Components of a Mental Status Assessment

Appearance

• Age (chronological age and whether person looks this age)
• Sex, Race
• Body build (thin, obese, athletic, medium)
• Position (lying, sitting, standing, kneeling)
• Posture (rigid, slumped, slouched, comfortable, threatening)
• Eye contact (eyes closed, good contact, avoids contact, stares)
• Dress (what individual is wearing, cleanliness, condition of clothes, neatness, appropriateness of garments)
• Grooming (malodorous, unkempt, dirty, unshaven, overly meticulous, hairstyle, disheveled, makeup)
• Manner (cooperative, guarded, pleasant, suspicious, glib, angry, seductive, ingratiating, evasive, friendly, hostile)
• Attentiveness to examiner (disinterested, bored, internally preoccupied, distractible, attentive)
• Distinguishing features (scars, tattoos, bandages, bloodstains, missing teeth, tobacco-stained fingers)
• Prominent physical irregularity (missing limb, jaundice, profuse sweating, goiter, wheezing, coughing)
• Emotional facial expression (crying, calm, perplexed, stressed, tense, screaming, tremulous, furrowed brow)
• Alertness (alert, drowsy, stupor, confused)

Motor/Behaviour

• Retardation (slowed movements)
• Agitation (unable to sit still, wringing hands, rocking, picking at skin or clothing, pacing, excessive movement, compulsive)
• Unusual movements (tremor, lip smacking, tongue thrust, mannerisms, grimaces, tics)
• Gait (shuffling, broad-based, limping, stumbling, hesitation)
• Catatonia (stupor, excitement)

Speech

• Rate (slowed, long pauses before answering questions, hesitant, rapid, pressured)
• Rhythm (monotonous, stuttering)
• Volume (loud, soft, whispered)
• Amount (monosyllabic, hyper-talkative, mute)
• Articulation (clear, mumbled, slurred)
• Spontaneity

Mood/Affect

• Stability (stable, fixed, labile)
• Range (constricted, full)
• Appropriateness (to content of speech and circumstance)
• Intensity (flat, blunted, exaggerated)
• Affect (depressed, sad, happy, euphoric, irritable, anxious, neutral, fearful, angry, pleasant)
• Mood (reported by patient/client)

Thought Content

• Suicidal or homicidal ideations (intent, plan, access to means, time-frame)
• Depressive cognition (guilt, worthlessness, hopelessness)
• Obsessions (persistent, unwanted, recurring thought)
• Ruminations
• Phobias (strong, persistent, fear of object or situation)
• Ideas of reference
• Paranoid ideation
• Magical ideation
• Delusions (false belief kept despite no supportive evidence)
• Overvalued ideas
• Thought broadcasting, insertion or withdrawal
• Other major themes discussed by patient/client

Thought Process

• Coherence (coherent, incoherent)
• Logic (logical, illogical)
• Stream (goal-directed, circumstantial, tangential [diverges suddenly from a train of thought], looseness of associations, flight of ideas, rambling, word salad)
• Perseveration (pathological repetition of a sentence or word)
• Neologism (use of new expressions, phrases, words)
• Blocking (sudden cessation of flow of thinking and speech related to strong emotions)
• Attention (distractibility, concentration)

Perception

• Hallucinations (auditory [including command, running commentary], visual, olfactory [smelling], gustatory [taste], tactile)
• Illusions (misinterpretation of actual external stimuli)
• Depersonalization
• Déjà vu, Jamais vu

Cognition

• Orientation (time, person, place)
• Memory (short-term, long-term)
• Intellect
• Abstract thought
• Capacity to read and write
• Level of consciousness

Insight/Judgement

• Awareness of illness (insight)
• Ability to make a decision wisely considering pros and cons for a course of action