Comprehensive MSE

MSE Generator

Mental Status Examination (MSE) Generator

Well-Groomed Details Neatly combed hair Clean clothing Trimmed nails Fresh breath

Disheveled Details matted hair body odor stained clothing

Neglected Details unbrushed teeth strong body odor unwashed hair

Overly Meticulous Details excessively groomed perfectly symmetrical hair polished shoes an overly clean appearance possibly spending hours on grooming rituals

Situational Grooming Variations Details typically well-groomed but appears disheveled due to an acute crisis (e.g., recent trauma, hospitalization, or substance intoxication)

Sensory Sensitivities Details autism spectrum disorder sensory overload tactile sensitivity

Environmental Constraints Details homelessness lack of access to hygiene facilities

Inappropriate for Context Details bright or flamboyant clothing mismatched items (e.g., one shoe missing)

Seasonal Inappropriateness Details wearing heavy winter clothing in hot weather unaware of the temperature

Tattered or Dirty Clothing Details torn soiled clothing

Unusual or Eccentric Details revealing overly dramatic clothing excessive jewelry

Cultural Considerations Details hijab sari kilt

Posture Details Relaxed Posture Slumped Posture Rigid Posture Unusual Posture Restless Posture Pain-Related Posture Neurological Influences

Relaxed Posture Details sits comfortably with shoulders back and legs uncrossed

Slumped Posture Details slouch heavily shoulders hunched head down

Rigid Posture Details sit upright with tense shoulders clenched hands

Rigid Posture Details standing motionless arms outstretched

Restless Posture Details shift positions frequently unable to sit still

Pain-Related Posture Details sits stiffly shifts uncomfortably

Neurological Influences Details Parkinsonian rigidity dystonic postures

Congruent Expression Details bright smile animated eyes teary eyes furrowed brow

Flat Affect Details minimal facial movement blank or “mask-like” expression Parkinson’s disease

Incongruent Expression Details indicating a disconnect between mood and expression

Anxious Expression Details wide eyes raised eyebrows tense mouth reflecting worry or fear

Avoidant Eye Contact Details avoid eye contact looking down or away sensory overload

Developmental disorders Details Autism

Fleeting Eye Contact Details glance briefly mistrust hypervigilance

Intense or Staring Details overly intense eye contact confrontational overly engaged heightened arousal

Trauma-Related Eye Contact Details PTSD

Cultural Variation Eye Contact Details direct eye contact may be considered disrespectful due to Cultural Variation

Weight Changes Details emaciated visible bones and thin limbs obese

Hair Details hair loss scalp conditions trichotillomania (hair-pulling disorder) Alopecia

Odor Details body odor breath odor

Skin Condition Details sores meth mites scratched

Visible Health Issues Details Scars from self-harm track marks from intravenous drug use

Neglect of Health Details swollen legs from heart failure

Assistive Devices Details Wheelchairs Canes Prosthetics

Appearing Older Details prematurely aged wrinkles graying hair weathered complexion

Appearing Younger Details appearing younger than their age scalp conditions

Consistent with Age Details Appear their stated age

Stress-Related Aging Details gaunt tired appearance making them seem older due to stress or poor sleep

Lifestyle Factors Details smoking sun exposure malnutrition

Cosmetic Alterations Details excessive makeup plastic surgery

Medication Effects Details Long-term use of certain medications (e.g., corticosteroids) might cause puffiness or other changes that alter apparent age

Normal Motor Activity Details moves smoothly purposeful gestures

Tremors or Tics Details involuntary tremors facial tics jerky movements Huntington’s disease

Stereotyped Movements Details repetitive movements rocking hand-flapping ritualistic movements

Cooperative Details answers questions willingly engages with the clinician appears open

Hostile or Guarded Details defensive sarcastic resistant

Withdrawn Details speak minimally avoid engagement emotionally distant

Apathetic Details indifference lack of emotional investment

Overly Familiar Details Overly friendly using excessive humor or flirtation

Erratic Details alternate between cooperative and agitated behavior unstable thought processes

Seductive or Manipulative Details flirtatious gestures compliments histrionic personality disorder

Childlike Demeanor Details regressive immature behavior giggling speaks in a childlike tone

Accessories or Tattoos/Piercings Details Culturally Significant Accessories Functional Accessories Excessive Accessories Tattoos with Clinical Relevance Unusual Piercings Temporary Markings

Culturally Significant Accessories Details wearing religious symbols (e.g., a cross, prayer beads) reflect spiritual beliefs

Functional Accessories Details medical alert bracelets hearing aids

Excessive Accessories wear multiple rings necklaces bright accessories

Tattoos with Clinical Relevance skulls or knives tattoos gang symbols

Unusual Piercings Details Multiple or extreme piercings (e.g., facial spikes)

Temporary Markings Details henna body paint

Normal Rate Details Conversational pace steady flow

Rapid/Pressured Speech Details Fast hard to interrupt

Slowed Speech Details Delayed long pauses

Variable Rate Details ⦁ Variable Rate: Alternates rapid and slow (e.g., schizophrenia)

Contextual Factors Details Cultural or linguistic influences on perceived rate

Normal Volume Details Audible appropriate for setting

Loud Volume Details Excessively loud

Soft/Whispered Speech Details Barely audible

Muted/Monotone Volume Details Lacks dynamic range

Neurological Considerations Details Hypophonia from Parkinson’s or stroke

Fluent Speech Details Smooth uninterrupted flow

Stuttering/Stammering Details Repetition of sounds

Speech Blocking Details Sudden pauses

Cluttering Details Rapid jumbled speech

Developmental/Cultural Factors Details Non-native speakers childhood stuttering

Clear Articulation Details Distinct pronunciation

Slurred Speech Details Mumbled words

Dysarthria Details Effortful distorted speech

Overly Precise Articulation Details Exaggerated clarity

Medical Considerations Details Dental issues oral injuries

Normal Prosody Details Natural emotional inflection

Monotone Prosody Details Flat robotic tone

Exaggerated Prosody Details Dramatic sing-song

Incongruent Prosody Details Mismatches content

Cultural Nuances Details Reserved inflection in some cultures

Normal Latency Details Prompt timely responses

Increased Latency Details Long pauses

Decreased Latency Details Impulsive immediate answers

Variable Latency Details Inconsistent timing

Neurological Factors Details Delays from aphasia or brain injury

Normal Quantity Details Balanced responsive speech

Increased Quantity (Logorrhea) Details Verbose excessive (e.g., mania)

Decreased Quantity (Poverty of Speech) Details Minimal short answers (e.g., schizophrenia

Muteness Details No speech (e.g., catatonia, severe depression)

Lack of Spontaneity Details Only responds when prompted (e.g., dementia)

Mood Subcategories

Euthymic Mood: Reports feeling “normal” or content
Depressed Mood: Reports sadness, hopelessness
Elevated/Euphoric Mood: Reports elation, grandiosity
Anxious Mood: Reports nervousness, worry
Irritable Mood: Reports frustration, anger
Cultural Considerations: Cultural norms affect mood reporting.

Affect Quality Details Appropriate Affect: Expression matches context (e.g., smiling when happy). Flat Affect: No emotional expression Blunted Affect: Reduced emotional expression Labile Affect: Rapid emotional shifts Inappropriate Affect: Expression mismatches context

Affect Range Details Full Range: Wide variety of emotions (e.g., normal functioning). Constricted Range: Limited emotional variety (e.g., depression). Expansive Range: Exaggerated emotional variety (e.g., mania). Fixed Affect: Single dominant expression (e.g., catatonia). Neurological Considerations: Parkinson’s mimicking constricted affect.

Affect Quality Details Normal Intensity: Proportionate emotional expression Exaggerated Intensity: Overly strong emotions Diminished Intensity: Weak emotions Absent Intensity: No emotional expression Cultural Nuances: Cultural differences in emotional intensity.

Congruence of Mood and Affect Details Congruent: Mood matches affect Incongruent: Mood mismatches affect Partially Congruent: Partial alignment Contextual Mismatch: Mismatch due to external factors Neurological Factors: Incongruence from pseudobulbar affect.

Stability of Mood and Affect Details Stable: Consistent emotional state Labile: Rapid, unpredictable shifts Fluctuating Mood: Changes over days/weeks Reactive Affect: Appropriate emotional shifts Trauma-Related Instability: Situational emotional changes

Coherence Details Coherent Thought: Logical, clear ideas (e.g., normal functioning). Tangential Thought: Strays from topic Loose Associations: Weakly connected ideas Incoherent Thought (Word Salad): Incomprehensible speech Cultural/Linguistic Considerations: Language barriers mimicking disorganization

Goal-Directedness Details Goal-Directed Thought: Focused, relevant responses. Circumstantial Thought: Excessive details but reaches goal Derailment: Veers off topic, no return (e.g., schizophrenia). Flight of Ideas: Rapid topic shifts, loosely related (e.g., mania). Neurological Factors: Dementia mimicking derailment

Speed of Thought Details Normal Speed: Typical pace of ideas Accelerated Thought: Rapid, overwhelming ideas Slowed Thought (Bradyphrenia): Sluggish thinking Blocked Thought: Sudden thought interruption Medication Effects: Antipsychotics slowing thought

Continuity Details Continuous Thought: Smooth and logical flow Perseveration: Repeated ideas Thought Blocking: Abrupt cessation Clang Associations: Sound-based links Neurological Considerations: Aphasia or seizures disrupting continuity.

Congruence of Mood and Affect Details Logical Associations: Meaningful connections Loose Associations: Weakly connected ideas Overinclusive Associations: Excessive details Idiosyncratic Associations: Bizarre logic Cultural Nuances: Metaphorical language resembling loose associations

Thought Content Subcategories

Delusions Obsessions Suicidal and Homicidal Ideation Preoccupations

Delusions Details No Delusions: Realistic, culturally appropriate beliefs (e.g., normal functioning). Paranoid Delusions: Beliefs of persecution (e.g., schizophrenia). Grandiose Delusions: Beliefs of special status (e.g., mania). Somatic Delusions: False beliefs about the body (e.g., delusional disorder). Bizarre Delusions: Implausible beliefs (e.g., schizophrenia) Cultural Considerations: Normative spiritual beliefs vs. delusions.

Obsessions Details No Obsessions: No intrusive thoughts Contamination Obsessions: Thoughts about germs Harm Obsessions: Fears of causing harm Symmetry/Order Obsessions: Need for “just right” Religious/Moral Obsessions: Thoughts about sin (e.g., scrupulosity) Cultural Nuances: Normative preoccupations vs. obsessions.

Suicidal and Homicidal Ideation Details No Ideation: No thoughts of self-harm or harm to others Passive Suicidal Ideation: Wishing to die, no plan Active Suicidal Ideation: Intent or plan to die Homicidal Ideation: Thoughts of harming others Transient Ideation: Fleeting thoughts, no intent Cultural/Contextual Factors: Idiomatic expressions vs. true ideation

Preoccupations Details No Preoccupations: Varied, non-fixated thoughts (e.g., normal functioning). Health Preoccupations: Worry about illness Financial Preoccupations: Focus on money Relationship Preoccupations: Fixation on interpersonal issues Performance Preoccupations: Worry about work/school Cultural Norms: Normative cultural concerns vs. preoccupations

Perception Subcategories

Hallucinations Illusions Depersonalization and Derealization Other Sensory Abnormalities

Hallucinations Details No Hallucinations: No false sensory perceptions Auditory Hallucinations: Hearing voices/sounds Visual Hallucinations: Seeing things not present Tactile Hallucinations: Feeling sensations Olfactory/Gustatory Hallucinations: Smelling/tasting things Hypnagogic/Hypnopompic Hallucinations: Sleep-related perceptions Cultural Considerations: Spiritual experiences vs. hallucinations.

Illusions Details No Illusions: Accurate perception of stimuli Visual Illusions: Misinterpreting visual stimuli Auditory Illusions: Misinterpreting sounds Tactile Illusions: Misinterpreting touch Contextual Factors: Illusions in ambiguous environments. Cultural Nuances: Spiritual misperceptions vs. illusions.

Depersonalization and Derealization Details No Depersonalization/Derealization: Intact sense of self/reality (e.g., normal functioning). Depersonalization: Feeling detached from self (e.g., PTSD). Derealization: World feels unreal (e.g., panic disorder). Transient Experiences: Brief episodes during stress (e.g., acute stress). Neurological Causes: Seizures or migraines mimicking dissociation. Cultural Considerations: Intentional altered states vs. pathology.

Abnormalities Details No Sensory Abnormalities: Normal sensory processing (e.g., healthy functioning). yperesthesia: Increased sensitivity (e.g., autism, migraines). Hypoesthesia: Reduced sensitivity (e.g., depression). Distorted Perceptions: Altered size/time perception (e.g., LSD intoxication). Synesthesia: Blending of senses (e.g., neurological conditions). Medical Considerations: Neuropathy or deficiencies mimicking abnormalities.

Orientation Details Fully Oriented: Aware of time, place, person, situation Disoriented to Time: Unaware of date/day Disoriented to Place: Unaware of location Disoriented to Person: Unaware of self/others Disoriented to Situation: Unaware of context Cultural/Contextual Factors: Language or calendar unfamiliarity mimicking disorientation.

Attention and Concentration Details Intact Attention: Focused, performs tasks accurately Impaired Attention: Easily distracted Poor Concentration: Cannot sustain focus Hypervigilance: Excessive focus on stimuli Fluctuating Attention: Waxes and wanes Medical Considerations: Sedatives or medical conditions impairing attention.

Memory Details Intact Memory: Accurate immediate, short-term, long-term recall Impaired Immediate Memory: Poor working memory Impaired Short-Term Memory: Poor recall after delay Impaired Long-Term Memory: Poor recall of past events Selective Memory Deficits: Gaps tied to emotional events Cultural/Educational Factors: Limited education mimicking impairment.

Language Details Intact Language: Fluent comprehension and expression (e.g., normal functioning). Aphasia (Expressive): Difficulty producing speech Aphasia (Receptive): Difficulty understanding speech (e.g., Wernicke’s aphasia). Dysnomia: Difficulty naming objects (e.g., early dementia). Mutism: No speech (e.g., catatonia). Cultural/Linguistic Considerations: Language barriers mimicking aphasia.

Executive Functioning Details Intact Executive: Fluent comprehension and expression (e.g., normal functioning). Aphasia (Expressive): Difficulty producing speech Aphasia (Receptive): Difficulty understanding speech (e.g., Wernicke’s aphasia). Dysnomia: Difficulty naming objects (e.g., early dementia). Mutism: No speech (e.g., catatonia). Cultural/Linguistic Considerations: Executive barriers mimicking aphasia.

Insight and Judgement Subcategories

Level of Insight Insight into Specific Symptoms Judgment in Decision-Making Judgment in Social Situations

Level of Insight Details Full Insight: Recognizes condition and need for treatment Partial Insight: Acknowledges some aspects, minimizes others Poor Insight: Limited awareness of condition No Insight (Denial): Complete denial of issues (e.g., mania). Cultural Considerations: Stigma influencing denial. Neurological Factors: Dementia mimicking poor insight

Insight into Specific Symptoms Details Full Symptom Insight: Recognizes symptoms as pathological Partial Symptom Insight: Recognizes some symptoms, not others Poor Symptom Insight: Misattributes symptoms No Symptom Insight: Unaware symptoms are abnormal (e.g., mania). Cultural Nuances: Spiritual beliefs vs. pathological symptoms. Substance Effects: Intoxication clouding symptom awareness.

Judgment in Decision-Making Details Intact Decision-Making: Appropriate decisions with foresight Impaired Decision-Making: Poor decisions, no consequence awareness Impulsive Decision-Making: Acting without forethought (e.g., ADHD). Indecisiveness: Struggles to decide Neurological Considerations: Frontal lobe damage impairing judgment. Cultural/Contextual Factors: Cultural values shaping decisions.

Mental Status Examination (MSE) Generator

Appearance Subcategories

Speech Subcategories

Mood Subcategories

Affect Subcategories

Thought Process Subcategories

Thought Content Subcategories

Perception Subcategories

Cognition Subcategories

Insight and Judgement Subcategories