MENTAL STATUS EXAMINATION TECHNIQUES and PSYCHIATRIC

ASSESSMENT

Note:

1. A MENTAL STATUS EXAM is part of a psychiatric/mental health assessment. The mental

status exam focuses on the client’s current functioning in a variety of areas. However, a
complete assessment also adds pertinent medical and psychiatric history, coping skills or
assets, and other components that are not part of a mental status exam.
2. The examiner conducts the mental status exam via direct interview and observation; content
from staff, family, and/or the chart can be incorporated into the assessment otherwise, e.g.
as history, but should not be used to complete the mental status portion of the assessment
unless the data is otherwise unavailable, e.g. (“Pt refuses to respond when asked about
suicidal ideation and intent, but his father reports that he found the pt poised to cut his wrists
with a piece of broken glass on 6/12/2010, and noted that the pt has been despondent since
breaking up with his girlfriend on 6/2/10, which followed being laid off from his job on
5/30/2010”.
3. SIGNIFICANT FINDINGS SHOULD BE DISCUSSED AS APPROPRIATE. E.g. if the patient is
experiencing command hallucinations, discuss their implications for pt safety, needed
discharge precautions, patient and family teaching, etc. Other examples of findings meriting
further discussion include other risk issues, impact of treatment non-adherence, lack of
support systems or insight, etc.
4. IT IS IMPORTANT TO VALIDATE YOUR FINDINGS AS MUCH AS POSSIBLE. Pts may deny
symptoms or loss of function d/t anosognosia (the inability to recognize one’s own illness),
denial, or a desire to present themselves in a more positive light. Issues such as substance
abuse or risk to self are not infrequently minimized or concealed. Therefore the examiner
should note whether the pt’s reports are consistent or inconsistent with his behavior and
other indicators. E.g. “Pt denies hallucinations but is observed whispering to self and appears
to be responding to internal stimuli” or “Pt denies and does not evidence hallucinations”. This
is especially important for data that is more likely to be misrepresented and/or data that is
more critical to safety or treatment (e.g. suicidality). It may also be helpful to note when there
are conflicts between the pt’s reports and those of others such as staff or reliable family, even
when the examiner does not himself observe the contradiction.
5. AVOID USE OF SUBJECTIVE ADJECTIVES SUCH AS “NORMAL”; instead, describe what
you observe. E.g. instead of “Affect is normal”, one could note that “Affect is appropriate for
the circumstances, euthymic, and without lability”. Other descriptors that are often used in
cases where no abnormalities are noted include: “(function) is intact”, “(function) is
unremarkable”, “Pt does not evidence (abnormal function)”.
6. Be alert for the influence of culture. A pt who is homeless, frequently hungry, and
without any income might well respond differently than one who is financially or residentially
stable when his judgment is tested (e.g. . he might keep some of the money in a found
wallet).
7. For each category of assessment, note both the presence and the absence of
dysfunction or symptoms. If one mentions only that some symptoms are present but does
not note that others are absent, the reader cannot know for certain if other possible
symptoms were absent or simply overlooked by the examiner. E.g. “Pt demonstrated flight of
ideas but did not demonstrate looseness of associations, referentiality, magical thinking, or
cognitive slowing’

MENTAL STATUS ASSESSMENT TECHNIQUES

Data or Function Examples of Assessment Options

1. Reason for admission (chief “What led to you being in the hospital?” “Tell me about how
complaint) you came to be admitted here.” “What events led to your
admission?”
2. General Description/Physical Observe pt’s appearance: describe pt’s apparent vs. actual
appearance age; dress (casual vs. formal, clean vs. unclean, appropriate
for the weather vs. not, etc); grooming and hygiene (well-
kempt vs. unkempt, presence or absence of body odor); body
modifications (piercings, tattoos, intentional scarring); visible
deformities, scars, lesions; anything else that is unusual or
notable about the patient’s appearance.
3. Posture Observe Pt’s position, gestures, and other remarkable motor
behavior. Possible descriptors include unremarkable, stiff,
rigid, erect, slumped, bizarre, posturing (describe), etc.
4. Facial expression Observe the dominate expression on the pt’s face; possible
findings include unremarkable, impassive, expressionless,
labile, grimacing, hypervigilant, etc
5. Eye contact Observe; possible descriptors include direct, minimal,
piercing, sustained, intermittent, etc.
6. Motor activity Observe behavior; possible findings include: unremarkable,
motor retardation, lethargic, motor restlessness, increased
muscular tension, tics, posturing, tremors, unusual gestures
or mannerisms, repetitive motions, compulsive actions,
echopraxia
7. Relatedness to interviewer Observe manner and comfort r/t how pt relates to and
interacts with the examiner. Possible findings include:
pleasant, friendly, open vs. closed body posture, withdrawn,
reticent, resistant, inappropriate r/t roles and boundaries
(describe, e.g. seductive), suspicious, guarded, angry, hostile,
resistant, shy, negativistic, cooperative vs. uncooperative,
apathetic, defensive
8. Affect Observe apparent emotional tone and display of emotion in
the present moment. Possible findings: constricted,
expansive, stable, labile, flat, blunted, hyperreactive,
congruent or incongruent with thoughts/situation, tearful,
laughing, etc.
9. Mood Ask pt to describe his prevailing mood/emotion at the present
time. Possible finding findings/descriptors include: euthymic,
dysthymic, dysphoric, euphoric, sad, anxious, fearful, angry,
empty, sad/depressed, hopeless, despairing, etc
10. Orientation Ask pt his name, the date, his location, and the situation he is
in. If he does not know the date, ask for the day of the week;
if unable to provide the day, ask for the month, and if
unsuccessful ask for the season; ask for the year in all cases.
Describe the pt’s orientation to time, place, person, situation,
including quoted responses if disoriented.
11. Level of Consciousness Observe the pt’s degree of consciousness. Possible findings
include: Unremarkable; fully alert; mild; moderately, or
severely impaired; appears tired; readily falls asleep unless
stimulated; difficult to awaken; etc
12. Memory Observe for indications of impaired memory (does or does not
recognize examiner on subsequent visits; does or does not
recall topic of recent interactions, groups, TV programs;
cannot find way back to room; becomes lost when driving in
once-familiar surroundings; etc). Test recent memory by
naming three common objects (e.g. cat, ball, dog), having pt
repeat these, and then asking pt to recall these at 5 minutes
and 15 minutes. Test remote memory by asking pt to recall
events to which pt was exposed or had knowledge of, and
that are known to the examiner; e.g. pt’s previous address,
mother’s maiden name, past three employers, first girlfriend,
 first pet, etc. Describe the findings, e.g. “Remembers three of
five objects at five minutes”. Other descriptors include: Intact;
mildly, moderately, or severely/grossly impaired; etc
13. Concentration and Attention Observe the pt’s ability to concentrate and maintain focus
and attend to the interaction and environment. Test the pt’s
ability to concentrate by asking him to serially subtract seven
from 100, or to spell a common 6-8 letter word in reverse
(e.g. “world”); if the pt is unable to complete serial sevens,
ask him to subtract 3 from 20 and continue to serially
subtract 3 from each result. Possible findings include:
Unremarkable; mild; moderately, or severely impaired; lacks
alertness; hyperalert; appears tired; minimally responsive;
easily or readily distracted; maintains focus; returns
spontaneously to previous topic when interrupted; etc
14. Abstract vs. Concrete Thinking Ask pt to interpret a proverb such as “The grass is always
greener on the other side of the fence” or “Strike while the
iron is hot”. The proverb should be familiar to the pt if
possible. If pt is unable to respond to proverbs, observe for
situations wherein the pt demonstrates concrete thinking vs.
the ability to think abstractly. Describe the pt’s response or
your related observations.
15. Judgment Ask pt to describe how he would respond to a hypothetical
situation wherein a decision is required; the situation should
be one that any person might encounter. E.g. “What would
you do if you were at home (in your apt, room, etc) and you
smelled smoke?” or “What would you do if you found a wallet
on the sidewalk?” If the pt is unable to respond to this inquiry,
observe and describe judgment that is apparent in decisions
made recently. Note whether judgment is intact or impaired,
briefly describing the pt’s response or other data on which
your conclusions are based.
16. Insight Assess the pt’s understanding and appreciation of his illness,
symptoms, treatment and related events/experiences. Ask
the pt to describe the reason for his coming to the attention
of treatment staff and compare it to the facts. Ask the pt what
he believes is wrong vs. what staff or family believe is wrong,
and to discuss his beliefs about any variances that might exist
in the differing perspectives. Ask the pt what he feels is
wrong and what he feels would most be helpful. Validate your
findings by inquiring for any incongruent data such as
medication nonadherence in a pt who reports that he has a
mental illness and needs to take his meds. Summarize
findings as “judgment intact” or “judgment mildly
(moderately, grossly) impaired”, adding a brief description of
the pt indicators upon which your conclusions are based.
17. Speech Observe the pt’s speech characteristics and patterns. Possible
findings include: rate unremarkable, rapid, slow; soft vs. loud;
impoverished (poverty of speech) vs. spontaneous (fluent) vs.
verbose; fragmented; pressured; etc
18. Thought Content Ask the pt what he tends to think about, what thoughts he
may have had that were troubling or unusual, what issues
concern him most, and other questions that focus on the
content of his thoughts. Observe and note the predominant
trends and preoccupations (content or topics that prevail, or
basic themes that pervade various topics, such as loneliness
or mistrust); document fears, fantasies, dreams, ambitions,
optimism, pessimism, obsessions, phobias, etc. Note any
 depressive characteristics such as self-deprecation, negative
thinking, self-criticism, etc. Note grandiose themes or
elements such as unrealistic plans or preoccupation with
actual or desired wealth, power or success. Note delusional
thinking (false beliefs held despite evidence to the contrary)
and document examples, noting the type. Also note the
presence or absence of ideas of reference, thought
broadcasting, thought insertion, magical thinking, etc.
19. Thought Process Observe the pt’s thought processes as evident in speech and
behavior. Note whether the thought processes are logical,
coherent vs. incoherent, well-organized or disorganized. Note
also the presence or absence of circumstantial or tangential
thinking, neologisms, flight of ideas (FOI), looseness of
associations (LOA), perseveration, confabulation, thought
blocking, word salad, etc.
20. Perceptions Elicit the pt’s perceptions via interview; possible questions
include “Do you ever see or hear things that other others
might now see?” or “Tell me what you are experiencing now”
(used especially when the pt appears to be responding to
internal stimuli). If the pt reports hallucinations, note whether
he perceives them as being inside his head (e.g. self-talk,
which is not really a hallucination), or as coming from outside
(which is more typical of hallucinations). Note that if one asks
“Do you ever hear voices?”, a pt may respond positively
simply because they assume you mean internal self-talk;
specifying “voices that others do not hear” can help avoid this
problem.
Observe for behavior suggestive of hallucinatory activity:
turning the head as if to attend to sounds from a particular
direction, suddenly stopping mid-sentence or mid-activity (as
if interrupted by an unseen person or other perception), lips
moving, talking when alone (as if to unseen others, which pts
may do mostly when they do not believe they are being
observed), inappropriate affect (that is incongruent with the
external circumstances, but might reflect internal stimuli),
etc.
Inquire as to whether the pt experiences the hallucinations as
persistent or intermittent, intrusive or in the background, and
disruptive or able to be ignored. Determine the content and
themes of the hallucinations: e.g. are they comforting or
accusatory or condemning, or do they provide a running
commentary on the pt’s activity or environment? Assess for
patterns in the pt’s experience: do they tend to occur or
worsen at certain times or under certain circumstances (e.g.
when the pt is alone or fearful)? Attempt to place them on a
timeline: determine when they occurred or worsened, and
what circumstances preceded the perceptions.
IN ALL CASES WHEREIN AUDITORY HALLUCINATIONS ARE
PRESENT OR SUSPECTED, DETERMINE IF COMMAND
HALLUCINATIONS ARE PRESENT (“Tell me what you hear”). If
command hallucinations are present, assess the pt’s response
to these: “What do you do when you hear a voice telling you
to take an action?” or “What would you do if you heard a
voice you thought was God telling you to hurt another
person?”.
Note: hallucinations may be vague or unformed: sounds,
colors, distorted appearance in real objects, or distortion of
 existing sounds. Note the presence or absence of sensations
(tactile hallucinations), smells (olfactory hallucinations) or
tastes (gustatory hallucinations) that do not appear to be
based in reality.
Assess the pt’s reality testing, i.e. his ability to determine
if the perception is based in reality; e.g. “What do you think is
the origin (cause, etc) of the voice you hear?” “Do you believe
the voice is real or that it is a hallucination?”.
Observe for the presence or absence of illusions (mistaking a
coat rack in a dark corner for a person).
21. Pain Ask the pt whether pain is experienced, and when present,
assess its characteristics: onset, triggers, location, nature
(sharp vs. dull, etc), radiation, relief measures, intensity on a
0-10 scale, and its impact on activities of daily living (ADL’s).
22. Risk for harm to self Complete an inventory of risk factors, noting their presence or
absence, and including but not limited to: suicidal thoughts (if
present, assess the degree to which they preoccupy the
client, how intrusive they are, the presence of a plan, the
lethality of any plan; the pt’s likelihood of acting on any
tentative plan); past attempts by the pt (and/or by peers or
significant others); significant losses (tangible or intangible)
and anniversaries of such losses; impulsiveness; despair or
dysphoria; depressed mood; presence of command
hallucinations; a belief that death would bring relief or would
benefit others; psychosis; substance abuse; termination
activities such as giving away belongings, wrapping up
affairs, or saying goodbye to others; history of self-injurious
behavior/mutilation; the pt’s access to the means of suicide
(e.g. “Are there guns in your house?”). The assessment
should be direct but empathic; e.g. “Sometimes a person who
is depressed can feel so very bad that it seems as if the pain
is unbearable, so bad that they wish they were dead; tell me
how it feels to you.” and “You have suffered many losses
recently; have these losses ever led you to consider hurting
yourself?” Note that while a pt may not have thoughts or
intent re: hurting himself, he might experience a passive
longing for death, which may later progress toward
suicidality. Also: assess the pt’s coping skills: how does he
cope, how well does he believe it works, and what does he do
when it does not work.
Also assess the pt’s ability to maintain his own safety in terms
of moving about his environment safely, interacting with
others in a manner that does not create conflict or violent
responses, providing for own medical or health needs,
assuring adequate intake and rest, and providing for
protection from dangerous weather via shelter and clothing.
The examiner can note the pt’s history in these regards,
observe current behavior and responses, and ask the pt how
he would respond in hypothetical situations.
23. Risk to others Complete an inventory of risk factors, noting their presence or
absence, and including but not limited to: paranoia; a belief
that violence is justified or necessary; thoughts about hurting
others; urges or intent to hurt others; anger towards others;
impulsivity; substance abuse; history of assault; frustration
intolerance; lack of empathy for others or other antisocial
traits; history of property destruction or harming animals;
psychosis. Assess the pt’s strategies for managing anger and
 frustration, e.g. “What do you do when you become angry?”
or “What is the most embarrassing or regrettable thing you
have ever done when angry?” or “Tell me about a time when
your anger got you into trouble”.
24. Substance Use and Abuse Ask the pt if he has occasion to use illegal substances and/or
medications not as prescribed by his health care provider. If
so, note the substances used; the route, amount and
frequency of their use; the reasons for and circumstances of
their use (e.g. when under stress); the consequences of their
use (impact on relationships, ADL’s, health, employment,
school and other role performance; resulting injuries,
illnesses, hospitalizations, arrests, incarcerations); the pt’s
perceived control over this use; the presence or absence of
craving when not using the substance (and how the pt
responds to cravings). Ask if the pt’s peers or family have
expressed concerns about his substance use, and if he has
been stopped for possibly driving under the influence (or for
often-related offenses such as public urination, public
indecency, or disorderly conduct). Inquire about past
treatment for substance abuse. Note whether the pt has a
history of prescriptions from multiple providers and/or of
seeking care in multiple settings.
25. Compulsive Behaviors Observe for and inquire about behaviors such as gambling,
sexual addictions, compulsive counting or numbering, and
frequency of hand washing; ask if the pt has any rituals or
behaviors that he uses to reduce anxiety or that he feels he
must engage in in order to feel comfortable.
26. Social and role functioning Inquire about and observe for impaired social functioning;
examples include conflict or impaired performance in work,
school, parental or other roles; inability to develop or
maintain support systems; conflict with others; aversion to
social situations; loss of relationships, employment or school
enrollment. Observe and describe social skills such as
communication skills.
27. Other Neurological deficits can be elicited by the following
techniques:
1. ask the pt to complete a task involving three steps given at
one time (e.g. “Write your name on this paper, fold it in
half, then fold it in half again”)
2. ask the pt to identify common objects such as a coin, key
or pencil, first visually and then by touch alone, with eyes
closed;
3. ask the pt to draw the face of an analog clock

7-2010, E A Herzog