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MENTAL STATUS EXAM

1. GENERAL APPEARANCE

a. Dress

Conventional: Customary; sanctioned by usage; traditional


Meticulous: Overly neat and clean, unusually careful of detail
Eccentric: Peculiar or unusual
Seductive: Inappropriate dressing to enhance sexual
desirability
Disheveled: Untidy; rumpled; in disrepair; dirty

b. Grooming

Well-groomed: Clean and neat


Dirty: Hair, clothes and/or skin dirty
Unkept: Hair not combed; buttons undone or incorrect

c. Hygiene

Good:
Fair:
Poor:

c. Facial Expression

Sad: Downcast and gloomy expression


Happy: Smiling; laughing
Angry: Frowning, scowling
Unremarkable: Lack of symptoms to arouse notice
Relaxed: Lack of tension; calm, loose muscles
Tense: Muscle taunt; showing emotional strain
Crying: Tearful
Suspicious: Looking around constantly as if worried about
threat;
guarding information
Poor eye contact: Not meeting eyes of interviewer

d. Make-up

Not applicable: For men


Appropriate: Accenting client’s natural features appropriately
Not wearing: Absence
Peculiar/Bizarre: Heavy; exaggerated, or unnatural

e. Body

Wt./Ht. : Weight that is proportionate for height


Obese: Extremely fat or corpulent
Slender: Small in cross section compared to length
Emaciated: Extremely underweight

f. Speech

Audible/Inaudible: Loud enough to be heard by interviewer or not


Clear/Slurred: Distinct or indistinct
Pressured: Speaks very rapidly and continuously
Stammering: Uses involuntary halts, breaks and repetitions
Rapid/Slow:
Mumbling: Speaks in low tone and without articulation
Halting: Uses irregular rhythm
Garbled: Facts and sequence confused and mixed up
Incoherent: Disjointed and unintelligible
Even: Speech is smooth, steady, and constant

2. INTERVIEW BEHAVIOR

a. Attitude

Hostile: Angry, resentful or unfriendly


Euphoric: Demonstrates an exaggerated feeling of well-
being
Threatening: Makes verbal or physical threats
Withdrawn: Avoids interpersonal interaction; stays to self
Defensive: Inappropriately defends against questions
Manipulative: Attempts to get own way using indirect means
Evasive: Avoids honest, overt, candid interaction
Passive: Does not initiate anything; accepts what’s offered
Dramatic/ Using theatrical appearance, speech and/or
behavior
Grandiose:
Naive: Artless, shows lack of knowledge or experience
for age
Aggressive: Overly assertive; insistent on getting own way
Negativistic: Says no to reasonable requests consistently
Overly cooperative: Excessive attempts to please
Ingratiating: Overly compliant to elicit favor and approval
Self Deprecating: Self-degrading; expresses feeling unworthy
Affectations: Posturing with artificial airs
Seductive: Flirtatious, sexual display; excessive intimacy
Disdainful: Superior attitude; disgust for others

b. Posture

Erect: Upright and straight


Slouched: drooping back and shoulders
Rigid: Stiff and inflexible; strongly resistant
Guarded: Appears to protect self from danger

c. Gait/Mobility

Steady: Walks without wavering


Even: Pace is at consistent rate
Limps: Gait is uneven due to weakness or deformity of
limb
Shuffles: Walks while dragging feet instead of lifting them
Staggers: Swaying and uncertain gait

d. Level of Awareness

Attentive: Keeps mind on what is going on around them


Drowsy: Appears to want to go to sleep
Distractible: Distracted by environmental diversions
Inattentive: Unable to pay attention even briefly
Confused: Unable to distinguish between ideas; jumbled
thoughts
Stuporous: Has some moments of unconsciousness
Hypervigilant: Heightened awareness of what goes on around
them

3. ORIENTATION

a. Date and Time


b. Person
c. Place
d. Situation

4. MEMORY

a. Amnesia
b. Short term
c. Long term

5. AFFECT

a. Outward expression of feelings

Appropriate: Expressions suitable for situation


Angry: Displays passionate displeasure
Blunted: Appears insensitive, unperceptive, and slow to
respond
Worried: Disturbed about specific event or outcome
Flat: Minimal expression with small or no range
Elevated: Unusually high spirits
Depressed: Unusually low spirits, dejected
Labile: Great variability of expression from moment to
moment
Congruent: Non verbal and verbal expression of feelings
match

6. THOUGHT PROCESSES

a. How the individual Thinks

Logical: Answers and thinking consistent with correct


reasoning
Rambling: Wandering, disconnected thoughts
Incoherent: Disjointed and confused
Confabulation: Filling in memory gaps by guessing or making up
Blocking: Sudden stop in train of thought in the middle of
thought
Circumstantial: Proceeding indirectly to goal idea with many
tedious details and irrelevant additions

Tangential: Thoughts veer from the main topic and never


return to it
Perseveration: Persistent, involuntary repetition of a phrase or
idea
Flight of Ideas: 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: Focus on own lack of success


Impoverished: Very little thought content
Paranoia: Persistent, unrealistic belief that one is unsafe
Apathy: Absence of caring; indifferent
Phobias: Worries about a specific object or situation
Obsessions: Repetitive, unwanted ideas that intrude into
thoughts
Ideas of Guilt: Focus on the belief that the patient acted in ways
contrary to how he believes he should have acted
Ideas of
Hopelessness: Focus that there is no available prospect for
happiness
Ideas of
Worthlessness: Constant belief that one is of no value
Somaticism: Focus on physical ailments or complaints
Thoughts of
Persecution: Believes others are planning to harm or interfere
Disassociation: Disconnection between thoughts, emotions and
sensations

b. Hallucinations

Auditory: Hearing things when there is no external stimulus


Visual: Seeing things when there is no external stimulus
Olfactory: Smelling odors with no actual basis
Tactile: Feeling touch sensation when there is no stimulus

c. Delusions

Persecution: Believing others are out to get him when there is


no realistic basis for fear
Grandeur: Unrealistic belief that one has unique and special
status
or abilities
Thought
Broadcasting: Belief that one can read others’ minds
Reference: Believe that one is the topic or reference point for
conversations or activities going on around one
Influence: 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 Inability to evaluate situations and make sound


Judgment: decisions leading to appropriate and effective
actions when dealing with others
Lacks Personal Inability to evaluate situations and make
Judgment: decisions leading to appropriate and effective
actions for self.
Insight:
Excellent: Understands the severity of his illness, the need
For treatment, and some of the dynamics
involved
Moderate: Knows why his is in treatment with some
understanding of what the problem is
Little or None: Does not know why he is in treatment