Mental State Examination – Part 1

What Is the Mental State Examination?

"The examination of mental state is the assessment and observation of an individual's mental condition and related behaviour at a given point in time."

The Mental State Examination (MSE) is the psychiatric equivalent of the physical examination in general medicine. It is a systematic and structured description of the patient's mental functioning as observed and elicited at the time of assessment. In contrast to the history — which describes the longitudinal course of symptoms and life events — the MSE captures a cross-sectional snapshot of the patient's current mental state.

The MSE is usually completed at the end of the interview, once history taking has been performed. However, in practice, observation of the patient's behaviour, affect, mood, thought process, and understanding of their illness is a continuous process from the moment the patient enters the room to the moment they leave.

The MSE also allows the clinician to fill any gaps that may have been left unaddressed during history taking — particularly the risk assessment for self-harm and harm to others.

The Components of the Mental State Examination

The following is the standard order in which the mental state is formally described. The observations underpinning each section may have been made at different stages of the consultation — in the waiting room, during history taking, or during the MSE itself — and even as the patient leaves:

1. Appearance and Behaviour — general appearance, dress, hygiene, eye contact, psychomotor activity (agitation or retardation), rapport, level of engagement
2. Speech — rate, volume, tone, spontaneity, fluency, coherence, and any abnormalities
3. Affect and Mood — subjective mood (what the patient reports) and objective affect (what the clinician observes); reactivity, range, and congruence with thought content
4. Thought Process
   • Form (how thoughts are linked and communicated)
   • Content (what the patient is thinking about — beliefs, worries, obsessions, delusions)
   • Whether thoughts are goal-directed or not
5. Perception — presence or absence of hallucinations (in all sensory modalities), illusions, pseudohallucinations, depersonalisation, and derealisation
6. Cognition
   • Attention and concentration
   • Orientation in time, place, and person
   • Short- and long-term memory
7. Insight and Judgement — the patient's understanding of their condition and their attitude towards treatment
8. Mini Mental State Examination (MMSE) or MoCA — formal cognitive screening where indicated (e.g. suspected dementia, delirium, or acquired brain injury)
9. Risk Assessment — detailed assessment of risk to self (suicide, self-harm) and risk to others, where indicated

Evaluation Process: Types of Psychopathology

As in other branches of medicine, abnormal findings of the mind are understood to be pathological. In psychiatry, these are collectively termed "psychopathology." When asked to describe the psychopathology of a given patient, we are concerned only with the abnormal findings and observations about the patient's mental state and related behaviour at the time of assessment. Other symptoms, signs, and historical information are recorded in the history.

Once the presenting psychopathology — or the notable absence of expected symptoms — has been recorded, the next step is to understand and interpret its significance. There are four recognised approaches:

1. Descriptive Psychopathology

This approach records verbatim the patient's description of their mood, thought process, and perceptual abnormalities, and then uses the process of empathy to understand how the patient may be feeling given their described emotions, feelings, beliefs, and concerns. Descriptive psychopathology is the foundation of clinical psychiatric assessment — it aims to describe phenomena as accurately as possible before interpreting them. The seminal work of Karl Jaspers (General Psychopathology, 1913) remains the philosophical foundation of this approach.

2. Phenomenology

Phenomenology is the patient's personal understanding of their current psychopathology — why they are behaving as they are, and the significance of their delusions, hallucinations, or other experiences. It explores the "lived experience" of mental illness from the patient's own perspective, without imposing external theoretical frameworks.

3. Interpretative Psychopathology

This is based on the interpretation and understanding of the patient's signs and symptoms in relation to preconceived theoretical frameworks. This approach is largely employed by analytic psychotherapists in their clinical work — understanding, for example, how unconscious conflict may manifest as symptoms.

4. Experimental Psychopathology

This is where researchers carry out scientific studies in controlled environments — for example, inducing a certain behavioural response to a given stimulus. This method is often employed in behavioural psychotherapy research to understand how conditioned responses are acquired and can be extinguished.

Excluding Physical Causes

In current medical and psychiatric practice, what is most relevant is to exclude the possibility of any underlying physical cause for the presenting psychopathology. For example:

• Acute onset of visual hallucinations in an older person may indicate delirium secondary to infection, metabolic disturbance, or medication toxicity — rather than a primary psychotic illness.
• A history of chronic visual hallucinations in a blind or partially sighted person may represent Charles Bonnet Syndrome — vivid, complex visual hallucinations arising from visual loss, without psychotic illness.
• Thyroid disease, temporal lobe epilepsy, autoimmune encephalitis (e.g. anti-NMDA receptor encephalitis), and many other medical conditions can present with psychiatric symptoms.

Always request appropriate physical investigations — including blood tests, an ECG, and neuroimaging where indicated — before attributing symptoms to a primary psychiatric cause.

Practical Considerations

To carry out a full Mental State Examination, you need an appropriate environment in which to interview the patient and their cooperation and willingness to be examined. If a full MSE is not possible — for example, because the patient is uncooperative, acutely agitated, or refuses to engage — those reasons should be recorded clearly and the clinical interpretation documented. A further attempt should be arranged at an appropriate time.

The full process of the Mental State Examination is described in Mental State Examination – Part 2.