Components of a Mental Status Assessment o Spontaneity

Appearance
o Age (chronological age and whether person looks this
age)
o Sex, Race Mood/Affect
o Body build (thin, obese, athletic, medium) o Stability (stable, fixed, labile)
o Position (lying, sitting, standing, kneeling) o Range (constricted, full)
o Posture (rigid, slumped, slouched, comfortable, o Appropriateness (to content of speech and
threatening) circumstance)
o Eye contact (eyes closed, good contact, avoids o Intensity (flat, blunted, exaggerated)
contact, stares) o Affect (depressed, sad, happy, euphoric, irritable,
o Dress (what individual is wearing, cleanliness, anxious, neutral, fearful, angry, pleasant)
condition of clothes, neatness, appropriateness of o Mood (reported by patient/client)
garments)
o Grooming (malodorous, unkempt, dirty, unshaven, Thought Content
overly meticulous, hairstyle, disheveled, makeup) o Suicidal or homicidal ideations (intent, plan, access to
o Manner (cooperative, guarded, pleasant, suspicious, means, time-frame)
glib, angry, seductive, ingratiating, evasive, friendly, o Depressive cognition (guilt, worthlessness,
hostile) hopelessness)
o Attentiveness to examiner (disinterested, bored, o Obsessions (persistent, unwanted, recurring thought)
internally preoccupied, distractible, attentive) o Ruminations
o Distinguishing features (scars, tattoos, bandages, o Phobias (strong, persistent, fear of object or situation)
bloodstains, missing teeth, tobacco-stained fingers) o Ideas of reference
o Prominent physical irregularity (missing limb, o Paranoid ideation
jaundice, profuse sweating, goiter, wheezing, o Magical ideation
coughing) o Delusions (false belief kept despite no supportive
o Emotional facial expression (crying, calm, perplexed,
evidence)
stressed, tense, screaming, Dress (what individual is o Overvalued ideas
wearing, cleanliness, condition of clothes, neatness,
o Thought broadcasting, insertion or withdrawal
appropriateness of garments)
o Grooming (malodorous, unkempt, dirty, unshaven, o Other major themes discussed by patient/client
overly meticulous, hairstyle, disheveled, makeup)
o Manner (cooperative, guarded, pleasant, suspicious, Thought Process
o Coherence (coherent, incoherent)
glib, angry, seductive, ingratiating, evasive, friendly,
hostile) o Logic (logical, illogical)
o Attentiveness to examiner (disinterested, bored, o Stream (goal-directed, circumstantial, tangential
internally preoccupied, distractible, attentive) diverges suddenly from a train of thought), looseness
o Distinguishing features (scars, tattoos, bandages, of associations, flight of ideas, rambling, word salad)
bloodstains, missing teeth, tobacco-stained fingers) o Perseveration (pathological repetition of a sentence or
o Prominent physical irregularity (missing limb, word)
jaundice, profuse sweating, goiter, wheezing, o Neologism (use of new expressions, phrases, words)
coughing) o Blocking (sudden cessation of flow of thinking and
o Emotional facial expression (crying, calm, perplexed, speech related to strong emotions)
stressed, tense, screaming, tremulous, furrowed o Attention (distractibility, concentration)
brow) o Hallucinations (auditory [including command, running
o Alertness (alert, drowsy, stupor, confused) commentary, visual, olfactory (smelling], gustatory
[taste], tactile)
Motor/Behaviour o Illusions (misinterpretation of actual external stimuli)
o Retardation (slowed movements) o Depersonalization
o Agitation (unable to sit still, wringing hands, rocking, o Déjà vu, Jamais vu
picking at skin or clothing, pacing, excessive
movement, compulsive) Cognition
o Unusual movements (tremor, lip smacking, tongue o Orientation (time, person, place)
thrust, mannerisms, grimaces, tics) o Memory (short-term, long-term)
o Gait (shuffling, broad-based, limping, stumbling, o Intellect
hesitation) o Abstract thought
o Catatonia (stupor, excitement) o Capacity to read and write
o Level of consciousness
Speech
o Rate (slowed, long pauses before answering Insight/Judgement
questions, hesitant, rapid, pressured) o Awareness of illness (insight)
o Rhythm (monotonous, stuttering) o Ability to make a decision wisely considering pros and
o Volume (loud, soft, whispered) cons for a course of action
o Amount (monosyllabic, hyper-talkative, mute)
o Articulation (clear, mumbled, slurred)