MENTAL STATUS EXAMINATION

Sweekaar Academy of Rehabilitation Sciences,

Secunderabad.
 Mental Status Examination
• The Mental Status Exam, is just that, an exam. It is your
chance to observe the patient, and record for the reader an
accurate account of your observations of what the patient was
like at the time you saw them. It is not a place for
summation, and the use of terms like “normal” or “within
normal limits” to summarize aspects of the exam is inadequate
and inappropriate.
• The purpose of the exam is to give a "snapshot" of the patient
as he presented during the interview.
• It is cross sectional, but it is not limited to one point—the
examiner assesses throughout the interview, and then records
the data in a structured format.
Components of the Mental Exam
• The full mental status exam is a systematic
check of emotional and cognitive functioning.
• Four components:
A = Appearance
B = Behavior
C = Cognition
T = Thought Processes
 Complete Mental Status Exam
Appearance and Behavior Thought and Perceptions
 Appearance  Thought Processes
 Posture and Motor Behavior  Thought Content
 Dress, Grooming and Personal  Perceptions
Hygiene  Insight
 Facial Expression  Judgment
 Attitude, Manner, Rapport

Speech and Language Cognitive Functions

 Quantity  Level of Consciousness
 Rate  Orientation
 Loudness  Attention
 Articulation of Words  Remote Memory
 Fluency  Recent Memory
 New Learning Ability
 Higher Cognitive Functions
 Information &Vocabulary
Mood & Affect  Calculating Ability
 “How are your spirits?”  Abstract Thinking
 Constructional Ability
 Hierarchy of steps
•The first steps of the mental
status exam must be accurately
assessed to ensure validity for
the steps to follow.
(i.e..consciousness language)
 General Appearance

• Appearance, grooming, identifying marks (tattoos,

scars, unusual make up)
• Attitude to examiner
• Posture
• Body movements
• Dress
• Does patient look younger or older than stated age?
 Appearance & General Behavior

• Describe the patient's physical characteristics & general behavior;

is it appropriate, bizarre, incongruous, or agitated?

• Consider personal self-care (cleanliness in general, hair,

cosmetics, dress), facial expression (anxious or depressed or

elated).

• Are they relaxed or tense and restless; slow, hesitant, or

repetitive? How do they behave? Are they open or guarded,

hostile, & threatening?

Appearance & General Behavior
• Are they distractible, or unresponsive? Do they appear
frightened or frightening? Do they respond abnormally to
external events? Can their attention be held & diverted?
• Does the pt appear over-emotional (are they dancing &
singing, / withdrawn, tearful, & sullen; wringing hands
with anxiety/ relaxed; preoccupied & perplexed, / do they
show little emotional expression)?
Appearance & General Behavior
• Do they appear to be responding to hallucinations? Does their
behavior suggest disorientation? Specify orientation if doubtful.
Do movements and attitudes have an apparent purpose or
meaning? Describe any motor abnormalities such as gestures,
grimaces, tics, mannerisms, stereotypes, waxy flexibility, slowness,
tremor, and rigidity. If the patient is inactive, do they resist passive
movements, obey commands, or indicate awareness at all?
 Appearance & General Behavior

• Appearance may suggest personality traits. Collaborative data

must always be obtained.

• A high degree of attention to correctness, cleanliness, tidiness

and detail suggests obsessional traits. In many instances, but

not always, conservatism in appearance is a feature of

obsessional traits.
• A high degree of attention to fashion may suggest narcissistic

traits. The above points regarding fashion and the desire to

belong to a group must be considered.

• A high degree of attention to flamboyant or seductive

appearance may suggest histrionic traits. Flamboyant

appearance may also be a feature of the isolated eccentric or

the charismatic leader.

 Motoric Behavior

• Psychomotor agitation or retardation: restless,

hand wringing, sighing, fidgety, slowed,
delayed.
• Abnormal Movements: tics, stereotypy,
tremors, catatonia, mannerisms, grimacing,
echopraxia, waxy flexibility.
 TICS
• A tic is a sudden, repetitive, nonrhythmic motor
movement or vocalization involving discrete muscle
groups. Tics can be invisible to the observer, such as
abdominal tensing or toe crunching. Common motor and
phonic tics are, respectively, eye blinking and throat
clearing.
• Two types: motor or phonic and simple or complex.
• Motor tics are movement-based tics affecting discrete
muscle groups.

• Phonic tics are involuntary sounds produced by moving air

through the nose, mouth, or throat.

• Simple motor tics are typically sudden, brief, meaningless

movements that usually involve only one group of muscles,
such as eye blinking, head jerking, or shoulder shrugging.
• A simple phonic tic can be almost any sound or noise, with
common vocal tics being throat clearing, sniffing, or grunting.

• Complex motor tics are typically more purposeful-appearing

and of a longer nature. They may involve a cluster of
movements and appear coordinated. For ex: pulling at clothes,
touching people, touching objects, echopraxia (involuntary
repetition or imitation of another person's
actions) and copropraxia (involuntarily performing obscene or
forbidden gestures, or inappropriate touching.).
• Complex phonic tics include echolalia (repeating
words just spoken by someone else), palilalia
(repeating one's own previously spoken words),
lexilalia (repeating words after reading them),
and coprolalia (the spontaneous utterance of socially
objectionable or taboo words or phrases). 
 STEREOTYPY

• Stereotypy is intentional, repetitive, non

functional behavior such as body-rocking or
head-banging.
 TREMORS

• A tremor is an involuntary, somewhat rhythmic,

muscle contraction and relaxation involving to and
fro movements (oscillations or twitching) of one
or more body parts. It is the most common of all
involuntary movements and can affect the hands,
arms, eyes, face, head, vocal folds, trunk, and legs.
 CATATONIA
• ‘Catatonic symptoms’ occur when the pathological mental state is

expressed in motor anomalies. They may be categorised as the following.

• ‘Catatonic Stupor’ in which movement ceases and the patient is

unresponsive to the spoken word or even to painful stimuli. There is

usually also the failure to take food or fluid. Accordingly, the life of the

patient may be in danger.

• ‘Catatonic Posturing’ in which the patient assumes a posture which is then

maintained. This might be a strange posture such as standing on one leg

with the arms out sideways in the middle of the front path, but it is usually

more subtle and may simply impress as an awkward or uncomfortable way

to sit or stand.
• ‘Catatonic Rigidity’ in which a posture is maintained against the

interviewer’s attempts to move the limbs or the whole patient.

• ‘Waxy Flexibility’ in which the interviewer can change the

position of the patient’s limbs, and in the process the limbs feel

to the interviewer as if they are made of wax. (The new posture

is usually then maintained for at least a few seconds and

sometimes minutes.)
 Attitude To Interviewer

• Cooperative, aggressive, guarded, seductive,

indifferent, apathetic, sarcastic, irritable.
 SPEECH

• Slow, fast, pressured, spontaneous, stuttering,

staccato.
• Pitch, articulation (the clarity with which words are
spoken), aphasia (loss or impairment of language
caused by brain damage, Benson;1992), coprolalia,
echolalia, mute, paucity.
 SPEECH
• Speech: Quantity of speech (e.g., talkative, sparse), rate (e.g., rapid, slow),
volume (e.g., whispered, loud), spontaneous, impediments (e.g., stuttering,
lisp), and rhythm.

• Form of the speech rather than content is considered here. Do they say much
or little, speak loudly or quietly, talk spontaneously or only in answer, slowly
or quickly, hesitantly or promptly, to the point or wide of it, coherently,
anxiously, discursively, loosely with interruptions, with sudden silences, with
frequent changes of topic? Record content- do they use strange words or
syntax, rhymes, puns, clang associations? Write examples of these verbatim .
 MOOD
• Mood has been defined (Kaplan and Saddock, 1991) as a
pervasive and sustained emotion, subjectively experienced and
reported by the patient, as well as observed by others.
• Emotional state recorded in the patient’s own words (e.g.,
“depressed,” “anxious,” “scared,” “happy,” “angry”).
• As mood has a subjective component, it is necessary to
enquire. Must be followed by a comment as to whether this is
consistent with the interviewer’s finding.
 MOOD
• Direct question such as 'How do you feel in yourself?', 'What is
your mood like ?', 'How about your spirits?'.

• Symptoms and behaviors associated with mania (elevated mood,

little need for sleep or food, excessive energy, reckless behavior,
initiation of multiple tasks without completion, distractibility)
and anxiety (tremor, dry mouth, butterflies, blurred vision,
sweating) should also be evaluated and recorded here.
 MOOD
• If depressive mood is suspected make specific enquiry about sadness,

diurnal variation of mood, initial and middle insomnia, early morning

wakening. Consider any suicidal ideas or plans, attitudes to the future,

hopelessness, self-esteem, worthlessness, and guilt. Note any loss of

appetite, weight, energy, motivation or libido, or constipation. Observe

the constancy of the mood during the interview, those influences that

change it and the appropriateness of the patient's apparent emotional state

to what they say. Note evidence of flatness or lability of affect, and

specify any indications that the patient is concealing their true feelings.
 Assessment of mood on various dimension: A particular mood is not necessarily

abnormal or pathological but must be evaluated in context of the patient’s entire

history and psychiatric mental status examination. Assessment of mood of any

individual is very difficult but there are some dimensions on which mood can be

assessed (Tasman, 2003).

(a) Quality: mood can be characterized as depressed, dysphoric, elevated irritable. Quality

of mood can be assessed by asking the patient “how do you feel?” & “And what is

your mood?”

(b) Stability: to what extent does mood remain constant over time. It can be assessed by

asking “do you always feel like this?”

(c) Reactivity: ability to react emotionally to the innate changes in the environment and it

is assessed by asking “Does your mood ever change?” or “When does your mood

change?”
(d) Intensity: A degree to which a emotion is experienced and is clinically

assessed by asking “what is it like to feel this way?” or “on the scale of 0-

10 how would you rate your mood?”

(e) Duration: Duration is regarded as the basis for the experience of the

passage of time. It can be assess by asking “How long have you felt this

way?”

(f) Congruence: whether the emotion shown is congruent with thought

content. This is based on impression of the interviewer.

 SUICIDAL THOUGHTS AND ACTIONS
• The questions form a natural hierarchy, which is followed as far as necessary:

• Do you feel that you have a future?

• Do you feel that life's not worth living?

• Do you ever feel completely hopeless?

• Do you ever feel you'd be better of dead and away from it all?

• Have you made any plans?

• Have you ever made an attempt?

• What prevents you from doing so?

• Have you made any arrangements for your affairs after your death?
WARNING SIGNS OF SUICIDE
• Prior suicide attempts

• Depression

• Social withdrawal

• Self-mutilation

• Anorexia

• Verbal suicide messages

• Death themes in art, writing, or behaviors

• Giving away prized possessions

AFFECT
 AFFECT
• Affect: has been defined (Kaplan and Saddock, 1991) as: 1) the expression
of emotion as observed by others; and 2) varying over time, in response to
changing emotional states.
• The interviewer’s observation of the patient’s emotional state, or how they
felt at a given moment which includes the general quality (e.g., dysphoric,
euthymic) and depth of the affect (e.g., normal, blunted, or flat) (comments
can include range of emotions like broad, restricted, blunted, flat,
inappropriate, labile, consistent with the content of the conversation and
facial expressions, pessimistic, optimistic) as well as inappropriate signs
(began dancing in the office, verbally threatened examiner, cried while
discussing recent happy event and unable to explain why).
• Think of the weather, which varies slightly from day to day.. Affect may be

labile (alternating rapidly between two extremes) or inappropriate

(incongruence between subject matter and emotional expression).

• Congruent or incongruent with mood

• Range and depth of emotional state

• Appropriate or not to situation

• Mobility

• Reactivity
• Assessment of affect

• Assessment of affect is very difficult on the basis of verbatim of an individual

because some time what the person speaks or shows might be incompatible. So
we need to assess the affect cros-sectionally on the basis of certain dimensions
(Tasman, 2003).
• Quality: Quality(valence): Happy, sad, angry. It should be assessed in two
forms:
– Subjectively: How do you feel in yourself?

– Objectively: Observation of interviewer.

• There are some qualities of sad and happy mood which are as follows-

– Observed depression includes sad, mournful look, tears, gloomy tone of

voice, voice chokes on distressing topic (WHO, 1998).
 Dysphoric includes sustained emotional states such as sadness, anxiety or
irritability.
– Anxiety: Feeling of apprehension caused by anticipation of danger
which may be internal or external (Sadock & Sadock) or anxiety is an
unpleasant affective state with the expectation, but not the certainty of
something untoward happening (Fish.1984).
– Irritability: It can be defined as liability to outburst or as state of poor
control over aggressive impulses directed toward others; most
frequently to those nearest and dearest (Fish,1984). State in which a
person is easily annoyed and provoked to anger (Sadock & Sadock)
– Sadness: Emotional mood tending toward sorrow. Relative passivity
and diminished muscular tone with weeping characteristics .
• Observed Hypomanic - Abnormal cheerfulness & sense of well being,
Elevated: exaggerated feeling of well-being, euphoria, or elation.
 a) Euphoric: increased sense of psychological well-being with cheerful thoughts and lack of
response to depressing influence so that everything is seen in the best possible light
(Fish,1984).
b) Elation: feeling of well-being and euphoria leading to faulty judgment, general
overactivity & disinhibited behavior (Fish, 1984).

c) Exaltation: feeling of intense elation and grandeur; seen in sever mania((Taylor & Vaidya,
2006).

d) Ecstasy: intense sense of rapture or blissfulness; seen in delirious and stupors mania.

• Expansive: lack of restraint in expressing feelings (Taylor & Vaidya, 2006).

• Euthymic: mood in normal range implying absence of depressed or elated
mood.
• Range: The range of the affect is characterized by the variety of emotional
expression. Normal individual express different feeling at different times.
(a) Full range: Patients who appropriately express many different
emotions have a full or broad range of affect.
(b) Restricted range: person shows only a fixed or immobile affect found
only in one type of emotion.
• Intensity: Intensity of affect (the strength of emotional expression)
normally varies according to the situation. Those with limited emotional
expression with may have blunted or flattered affect
• Flat affect: When no affect is displayed it is reported as to be
flat or absence of emotional response”. Or absence of
appropriate outwardly emotional responses
• Blunted affect: as “greatly diminished emotional
response”(Tasman, 2003) or expressionless face and voice
uniform, whatever the topic of conversation is, patient is
indifference to distressing topic (whether delusional or normal)
• Mobility: The mobility of affect is related to ease and speed with which
one move from one to another type of emotion. Changes in type and
intensity of emotional expression normally occur gradually.
• Constricted affect: Reduced mobility is also referred as constricted affect.
• Fixed affect: When affect is extremely constricted to one emotion it is
called fixed or immobile emotion.
• Labile affect: Pathologically increased mobility of affect is referred to as
labile Or rapid shift from one to another without persistence of any one
affect (WHO, 1998). 
• Reactivity: The reactivity is extent to which the affect changes in response to
environment stimulus. When patient does not respond to examiner’s provocation
joking, the affect is nonreactive. (Tasman.2003).
• Communicability: The expression of affect communicates to others, the
emotional response to events, interaction, behavior, and situations (Tasman, 2003)

• Appropriateness: It refers when there is congruence between the expressed

quality of emotion and the situation. (Taylor & Vaidya, 2006). Paramimia refers as

lack of unity between the various modes of expression of emotion. Parathymia is a

expression of an emotion that is the exact opposite of what is expected under the

circumstances (e.g. laughing at tragic news), or the expression of emotions that

appear unnatural, exaggerated or theatrical (Sims,2009).

 CLASSIFICATION OF AFFECT

• Appropriate (normal) affect: The affect suggests the full range and

depth of internal feeling states which is culturally consistent with

the conversation (which introduces various subjects) or interaction.

• Flat affect: When the affect is flat, there is little if any change in

the quality and quantity of affect with the introduction of different

topics of conversation. If it is present, a comment on whether it is

mild, moderate or severe may be attempted.

• Inappropriate (incongruent) affect: indicates an internal
feeling state which is not culturally consistent with the
conversation or interaction. The word ‘inappropriate’
means that the affect is inappropriate to the thought
content. ((laughter while discussing being sacked or the
death of a loved person).
• Must be used with caution.
• Labile affect: The affect changes suddenly and
frequently, suggesting sudden and frequent changes
in emotions, but these changes are culturally
excessive in the given environment.
PERCEPTUAL ABNORMALITIES
• Perception is the process of transferring physical stimulation into
psychological information.
• Depersonalization involves an alteration in the perception or experience of
the self, in which the usual sense of one’s own reality is temporarily lost or
changed.
• Derealization is an alteration in the perception of one’s surroundings so
that the reality of the external world is lost—the world may appear two-
dimensional as a stage set, sizes and shapes may be perceived as changed
and others may appear mechanical or puppet like.
• Delusional mood is present when a patient feels that familiar
surroundings have changed in a puzzling way which may be
difficult or impossible to describe, but which seems to be
especially significant. This symptom may be experienced as
ominous or threatening.
• Hallucinations: Hallucinations are false sensory perceptions not associated

with external stimuli. There may or may not be delusional interpretation of

the hallucinatory experience. Hallucinations suggest psychosis only when

there is impaired reality testing.

• Types of hallucinations:

– Non-verbal auditory hallucinations

– Verbal auditory hallucinations

– Tactile and somatic hallucinations

– Visual hallucinations

– Gustatory and olfactory hallucinations

• Illusions are misperceptions of stimuli. They are
usually transitory and can be corrected when attention
is drawn to the mistake. Here, stimuli from a
perceived object are combined with a mental image to
produce a false perception.
• Hypnopompic and hypnogogic experiences
• The source, content, vividness, reality, duration, and
time of occurrence (e.g. at night, when alone, when
falling asleep, or awakening). Exacerbating or
ameliorating factors as well as the patient's insight
into the cause, as well as the significance and
emotional impact, of any perceptual abnormality.
 THOUGHT
THOUGHT PROCESS

• Thought process disturbance: Refers to the logical and semantic

connections between patient’s thoughts (form). Verbal

expression can follow a linear and logical train of thought

called goal-directed (normal), or lapse into increasing levels of

disorganization, such as circumstantial thought processes,

tangentiality, flight of ideas, thought blocking, loosening of

associations, word salad, or neologisms, clang associations )

Thought Disturbance Description

Circumstantiality Speech includes irrelevant details but

eventually makes a point
Tangentiality Speech is not goal-directed, and a point is
never made
Flight of ideas Rapid thinking with fast changes in topics;
ideas are related, but speech may be
difficult to follow
Loosening of associations Flow of thought with ideas that are
coherent but unrelated
Thought blocking Flow of thought is interrupted by silence,
and the patient does not return to the
same topic when speech resumes
Word Salad Individual ideas and speech are
incoherent
Clang associations Word association by rhyming

Neologisms Creating new words

 THOUGHT CONTENT
• Thought content disturbance: Refers to what the patient is thinking.

Examples of thought content include:

• Suicidal ideation,

• Homicidal ideation,

• Paranoid content,

• Obsessions (persistent intrusive thoughts which are disturbing)

• Compulsions (repetitive, intentional behaviors that are performed in
response to obsessions)
• Poverty of content,
• Delusions: are false unshakeable beliefs which are out of
keeping with the patient’s social, cultural and educational
background. (bizarre, paranoid, grandiose, persecutory,
reference, somatic, erotomanic, control, nihilistic )
• Thought broadcasting, insertion, withdrawal

• Suicidal, homicidal thoughts

• and Phobias.

– General themes that characterize the patient’s thinking

should be described (e.g., anger at their parents).

Thought Content Description

Delusions Fixed, false beliefs without a cultural basis

Ideas of reference Belief that others are discussing about or

criticizing the patient
Ideas of influence Belief that other forces control the
patient’s behavior
Paranoid ideation Thoughts of being harmed, followed, or
persecuted
Obsession A recurrent thought experienced as
intrusive
Compulsion A repetitious act designed to alleviate
anxiety
Poverty of content Thought that is vague, repetitious, or
obscure
Phobia An unfounded fear that triggers panic
• Abnormal thoughts should be described
comprehensively and their precipitants, mode
of onset, duration, intrusiveness, frequency,
congruity with mood, fixity, and effect upon
the patient's functioning noted. The description
should include obsessional rumination/
compulsion, overvalued idea, idea of
reference, or delusion including delusions of
passivity & thought possession.
• Thoughts of harm towards self or others should be recorded

including; the onset, frequency, planning, preparation, and

desire to harm. The patient should also be asked whether they

believe they are capable of realizing these thoughts, and

whether there are any factors that prevent them from

completing the act.

• Abnormal beliefs and interpretations of events: Specify the
content, mode of onset, and degree of fixity of any unusual or
abnormal beliefs about the environment (e.g. ideas of reference,
misinterpretations or delusions; beliefs that they are being
persecuted, that they are being treated in a special way, or are the
subject of an experiment. Delusions of body, delusions of passivity,
of influence, thought reading, or insertion or thought withdrawal.
 COGNITION
• Consciousness: alert versus obtunded/comatose

• Orientation: person, place and time

• Attention: ability to attend to interview, repeat
ask to repeat, including after interrupting

• Concentration
• Calculation
• Memory: Registration
– ability to repeat information immediately
• Short term recall: debatable how long to wait. Should
introduce other information in the interim
• Long term

– Historical events, etc.

• Intelligence
 LEVEL OF CONSCIOUSNESS
• Alert: awake or readily aroused
• Lethargic: not fully alert, looks drowsy
• Obtunded: sleeps most of the time, difficult to arouse
• Stupor or semi-coma: responds only to vigorous shake

• Coma: completely unconscious, no response to pain or to

external or internal stimuli; deep coma has no motor response
 ORIENTATION

• Assess orientation, record their answers to

questions about their own name and identity,
the place where they are, the time of day, the
date.
 ATTENTION AND CONCENTRATION

• Orientation to time, place, & person. ( changes seen with organic

brain disorders)

• To test concentration and attention, ask the patient to tell the days

or the months in reverse order, or do simple arithmetical problems

such as subtraction of serial 7s from 100, naming the days of the

week or months of the year in reverse order, spelling the word

"world", their own last name, or the ABC's backwards. Give digits

to repeat forwards, and then others to repeat backwards, and

record how many the patient can reproduce in each direction.

 MEMORY
• In all cases memory should be assessed by comparing the patient's account of their

life with that given by others, and by examining the patient's account for intrinsic

evidence of gaps or inconsistencies. Record memory for recent events whether there

is selective impairment for special incidents, periods, or recent or remote events,

Record confabulation or false memories. Retrograde and anterograde amnesia must

be specified in detail in relation to head injury or epileptic phenomena.

• Short-term (immediate) memory test: The most common test is to ask the patient to

repeat sequences of digits. Three digits are given first and the patient is asked to

repeat them. If this is performed successfully, four digits are given and so on, until

the patient makes mistakes.

• Recent memory test: A common method is to test the patient’s ability to learn

three or four unrelated words. Patients are advised that their memory should

be tested, that they will be given some words to remember, and that later in

the interview they will be asked to recall them. The words are said at the rate

of about one word per second. The patient is asked to repeat them, to ensure

that they have been registered properly. The interview then proceeds and the

patient is distracted and must attend to other material. Some minutes later the

patient is asked to recall the words.

• Remote memory : The names and dates of birth of the patient’s children may

also be available, as might the patient’s wife’s (in the case of a married male)

and mother’s maiden name, and these form reasonable questions.

 ABSTRACT THINKING
• Abstraction Skills: These are based on proverbs and sayings
("What do people mean when they say..."), similarities ("How
are a ______ and a ______ alike? Different?"),
 INTELLIGENCE

• The patient's expected intelligence should be

gauged from their history, general knowledge,
and educational and occupational record.
 INSIGHT
• Insight: In Psychiatry, insight may be broadly defined as awareness

of one’s own mental condition. It is the awareness of physical and

mental limitations, denial of illness, ascribing blame to outside

factors, recognizing need for treatment. What is the patient's attitude

to their present state, do they see it as 'physical', 'mental', or

'nervous', or as needing treatment? What does the patient attribute it

to? Are they aware of any mistakes they made spontaneously or in

response to tests? How does the patient regard them and other details

of the condition? Do they recognize the need for treatment?

 GRADES OF INSIGHT
• Grade I- Complete denial of illness

• Grade II- Slight awareness of being sick but denying it at the

same time.

• Grade III- Awareness of being sick but blaming it on external

factors.

• Grade IV- Attributing that illness is due to something

unknown in the patient.

• Grade V- Intellectual Insight

• Grade VI- True Emotional Insight

 JUDGMENT

• Requires
– Insight
– Cognitive functioning
– Other abstract abilities
– Conceptualization
– Forward thinking
– Appreciation of what “rational people” would do.
 JUDGMENT
• Judgment: appropriate responses to social situations. Provide a
common scenario and ask what they would do (e.g. "If you found a
letter on the ground in front of a mailbox, what would you do with
it?"). What do they propose to do when they have left the hospital
or clinic? What is the patient's attitude to supervision and care?

• Reliability: Accurate and consistent reporting of symptoms,

truthfulness, and extent of disclosure.
 FORMULATION

• The formulation is a picture of the individual and it

includes the unique characteristics of each patient's
case that are needed for the process of management.
• The formulation follows a logical sequence.
– Demographic data: Begins with the name, age, sex,
occupation, and marital status.
 DESCRIPTIVE FORMULATION
• Describe the nature of onset was it acute/ insidious, the total duration of the

present illness, & the course Then list the main symptoms & signs that

characterize the disorder: try to be selective by choosing signs & symptoms

either for greater diagnostic specificity or for their predominance in severity

or duration. Avoid long lists of minor or transient symptoms and

negative findings, but include those that help to exclude other possible

diagnoses. These basic data are derived chiefly from the history of the

present illness, the mental state, & physical examinations, & are used to

determine the diagnosis in the next section. Note that this is not usually the

place to bring in other aspects of the history.

• Differential diagnosis : List in order of probability all diagnoses that
should be considered and include any disorders that you will wish to
investigate. These diagnoses will be based on the descriptive formulation
above. Give the evidence for and against each diagnosis that you
consider. Include any current physical illness that may account for some
or all of the phenomena. Remember that you will frequently need to
consider supplementary diagnoses in addition to the primary diagnosis,
for example alcohol dependence in the patient presenting with delirium,
or a personality disorder in a patient with an anxiety state.
 FORMULATION
• Etiology : Contributory factors should be evident mainly from the
fly & personal histories, the h/o previous illness, & the pre-morbid
personality. Arrange etiological factors according to the bio-
psychosocial model subdividing each domain into predisposing,
precipitating, and perpetuating factors. Try to answer two
questions: why has this patient developed this particular disorder,
& why has the disorder developed at this particular time?
 FORMULATION
• Investigations : List all the investigations that are required to support your preferred

diagnosis and to rule out the alternatives, and also list any that you think are required

to improve your understanding of the etiology . Give reasons for investigations if they

are not self-evident. Remember that the thorough investigation of an illness requires

effective enquiry into all the relevant domains of the bio-psychosocial model; hence

include psychological investigations as well as relevant social enquiry.

• Treatment : Outline the treatment plan that you wish to follow. This should stem

logically from your discussion of the etiology as well as from the diagnosis.

• Prognosis : Describe the expected outcome of management of this illness episode,

with regard to both the symptoms and subsequent function and the risk of relapse.
When do we do a full mental status exam?

• When family members are concerned about a person’s

behavioral changes, such as memory loss or inappropriate
social behavior.
• Brain lesions (trauma, tumor, or CVA)

• Aphasia (impairment of language secondary language

dysfunction as well as emotional problems.
• Symptoms of psychiatric mental illness.
ANY QUESTIONS?
THANK YOU