Mental Status Examination in Primary

Care: A Review
DANIELLE SNYDERMAN, MD, and BARRY W. ROVNER, MD, Thomas Jefferson University,
Jefferson Medical College, Philadelphia, Pennsylvania

The mental status examination is an essential tool that aids physicians in making psychiatric diagnoses. Familiarity
with the components of the examination can help physicians evaluate for and differentiate psychiatric disorders. The
mental status examination includes historic report from the patient and observational data gathered by the physi-
cian throughout the patient encounter. Major challenges include incorporating key components of the mental status
examination into a routine office visit and determining when a more detailed examination or referral is necessary.
A mental status examination may be beneficial when the physician senses that something is not quite right with a
patient. In such situations, specific questions and methods to assess the patients appearance and general behavior,
motor activity, speech, mood and affect, thought process, thought content, perceptual disturbances, sensorium and
cognition, insight, and judgment serve to identify features of various psychiatric illnesses. The mental status exami-
nation can help distinguish between mood disorders, thought disorders, and cognitive impairment, and it can guide
appropriate diagnostic testing and referral to a psychiatrist or other mental health professional. (Am Fam Physician.
2009;80(8):809-814. Copyright 2009 American Academy of Family Physicians.)

A
This article exempifies lthough it is unrealistic to routinely Important observations of appearance may
the AAFP 2009 Annual perform a comprehensive mental include the disheveled appearance of a
Clinical Focus on manage-
ment of chronic illness. status examination (MSE) in a patient with schizophrenia, the self-neglect
single primary care office visit, of a patient with depression, or the provoca-
incorporating key components of a formal tive style of a patient with mania.
MSE when the physician senses that some-
thing is not quite right with the patient Motor Activity
can help the physician identify psychiat- Observations of motor activity include body
ric illnesses, follow up as needed for more posture; general body movement; facial
extensive evaluation, and make referrals expressions; gait; level of psychomotor activ-
when necessary. The examination can also ity; gestures; and the presence of dyskinesias,
help distinguish mood disorders, thought such as tics or tremors.2 Psychomotor retar-
disorders, and cognitive impairment.1,2 Key dation (a general slowing of physical and
components of the MSE are summarized in emotional reactions) may signify depression
Table 1.1-4 or negative symptoms of schizophrenia.5 Psy-
chomotor agitation may occur with anxiety
Appearance and General Behavior or mania. Changes in motor activity over
The MSE begins when the physician first time may correlate with progression of the
encounters and observes the patient. How patients illness, such as increasing bradyki-
the patient interacts with the physician and nesia with worsening parkinsonism. In addi-
the environment may reveal underlying tion, changes in motor activity may be related
psychiatric disturbances or clues signifying to treatment response (e.g., parkinsonism
the patients emotional and mental state. secondary to an antipsychotic medication).
Collaborative observations from office staff
may also be useful.1 If the physician has Speech
known the patient for some time, it may be Observations of speech may include rate,
helpful to acknowledge and document any volume, spontaneity, and coherence. Inco-
changes that have occurred over time that herent speech may be caused by dysarthria,
may correlate with changes in mental health. poor articulation, or inaudibility.2 The form


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 Table 1. Components of the Mental Status Examination

Component Elements to assess Potential illnesses

Appearance Body habitus, grooming habits, interpersonal style, degree of eye Disheveled appearance may suggest schizophrenia
and general contact, how the patient looks compared with his or her age Provocative dress may suggest bipolar disorder
behavior Appearance: well-groomed, immaculate, attention to detail, unkempt, Unkempt appearance may suggest depression,
distinguishing features (e.g., scars, tattoos), ill- or well-appearing psychosis
Eye contact: good, fleeting, sporadic, avoided, none Poor eye contact may occur with psychotic disorders
General behavior: congenial, cooperative, open, candid, engaging, Paranoid, psychotic patients may be guarded
relaxed, withdrawn, guarded, hostile, irritable, resistant, shy,
Irritability may occur in patients with anxiety
defensive

Motor activity Body posture and movement, facial expressions Parkinsonism, schizophrenia, severe major depressive
Akathisia (restlessness), psychomotor agitation: excessive motor disorder, posttraumatic stress disorder, anxiety,
activity may include pacing, wringing of hands, inability to sit still medication effect (e.g., depression), drug overdose
or withdrawal, anxiety
Bradykinesia, psychomotor retardation: generalized slowing of
physical and emotional reactions Symptoms may develop within weeks of starting or
increasing dosages of antipsychotic agents
Catatonia: neurologic condition leading to psychomotor
retardation; immobility with muscular rigidity or inflexibility; may Tendency toward exaggerated movements occurs in
present in excited forms, including excessive motor activity the manic phase of bipolar disorder and with anxiety

Speech Quantity: talkative, expansive, paucity, poverty (alogia) Schizophrenia; substance abuse; depression; bipolar
Rate: fast, pressured, slow, normal disorder; anxiety; medical conditions affecting
speech, such as cerebrovascular accident, Bell
Volume and tone: loud, soft, monotone, weak, strong, mumbled
palsy, poorly fitting dentures, laryngeal disorders,
Fluency and rhythm: slurred, clear, hesitant, aphasic multiple sclerosis, amyotrophic lateral sclerosis
Coherent/incoherent

Mood and Mood: patients subjective report of emotional state Depression, bipolar disorder, anxiety, schizophrenia
affect Affect: physicians objective observation of patients expressed
emotional state

Thought Form of thinking, flow of thought Anxiety, depression, schizophrenia, dementia,

process delirium, substance abuse

Thought What the patient is thinking about Obsessions, phobias, delusions (e.g., schizophrenia,
content alcohol or drug intoxication), suicidal or homicidal
thoughts

Perceptual Hallucinations Schizophrenia, severe unipolar depression, bipolar

disturbances disorder, dementia, delirium, acute intoxication and
withdrawal

Sensorium and Sensorium: level and stability of consciousness Underlying medical conditions, dementia, delirium
cognition Cognition: attention, concentration, memory

Insight Patients awareness and understanding of illness and need for Bipolar disorder, schizophrenia, dementia, depression
treatment

Judgment Patients recognition of consequences of actions Bipolar disorder, schizophrenia, dementia

Information from references 1 through 4.

810 American Family Physician www.aafp.org/afp Volume 80, Number 8 October 15, 2009
Sample questions

of speech is more important than the content

of speech in this portion of the examination,
and may provide clues to associated disor-
ders. For example, patients with mania may
speak quickly, whereas patients with depres-
sion often speak slowly.

Mood and Affect

Mood is the patients internal, subjective
emotional state.1 Of note, this is one of the
few elements of the MSE that rely on patient
self-report in addition to physician observa-
tion. It is helpful to ask the patient to report
his or her mood over the past few weeks, as
opposed to merely asking about the moment.

It may also be helpful to determine if mood

remains constant over time or varies from
visit to visit. Physicians may perform a more
objective assessment by asking the patient
at each visit to rate mood from 1 to 10 (with
How are your spirits?
1 being sad, and 10 being happy).
How would you describe your mood?
Affect is the physicians objective observa-
Have you felt discouraged/low/blue lately?
tion of the patients expressed emotional state.
Have you felt angry/irritable/on edge lately?
Often, the patients affect changes with his or
Have you felt energized/high/out of control lately?
her emotional state and can be determined
by facial expressions, as well as interactions.
Descriptors of affect may address emotional
Obsessions: Do you have intrusive thoughts or images that you cant get out of range (broad or restricted), intensity (blunted,
your head? flat, or normal), and stability.1 Affect may or
Phobias: Do you have an irrational or excessive fear of something? may not be congruent with mood, such as
Delusions: Do you think people are stealing from you? Are people talking behind
when a patient laughs when talking about
your back? Do you think you have special powers? Do you feel guilty, as if you
committed a crime? Do you feel like you are a bad person? (Positive responses the recent death of a family member. Addi-
to last two questions may also suggest a psychotic depression) tionally, affect may not be appropriate for a
Suicidality: Do you ever feel that life is not worth living? Have you ever thought given situation. For example, a patient with
about cutting yourself? Have you ever thought about killing yourself? If so, delusions of persecution may not seem fright-
how would you do it?
ened, as expected. Inappropriateness of affect
Homicidality: Have you ever thought about killing others or getting even with
those who have wronged you?
occurs in some patients with schizophrenia.

Do you see things that upset you? Do you ever see/feel/hear/smell/taste things Thought Process
that are not really there? If so, when does it occur? Have you had any strange
sensations in your body that others do not seem to have? Thought process can be used to describe a
patients form of thinking and to character-
See Tables 2 and 3
ize how a patients ideas are expressed dur-
ing an office visit. Physicians may note the
What brings you here today? What is your understanding of your problems? Do rate of thought (extremely rapid thinking
you think your thoughts and moods are abnormal? is called flight of ideas) and flow of thought
What would you do if you found a stamped envelope on the sidewalk? (whether thought is goal-directed or disor-
Physician should adapt questions to clinical circumstances and patients education ganized).2 Additional descriptors include
level whether thoughts are logical, tangential,
circumstantial, and closely or loosely associ-
ated. Often, a patients thought process can be
described in relation to a continuum between

October 15, 2009 Volume 80, Number 8 www.aafp.org/afp American Family Physician 811
Mental Status Examination
Table 2. Assessment Tools for the Elements of Cognition

Cognitive element Assessment tools

Language functions Naming, reading, writing

goal-directed and disconnected thoughts.2
Visuospatial ability Copying a figure; drawing the face of a clock
Incoherence of thought process is the lack of
Abstract reasoning Explaining proverbs; describing similarities
coherent connections between thoughts. (e.g., comparing an apple to a pear)
Executive functions List making (e.g., name as many animals [or fruits or
Thought Content vegetables] as you can in one minute); drawing the
Thought content describes what the patient face of a clock
is thinking and includes the presence or General intellectual Identify the previous five presidents; physician must
level/fund of take into account the patients education level and
absence of delusional or obsessional think-
knowledge socioeconomic status; screen for mental retardation
ing and suicidal or homicidal ideas. If
Attention and Spell world forward and backward, subtract serial
any of these thoughts are present, details concentration sevens from 100
regarding intensity and specificity should be Memory Mini-Cog, MMSE
obtained.
More specifically, delusions are fixed, false Mini-Cog = Mini-Cognitive Assessment Instrument; MMSE = Mini-Mental State
Examination.
beliefs that are not in accordance with exter-
nal reality. Delusions can be distinguished
3

from obsessions because persons who expe-

rience the latter recognize that the intrusiveness of their the patient to spell world forward and backward, or to
thoughts is not normal. Bizarre delusions that occur subtract serial sevens from 100. Another key element of
over a period of time often suggest schizophrenia and cognition is the patients memory. A deeper understand-
schizoaffective disorder, whereas acute delusions are ing of memory function and brain systems has served to
more consistent with alcohol or drug intoxication. refine and expand the classification of short- and long-
term memory into four memory systems (Table 3).6 In
Perceptual Disturbances the cognitive portion of the MSE, it is important that
Hallucinations are perceptual disturbances that occur questions match the patients education level and cul-
in the absence of a sensory stimulus. Hallucinations tural background.
can occur in different sensory systems, including audi- A systematic approach to evaluating for cognitive
tory, visual, olfactory, gustatory, tactile, or visceral.2 impairment is helpful. The most commonly used method
The content of the hallucination and the sensory system is the Mini-Mental State Examination (MMSE), which
involved should be noted. Hallucinations are symptoms takes five to 10 minutes to administer. The MMSE has
of a schizophrenic disorder, bipolar disorder, severe been validated and used extensively in practice and in
unipolar depression, acute intoxication, withdrawal research. In clinical practice, it is usually used to detect
from alcohol or illicit drug use, delirium, and dementia. cognitive impairment in older patients. The MMSE
Perceptual disturbances may be difficult to elicit during includes 11 questions that test five areas of cognitive
an office visit because patients may deny having hallu- function: orientation, registration, attention and cal-
cinations. The physician may conclude that hallucina- culation, recall, and language.7 Using the MMSE as a
tions are present if the patient is responding to internal screening instrument has not been supported because
stimuli as if the patient is hearing somebody speaking the specificity of screening tools is poor despite good
to him or her. sensitivity.8 Table 4 summarizes U.S. Preventive Services
Task Force screening recommendations for cognitive
Sensorium and Cognition impairment and other mental disorders.8,9 However, the
The evaluation of a patients cognitive function is an MMSE is a useful measure of change in cognitive status
essential component of the MSE. The assessment of sen- over time, as well as potential response to treatment. The
sorium includes the patients level and stability of con- test is limited in patients who have visual impairment,
sciousness. A disturbance or fluctuation of consciousness are intubated, or have a low literacy level.10
may indicate delirium. Descriptors of a patients level of Another tool for assessing cognition is the Mini-
consciousness include alert, clouded, somnolent, lethar- Cognitive Assessment Instrument (Mini-Cog), which
gic, and comatose. combines a clock drawing test and a three-word memory
Elements of a patients cognitive status include atten- test. Advantages of the Mini-Cog include its brevity, its
tion, concentration, and memory. Table 2 presents assess- validity irrespective of the patients education level and
ment tools for these and other elements of cognition. language, and its high sensitivity for identifying adults
Attention and concentration can be assessed by asking with cognitive impairment.11

812 American Family Physician www.aafp.org/afp Volume 80, Number 8 October 15, 2009
 Table 3. Classification of Memory Systems

Memory type Description Significance of deficit Examples

Episodic Ability to recall personal May be transient secondary to seizure, concussion, Knowing what you had for breakfast,
experiences amnesia, medication use, hypoglycemia how you celebrated your last
Also occurs with degenerative disorders, including birthday
Alzheimer disease, vascular dementia, dementia
with Lewy bodies
Semantic Ability to learn and store Most common with advanced Alzheimer disease Knowing who is the president of the
conceptual and factual United States, how many planets
information are in the solar system
Procedural Ability to learn behavioral Most common with Parkinson disorders Learning to ride a bike, play a musical
and cognitive skills May also occur with Huntington disease, instrument, swim
that are used on an cerebrovascular accident, tumors, depression
unconscious level (secondary to effect on basal ganglia)
May not be present in early Alzheimer disease
Working Ability to temporarily Combination of attention, concentration, and Remembering a list of seven words in
maintain information short-term memory order, a phone number
May occur with delirium

Information from reference 6.

Insight dysfunction, suggesting that cognitive impairment may

Insight is the patients awareness and understanding be the basis for lack of insight in patients with schizo-
of his or her illness and need for treatment. When evaluat- phrenia.14 Patients with dementia may also lack insight,
ing a patients insight, the physician may assess the degree a feature that is particularly characteristic of frontotem-
to which the patient understands how the psychiatric ill- poral dementia affecting function and performance.15
ness impacts his or her life, relationship with others, and Patients in the manic phase of bipolar disorder may dem-
willingness to change. Evaluating insight is crucial for onstrate little insight, whereas patients having a depres-
making a psychiatric diagnosis and for assessing poten- sive episode may overemphasize problems.3
tial adherence to treatment. Compared with patients with
other psychiatric disorders, those with schizophrenia are Judgment
often unaware of their mental illness and often have a Judgment, the ability to identify the consequences of
poorer response to treatment.12,13 A recent study showed actions, can be assessed throughout the MSE,2 by asking
an association between unawareness and executive What would you do if you found a stamped envelope

Table 4. USPSTF Screening Recommendations for Mental Disorders

Disorder Recommendation Clinical considerations

Dementia The evidence is insufficient to recommend for Sensitivity and specificity of the MMSE range from 71 to 92 percent
or against routine screening for dementia in and 52 to 96 percent, respectively, depending on the cutoff for
older adults an abnormal test result8
Accuracy is also reliant on patient age, education level, and ethnicity
Depression Screening adults for depression is recommended The following two-question screen can be as effective as longer
in clinical practices that have systems in place to instruments (sensitivity = 96 percent, specificity = 57 percent) 9
assure accurate diagnosis, effective treatment, Over the past two weeks, have you felt down, depressed, or
and follow-up hopeless?
Over the past two weeks, have you had little interest or pleasure
in doing things?
Illicit drug The evidence is insufficient to determine the Physicians should evaluate for symptoms and signs of drug use
use benefits and harms of screening for illicit drug use
in adolescents, adults, and pregnant women

MMSE = Mini-Mental State Examination; USPSTF = U.S. Preventive Services Task Force.
Information from references 8 and 9.

October 15, 2009 Volume 80, Number 8 www.aafp.org/afp American Family Physician 813
Mental Status Examination

Address correspondence to Danielle Snyderman, MD,

SORT: KEY RECOMMENDATIONS FOR PRACTICE 1015 Walnut St., Suite 401, Philadelphia, PA 19107
(e-mail: [email protected]). Reprints
Evidence are not available from the authors.
Clinical recommendations rating References
Author disclosure: Nothing to disclose.
The mental status examination can help C 1, 2
distinguish mood disorders, thought REFERENCES
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DANIELLE SNYDERMAN, MD, is an instructor in the Department of Fam-
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814 American Family Physician www.aafp.org/afp Volume 80, Number 8 October 15, 2009