Dr Andrew Vanlint

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Adj Assoc Prof Anthony Llewellyn


Anthony is the Managing Director and the face of AdvanceMed and the Career Doctor YouTube Channel. A Consultant Psychiatrist with extensive medical education and medical human resources experience, Anthony has served over 12 years in various Managerial and Directorial roles, including 4 years as the Medical Director of the Health Education & Training Institute and recently completed a guide into Best Practice for Selection of Trainees into employment roles for the Royal Australasian College of Physicians. He is currently working on a similar project for the Royal Australian and New Zealand College of Radiologists.

Anthony is an expert in Medical HR. He has reviewed numerous CVs, chaired and conducted over a thousand job interviews and provided advice to a number of employers and Colleges about selection processes. Each year Anthony helps over 1,000 doctors with various medical career challenges, including clocking up over 700 coaching hours per year.
Anthony is also an Adjunct Associate Professor at the University of Newcastle’s School of Medicine & Public Health.

Anthony was born on Mouheneenner land in Hobart (Tasmania) and pays respect to the traditional owners of lands he lives and works on, and elders past and present. 

He also has a keen interest in technology and marketing and was previously Chief Technical Officer and a founder of the highly popular onthewards.org project – a website and application designed to assist medical practitioners in their earliest days of postgraduate practice.

The Mental State Examination in Psychiatry

mental state examination

Experienced psychiatrists record most of the information about the MSE while taking a history.  This process can pose a difficulty for a new student to psychiatry.

In other areas of medicine, there is perhaps a clearer division between the taking of the history and the performance of a physical examination although again experienced physicians often integrate examination and history.

I would suggest that when starting out in psychiatry it may be better for you to think about separating the taking of the history from the taking of the mental state examination until you are more comfortable with both processes.

For some students, however, this may not feel natural.  In this case, I would still suggest that you still deliberately allocate some of your time towards the end of the interview to run through a checklist of the mental state examination (this is what I do in my clinical practice).  Again, you may be familiar with this sort of approach in medicine.

This assessment involves noting behaviour such as smiling, laughing, crying, but also the feelings generated in the interviewer. An important skill is the ability to reflect on how the patient makes you feel. Psychodynamic viewpoints often use the concepts of transference and counter-transference to describe the two-way transfer of feelings. For example, some patients may easily become dependent on their doctor, transferring feelings that they would normally have towards a parental figure. Similarly, the previous personal experience of a doctor may influence his or her reaction to the patient: this is called counter-transference.

Being aware of this counter-transference helps understand your reaction to the patient and may also help you to keep yourself healthy, particularly if such feelings are strong.

So what is in fact the difference between the history and the mental state examination?  Well, the textbooks will tell you that the history is an account of what has happened to the patient and gives a longitudinal perspective, whereas the mental state is what is happening to the patient right now.

In point of fact, the distinction is often not so clear and another way of looking at the MSE is a way of collecting and reporting on the current symptoms of the patient some of which will have been occurring for some time, some of which may be occurring close to or at the time of interview, others of which may be part of the current episode but perhaps not present exactly at the time of the interview.

Some of the information between history and MSE will overlap.  For example, if the patient has developed delusions, the history will indicate what they are and how long they have been present, while the MSE will record the types of delusions and the patient’s reaction to them.   As another example, the patient may appear tired on MSE, they may report as part of their history that they have been suffering from insomnia for the last 4 weeks.

Non-verbal behaviour is generally regarded as more difficult to control consciously than verbal behaviour, so it is powerful evidence of the mental state and a major focus of the MSE.

It is particularly important to note if there is a discrepancy between what is said and the non-verbal signals. For example, the patient may be reluctant to acknowledge that they are experiencing auditory hallucinations, however, their distractibility by unseen stimuli which interrupts the conversation flow indicates that auditory hallucinations are likely present.

Non-verbal behaviour is generally regarded as more difficult to control consciously than verbal behaviour, so it is powerful evidence of the mental state and a major focus of the MSE.

A key difference between the physical examination and the MSE is that in the physical examination we are using our body and in some cases instruments (for e.g. a stethoscope) to gather information.

In the MSE we are using our mind to gather information.  It is important to attempt to understand the person’s experience.

Phenomenology is the study of subjective experience.  It is also the term that we use in psychiatry to describe various mental state findings.  Phenomenology is, in fact, a field of philosophy introduced to medicine by the German Psychiatrist Karl Jaspers.

In taking the mental state and describing the phenomenology therefore it is actually both useful and ok to note your own feelings as valid diagnostic data when assessing mood.


I have seen many different formats for recording the MSE and most frameworks are ok in my opinion

If you would like a mnemonic then ABCDE, SIR will probably suffice

A Appearance

B Behaviour

C ognition & Content- including orientation, memory and speech plus thoughts (content)

D Delusions and Hallucinations

E Emotions- including Mood and Affect

S Suicidal thoughts- must be enquired about in every MSE

I Insight & Judgement

Personally, I prefer a slightly longer list of headings:

  • Appearance & Behaviour – here I include any signs of medication side effect, I also normally describe any rapport issues at this time
  • Speech – here I include both speech quality as well as form (as in formal thought disorder)
  • Content – here we are talking about both delusional ideas (ego syntonic) as well as neurotic or anxious symptoms (ego dystonic)
  • Mood – here I tend to include all those symptoms either consistent with a depressive or manic disorder, as well as my risk assessment questions
  • Affect – how the person appears during the interview versus how they are describing themselves
  • Perceptions
  • Cognition – including memory
  • Insight & Judgement

Some useful tips and examples for obtaining the MSE

Appearance and Behaviour

This is generally performed by observation.  Consider clothing & self-care, apparent age versus stated, level of activity, presence of abnormal movements indicative of side effects.  Is the person easily engaged in the interview or is there some difficulty establishing rapport. 

For assessing EPSEs check out this useful video from psychscenehub.

Describe the volume & tone as well as the rate of speech.  You may notice rapid speech which in the context of thoughts moving rapidly from one idea to another is “flight of ideas” which is consistent with mania.  Rule of thumb “if the person is confusing you” they probably have thought disorder which normally indicates either mania or psychosis.

Ask the person to describe how they are experiencing their thoughts.


“Do you have any worries or other things you keep thinking about?” Is a good question to kick off here which will likely elicit any anxious or ruminating thoughts as well as possibly delusional ideas.

“Do you feel anyone might be planning to harm you?” is good for persecutory delusions.

“Do you feel you have any special powers?” is good for bizarre or grandiose delusions.


I generally find that if the person has a mood disorder I have already covered mood by the time I get to compiling the MSE.  However, it’s always important to ask about mood symptoms in all patients, in particular, the presence of suicidal thoughts.

Try a normalizing approach here.

Many people have thoughts about suicide and as a health professional it’s important for me to ask you if you have had such thoughts?”


How does the patient make you feel?

Do they remain relatively the same in their feelings during the course of the interview or are they all over the place labile affcet (Labile affect is generally indicative of a significant mood disturbance, normally Bipolar I Mania although can also occur in Schizoaffective Disorders as well as a range of organic conditions)?  Is their affect appropriate to the topic of conversations i.e. do they look sad when talking about sad things.  Mood congruency is particularly noted when discussing the persons reaction to delusional symptoms. For e.g. classically if psychosis is present in Depression it is normally of a mood-congruent nature, i.e. delusions of persecutions or nihilistic delusions (ideas that the body is rotting or in fact already dead).  Or is their affect disconnected? Mood incongruency can be a little tricky to interpret. It is classically seen in schizophrenia where the patient may be for e.g. experiencing grandiose delusions but seem largely unaffected emotionally by these. It can also occur in both mania with psychotic features (e.g. persecutory delusions) as well as Major Depression with psychotic features.”


“Have you had any unusual experiences?” works well for ideas of reference but you may need to specifically ask about experiences related to the television, radio, computer etc…

“Have you heard voices when there appears to be no one there?” is generally okay for auditory hallucinations.  Note many persons experiencing auditory hallucinations are fearful of revealing this fact so they may be more obvious in their behaviour.

Cognition & Memory

At the minimum consider whether the person appeared to be grossly normal.

Are they oriented to time, place and person?

Are they able to remember recent news events?

Are they able to keep in tune with the interview?

If in doubt perform a short formal cognitive assessment using a standardised instrument.

Don’t rely on just one observation. Remember that cognition and memory can be impaired in a range of organic as well as mental health conditions.  The reliability of one observation or even one MMSE is not as good as a series of observations.

Insight & Judgement

Again often difficult to assess in one interview as insight and judgement often need to be considered relative to the choice confronting the person.

Some good general questions:

“What do you think is going on?”

“Do you feel that you are ok or is there a problem?”

“Do you feel that you are safe?”

It is always important to ask about mood symptoms in all patients, in particular, the presence of suicidal thoughts.

How to describe the MSE

I would encourage students to not get overly caught up in phenomenological definitions.  In most cases, its okay just to describe what is going on in lay terms.

For example, if you are not sure if the person’s affect is labile you could just say that they had quite a range of affect during the interview, with laughter, sadness and irritability at times and you felt that this was unusual.

There are a limited number of phenomenological terms you should be familiar with.  These include:

  • Delusions. For early career purposes, the classical definition of fixed, false beliefs held in the face of conflicting evidence and not consistent with culture and background will suffice. However, it’s interesting to note that we rarely set out to collect evidence that conclusively disproves a delusion. Others might note that a person holds an idea with a level of ‘delusional intensity’.
  • Thought Disorder. This is normally broken into two components: 1. Formal Thought Disorder (a disorder of the flow and logic of thought) which can be seen in a range of conditions, including mania, schizophrenia and depression; Disorder of Content (e.g. delusions but also neuroses & obsessions).
  • Hallucinations
  • Insight
  • Judgement

Flight of Ideas versus Tangentiality (or Loosening of Associations)

I am often asked by students what the difference is between flight of Ideas and tangentiality (or loosening of associations).  In and of themselves these two types of thought disorder can appear to be very similar as both are characterized by thoughts appearing illogical and disconnected.

As we have talked about previously its important to use all parts of your mind as the diagnostic instrument when capturing the MSE or phenomenology.  Thought disorder will likely be one of many phenomena present in a patient which either cluster around a problem with mania or psychosis.

Which is to say if the patient appears to be suffering mania its probably flight of ideas and if the patient appears to be suffering psychosis it’s likely to be tangentiality.

For a more thorough and in-depth discussion of this subject go here

Putting it all together with the History

It is helpful to consider the psychiatric assessment as a hierarchical process where we are seeking to exclude certain conditions first based upon their significance as well as different options for management.  Whilst the history can tell us much about what has been happening to the patient, the mental status examination can really help us hone in on the why?

In general, we want to exclude the presence of a physical condition first, before moving on to exclude a functional psychosis (for e.g. schizophrenia) or mania, followed by excluding neurotic conditions (anxiety disorders and depressive disorders) and finally then personality disorder.

Of course, there are other conditions in psychiatry that do not neatly fit into these categories so this is meant as a guide only.

Some helpful videos and other resources

The following videos were prepared by an Australian organization the Palmerston Organisation for the training of Alcohol and Other Drug Professionals and they nicely highlight examples of mental state features in 3 different cases:

As part of the Perth Co-occurring Disorders Capacity Building Project, 3 case vignettes complete with video explainers were developed for a target audience of alcohol and drug counsellors in order to better teach the mental state examination.  Because the target audience is in a related field to psychiatry I think the videos are also pitched quite well at a medical student and JMO level.  In particular, the approach taken is to not get overly pedantic about precise phenomenological descriptions but to describe well the findings.

A training guide complete with an overview of the MSE in the 3 cases is provided here.

A suggested guide to MSE is provided here.

Across the Tasman the University of Auckland have developed a series of videos for a medical student and general practice trainee audience.  Unfortunately, these are not available on a streaming service or creative commons (I have asked) so you will have to go here to check them out yourself but they are very good albeit a little dated (from the 90s by the look of it).

The University of Nottingham have also published a series of example video interviews which are once again very handy for practising the MSE.  Again they are a little bit dated but I think demonstrate some good signs, including some of the interesting findings in relation to appearance and behaviour.

Finally, the other Newcastle University has an extensive youtube channel with videos demonstrating a range of disorders as well as some abnormal movements, including catatonia and dystonia.

3 responses to “The Mental State Examination in Psychiatry”
  1. Carl Avatar

    Hi Anthony,
    I’d like to ask a question if you don’t mind: What is the correct definition of the term “loosening of associations”? And what is the difference between loosening of associations, derailment, and tangentiality?
    Thank you.

    1. Anthony Llewellyn Avatar
      Anthony Llewellyn

      Hi Carl that’s a good question.

      You will get differing opinions amongst psychiatrists.

      These phenomenon often look (sound) similar in practice.

      I prefer a pragmatic approach. Generally loosening of associations is seen in mania whereas tangentiality and derailment is more often seen in psychosis.

      This is probably the main distinction.

    2. Victor Avatar

      Hi Carl & Anthony,

      Admittedly, there is no uniformity in the way various authors define formal thought disorders terminology. Sometimes, conflicting definitions are seen. However, here is my take on Carl’s questions (and I suppose the following definitions reflect the view of a significant proportion of experts in the field of psychiatry):

      1) Tangentiality: there is a move from thought to thought that relate in some way (oblique relationship) but the patient never gets to the point. Although tangentiality occurs in some people with psychiatric disorders (e.g. schizophrenia, mania, and organic disorders), it can also occur in normal people.

      2) Flight of ideas: there is an abnormal connection between consecutive thoughts in the context of accelerated thinking (pressured speech). The connections between thoughts, though understandable, are abnormal because they are based on rhyme, pun, or distractions in the environment. Flight of ideas is characteristic of mania.

      3) Loosening of associations: there is illogical shifting between unrelated topics. In other words, there is no discernible link between statements. For example: “I love oranges. My uncle works at the coal mines. I think it’s going to rain.” In this example, there is no link between the three sentences. An extremely severe form of loosening of associations is called word salad — an unintelligible mixture of random words and phrases.

      Synonyms for loosening of associations include “derailment” and “knight’s move thinking”. That is, “loosening of associations”, “derailment”, and “knight’s move thinking” all refer to the same thing.

      Typically, loosening of associations occurs in schizophrenia but it can sometimes also occur in mania if the rate of speech is extremely rapid. Although the flight of ideas of a manic patient may sometimes be difficult to distinguish from the loosening of associations seen in schizophrenia, the flight of ideas we see in bipolar disorder is fundamentally different from the formal thought disorder we encounter in schizophrenia. First, flight of ideas is more liable to our understanding whilst the schizophrenic loosening of associations is profoundly incomprehensible. Secondly, in flight of ideas, if the speech was to be slowed down, links between clauses would become demonstrable, and even lapses in link would be understandable whereas in schizophrenia, there are far less links between clauses and, even when they exist, the links tend to be idiosyncratic.

      Furthermore, the origins of both thought disorders are also probably different because in schizophrenia, it seems likely that frontal lobe abnormalities of error monitoring and failure of working memory make speech intrinsically problematic. The schizophrenic patient is unable to remember from second to second the goal of speech, and is also unable to monitor and screen out intrusions, errors, etc. On the other hand, in mania, it is the speed of thinking and the easy distractibility that allows for intrusions — hence, the elemental aspects of speech like rhyme, alliteration and semantic property determine word choice and alter the goal of speech in mania. And if not aspects of speech, then the physical environment that is redolent in imagery, in events, in colour, and shapes capture the goal of speech and alter it in mania. This too can happen in schizophrenia with the proviso that it is the monitoring abnormalities that determine the end product of speech (hence the sometimes similarity between speech in mood disorder and schizophrenia).

      Hope this helps.


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