Mental State Examination 4 – Cognition and Insight

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).
  • Evaluate patients’ mental state and use appropriate terminology to describe abnormalities.
  • Consider patients’ experience of suffering mental disorders to guide empathic, non-judgemental and knowledgeable patient care across all medical specialties.
  • Screen for and identify cognitive impairment, using standardised tools such as the Montreal Cognitive Assessment (MoCA).


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 12

Cognition, Insight and Putting It All Together

For the final session on the MSE we are going to focus on how to assess cognition and insight, as well as drawing upon what you have learnt in the previous three sessions to hopefully get you confident in being able to carry out a full MSE.

But before all that, let’s do some revision on what we covered in the previous session…

Cognition Part 2 of 12

Cognition is a complex and multifaceted concept, which in its broadest sense means all the mental activities that allow us to perceive, integrate and conceptualise the world around us.  It encompasses processes such as…

  • Attention
  • Consciousness
  • Memory of all types e.g. working/short-term memory; long-term memory (recent), long-term memory (remote)
  • Judgement
  • Reasoning
  • Problem solving
  • Decision-making
  • Comprehension
  • Production of language.

Impairment in cognition can be generalised (i.e. affects multiple domains) or specific (i.e. affects one domain only).

An altered level of consciousness is generally associated with a generalised impairment in all aspects of cognition, as it is very difficult to concentrate on any tasks when feeling very agitated or drowsy.

At this stage, all you need to know is how to do a basic screening test for cognitive impairment and when to refer or carry out further assessment.

Assessing Cognition Part 3 of 12

The key thing when assessing cognition is to use a standardised test. Many patients maintain a good social veneer, making it surprisingly easy to miss cognitive impairment if it is not formally assessed.

There is a wide range of tests available of varying comprehensiveness, length and generalizability across cultures. The one you choose depends on the time available and degree of concern about a patient’s cognition.

For example, if you have no concerns for a patient’s cognition then a short screening or ‘mini’-test could suffice, however, if a patient came to you with a particular concern e.g. memory problems or word-finding difficulty, then you may want to do a more comprehensive standardised test, or refer to a specialist.

The cognition of all patients should be screened as a minimum by checking their orientation to place, person and time, and if their working (i.e. short-term) memory is intact.

To ensure the result of cognitive assessment reflects cognitive abilities, rather than other difficulties, as far as possible, ensure that the patient has their glasses and/or hearing aid, is not hungry, needing the toilet or exhausted.[1]

A couple of good questions you could ask include…

  • ‘Do you know where you are right now?’
  • ‘Do you know what is today’s date?’
  • ‘What day of the week is it?’
  • ‘What year is it?’

Standardised Basic Cognitive Screening Tests Part 4 of 12

There are many standardised tests that you can use to carry out a basic cognitive screen:

  • Six-item Cognitive Impairment Test (6CIT)
  • Mini mental state examination (MMSE)
  • Mini-Addenbrooke’s Cognitive Examination (Mini-ACE)
  • Montreal Cognitive Assessment (MoCA)

A longer and more comprehensive test which you may find being used clinically include:

  • Addenbrooke’s Cognitive Examination (ACE3)

The main cognitive screening tests we’re going to discuss are the 4AT and the MoCA

The 4AT Part 5 of 12

Use left and right arrow to change slide in that direction whenever canvas is selected.

The 4AT is a rapid assessment test for delirium and cognitive impairment. It takes less than 2 minutes, making it a useful tool in assessing basic cognition in all patients.

The 4AT consists of tests for…

  • Alertness
  • AMT4 (abbreviated mental tests – 4)
    • Age
    • Date of birth
    • Place (name of hospital or building)
    • Current year
  • Attention (months backwards test) Ask the patient: ‘please tell me the months of the year in backwards order, starting at December
  • Acute change or fluctuating course Evidence of significant change or fluctuation in: alertness, cognition, other mental function (e.g. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs.

The MoCA Part 6 of 12

The MoCA is a 10-minute; 30-point cognitive test that tests the domains of attention, language, memory, visuo-spatial skills and executive functioning.

It is a more detailed test than the 4AT, and may be considered, for example, if a patient has scored poorly on basic cognitive screening.

Executive Functioning Part 7 of 12

The term ‘executive functions’ refers to the higher-level cognitive skills you use to control and coordinate your other cognitive abilities and behaviours e.g. who we are, how we organize our lives, how we plan and how we then execute those plans, are all largely guided by our executive system.

The frontal lobes are the main control system for this.

To assess for decline in executive function, you can perform the frontal assessment battery (FAB) test. This is a brief (10-min) test of executive function, which can be done at the bedside.

All you need to know at this stage is that if you have a sense that someone’s executive functioning might be impaired, one needs to test for this specifically and that that can be done by implementing a FAB test.

Reporting Cognition Part 8 of 12

Once you have screened/formally tested a patient’s cognition and there were no concerns you might say something like, ‘cognition is grossly normal and orientated to time, person and place’.

An example of somebody who appeared confused might be reported like…

“Patient appeared confused and disorientated. They did not know where they were, nor what time of day it was, and had to ask for questions to be repeated several times. They scored 17/30 on MMSE, losing points for orientation to time, orientation to place and recall.”

Insight Part 9 of 12

Insight can be defined as ‘the correct attitude to morbid change in oneself’. It is a deceptively simple concept that includes beliefs about the nature of the symptoms, their causation, and the most appropriate way of dealing with them.[6]

It is not an all or nothing attribute. It is often described as good, partial or poor, and can often vary over time.

The question of whether the patient has insight into the nature of their symptoms tends only to arise in psychiatric illnesses.

In general, a patient with physical illness knows that their symptoms represent abnormality and seeks their diagnosis and appropriate treatment.

In contrast, a variety of psychiatric illnesses are associated with impairment of insight and the development of alternative explanations by the patient as to the cause of their symptoms, for example:

  • An elderly man with early dementia who is unable to recall where he leaves objects and attributes this to someone stealing them. He angrily accuses his son of the ‘crime’.
  • An adolescent with developing schizophrenia, who believes his auditory hallucinations and sense of being watched are caused by a neighbour who has planted cameras and loudspeakers in his flat. He repeatedly calls the police and asks them to intervene.

When determining whether or not a patient has insight, you might find it helpful to answer the following questions

  • Does the patient believe that their abnormal perceptions are symptoms?
  • Does the patient believe their symptoms are attributable to illness?
  • Do they believe that the illness is psychiatric?
  • Do they believe that psychiatric treatment might benefit them?
  • Would they be willing to accept advice from a doctor regarding their treatment?
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Beyond the simple question of whether the patient has impairment of insight or not, it is also important to understand how the patient views their symptoms, as this may influence their adherence and future help-seeking behaviour.

It is important to note that disagreement with the doctor as to the best course of action does not necessarily indicate lack of insight.

A patient may very well not agree to be admitted to hospital or to take a particular medication despite having full insight into the nature of their symptoms.

In these cases the doctor should be sure to clarify that the patient has all the necessary information to make a suitable decision before considering the possible need for compulsory treatment.

Questions Part 10 of 12

Watch this video and write a brief report on the patient’s cognition and insight. Compare your answer by clicking the button at the end.

Summary Part 11 of 12

Hopefully by now it will make more sense to you and you will feel more confident in being able to carry out an MSE and pick up on signs and symptoms that might be detectable upon questioning or inspection of the patient.

When putting it all together remember to try and recall the major domains, and then work through them systematically.

If possible, try and note down as many examples as possible of what the patient says that supports your findings, and remember to only include signs and symptoms that are present at the time of the examination.

Good luck – you’ll do great!

Part 12 of 12

If you would like to try doing a full mental state examination, click here to watch an 8 minute clip of an interview with a patient and write how you would describe their MSE.

The password is lithium18

Afterwards, compare your answer with the example below.

 Appearance and Behaviour

The patient is an age-congruent female wearing bright coloured clothes, specifically a peach-coloured hat and trousers, with a flamboyant Mickey Mouse jumper. She is also wearing sunglasses indoors, and uses big gestures when she speaks. There is good rapport with the interviewer, slightly overfamiliar and intrusive during some moments during the interview (eg: pretending to be interviewing the doctor and asking the doctor about her clothes). There are no abnormal movements noted, although she does not seem to be able to sit still for long periods of time. She does not appear to be responding to unseen stimuli.

Speech and Thought

The patient’s speech is of loud volume, but with normal rate and rhythm. There is no obvious sign of pressure of speech, or any evidence of formal thought disorder.

While she does not display any overt delusions of grandeur, she does have grandiose thoughts of exaggerated self-importance, including making plans to leave her job to become a TV/radio presenter at the BBC. She has been making plans to redecorate her house, believes that she has enough money to support herself, and has an ability to connect emotionally with other people including strangers on the street. She does not think that her behaviour maybe risky, including driving. She denies any thought of harming self or others. There is no overt evidence of delusions of thought possession/control or passivity phenomena.

Mood and Perception

She describes her mood subjectively as ‘great’, and objectively she does appear elated. At some points during the interview, she appears a bit irritable when challenged regarding risk. She describes having increased energy She denies having any perceptual abnormalities.

Cognition and Insight

Cognition was not formally tested. She appears to have poor insight into her current condition, believing that she no longer has bipolar disorder and that she is not currently unwell. She also does not think she that she requires treatment.