Mental State Examination 2 – Speech and Thought

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), specifically patients’ speech and thought.
  • Evaluate patients’ speech and thought in their mental state 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 11

Before we get started, let’s quickly recap on the last session, which was about the domains of appearance and behaviour:

Speech and Thought Part 2 of 11

Is it all coming back to you?

Great! Let’s move on then to learning about the next two domains of the MSE:

Speech and Thought.

How a person speaks can be abnormal in a number of mental disorders and should be observed and commented upon. This should be described in terms of…

  • the ‘latencies’ – the time between you asking a question and the patient replying
  • the ‘volume’ – both how loudly one speaks and the number of words one uses
  • the ‘rate’ – how fast one gets the words out
  • the ‘rhythm’ – the regularity of phrasing within sentences
  • the ‘intonation’ – the amount of inflection, or cadence (the ‘lilt’) in the voice
  • the ‘prosody’ – the extent to which one uses emphasis to convey meaning that grammar alone cannot

Speech Part 3 of 11

To begin with, is there any speech at all?

A small number of patients are mute during interview. If so comment on…

  • Apparent level of comprehension – does the patient appear to understand what is said? e.g. shakes or nods head appropriately
  • Level of alternate communication – can they write answers down, do they point or use gestures?
  • Level of structural impairment of the organs of speech i.e. is there any evidence of dysarthria? (difficult or unclear articulation of speech that is otherwise linguistically normal)

What is the volume of speech?

  • Does the patient whisper? Or speak inappropriately loudly?
  • Is there stuttering or slurring of speech?
  • Are answers unduly brief or monosyllabic?
  • Conversely, are they inappropriately prolonged? (NB: this could also be because of speed of speech)

What is the rate of speech?

  • Is the patient’s speech unusually slow or unusually rapid (pressured speech)?
  • This may reflect acceleration or deceleration in the speed of thought

What is the latency of speech?

  • Does the patient respond spontaneously?
  • Are there long pauses between asking a question and the patient responding?

What is the tone and rhythm of speech?

  • Does the intonation of the patient’s voice and rhythm of the sentences conveying meaning? e.g. the rise in tone at the end of a question

Thought Part 4 of 11

Describing the disturbance of a patient’s thoughts is one of the most challenging tasks, as it is impossible to know what patients are actually thinking, thus it has to be inferred from their speech and behaviour.

Problems with thinking are considered in the MSE under three headings:

  • Thought form i.e. how the patient is thinking
  • Thought content i.e. what the patient is thinking (the beliefs they hold)
  • Thought possession i.e. Schneider’s first-rank symptoms which are a group of symptoms which have special significance in the diagnosis of schizophrenia

Thought Form Part 5 of 11

Thought form deals with the ‘mechanics’ of the patient’s thoughts i.e. how the patient is thinking. This is of diagnostic use as in many psychiatric disorders, thinking ‘slips’ to a less sophisticated level as a consequence of the illness.

This results in disorders of thought form, where the ability to express ideas cogently and coherently is compromised or lost completely. The stream of goal-directed thought is disrupted by irrelevancies to the extent that the goal gets lost.

The first thing to note, therefore, is how easy is it for you to follow what the person is saying…

Do you have a sense of where they are going with their thoughts?

  • Do they go off on a lot of tangents?
  • Do they seem to be including too much information?
  • Do they eventually get to the ‘goal’ or not?
  • Do their thoughts seem to jump from one ‘connection’ to another really quickly?
  • Are these break-points logical or is it hard to see the connections?

Images from: Marwick K, Birrel S. The psychotic patient. In: Crash Course: Psychiatry. 4th edition. Elsevier Ltd; 2015. p. 65-75.

Thought Content Part 6 of 11

Thought content deals with the beliefs the patient holds and the prominent themes that arise within them i.e. what the patient is thinking.

Some questions that you may find useful in assessing disorders of thought content are…

  • What are the prominent themes of the person’s thinking?
  • Are they preoccupied with anything in particular?
  • Are these themes only revealed in response to your questioning, or were they raised spontaneously?
  • Are they congruent with the patient’s mood?
  • How amenable to discussion and alternative explanation are core beliefs?

The key pathologies of belief psychiatrists are most concerned with are primary and secondary delusions, or overvalued ideas, and obsessions.

Delusions Part 7 of 11

A delusion is an unshakeable false belief that is not accepted by other members of the patient’s culture

It is important to understand the following characteristics of delusional thinking:
  • To the patient, there is no difference between a delusional belief and a true belief – they are the same experience.
  • Therefore, only an external observer can diagnose a delusion.
  • The delusion is false because of faulty reasoning E.g. a man’s delusional belief that his wife is having an affair may actually be true (she may indeed be unfaithful), but it remains a delusion because he reason he gives for this belief is undoubtedly false, for example, she ‘must’ be having an affair because she is part of a top-secret sexual conspiracy to prove that he is a homosexual.
  • It is out of keeping with the patient’s social and cultural background E.g. a belief in the imminent second coming of Christ may be appropriate for a member of a religious group, but not for a formerly atheist, middle-aged business man.

Overvalued Ideas Part 8 of 11

An overvalued idea is a plausible belief that a patient becomes pre-occupied with to an unreasonable extent. The key feature is that the pursuit of this idea cause considerable distress to the patient or those living around them.

They are distinguished from delusions by the lack of gross abnormality in reasoning; these patients can often give fairly logical reasons for their beliefs.

They differ from obsessions in that they are not seen as recurrent intrusions.

Thought Possession Part 9 of 11

Thought possession, also falls under thought content in that it involves delusions of control in which there is a false belief that one’s thoughts, feelings, actions or impulses are controlled or ‘made’ by an external agency, e.g. believing that one was made to break a window by demons.

Delusions of thought control include:

Thought insertion: belief that thoughts or ideas are being implanted in one’s head by an external agency

E.g. ‘the patient repeatedly complains of having disturbingly violent thoughts, which, she claims, are being sent to her by Satan’

Thought withdrawal: belief that one’s thoughts or ideas are being extracted from one’s head by an external agency

E.g. ‘the man continually blames his poor memory on “government agents” who he claims are able to steal his thoughts’

Thought broadcasting: belief that one’s thoughts are being diffused or broadcast to others such that they know what one is thinking

Eg: ‘a woman refuses to explain her problem, saying, “I know you know what I’m thinking. Everybody hears what I’m thinking.”

Questions Part 10 of 11

Summary Part 11 of 11