How to Write a Psychiatric Mental Status Examination (MSE)
Core MSE Structure and Components
The mental status examination should systematically assess nine key domains: appearance, behavior, cooperation, speech, thought process, thought content, affect, mood, perceptions, and suicidality (ABC-STAMPS framework). 1
The MSE is analogous to the physical examination and provides a structured template to collect clinical data through both direct observation and patient report. 2, 1, 3
Essential Domains to Document
Appearance and Behavior: Document grooming, hygiene, dress appropriateness, eye contact, and any unusual physical characteristics or behaviors. 1, 3
Motor Activity: Observe for psychomotor agitation, retardation, abnormal movements, tics, or bizarre behaviors that persist beyond acute intoxication. 4, 5
Speech: Assess rate, volume, tone, spontaneity, and coherence. Note if speech is pressured, slowed, or disorganized. 1, 3
Mood and Affect: Mood is the patient's subjective emotional state (ask directly: "How is your mood?"). Affect is your objective observation of emotional expression, including range, appropriateness, intensity, and stability. 1, 3, 5
Thought Process: Evaluate organization and flow of ideas. Look for tangentiality, circumstantiality, loose associations, flight of ideas, or thought blocking. 4, 3
Thought Content: Document delusions, obsessions, preoccupations, suicidal ideation, homicidal ideation, and any bizarre beliefs. Specifically assess for running commentary hallucinations or conversing voices, which are particularly significant in schizophrenia. 4, 3
Perceptions: Identify hallucinations (auditory, visual, tactile, olfactory) and illusions. Determine if the patient has insight into the unreality of these experiences. 4, 3
Cognition and Sensorium: Assess level of consciousness, orientation (person, place, time, situation), attention, concentration, and memory (immediate, recent, remote). 4, 3
Insight and Judgment: Evaluate the patient's understanding of their illness and ability to make reasonable decisions. 4, 3
Special Considerations for Schizophrenia with Substance Abuse
Critical Diagnostic Distinctions
When evaluating a patient with schizophrenia and substance abuse history, document whether psychotic symptoms persist beyond one week after confirmed detoxification—this is the primary threshold for distinguishing primary schizophrenia from substance-induced psychosis. 6
Obtain urine toxicology screening to document current substance use, as up to 50% of schizophrenia patients have comorbid substance abuse. 6, 7
Specifically document the presence of formal thought disorder, which distinguishes true schizophrenia from substance-induced or psychotic-like symptoms. 6
Note negative symptoms (flat affect, social withdrawal, anergia, poverty of speech) as these are more prominent in primary schizophrenia than substance-induced presentations. 4, 6
Trauma and Dissociative Phenomena
In patients with trauma history, carefully distinguish between true psychotic symptoms and dissociative phenomena (intrusive thoughts, derealization, depersonalization), as maltreated patients report significantly higher rates of psychotic-like symptoms that may not represent true psychosis. 8, 6
Document any history of childhood abuse, neglect, or exposure to violence, as these developmental factors contribute to both personality pathology and psychotic presentations. 8
Documentation Strategy
Recording Observations
Use detailed descriptive psychopathology rather than diagnostic labels when documenting MSE findings. 2
Record specific observable behaviors and verbatim examples of abnormal speech or thought content rather than interpretive summaries. 2, 5
Document both positive symptoms (hallucinations, delusions, disorganized speech/behavior) and negative symptoms (flat affect, anergia, social withdrawal, poverty of speech). 4
Note the phase of illness: prodromal (deterioration before psychosis), acute (predominance of positive symptoms), recuperative (persistent negative symptoms after acute phase), or residual (between acute episodes). 4
Collateral Information
Never rely solely on patient self-report, especially in personality disorders and psychotic conditions where impaired insight is a core feature. 8
Gather information from family members, prior treatment records, and other collateral sources, as discrepancies between self-report and informant reports are diagnostically informative. 8
Interview patients and caregivers both together and separately to obtain comprehensive information. 4
Common Pitfalls to Avoid
Do not miss substance-induced presentations: Document the temporal relationship between substance use and symptom onset. Alcohol, cocaine, amphetamines, hallucinogens, PCP, and marijuana are primary substances causing psychotic reactions. 6
Do not confuse bipolar disorder with schizophrenia: Approximately 50% of adolescents with bipolar disorder are initially misdiagnosed as having schizophrenia. Systematically assess for mood disorder first, as manic episodes frequently include schizophrenia-like symptoms at onset. 4, 8, 6
Do not overlook medical causes: Complete blood count, serum chemistry, thyroid function, and urinalysis should be obtained to rule out medical conditions causing psychiatric symptoms. 6
Recognize diagnostic uncertainty: Misdiagnosis is common at onset, and approximately 36% of youth initially diagnosed with schizophrenia receive different diagnoses at 10-year follow-up. Plan for longitudinal reassessment. 4, 6
Safety Assessment
Always evaluate current suicidal or aggressive ideation, as schizophrenia carries a 10% lifetime suicide risk and patients with comorbid substance abuse have elevated mortality risk. 4, 8
Document whether the patient continues to endorse desire to die, remains agitated or severely hopeless, can engage in safety planning, and has adequate support systems. 4
For high-risk patients, ensure personal and belongings search, hospital attire, safe environment without access to medical equipment, and close staff supervision. 4