Mental Status Examination & Case History

Mental Status Examination is a standardized format in which the clinician records

psychiatric signs.It records the symptoms and primary complaints present at the time of
psychiatric interview.MSE reveals the conscious mental experience or phenomenological data of
the client .It is a hierarchical examination that needs to approached diligently miss might lead to
wrong diagnosis.

History Of Mental Status Examination

●The MSE derives from an approach to psychiatry known as descriptive psychopathology or
descriptive phenomenology, which developed from the work of the philosopher and psychiatrist
Karl Jaspers.
● It is distinct from an interpretive or psychoanalytic approach which assumes the analyst might
understand experiences or processes of which the patient is unaware, such as defense
mechanisms or unconscious drives.
● In 1918, Adolf Meyer developed an outline for a standardized method to evaluate a patient’s
“mental status” for psychiatric practice

Purpose Of Mental Status Examination

●The goal of MSE is to evaluate, quantitatively and qualitatively, a range of mental functions and
behaviors at a specific point in time.
●The MSE must be interpreted along with the presenting history, physical exam, and laboratory
and radiologic studies.
●The mental status examination can help distinguish between mood disorders, thought disorders,
and cognitive impairment, and it can guide appropriate diagnostic testing and referral
●Its major goal is evaluation the functioning or state of the individual at the present time

COMPONENTS OF MSE

1. GENERAL BEHAVIOR

Appearance
A person’s appearance can provide
useful clues into their quality of selfcare,
lifestyle and daily living skills.

● Distinctive features
● Clothing
● Grooming
● Hygiene
2. PSYCHOMOTOR ACTIVITY
As well as noting the behaviour of a person during the examination, attention should be
payed to behaviours typically described as non-verbal communication. These can reveal much
about a person’s emotional state and attitude.

● Facial expression
● Body language and gestures
● Posture
● Eye contact
● Response to assessment itself
● Rapport and social engagement
● Level or arousal (e.g. calm, agitated)
● Anxious or aggressive behaviour
● Psychomotor activity and movement (e.g. hyperactivity, hypoactivity)
● Unusual features (e.g. tremors, or slowed, repetitive, or involuntary movements)

3. THOUGHTS
A person’s thinking is generally evaluated according to their thought stream, content,
form, process and possession.

Stream:
● Flight of areas
● Retardation of thinking
● Circumstantiality
● Perseverance
● Thought Blocking
Content:
● Delusions (rigidly held false beliefs not consistent with the person’s background)
● Overvalued ideas (unreasonable belief, e.g., a person with Anorexia believing they are
overweight)
● Preoccupation
● Depressive Thoughts
● Self-harm, suicidal, aggressive or homicidal ideation
● Obsessions (preoccupying and repetitive thoughts about a feared or catastrophic
outcome, often indicated by its associated compulsive behaviour)
● Anxiety (generalized i.e., heightened anxiety with no specific referent; or specific i.e.,
phobias.
Form:
● Screening for perpetual disturbance is critical for detecting serious mental health
 problems like psychosis (this is relatively rare in young children, though peak onset is
between 19 and 22 years), cases of severe anxiety and mood disorders. It I also
important in trauma and substance abuse. Perceptual disturbances are typically marked
and may be disturbing or frightening.
● Presence of formal thought

Dissociative Symptoms:
● Derealisation (feeling that the world or one’s surroundings are not real)
● Depersonalization (feeling detached from oneself)

Illusions:
● The person perceives things differently to usual ways, but accepts that they are not real

Hallucinations:
● Probably the most widely known form of perceptual disturbance
● Hallucinations are indistinguishable from reality for the sufferer
● Can affect all sensory modalities, although auditory hallucinations are the most common
● In children, it is common to experience self-talk or commentary as in internal “voice”
● Command hallucinations (voices telling the person to do something) should be
investigated
● Important to note the degree of fear and/or distress associated with the hallucinations.

Process:
Thought process refers to the formation and coherence of thoughts and is inferred very
much through the person’s speech and expression of ideas.
● Highly irrelevant comments (loose association or derailment)
● Frequent changes of topic (flight of ideas and tangential thinking)
● Excessive vagueness (circumstantial thinking)
● Nonsense words (or word salad)
● Pressured or halted speech (thought racing or blocking)

Possession:
Obsession & Compulsions
● Thought alienation with respect to obsession
● Nature
● Identification
● Doubts
● Imagery
● Impulses
4. MOOD & AFFECT
It can be useful to conceptualize the relationship between emotional affect and mood as
being similar to that between weather (affect) and the season (mood). Affect refers to immediate
expressions of emotions, while mood refers to emotional experience over a more prolonged
period of time.

Affect:
● Range (e.g. restricted, blunted, flat expansive)
● Appropriateness (e.g. appropriate, inappropriate, incongruous)
● Stability (e.g. stable, labile)

Mood:
● Happiness (e.g., ecstatic, elevated, lowered, depression)
● Irritability (e.g. explosive, irritable, calm)
● Stability (e.g. stable, labile)

5. SPEECH
Speech can be a particularly revealing feature of a person’s presentation and should be
described behaviourally as well as considering its content. Unusual speech is sometimes
associated with mood and Anxiety problems, Schizophrenia, and organic pathology.
● Speech rate (e.g. rapid, pressured, reduced tempo)
● Volume (e.g. loud, normal, soft)
● Quantity (e.g. minimal, voluble)
● Ease of conversation

6. COGNITION
This refers to a person’s current capacity to process information and is important because it
is often sensitive (although, in young children usually secondary) to mental health problems.

● Level of consciousness (e.g. alert, drowsy, intoxicated, stuporose)

● Orientation to reality (often expressed in regard to time/place/person – e.g. awareness
of the time/day/date, where they are, ability to provide personal details)
● Memory functioning (including immediate or short term memory, and memory for
recent and remote information or events)
● Literacy and arithmetic skills
● Visuospatial processing (e.g. copying a diagram, drawing a bicycle)
● Attention and Concentration (e.g. observations about level of distractibility or
performance on a mentally effortful task – e.g. counting backwards by 7s from 100)
● General knowledge
Language (e.g. naming objects, following instructions)
● Ability to deal with abstract concepts (e.g. describing conceptual similarity between two
things)

● Insight:
o Acknowledgement of a possible mental health problem
o Understanding of possible treatment options and ability to comply with these
o Ability to identify potentially pathological events (e.g. hallucinations, suicidal
impulses)

● Judgment:
o Refers to a person’s problem-solving ability in a more general sense
o Can be evaluated by exploring recent decision-making or by posing a practical
dilemma (e.g. what should you do if you see smoke coming out of a house?)

Case History

APA defines case history as a record of information relating to a person’s psychological

or medical condition. Used as an aid to diagnosis and treatment, a case history usually contains
test results, interviews, professional evaluations, and sociological, occupational, and educational
data. Also called patient history.It is a planned professional conversation that enables the patient
to communicate his/her symptoms, feelings and fears to the clinician so as to obtain an insight
into the nature of patient's illness & his/her attitude towards them.
.
Objectives Of Case History

●To establish a positive professional relationship.

●To provide the clinician with information concerning the patient’s past medical & personal
history.
● To provide the clinician with the information that may be necessary for making a diagnosis.
● To provide information that aids the clinician in making decisions concerning the treatment
of the patient.
Method Of Obtaining Case History
●Psychiatric Interview: It tends to be descriptive, historical, and qualitative, The psychiatric
interview is a key diagnostic instrument for psychiatrists given that laboratory exams do not
provide evidence for psychopathologic processes.. The interview can be of two types:
a.Freedom Interviews,
b. Standardized Interviews
●The purpose of the psychiatric interview is to establish a therapeutic relationship with the
 patient in order to collect, organize, and synthesize data that can become the basis for a
formulation, differential diagnosis, and treatment plan
Components of Case History
Before taking the case history of any client the counselor should record the date, time and
place of interviewing / investigating and the name of counselor. The main components are as
follows

A. Client’s Profile – Identification Data -

This includes a detailed description / socio demographic details of the client. This includes -

● Name: ● Languages known:

● Client Code/ Unique Identification ● Educational Qualification:
Code: ● Occupation:
● Age (Date of Birth): ● Family Income (annual):
● Sex: ● Religion:
● Marital Status: ● Nationality:
● Address: ● Identification marks (minimum
● Father’s Name/Spouse’s Name: two):
● Mother tongue:

B. Details of the Informants

If anyone has referred any patient for counseling to any doctor for any illnesses, the
counselor will record the informant's details. Which includes-
Informant 1
Name:
Relationship with the client:
Duration of relationship:

C. Reasons for Referral / Purpose of Visit

● Why has the client been referred and what is the purpose of the visit?
● Letter of Referral
● If the client visits on their own they should mention their purpose of visit.

D. Presenting Chief Complaints - The present complaints to be written in chronological order

and also the most impressing or important factor/complaint to be mentioned.

E. History of Present Illness - A detailed history of the present illness from onset to the time of
consultation in a chronological order of its evolution and its course. This includes-
● When was the client last entirely well?
 ● Onset
o Abrupt (less than 48 hours)
o Acute (few hours to two weeks)
o Sub-acute (few weeks)
o Insidious (few weeks to a few months)
o Chronis (several months to years)
● Duration (of the present illness)
● Provocative/alleviative factors/variables (seasonal/diurnal)
● Course
o Continuous
o Fluctuating
o Episodic (episodes of symptoms with periods of normalcy)
o Unclear (Fluctuating/ Deteriorating/ Improving)
● Precipitating Factors - The triggering factor should be mentioned. It may be physical or
may be the consequence of either illness or any other event that just preceded the illness.
Mention detailed accounts about the factors should be given
● Baseline
● Associated Disturbances -
Impairment in other areas of functioning such as sleep, weight changes, sexual life, social
life and occupation. Also mention any cardiovascular changes such as shortness of breath
especially on exertion, fainting or syncope, sweating on feeding, chest pain, palpitation, edema,
cyanosis, squatting etc.
● Negative History-
Related to organic/ other physical problems such as vomiting, pain, fever, headache,
memory disturbances, cardiovascular disturbances, pervasive mood changes, substance misuse,
and confusion. Also, if fallen down and injured, and side effects of a drug medication. Mention
quality of each such disturbances: such as composition of vomit, kind and site of pain, etc. Also
mention the quality of the same such as amount and number of times vomiting, degree of fever,
number of headaches, etc.
● Treatment (if any)
for any of the above mentioned associated disturbances and negative history.

F. Systematic Inquiry
● Respiratory system- sore throat, earache, cough, chest infection, history of aspiration,
hemoptysis.
● Gastrointestinal system - abdominal pain, vomiting, jaundice, diarrhea/constipation, blood
in stool.
 ● CNS- syncope/dizziness, fits/seizures, headache, visual problems, numbness, unpleasant
sensations, weakness, frequent falls, incontinence.
● Genitourinary system - stream, dysuria, frequency of urination, incontinence,
enuresis/nocturia, hematuria.
● Rheumatological system - limp, joint swelling, hair loss, skin rash, dry mouth/mouth
ulcers, dry or sore eyes, cold extremities.

G. Past History
● Birth History - basic information will be included , eg, any mental or physical illness or
any issues faced by the parent or child during prenatal/postnatal. Or if the client has faced any
issues during the developmental stages of childhood.
● Past Medical History
○ Life Chart - History of similar and significant illness (physical or emotional
disturbance) in the past, its precipitating causes, duration, interval period, symptoms of each
episode(duration).
○ Treatment History - Treatment for the above-mentioned illness (medication, dosage,
duration, presence of side effects, regular follow-ups, resistance to treatment).

H. Family History (psychiatric/medical illness) - this components includes-

a. Genogram - draw the tree for three generations on both sides in case of genetic importance,
age and cause of death (if any) of the family members should be noted.
b. Age of mother and father, and number of years of their marriage (also mentioning the age
of the mother when the child was born)
c. Type of family (nuclear/joint/specify if others)
d. Anomalous family situation: Yes/No (step parents or adoption status)
e. Socio-economic status (lower/middle/upper) - along with socioeconomic status also
mentioned about - Parents education and occupation, House (made of, size, etc.), Cleanliness and
general hygienic conditions at home, Any pets at home etc.
f. Role functions
g. Child rearing practices
h. Communication pattern among family members and interpersonal relationships - this
includes the circumstances and environment at home and that should be noted.
i. Leader/Head of the family (nominal and functional)
j. History of illness in family - if any illness physical and mental or the present illness of the
client faced by anyone in the family should be recorded. This includes-
o Psychiatric - similar illness, other illnesses, major behavioural problems such as
delinquency, personality problems, suicide/suicidal attempts, epilepsy, substance abuse,
mental retardation, sexually deviant behavior
o Medical - especially hereditary.
 k. Attitude of family member’s towards the client’s illness:
l. Cultural and religious values of the family
m. Social support system

I. Personal and Social History

a. Childhood History - behavior during childhood to be mentioned, normal/abnormal/any
specific trauma/convulsions/fever/any other illness.
o Parental lack: Yes/No or also record if Dead/Absent for more than a year/habitually
away from home.
o Home atmosphere during childhood: Satisfactory/Unsatisfactory
o Behavioral and emotional problems- any particular habits, sleep disturbances, nail
biting, thumb sucking, tics, mannerisms, enuresis, sleep walking, temper tantrums,
stammering, morbid fears/phobias, night ???. Also conduct behaviors such as - frequent
fights, truancy, bullying/bullied, stealing, gang activities should be noted along with its
occurrence.
o Educational and School History - age of beginning and finishing formal education,
academic and extra-curricular achievements, interest in students, behaviour, and relationship
with peers, especially of opposite sex and teachers, any school phobia,
non-attendance/regularity, any learning difficulties, reasons for termination of studies [if
occurs prematurely] should be noted.
o Play History (which game was played and at what stage, with whom and where) o
Physical illness during childhood (special enquiry regarding Epilepsy, Meningitis and
Encephalitis)

b. Puberty - it depends on the gender. This includes-

o for females - Age of menarche and reaction to it, Regularity and duration of menses,
Length of each menstrual cycle, Last menstrual period, Any abnormalities in menstrual
cycle, Age of menopause
o for males - Nocturnal emission, Masturbation,
o Age of appearance of secondary sexual characteristics (in both males and females;
mention the time of facial hair growth etc.) also Anxiety related to puberty to be mentioned.

c. Occupational History - this will includes-

o Age of starting work
o Jobs held in chronological order
o Reasons for changing jobs
o Job satisfaction
o Work environment
o Relationship with authorities, colleagues/peers and subordinates
 o Appropriateness of job to the education and family background
o Present income
o Work shift
o Intervals of rest breaks during a work day

d. Sexual and Marital History

o Information about sexual information (how acquired, of what kind, how received,
adequacy of knowledge, attitude towards opposite sex, and same sex normal/abnormal).
o Masturbation (age of starting, frequency, guilt/attitude if any)
o Sexual experience (homo/hetero/pre or extra-marital/preferences)
o Adolescent sexual activity (if any)
o Gender Identity Disorder (if any)
o Duration of marriage(s) and/or relationship(s)
o The duration for which the partner was known before marriage
o Kind of marriage (arranged by parents with/without consent, self-choice, parental
consent)
o Number of marriage, divorces or separations
o Role in marriage
o Interpersonal and sexual relations
o Contraceptive measures used
o Sexual satisfaction
o Mode and frequency of sexual intercourse
o Psychosexual dysfunction (if any)

e. Alcohol and Substance History

o Eating fads/patterns
o Sleeping patterns
o Excretory functions
o Alcohol consumption (duration, amount and frequency)
o Tobacco consumption (duration, amount and frequency)
o Any drug addiction (if any, then duration, amount and frequency)
o Self-medication with drug

J. Pre-morbid Personality
● Social relation and Interpersonal relationships - The family attachment/dependence to
friends/groups/societies/clubs, to work and workmates; leader, aggressive, follower, organizer,
ambitious, submissive, adjustable, independent, introverted/extroverted, insensitive/sensitive to
criticisms, trusting or suspicious/jealous, emotionally controlled or quick tempered irritable,
tolerant, adaptive, or rigid, etc.
● Intellectual activities - hobbies, interests, books, plays, pictures, memory observations.
● Mood- bright and cheerful or despondent, worrying or placid, stung or calm/relaxed,
optimistic or pessimistic, self-depreciative or satisfied, mood stable/unstable.
● Attitude to work and responsibility - welcomes or worried by responsibility, makes
decisions easily or with difficulty, haphazard or methodological/meticulous, right or flexible,
cautious, foresight/impulsive, preserving or determined or easily bored and discouraged.
● Energy and Initiativeness (lethargic or sluggish, irregular fluctuations in energy levels)
● Fantasy Life (frequency or content of daydreaming)
● Habits

K. Summary- After the information are taken the counselor will be writing a summary of the
whole case history about the patients and also what kind of treatment the client is needed also
will be mentioned.

References
Gopinath,J.K(2018)Essentials Of Psychiatric Interviewing and Mental Status Examination,MM
Publishing House
Rachel M. Voss; Joe M Das(2021)Mental Status Examination,StatPearls
https://www.ncbi.nlm.nih.gov/books/NBK546682/
Christner, R. W., & Hollinger, J. (2022). Fundamental Guide to Conducting a Mental Status
Examination (MSE). Schoolhouse Educational Services.
Shipley, C. N. D. R. S. (2016, October 15). The Mental Status Examination. American Family
Physician. https://www.aafp.org/afp/2016/1015/p635.html
Components of the Patient History 9. (n.d.). ResearchGate. Retrieved February 2, 2022, from
https://www.researchgate.net/figure/Components-of-the-Patient-History-9_tbl3_2583120
57
Case history. (2017, November 16). Research & Learning Online.
https://www.monash.edu/rlo/assignment-samples/medicine-nursing-and-health-sciences/
writing-in-psychological-medicine/case-history