The mental status exam (MSE) is a crucial component of a comprehensive clinical evaluation. While it is particularly valuable in neurology and psychiatry, any practitioner should include an MSE in any thorough clinical evaluation, ranging from GPs to specialists. Though it may seem complex at first, with practice, performing a mental status exam can become second nature. Let’s take a few minutes to explore this health assessment tool and discuss some tips for seamlessly integrating it into your clinical practice.
What is the Mental Status Exam?
The mental status exam, or MSE, is a structured examination that utilizes interviewing techniques and observational skills to identify the psychological functioning of a patient at a specific point in time. The modern MSE is a descendant of evaluation techniques developed by Karl Jaspers’ work in descriptive psychopathy and descriptive phenomenology. Karl Jaspers argued that the only way to understand a patient’s lived experience is through the patient’s description. In other words, a clinician can only appreciate a patient’s experiences by listening to the patient’s account rather than relying solely on external observations or interpretations.
This perspective played a pivotal role in shaping the modern mental status exam, as Jaspers challenged the prevailing belief of the Freudian school of practice that clinicians could best understand psychopathology through external observations or interpretations of unconscious forces driving mental health symptoms. Like many aspects of medicine, the modern MSE integrates the strengths of both approaches. It incorporates the patient’s account of their lived symptomatic experience while relying on the clinician’s external observations and interpretations to guide diagnosis.
Components of the Mental Status Exam
Like a traditional physical examination, the mental status exam is divided into specific evaluation domains. The specific elements included in the exam tend to vary from institution to institution, but there tend to be more similarities than differences. A full mental status examination should consider appearance, attitude, behavior, described mood, facial language, body language, speech, thought content, thought processes, perceptions, cognition insight, and judgment.
Let’s briefly describe each portion of the MSE, review an example of how it may be documented or presented, and clinical pearls that suggest clinical findings.
Appearance
- Appearance is an observational component of the MSE and should include consideration of age, height, weight, hygiene, eye contact, and clothing.
- “An adult male that appears his stated age of average height and weight in weather and setting appropriate attire. He maintained good eye contact during the interview.”
- Clinical Pearl: Disheveled hygiene or poorly maintained clothing may suggest a patient is not attending to their activities of daily living, which can occur with mood disorders, substance use disorders, and psychotic disorders.
Attitude
Attitude may also be considered their level of cooperation. It considers the patient’s approach during the interview process. For instance, a patient who’s defensive when being interviewed can be regarded as defensive.
- “Patient was mostly cooperative during the interview but exhibited defensive tendencies when past violent behaviors are discussed.”
- Clinical Pearl: Patients who act as though they’re suspicious during clinical interviews may be experiencing paranoia.
Mood
- Mood is dependent on the patient’s described symptomatic experience. Ask them directly about their perceived mood (when possible) and specify it in quotation marks in your examination notes.
- “Patient describes their mood as ‘depressed.’”
Affect
Affect is dependent on the clinician’s external observations. When describing affect, include information that explains the patient’s body language and whether it matches their stated mood and overall range of emotional expression. For extra credit, commenting on mood reactivity can be useful in identifying certain forms of depression.
- “Their affect and body language appeared dysphoric and congruent with stated mood. Their overall range of emotional expression was narrow. They demonstrate mood reactivity at times.”
- Clinical Pearl: Mood reactivity is a classic symptom of “Major depressive disorder with atypical features.” The other symptoms associated with this diagnosis are hypersomnia, severe psychomotor slowing (“leaden paralysis”), and increased appetite.
- Clinical Pearl: Patients that have “inappropriate affect,” such as laughing without clear, humorous context or crying without contextual cause, may be experiencing pseudobulbar affect, which can occur with both neurological conditions and psychotic disorders.
Speech
Evaluation and description of a patient’s speech should assess tone of voice, rate of speech, prosody (rhythm) of speech, and any abnormal findings regarding speech.
- Speech: Normal rate, rhythm, tone, and prosody.
- Clinical Pearl: Increased rate of speech may suggest pushed or pressured speech, which can occur in manic episodes or hypomanic episodes in addition to acute intoxication on stimulants. Abnormal prosody of speech may indicate an underlying neurological pathology.
Language
Language describes the patient’s use of syntax and grammar while speaking. It can include findings such as difficulty finding words, confabulation, stuttering, and aphasia.
- Language: Patient exhibits intermittent stuttering at times but appears fluent and does not have word-finding difficulties”.
- Clinical Pearl: Language is important when considering diagnoses such as childhood-onset fluency disorder (stuttering) and Tourette’s.
- When working with an interpreter, asking the interpreter for their impression of the patient’s use of their preferred language is essential.
Thought Processes
- Thought processes refer to the rate of thought procession, the continuity of thought processes, and the overall quantity of thoughts.
- “Patient appeared linear and logical during discussion of recent events.”
- Clinical Pearl: Patients who appear to have rapid thought processes or appear to jump from topic to topic while speaking may be experiencing a “flight of ideas,” which is a classic symptom of manic episodes.

Thought Content
- Thought content is likely the portion of the MSE with the most variation amongst clinicians. Thought content seeks to describe if a patient is experiencing suicidal thoughts, homicidal thoughts, delusions, negative cognitive distortions, phobias, intrusive thoughts, preoccupations, or symptoms of psychosis such as thought blocking, thought insertion, and thought broadcasting. It tends to be the longest section of an MSE.
- “The patient did not have suicidal thoughts or homicidal thoughts. They did have delusions of surveillance, as they believe they are being monitored through a chip inserted in their brain.”
- Clinical Pearl: Thought broadcasting, thought insertion, and thought blocking are classic symptoms of psychosis.
Perceptions
Perceptions describe a patient’s reported experience of phenomena like visual and auditory hallucinations. It should also include the observations of the clinician concerning the patient experiencing perceptual disturbances, especially when there’s a concern about psychosis and the patient denies hallucinations.
- “The patient denied auditory and visual hallucinations but did appear to respond to internal stimuli while observed arguing out loud while alone in their room.”
- Clinical Pearl: Visual hallucinations in older patients may be a sign of acute delirium. Tactile hallucinations such as “pins-and-needles” and perceptions of “bugs on my skin” are common in substance withdrawal, especially alcohol and benzodiazepine withdrawal.
Insight & Judgement
- Insight and judgment refer to the patient’s ability to make rational decisions and their perceptions of their mental functioning. It’s also important to describe your rationale for each section.
- The patient’s insight appears to be fair, as they’re able to identify that they’re feeling depressed. They do not appear to appreciate the role of alcohol in their depression. Their judgment appears to be good, as they were able to recognize that medical treatment is prudent given their severe depression and sought out treatment of their own accord.”
- Clinical Pearl: Poor insight and judgment may suggest a patient is not sufficiently educated about their condition. In cases like this, take the time to explain your diagnosis to the patient because poor insight and judgment are significant risk factors for poor outcomes.
Cognition
Cognition should comment on a patient’s overall ability to reason and process information. Describing orientation, attention span, and recent and remote memory recollection in this section of the exam notes is prudent. The cognition section should include formal cognitive testing such as a MOCA or SLUMS when concerned about a neurocognitive disorder.
- “The patient was oriented to person, time, place, situation, and year. The patient’s recent memory regarding the trauma is impaired. Their remote memory appears intact based on their ability to furnish a complete medical history. Their attention span was poor, but this is likely due to their recent trauma prior to presentation”.
- Clinical Pearl: Carefully completing the cognition evaluation of the mental status exam is an essential tool for diagnosing acute delirium. In delirium, patients will exhibit fluctuating attention span and “waxing and waxing” cognition.
Conducting a Mental Status Exam (MSE)
The best way to learn the mental status exam is through practice. When seeing patients, we recommend completing a brief MSE without relying on external cues such as note templates. While this sounds daunting, it will allow you to develop your flow for assessing each component of the exam.
The MSE is also essential for students in graduate healthcare education programs, as standardized patient encounters often do not allow the use of templates. By developing a personalized flow, the conversation to discover the narrative information required for a thorough mental status exam will feel natural for you and the patient. While developing your technique of giving an MSE, a common mistake worth mentioning is feeling that you “must complete” each portion of the exam. This pressure can lead to safety concerns.
For example, asking a patient who is severely agitated if they’re having thoughts of wanting to harm staff may result in escalating the patient’s agitation further. In such situations, it can be better to infer the patient’s violent ideations by working backward from their displayed behavior. For instance, you may present or document, “Patient appears to have aggressive ideations. They were confrontational with hospital staff and threatened physical harm.” This ability to use subtle language can do wonders for maintaining clinical rapport with patients while completing an MSE.
Another helpful tip is to be honest with patients if they ask why certain questions are being asked. While it may feel better to avoid answering questions due to a concern that patients may adjust their answers to do well on the MSE, attempting to hide the intent of the evaluation can lead to distrust or anxiety in the patient. Finally, when documenting, we recommend using the domains described above just as most clinicians document a physical exam. When in doubt, explain your findings in the simplest terms.
Limitations and Considerations
A properly executed clinical assessment melds a patient’s symptomatic experience with external observations to allow for accurate clinical care. However, the mental status exam has limitations. For instance, patients with ulterior motives for presentation may know the right things to say to achieve their expected outcomes.
The MSE is also limited to patients who can fully engage in interviews, which isn’t feasible for very young children, averbal patients, or patients experiencing a neurocognitive disorder. Due to these limitations, it’s essential to use the MSE as one piece of a comprehensive evaluation that includes other clinical tools such as a physical exam, laboratory results, chart review, and collateral information from friends and family.
Practice to Prepare and Impress Your Peers
With enough practice, the MSE can be an invaluable tool for any healthcare provider. We hope this guide clarifies the importance of the mental status exam for you and your colleagues. It’s not every day that clinicians can learn and use an assessment tool with high accuracy, low cost, and low time commitment that can identify so many conditions!
Please share your thoughts about the mental status exam in the comments. Do you have questions about it? Would you like to see more content, such as deep dives into each section? Let us know below!
References
- https://www.osmosis.org/blog/nclex-qotd-mental-status-assessment
- https://pmc.ncbi.nlm.nih.gov/articles/PMC4421897/
- https://www.sciencedirect.com/science/article/pii/B9780122678059500328

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