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MENTAL STATUS ASSESSMENT / AN OUTLINE

Appearance

dress & grooming
manner, congruence, seductive, slovenly, fastidious..
gait & posture
rigid, slumped, spastic, handicaps.
physical characteristics
manner, congruence, seductive, slovenly, fastidious..
facial expression
sad, suspicious, angry, silly, bland, immobile,flat,contorted, peculiar.
eye contact
seeks, maintains, avoids, decrements, tracking.
tics and mannerisms
grimacing, yelps, grunds, hair-pulling, repetitive.
motor activity
restlessness, psychomotor retardation, agitation.

Speech

rate
manner, congruence, seductive, slovenly, fastidious..
pressure
normal, slow, rapid, racing
amplitude
audible, inaudible, loud, soft, mumbled..
rhythm
abrupt, stacatto, clipped, stretched, hesitant, labored..
quality-modulation
modulation-congruence.
associations
tight, tangential, loose, circumstantial, fragmented.
manner
concrete, abstract, literal, semantic, spontaneous.
idiosyncrasies
stutter, lisping, misuse, neological, praphrasias.
prosody
expressive, receptive ..

Affect

quality
flat, blunted, constricted, odd, perplexed, threatening, curious, .
mood
sad, anxious, guarded, agitated, mellow, happy, euphoric.
range
limited, constricted, variable, wide.
stability
labile, stable.
modulation quality-
appropriate, incongruent.
congruence
appropriate, incongruent, monotonic.
relatedness
related, unrelated, difficult..

Thought Process

process
flow of ideas, blocking, parapraxias, associations..
content
distortions, delusions, reference, depersonalization..
preoccupations
obsessions, phobias, somatic concerns, over-religiosity, supernatural, morbid..
suicidality, homicidality
history of threats, gestures, attempts..

Perceptual- conceptual

illusions
flow of ideas, blocking, parapraxias.
delusions
persecution, grandeur, reference, other.
derelium
confusion, fugue.
depersonalization
transient, episodic, (frequency-duration-intensity).
derealization
transient, episodic, (frequency-duration-intensity).
dissociation
transient, episodic, (frequency-duration-intensity).
hallucinations
auditory, visual, olfactory, tactile.
distortions
cognitive dissonance (leon festinger) - cbt:associated with emotional disturbance.
flash-backs
cognitive dissonance (leon festinger) - cbt:associated with emotional disturbance.

Sensorium

consciousness
hyper alert, confused, drowsy, clouded, alert .
orientation
time, place, person.
concentration
serial 7s, successive 7s, reciting.
memory
recent, remote, immediate.
fund of knowledge
current events, people.
abstraction
proverbs, similarities, analogies.
judgment
test for normative response to an event.
insight
critical, automatic,retrospective.

Manner of approach to interview(er)

Q1    Defensive
Easily offended, or feeling criticized, or difficulty in accepting observations.
Q1    Combative
Aggressive, or threatening, loud, agitated, could be frightening, ....
Q1    Tentative, Tenuous, Evasive
Frequent use of 'yes-but', 'if', 'maybe', 'perhaps', 'probably', 'sometimes', 'not always', 'it depends' .
Q1    Intellectual
Serious, Cerebral, Dispassionate, Unemotional, Failing to read between the lines, ...
Q1    Guarded - Vigilant
Pauses before answering, deliberates, reads between the lines, Non-Verbal Cues of guardedness, humorless, ...
Q1    Cooperative, collaborative, agreeable
Q1    Trusting, confiding, revealing
Q1    Haughty, pompous, arrogant.
Q1    Over-elaborate, given to exaggerations and/or hyperbole, embelishments.
Over-elaborate, given to exaggerations and/or hyperbole, embelishments.
Q1    Apathetic, indifferent, distant, aloof or oblivious.