MENTAL STATUS EXAM
1.
GENERAL APPEARANCE
a.
Dress
Conventional:
Meticulous:
Eccentric:
Seductive:
Disheveled:
b.
Grooming
Well-groomed:
Dirty:
Unkempt:
c.
Customary; sanctioned by usage; traditional
Overly neat and clean, unusually careful of detail
Peculiar or unusual
Inappropriate dressing to enhance sexual desirability
Untidy; rumpled; in disrepair; dirty
Clean and neat
Hair, clothes and/or skin dirty
Hair not combed; buttons undone or incorrect
Hygiene
Good:
Fair:
Poor:
c.
Facial Expression
Sad:
Happy:
Angry:
Unremarkable:
Relaxed:
Tense:
Crying:
Suspicious:
Poor eye contact:
d.
Make-up
Not applicable:
Appropriate:
Not wearing:
Peculiar/Bizarre:
e.
Downcast and gloomy expression
Smiling; laughing
Frowning, scowling
Lack of symptoms to arouse notice
Lack of tension; calm, loose muscles
Muscle taunt; showing emotional strain
Tearful
Looking around constantly as if worried about threat;
guarding information
Not meeting eyes of interviewer
For men
Accenting client’s natural features appropriately
Absence
Heavy; exaggerated, or unnatural
Body
Wt./Ht. :
Obese:
Slender:
Emaciated:
Weight that is proportionate for height
Extremely fat or corpulent
Small in cross section compared to length
Extremely underweight
f.
Speech
Audible/Inaudible:
Clear/Slurred:
Pressured:
Stammering:
Rapid/Slow:
Mumbling:
Halting:
Garbled:
Incoherent:
Even:
2.
Loud enough to be heard by interviewer or not
Distinct or indistinct
Speaks very rapidly and continuously
Uses involuntary halts, breaks and repetitions
Speaks in low tone and without articulation
Uses irregular rhythm
Facts and sequence confused and mixed up
Disjointed and unintelligible
Speech is smooth, steady, and constant
INTERVIEW BEHAVIOR
a.
Attitude
Hostile:
Euphoric:
Threatening:
Withdrawn:
Defensive:
Manipulative:
Evasive:
Passive:
Dramatic/
Grandiose:
Naive:
Aggressive:
Negativistic:
Overly cooperative:
Ingratiating:
Self Deprecating:
Affectations:
Seductive:
Disdainful:
b.
Artless, shows lack of knowledge or experience for age
Overly assertive; insistent on getting own way
Says no to reasonable requests consistently
Excessive attempts to please
Overly compliant to elicit favor and approval
Self-degrading; expresses feeling unworthy
Posturing with artificial airs
Flirtatious, sexual display; excessive intimacy
Superior attitude; disgust for others
Posture
Erect:
Slouched:
Rigid:
Guarded:
c.
Angry, resentful or unfriendly
Demonstrates an exaggerated feeling of well-being
Makes verbal or physical threats
Avoids interpersonal interaction; stays to self
Inappropriately defends against questions
Attempts to get own way using indirect means
Avoids honest, overt, candid interaction
Does not initiate anything; accepts what’s offered
Using theatrical appearance, speech and/or behavior
Upright and straight
drooping back and shoulders
Stiff and inflexible; strongly resistant
Appears to protect self from danger
Gait/Mobility
Steady:
Even:
Limps:
Shuffles:
Staggers:
Walks without wavering
Pace is at consistent rate
Gait is uneven due to weakness or deformity of limb
Walks while dragging feet instead of lifting them
Swaying and uncertain gait
d.
Level of Awareness
Attentive:
Drowsy:
Distractible:
Inattentive:
Confused:
Stuporous:
Hypervigilent:
3.
ORIENTATION
a.
b.
c.
d.
4.
Date and Time
Person
Place
Situation
MEMORY
a.
b.
c.
5.
Amnesia
Short term
Long term
AFFECT
a.
Outward expression of feelings
Appropriate:
Angry:
Blunted:
Worried:
Flat:
Elevated:
Depressed:
Labile:
Congruent:
6.
Keeps mind on what is going on around them
Appears to want to go to sleep
Distracted by environmental diversions
Unable to pay attention even briefly
Unable to distinguish between ideas; jumbled thoughts
Has some moments of unconsciousness
Heightened awareness of what goes on around them
Expressions suitable for situation
Displays passionate displeasure
Appears insensitive, unperceptive, and slow to respond
Disturbed about specific event or outcome
Minimal expression with small or no range
Unusually high spirits
Unusually low spirits, dejected
Great variability of expression from moment to moment
Non verbal and verbal expression of feelings match
THOUGHT PROCESSES
a.
How the individual Thinks
Logical:
Rambling:
Incoherent:
Confabulation:
Blocking:
Circumstantial:
Tangential:
Perseveration:
Flight of Ideas:
Answers and thinking consistent with correct reasoning
Wandering, disconnected thoughts
Disjointed and confused
Filling in memory gaps by guessing or making up
Sudden stop in train of thought in the middle of thought
Proceeding indirectly to goal idea with many tedious
details and irrelevant additions
Thoughts veer from the main topic and never return to it
Persistent, involuntary repetition of a phrase or idea
Continuous or rapid flow of speech that is not
disjointed or bizarre but which jumps from topic to topic
Loose Associations: Lack of logical relationship between thoughts or ideas
that follow each other
Indecision:
Inability to make up one’s mind
Neologism:
Coins new words that only the patient understands
Abstract:
Avoids specificity, extremely theoretical orientation
Rhyming:
Making words rhyme as in alliteration
Concretism:
Inability to think in general terms
Fabrication:
Create fictional fillers to bridge actual events
7.
THOUGHT CONTENT
a.
What the Individual Thinks About
Ideas of Failure:
Impoverished:
Paranoia:
Apathy:
Phobias:
Obsessions:
Ideas of Guilt:
Ideas of
Hopelessness:
Ideas of
Worthlessness:
Somaticism:
Thoughts of
Persecution:
Disassociation:
b.
Focus that there is no available prospect for happiness
Constant belief that one is of no value
Focus on physical ailments or complaints
Believes others are planning to harm or interfere
Disconnection between thoughts, emotions and
sensations
Hallucinations
Auditory:
Visual:
Olfactory:
Tactile:
c.
Focus on own lack of success
Very little thought content
Persistent, unrealistic belief that one is unsafe
Absence of caring; indifferent
Worries about a specific object or situation
Repetitive, unwanted ideas that intrude into thoughts
Focus on the belief that the patient acted in ways
contrary to how he believes he should have acted
Hearing things when there is no external stimulus
Seeing things when there is no external stimulus
Smelling odors with no actual basis
Feeling touch sensation when there is no stimulus
Delusions
Persecution:
Grandeur:
Thought
Broadcasting:
Reference:
Influence:
Believing others are out to get him when there is no
realistic basis for fear
Unrealistic belief that one has unique and special status
or abilities
Belief that one can read others’ minds
Believe that one is the topic or reference point for
conversations or activities going on around one
Belief that one’s thoughts or actions are controlled by
external forces or that one can control the thoughts
and actions of others.
8.
INTELLECT
a.
What is the Individual’s Level of Intellectual Functioning?
Functioning:
Average, higher than average, below average
Inadequate
Fund of Knowledge: Individual lacks normal amount of general information
Retarded:
Mental ability is markedly below average for age and
culture.
9.
JUDGEMENT AND INSIGHT
a.
Do the Individual’s Decisions and Behaviors Correlate to Reality?
Lacks Social
Judgment:
Lacks Personal
Judgment:
Insight:
Excellent:
Moderate:
Little or None:
Inability to evaluate situations and make sound
decisions leading to appropriate and effective
actions when dealing with others
Inability to evaluate situations and make
decisions leading to appropriate and effective
actions for self.
Understands the severity of his illness, the need
For treatment, and some of the dynamics involved
Knows why his is in treatment with some understanding
of what the problem is
Does not know why he is in treatment