vs. mood incongruent
• Quality: euthymic (normal), depressed, euphoric
(elevated, elated), anxious, angry, etc…
• Range: broad (full) vs. restricted
• Intensity: Blunted, flat
• Stability: stable vs. labile (Fluctuations)

Question 9

Perception

Answer 9

• Hallucinations: perceptual experiences with no
external stimuli (totally imagined sensory
perceptions)

• Auditory (i.e., hearing noises or voices that nobody else
hears);

• can be accusatory, threatening or commanding

• Visual (i.e., seeing objects that are not present);
• Tactile (i.e., feeling sensations when there is no stimulus
for them);
• Gustatory (i.e., tasting sensations when there is no
stimulus for them);
• Olfactory (i.e., smelling odors that are not present).

Question 10

Perception

Answer 10

•Illusions: misinterpretation of
sensory stimuli

•Delusion: False belief not based
in reality

•Obsessions: recurrent
persistent unwanted thoughts,
impulses, images

Question 11

Thought ( thought process & thought content )

Answer 11

• Refers to how the patient thinks.
• Normal: tight, logical and linear,
  coherent and goal directed
• Abnormal: associations are not clear/ organized/ coherent.

Question 12

Example of loose associations

Answer 12

• Loose Associations: Disorganized thoughts- unlinked thoughts,
jumps from one idea to another

“I always liked geography. My last teacher in that subject was
Professor August A. He was a man with black eyes. I also like black
eyes. There are also blue and grey eyes and other sorts, too…”

“The problem is insect; my brother used to collect insects; he’s
now a man 5 foot 10 inches; you know 10 is my favorite number; I
also like to dance, draw, and watch TV.”

Question 13

Example of tangential

Answer 13

• Tangential: move from thought to thought that relate in some way but never get to the point

“I really got mad as I was waiting in line at the grocery
store. I cannot stand lines. Waiting and waiting. I waited for a
long time to get my driver’s license. Driving these days is just
crazy.“

Question 14

Example of circumstantial

Answer 14

• inability to differentiate the essential from the non-essential.
• provide unnecessary detail but eventually get to the point

Question: “What is your name?”
Response: “Well, sometimes when people ask me I have to think
about whether or not I will answer because some people think it’s
an odd name even though I don’t really because my mom gave it
to me and I think my dad helped but it’s as good a name as any in
my opinion but yeah it’s Tom.”

Question 15

Example of flight of ideas

Answer 15

• Flight of Ideas: rapid jumping from idea to idea but with
understandable & often tenuous associations/frequent shifts in
conversation topics
• Involves continuous, rapid speech that changes focus from moment to
moment based on association, distractions, or plays on words.

• A person experiencing flight of ideas, for example, might deliver a 10-minute
monologue during which he or she jumps from talking about childhood, to a
favourite advertisement, to a moment of distorted body image, to political
ideology, concluding with a rant about his or her favourite flower.

Question 16

Flight of ideas

Answer 16

• Pressured speech: continuous, excessive, rapid, loud, and sometimes
incoherent speech that is difficult to interrupt and may continue even when no
one is listening, often seen in manic episodes

• Clang associations: thoughts associated by the sound of words in-
stead of meaning, and the patient uses rhyming and punning.

• “I fell down the well sell bell.”

Question 17

Thought content ( inquired / observed )

Answer 17

• Refers to what the patient thinks and talks about
• Verbalizations

• Including:
• Delusions- fixed, false & unshakeable beliefs,
not congruent with patient’s culture
• Obsessions- recurrent persistent unwanted
thoughts, impulses, images
• Suicidal & Homicidal thoughts
• Phobias- intense unreasonable fear leading
avoidance of feared object
• Déjà Vu- sense of familiarity with a new
perception

Question 18

Delusion ( Grandiose )

Answer 18

inflated sense of self-worth, power or wealth

Question 19

Delusion ( Persecutory )

Answer 19

others are trying to cause harm
- most common
- often referred to as a paranoid delusion, but that is a misuse of the word
paranoid, which is a more generic in meaning and does not imply a specific
type of delusion.

Question 20

Delusion ( Erotomania )

Answer 20

a person, usually of higher status, is in love with the patient

Question 21

Delusion ( Somatization )

Answer 21

has a physical defect

Question 22

Ideas of reference:

Answer 22

inaccurate interpretation that general events are personally
directed to his/her, such as a belief that something an announcer is saying on
the television is actually a coded message intended for the patient.

Question 23

Ideas of influence:

Answer 23

similar in that the patient may believe that somehow they
caused an unrelated event to happen (for example, believing that through one’s
will, one was able to cause an accident, even though one was not directly
involved in any way).

Question 24

Thought broadcasting:

Answer 24

belief that others can hear or know what he/she is

thinking

Question 25

Thought insertion:

Answer 25

belief that others putting ideas or thoughts into his head

Question 26

Though withdrawal

Answer 26

belief that others are taking his thoughts away and he is

powerless to stop it

Question 27

Suicide ideation

Answer 27

Existing Suicidal Ideation
• Urge (passive or active)
• Plan (how & when)

Denies suicidal ideation
• Hidden thoughts
• Close observation

Question 28

Insight and judgement

Answer 28

• Awareness of one’s own illness and/or situation

• Examples:
• “What brings you here today?”
• “What do you think is causing your
problems?”

• Intact (full), Impaired (partial), No insight (poor)

Question 29

Clinical examples : Insight

Answer 29

• Insight is often lacking with schizophrenia
and other psychotic states but this is not
always the case. Similarly patients with
organic impairment such as delirium and
dementia may have absent or diminished
insight.

• Insight can be described on a relative scale
with terms such as absent, limited, poor fair
and good

Question 30

Judgement

Answer 30

• An estimate of the patient’s real-life problem-solving skills.
• Is the patient realistic about limitations and life circumstances?
• The ability of cooperate with treatment?

• Examples
• “What would you do if you found your home gas stove is
switched on upon return?”
• “If you found a stamped, addressed envelope on the street,
what would you do with it?”
• “If you were in a movie theater and smelled smoke, what would
you do?”

Question 31

Clinical examples : judgement

Answer 31

• Judgement is regularly impaired in
dementia, delirium and psychosis including
schizophrenia as well as at times with
mental retardation

• Assessment of judgement helps determine
the patient’s capacity for independent
functioning

• When mental illness is shown to impair a
patient’s judgment so he/she is not capable
of signing a consent form or handling
finances, the court will declare a patient as
“ incompetent” for that task

Question 32

Cognition

Answer 32

• Level of consciousness (observed) (IMH)
• Vigilant, alert, drowsy, lethargic, stuporous, asleep,
comatose, confused, fluctuating.

• Orientation (inquired)
• Time: what year/month/day/time is it?
• Place: what city/building/floor/room are you in?
• Person: what’s your full name? when were you born?

Question 33

Concentration (inquired/observed)

Answer 33

• the ability to focus, sustain and appropriately shift mental attention

o Spelling Backwards – “World”
“Spell the word ‘world.’ Now spell the word ‘world’ backwards.”

o Calculations
o (Serial 7’s) “Starting with 100, subtract 7 from 100, and then keep
subtracting 7 from that number as far as you can go.”
o (Serial 3’s) “Starting with 20, subtract 3 from 20, and then keep subtracting 3
from that number as far as you can go.”
o Consulate money (marketing)
o Monitor for speed, accuracy, effort required, and monitor patient reactions
to the request

• MMSE

Question 34

Memory (Inquired)

Answer 34

• Immediate Memory
• “I am going to ask you to remember three words (color, object, animal – e.g.,
blue, table, and horse) and I will ask you to repeat them to me in 5 minutes.
Please repeat them now after me: blue, table, and horse.” – 5 minutes elapse –
“What were those three words I asked you to remember?”

• Recent Memory
• “What medications did you take this morning ?”
• Remote Memory
• “What were the dates of your graduation from secondary school/Poly/JC?”
• “When and where did you get married?”

Question 35

General Knowledge (Inquired/Observed)

Answer 35

• Must consider a person’s educational level.
• P6 level
• ? the current PM/ ? the current President

Question 36

Abstract Reasoning(inquired/observed)

Answer 36

• The ability to mentally shift back and forth between general
concepts.
• Can use metaphor/ proverbs
• “How would you describe the meaning of the following
sayings?”
“Rolling stone collects no moss”
• Can use description of two related objects
• Similarities – “How are the following items similar?”
• “an apple and an orange”
• “a chair and a table”

Question 37

Clinical Examples : Cognition

Answer 37

• Disorientation for time and place are usually
due to delirium but can occur with severe
dementia

• Disorientation for person is unusual even in
dementia and malingering should be suspected.
Rare case of dissociative state is possible.

• Disturbances of attention, concentration,
immediate and short-term memory is usually
due to delirium and can be characterized by
fluctuations.

• Recent memory is more severely impaired than
remote memory in dementia and persist when
there is no delirium