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Clinical Practice Guidelines

Mental state examination

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    PIC Endorsed

  • See also

    Acute behavioural disturbance: Acute management  
    Engaging with and assessing the adolescent patient

    Key points

      1. A mental state examination (MSE) is a part of every mental health assessment. Where possible it should be a participatory process, acknowledging the young person as the best person to examine their mental health and, with support, they should be empowered to describe their needs
      2. Interpretation of the MSE must keep in mind the young person’s age and developmental level
      3. If there is any indication of current suicidal or homicidal ideation in the young person, they must be referred for further assessment by a mental health clinician 

    Background

    • The MSE is used to gain an understanding of the young person’s psychological functioning at a particular point in time to direct care appropriately and make a decision as to when to consult with a mental health clinician
    • Many parts of the MSE will be performed intuitively every time one interacts with or observes others  

    Assessment

    • Ask the young person what name and pronouns they prefer
    • Closely observe body language and communication
    • Consider the emotional state and thought processes observed, as well as self-reported and described 

    The mental state examination

    Component

    What to assess

    Appearance

    Gender identity, gender expression, ethnicity, apparent age, body habitus, posture, cleanliness and grooming, hair/clothing style, cosmetics and jewellery, syndromic features, evidence of self-harm, neglect or physical abuse

    Behaviour

    Manner of relating to clinician and parents

    Ease of separation from parent, interaction with clinician (eg agitation, avoidance, defiance, eagerness to please, overfamiliar), eye contact, facial expression, signs of distress or discomfort. Note presence of psychotic phenoma (eg talking to self, laughing incongruently)

    Activity level

    Psychomotor slowing or agitation, sustained or episodic, goal-oriented or erratic, coordination, unusual postures or motor patterns (eg odd mannerisms, stereotypies, tics, tremors), gait

    Speech

    Quantity, quality, fluency (language skills), rate, rhythm, flow, volume, tone. Spontaneous and talkative to mute

    Mood

    Subjective description of how they are feeling, predominant emotion over days/weeks.
    0-10 scale can be used (0: extremely sad and/or wishing to end life immediately, 10: extremely happy)
    Does mood change at different times of the day, identify context to mood eg home, school, external factors
    What do they think would help their mood, what has worked in the past
    Explore sleep, appetite, interests, energy level, motivation

    Affect

    Current observed emotional state through non-verbal language. Describe:

    • type eg angry, anxious, apathetic, apprehensive, dysphoric, euphoric, euthymic, happy, irritated, sad)
    • range (constricted to labile)
    • reactivity (blunted or flat to reactive)
    • appropriateness, congruent or incongruent with described mood

    Thought

    Stream (ie speed)

    Poverty of thought (thought blocking), poverty of content (perseveration), racing thoughts, flight of ideas

    Form

    Logical and goal-directed or disordered (eg circumstantial, tangential, derailment, looseness of associations, word salad)

    Content

    Obsessions, compulsions, ruminations, overvalued ideations, delusions (eg persecutory, referential, grandiose, somatic, bizarre), phobias, magical thinking, thoughts of harm to self or others

    Perception

    Altered bodily experiences (eg depersonalization, derealisation), passivity phenomenon, illusion, hallucination (eg auditory, visual, olfactory, tactile, somatic)

    Cognition

    Level of consciousness

    Alert, drowsy, delirium, stupor

    Orientation

    Awareness or confusion of situation and surroundings, knowledge* of name, location, date, familiar people
    *be mindful of language barriers, age and ability for accurate testing

    Attention

    Need for redirection/repeating, sustained activity, distractibility

    Memory

    Immediate eg repeat numbers, names back
    Short-term eg recall three objects at 2 and 5 minutes
    Long-term eg recall events of past week

    Ability

    Impression of current abilities, concrete to abstract thinking

    Insight & Judgment

    Insight

    Intact, partial or poor insight
    Understanding of their condition
    Ability to identify potentially pathological events eg hallucinations, suicidal impulses
    Acknowledgement of a possible mental health problem, locus of control (internal vs external)

    Judgment

    Intact to impaired judgement
    Problem solving ability in context of current psychological state (can be explored by recent decision making)
    Consider the impact of external influences such as social media

    Consider consultation with a mental health clinician when

    Unusual, incongruous or concerning features noted in a mental state examination

    Consultation with a mental health clinician should occur when

    • A situation of immediate risk of harm to self or others by a young person
    • Risk of imminent departure from the emergency department by a young person known to be at risk of harm to self or others
    • An acutely psychotic/agitated young person, whose immediate management requires significant sedation which will subsequently impede psychiatric assessment

    Note: consultation with a mental health clinician is mandatory for a young person being held under a legislative act eg Assessment Order or Treatment Order

    Consider child safety principles and mandatory reporting requirements

    Last updated December 2024 

  • Reference List

    1. Akiskal HS. The mental status examination. The medical basis of psychiatry. 2008, pg 3-16
    2. American Academy of Child and Adolescent Psychiatry. Practice parameters for the psychiatric assessment of children and adolescents. Journal of American Academy of Child and Adolescent Psychiatry, 1997 pg 4–20
    3. Arciniegas DB. Mental status examination. Behavioural neurology and neuropsychiatry. Cambridge University Press 2013 pg 344-393
    4. Chang MY, Davis AS. Neuropsychological assessment. Encyclopedia of child behaviour and development, Boston 2011
    5. Daniel M, Gurczynski. Mental Status Examination. Diagnostic interviewing, Boston 2009 pg 61-88
    6. Harvey PD. Clinical applications of neuropsychological assessment, Dialogues Clin Neurosci 2012
    7. Mendez MF. The mental status examination handbook. 2022
    8. Soltan M, Girguis J. How to approach the mental state examination BMJ 2017
    9. Trzepacz PT, Barker RW. The psychiatric mental status examination. Oxford University Press 1993 pg 3-177