Mental State Examination 1 – Appearance and Behaviour

Learning outcomes

By the end of this CAL you will be able to:

  • Describe the general purpose and component parts of the Mental State Examination (MSE), especially patients’ appearance and behaviour.
  • Evaluate patients’ appearance and behaviour and use appropriate terminology to describe abnormalities.


Thank you to Neelom Sharma, Alexandra Pittock, Meroe Grove, Maia Forrester and Mercedes Smith for their major contributions to the content of this module.

Introduction Part 1 of 5

The mental state examination is a structured way of taking a ‘snapshot’ of a person’s psychological functioning. We do this by observing and describing a patient’s current state of mind.

Many of us already intuitively perform many parts of the MSE every time we interact with or observe others. For example, if you’re chatting to a friend and they don’t seem as smiley or talkative as usual, then you may pick up on this and interpret it as your friend’s mood being a little low.

Similarly, if someone is talking really fast and loudly with lots of wild gestures and a smile on their face, you may interpret this as them being excited about something, so their mood would be up.

The present mental state should include all noteworthy psychiatric symptoms evident over the previous few weeks. Taking an average of recommendations, this means a minimum of the past week, to a maximum of the past 4 weeks.

As the examining clinician, you have to choose – but use your common sense! Like all doctors, psychiatrists make diagnoses based upon history, examination and investigation. The primary aim of the MSE is to help the clinician formulate a diagnosis.

It is helpful to work through each domain in a systematic order.

In the next few slides, we have broken each of these domains down into a few questions that you may find helpful in asking yourself when making your observations.

They detail what kind of features you would want to look for in your patient, and what is important to comment upon in your report of the MSE.

But first…

Appearance and Behaviour Part 2 of 5

What is the patient’s general appearance?

  • What is their build – too thin or obese?
  • Compare what age they appear with their actual age – do they look their chronological age or do they seem ‘old’ or ‘well-preserved’?
  • What is the patient’s racial origin?
  • Do they have any stigmata of physical illness?

What is their manner of dress?

  • Are clothes appropriate to the weather and circumstances?
  • Is the patient dressed excessively formally, over-flamboyantly, or sexually provocatively?
  • Are clothes ‘put on’ properly – matching items (shoes, socks etc), buttons done correctly, etc.
  • Is the patient carrying any strange objects?

Is there any evidence of self-neglect?

  • Does the patient have lower than normal standards of self-care and personal hygiene?
  • Are they malodorous, unshaven, or dishevelled?
  • Do they smell of alcohol?
  • Is there any evidence of injury or self-harm?
  • Is there any evidence of intravenous drug use?

What is the patient’s demeanour at first contact and throughout the interview?

  • Are they relaxed, engaged or deferential – or angry, hostile and confrontational?
  • Do you feel comfortable in their presence or is the atmosphere threatening to you?
  • What is their level of eye contact e.g. reduced or inappropriately intense?

What is the patient’s level of activity during the interview?

  • Do they show psychomotor signs?
    • Restlessness, fidgetiness inability to settle in chair, need to pace etc.
    • Retardation (deficient posture, paucity of movement, slow response)
  • Is there a normal level of gesture or exaggerated gesticulation during conversation?
  • Is there poor eye contact and/or hunched shoulders?

Is the patient demonstrating any abnormal movements or postures? (i.e. is there any evidence of psychomotor abnormalities?)

  • Does the patient demonstrate repetitive or rocking movements, or bizarre posturing?
  • Do they perform voluntary, goal-directed activities in a bizarre way?
  • For patients on (or previously on) antipsychotics, is there any evidence of side-effects?

Is the patient’s behaviour socially inappropriate?

  • Is there overly familiar, or sexually forward behaviour?
  • Is the patient’s behaviour threatening, aggressive, or violent?
  • In manner or in speech does the patient appear hostile or threatening? Do you feel at risk?
  • Is there aggressive or violent behaviour on display during the interview? What prompts it?

Are you able to build a rapport with the patient?

  • It is useful to record the nature of the rapport established with the patient e.g. are they engaging and cooperative or do you feel threatened?
  • A positive rapport aids the formation of a constructive therapeutic relationship
  • A negative rapport can be highly counter-therapeutic.

Is the patient distractible or appearing to be responding to hallucinations?

  • Over-readily distracted by external or incidental stimuli (e.g. corridor noises etc)?
  • Does the patient appear to be attending to a stimulus/stimuli that is/are not objectively verifiable?
    • Hear a voice other than yours?
    • Looking around the room as if for the source of a voice?
    • Murmuring or mouthing soundlessly to themselves?
    • Episodes of giggling, verbal outbursts, or other unexplained actions?
  • Appear to see things others cannot?

Recording Appearance and Behaviour Part 3 of 5

Though this may seem like a great deal to have to recall, remember that you will probably have already noticed a lot of these things sub-consciously. If you ever get stuck in trying to remember it all just pay attention to the gut feeling you get when observing or listening to a patient, and ask yourself what is the evidence that you can see or hear that supports this?

Once you’ve had time to reflect on the information you’ve collected, it’s time to present it back in a systematic format.

Your aim in the Appearance and Behaviour domains is to paint a picture with words: somebody reading your description should be able to appreciate what it feels like to be in the room with the patient.

Questions Part 4 of 5

Now watch this video and write your example, then click the button at the end of the video to compare your answer.

Summary Part 5 of 5

Before looking at the next domains of the MSE, let’s quickly recap on the domains of appearance and behaviour: