Psychiatric history and mental-state examination

01Purpose and principlesWhat the assessment is for and the core concepts behind it.

Create conditions in which the person can give the best account available. Introduce your role, establish preferred name and pronouns, check language, literacy, sensory and neurodevelopmental needs, and explain the purpose of the conversation. Start with an open invitation such as what has been happening and what help is wanted. Follow with a chronological history of the presenting difficulty: onset, triggers, pattern, severity, associated experiences, effect on daily life, previous help and the person's own explanation. Distinguish exact words from clinical interpretation.

Cover previous mental-health episodes, diagnoses, admissions, psychological treatment, prescribed and non-prescribed medicines, response, adverse effects and adherence. Ask about medical and neurological illness, head injury, seizures, sleep, pain, reproductive context where relevant, alcohol, nicotine, caffeine, recreational substances and withdrawal. Developmental, educational, occupational, relationship, housing, financial, legal and trauma histories should be paced according to relevance and safety. Family history can inform vulnerability but is not destiny.

Describe rather than label the observed mental state. Appearance includes clothing, grooming, nutrition and injuries only where relevant. Behaviour includes engagement, eye contact, psychomotor change, abnormal movements and response to unseen stimuli. Characterise speech by rate, volume, quantity, latency, rhythm and coherence. Record subjective mood in the person's language and observed affect by range, reactivity, congruence and stability. Thought form concerns the organisation of ideas; thought content includes beliefs, preoccupations, guilt, hopelessness and risk. Explore hallucination-like experiences by modality, context, control, distress and meaning. Cognition requires attention, orientation and selected testing rather than a blanket statement. Insight should describe recognition, explanation and willingness to consider help, not simple agreement with the clinician.

Risk assessment is embedded throughout but should conclude with an explicit formulation. Identify the feared outcome, current intent, planning, means, past behaviour, recent change, intoxication, symptoms, relationships, safeguarding concerns, dynamic stressors, protective factors and the person's view of safety. Avoid predicting an individual outcome from a checklist or labelling risk as merely low, medium or high. State what makes harm more or less likely now, plausible scenarios, warning signs, immediate mitigations and review triggers.

Finish with a concise synthesis: principal problems, strengths, possible diagnoses and alternatives, physical exclusions, capacity for relevant decisions, risk formulation and agreed plan. Confirm what may be shared with the GP, family or other services. Give the person space to correct the summary. A high-quality record distinguishes their report, collateral report, direct observation and clinician inference, and documents uncertainty rather than converting incomplete evidence into certainty.

Key points

Begin with the person's account and priorities, then establish a dated chronology of symptoms, function, treatment, physical health, substances, development, relationships and previous episodes.
Explain privacy and its limits before sensitive questions; use a professional interpreter and communication adjustments rather than relying on relatives to translate clinical or risk information.
The mental-state examination is a description made during the encounter: appearance and behaviour, speech, mood and affect, thought, perception, cognition, insight and judgement.
Separate reported mood from observed affect, thought form from thought content, and perceptual experience from the person's interpretation of that experience.
Ask directly and calmly about self-harm, suicide, harm to others, self-neglect, abuse, exploitation, dependants, access to means and factors that help the person remain safe.
Assess capacity only when a particular decision is in doubt; diagnosis, detention, apparent irrationality or a low cognitive score does not establish incapacity.
Seek consented collateral information when it can clarify baseline, chronology, adherence and risk, while documenting source, relationship, potential bias and any confidentiality decision.
Complete physical observations and targeted examination when presentation, medicines or history indicate them; unexpected late onset or altered consciousness widens the medical differential.
End by summarising what has been understood, acknowledging uncertainty, agreeing immediate actions and recording who will review outstanding risks, results and diagnostic alternatives.

02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.

Depressive mental state

Reduced speech, slowed movement, restricted affect, guilt, hopelessness and suicidal thinking may cluster, but pain, delirium, medicines and neurological disease still require consideration.

Manic activation

Reduced need for sleep, increased activity, pressured speech, distractibility, expansive or irritable affect and risky behaviour support a manic syndrome when sustained and functionally significant.

Psychotic phenomena

Fixed unusual beliefs, thought disorganisation or hallucinations need phenomenological description, cultural context and assessment of distress, conviction, behaviour and associated mood or substance effects.

Delirious presentation

Acute onset, fluctuating arousal and impaired attention point toward delirium, even when hallucinations, fear or agitation initially resemble a primary psychiatric disorder.

Immediate risk state

Recent escalation, intent, available means, inability to delay action, severe agitation or collapse of protective arrangements makes urgent containment and specialist review necessary.

Red flags requiring action

Fluctuating attention or arousal, disorientation, fever, hypoxia, head injury, seizure, focal neurology or a new medicine exposure suggests an acute medical or neurological syndrome rather than uncomplicated primary psychiatric illness.
Current suicidal intent, a rehearsed or available method, recent high-lethality behaviour, command hallucinations, severe hopelessness or inability to collaborate with immediate safety measures demands same-day specialist assessment.
Threats linked to a named person, weapon access, escalating persecutory beliefs, intoxication or recent serious violence require specific inquiry, environmental safety and proportionate information sharing.
Mutism, posturing, stupor, marked negativism, excitement or autonomic disturbance can represent catatonia, which needs urgent medical assessment and must not be dismissed as non-cooperation.
A person who cannot understand, retain, use or weigh information about an urgent decision after practicable support needs a decision-specific capacity assessment and lawful substitute process.

03Method and interpretationA systematic approach to the test and its findings.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Initial clinical interview and chronologyFirst step
Why
Define symptoms, course, context, impairment, previous episodes, treatments and the person's goals.
Interpretation and limitations
A coherent timeline separates episodic from persistent change and highlights temporal links to illness, substances, medicines, trauma or social events; gaps should remain explicit rather than being guessed.
02
Structured mental-state examination
Why
Document current behaviour, speech, emotion, thinking, perception, cognition, insight and judgement.
Interpretation and limitations
Findings are time-limited observations influenced by language, culture, fear, intoxication and environment. They support, but do not independently establish, diagnosis or future risk.
03
Suicide, violence and vulnerability formulation
Why
Identify foreseeable harms, scenarios, dynamic drivers, means, affected people and protective arrangements.
Interpretation and limitations
Use specific evidence and actions rather than a numerical or categorical label. A stated denial is important but cannot replace assessment of behaviour, collateral evidence and recent change.
04
Decision-specific capacity assessment
Why
Determine whether the person can make a particular decision after all practicable communication support.
Interpretation and limitations
Record the relevant information and the person's ability to understand, retain, use or weigh and communicate it; an unwise decision or psychiatric diagnosis alone is insufficient.
05
Physical and neurological assessment
Why
Detect delirium, intoxication, withdrawal, injury, endocrine or neurological disease and treatment complications.
Interpretation and limitations
Select observations, examination and tests from the phenotype. Normal basic bloods do not exclude epilepsy, encephalitis, intoxication or structural brain disease when clinical warning features persist.
06
Consented collateral and record review
Why
Clarify baseline, longitudinal course, adherence, previous risk, dependants and discrepancies in the account.
Interpretation and limitations
Record who supplied information and how it was obtained. Collateral may be incomplete or conflicted, so corroborate material facts and preserve the patient's account.

04Clinical next stepsHow the result changes management or prompts escalation.

01Opening sequenceEngage, orient and obtain the storyFirst stepA person presents for psychiatric assessment in any clinical setting.

1Check immediate physical safety, privacy, communication needs and whether another person should be present before beginning a broad invitation.
2Build a dated account of symptoms, function, context, treatments and previous episodes, moving from open questions to focused clarification.
3Summarise periodically, distinguish observation from report and obtain permission before particularly sensitive or collateral enquiries.

02Mental-state sequenceDescribe each domain preciselyThe interview provides enough engagement for current-state examination.

1Record appearance, behaviour, psychomotor activity and speech using neutral observable language rather than character judgements.
2Explore mood, affect, thought form, thought content, perception and cognition with examples and the person's meaning attached to experiences.
3Describe insight, judgement, capacity and risk separately, noting limitations created by distress, language, intoxication or a brief encounter.

03Urgent escalationStabilise and formulate immediate dangerEscalationAcute medical change, imminent self-harm, serious violence risk or inability to maintain basic safety emerges.

1Pause routine history, obtain urgent assistance, reduce environmental hazards and assess physiological threats using the appropriate emergency pathway.
2Define the feared event, timeframe, intent, capability, means, affected people and existing safeguards, using collateral information where lawful and necessary.
3Arrange the least restrictive safe setting and observation, document capacity and legal authority, and provide a named handover with explicit review triggers.

04Closing sequenceShare synthesis and uncertaintyEnough information has been gathered to make an initial plan.

1Offer a plain-language summary of problems, strengths, working explanations, alternatives and what remains unknown, inviting correction.
2Agree immediate treatment, physical investigations, information sharing, crisis arrangements and follow-up responsibility with the person as far as possible.
3EscalationDocument separate evidence sources, the clinical formulation, capacity for relevant choices and the rationale for escalation or non-escalation.

05Risks, monitoring and follow-upComplications, safety checks and further assessment.

Repeat the mental-state and risk assessment after sleep, sobriety, treatment, environmental change or new collateral information because both presentation and danger can alter rapidly.
Track function as well as symptoms: eating, hygiene, medicines, money, parenting, attendance, relationships and ability to seek help can reveal improvement or deterioration.
Review outstanding physical results and adverse-effect monitoring, assigning a named clinician to act on each abnormality rather than leaving an unowned test list.
Revisit capacity whenever the decision, information, timing or mental state changes; do not carry a conclusion from one decision into another.
Confirm that the person and relevant supporters understand warning signs, crisis contacts, follow-up timing and how to seek earlier assessment.

06Special situationsVariants, exceptions and circumstances that change the usual approach.

Phenomenology before label

Describe what the person experiences, how certain they are, its context and effect before assigning a diagnostic term that may conceal important distinctions.

Silence has many meanings

Long latency may reflect depression, fear, language processing, thought disorder, catatonia, cognitive impairment or a deliberate wish not to answer.

Insight is multidimensional

A person may recognise distress and need help while rejecting one diagnostic explanation, so insight should not be reduced to agreement with medication.

Risk denial needs context

A denial of intent is meaningful evidence, but recent actions, access to means, shame, coercion and collateral reports may change the formulation.

Culture shapes expression

Idioms of distress, spirituality, family roles and mistrust can alter content and communication without making an experience pathological or risk-free.

07Common pitfallsFrequent interpretation and management errors.

01
Writing normal mental state without describing the domains actually assessed.
02
Calling affect incongruent merely because the person's expression differs from the clinician's expectation.
03
Using insight absent to mean that the person disagrees with the proposed diagnosis.
04
Concluding low suicide risk from a denial without exploring means, recent behaviour and protective arrangements.
05
Allowing a psychiatric presentation to end physical and neurological assessment prematurely.
06
Assuming incapacity from detention, psychosis, intoxication or an apparently unwise choice.
07
Recording a collateral allegation as established fact without naming its source.
08
Using family members or children as routine interpreters for sensitive clinical information.