4 Classification and assessment in psychiatry4.3 Clinical assessment
4.3.2 The mental state examination
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Written by Resident Doctor Committee · Published
New in the 2027 syllabus
The College added this topic for exams from January 2027.
What it is
The mental state examination is a structured account of the present. It describes the behaviour you observe and the experiences you elicit during the assessment. The history shows how these change over time.
Observation starts as soon as you meet the person: how they interact, move and speak. Sensitive experiences need direct, respectful questions.
When you write it up, keep the patient's words separate from your findings and your interpretation.
The domains
Domain | What to describe |
|---|---|
Appearance and behaviour | Self-care, activity, engagement, eye contact and abnormal movements |
Speech | Rate, volume, quantity, latency (delay before answering) and articulation |
Mood and affect | The emotional state the person reports, and the expression you observe, including range and reactivity |
Thought | Flow and organisation; beliefs, preoccupations, obsessions and ideas of harm |
Perception | Hallucinations, illusions and related experiences, with context and insight |
Cognition | Alertness, attention, orientation, memory and other functions the presentation points to |
Insight and judgement | Understanding of difficulties, what they are attributed to, views on treatment, and decisions in context |
Asking the questions
Start with open questions so the person can give their own account. Then use focused questions to clarify form, content, frequency, conviction, distress and consequences.
For a reported voice, explore what it sounds like, where it seems to come from, whose it is, when it happens, and its link to sleep, substances and mood.
For a concerning belief, consider cultural context and evidence. Whether you agree with it is not the test.
Ask directly about risk: self-harm, suicide, harm to others, neglect and vulnerability. Then ask about intent, access to means and protective factors.
Making sense of the findings
Mood and affect differ. Someone may say they feel empty yet show a reactive affect. Record both rather than forcing them to agree.
Insight has several parts. Accepting symptoms, attributing them to illness and accepting treatment may not go together.
Cognitive performance depends on language, education, hearing, vision, distress and fatigue, as well as brain function.
A calm interview does not cancel out recent dangerous behaviour or fluctuating symptoms. Combine it with the history and collateral information.
Recording uncertainty
If you did not test a domain, say so rather than recording it as normal.
Repeat the assessment when the presentation fluctuates, or when the person is too distressed, intoxicated or medically unwell for a reliable interview.