Elements of the Mental Status Exam
Appearance |
How does the client look? Well dressed with attention to detail? Well groomed? Age appropriate? |
Behavior |
What is the client’s activity level? Are there tics or stereotyped movements? How alert is the client? What are the client’s facial expressions? Do they match the content discussed? |
Attitude |
Is the client cooperative? Resistant? Fearful? |
Mood/Affect |
What is the client’s prevailing mood? Is there observable mood lability? Does the client show a range of affect? Is it appropriate to the content discussed? |
Speech |
Is the client understandable? Are there any speech abnormalities (e.g., stuttering)? Is the client’s speech pressured? |
Thought Process |
Is the client’s thought process circumstantial? Tangential? Is there evidence of flight of ideas? Is there poverty of thought? Perseverations? |
Thought Content |
Does the client exhibit delusions? Phobias? Obsessions? Is the client preoccupied? Does the client have suicidal thought? Thoughts of harming others? |
Perceptions |
Is the client experiencing hallucinations or illusions? |
Cognition |
Is the client alert and oriented? Can the client demonstrate attention and concentration? Is the client’s memory (short- and long-term) intact? |
Insight |
Does the client demonstrate understanding of his or her own symptoms or situation? |
Judgment |
Does the client demonstrate the ability to make sound, responsible decisions? |
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GABA (General Appearance, Behavior, Attitude)
General Appearance |
age/gender, appearance vs. stated age, body habitus, clothing, hygiene, grooming, physical abnormalities, tattoos, piercings |
Behavior |
posture, eye contact, mannerisms, tics, activity level, psychomotor retardation/activation, akathisia, automatisms, catatonia, choreoathetoid, compulsions, dystonias, tremors |
Attitude |
cooperative/uncooperative, seductive, flattering, charming, eager to please, entitled, controlling, hostile, guarded, critical, antagonistic, childish |
Mood and Affect
Mood |
Patient reported emotional tone in quotations |
Affect |
Physical expression of immediate feeling state. |
Type: |
euthymic, hyperthymic, elevated, euphoric, dysphoric, irritable, anxious |
Quality/range: |
Intense > full > constricted > blunted > flat |
Motility: |
Labile > supple/stable > sluggish |
Appropriateness to content: |
appropriate or not |
Speech
Speech |
Rate: |
pressured > rapid > regular > slowed |
Rhythm: |
prosody, cadence, latency, spontaneity |
Articulation: |
dysarthria, stuttering |
Accent/dialect: |
tone, volume/modulation |
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