MENTAL STATE EXAMINATION

INTELLIGENCE
David Wechsler defined intelligence as "the global capacity of the individual to act
purposefully, to think rationally, and to deal effectively with his environment".
Intelligence is important in a Mental Status Examination (MSE) because it helps to assess the
capacity for reasoning, understanding, and problem-solving. Also aids in diagnosing
intellectual disabilities, neurocognitive disorders, or secondary cognitive issues linked to
mental health conditions like schizophrenia or depression. It also helps tailor treatment plans,
differentiate between disorders, and address developmental or learning issues. Clinicians
infer intelligence through observations of vocabulary, abstract thinking, arithmetic, and
general knowledge, and may use formal tests like the WAIS for a more detailed evaluation.
During a mental status examination, the psychiatrist or psychologist is not really determining
the intelligence/fund of knowledge of an individual being examined. Instead, the professional
is assessing the individual’s use of words and their language expression. It’s a very rough
estimation and determination of intelligence. A general range of intelligence and
comprehension is noted, usually stating intellect within normal limits, below normal limits or
bright/above normal limits.
1. Comprehension – The ability to understand things. This assesses the patient’s ability
to understand the situation, think logically, and provide an appropriate response based
on their comprehension of the scenario.
Example: "If you saw smoke coming from your neighbor's house, what would you do?" "What
would you do if a family member fell ill in the middle of the night?" "Can you take this paper,
fold it in half, and give it back to me?"

2. General fund of knowledge - refers to a person’s accumulated knowledge about

common facts, cultural norms, current events, and basic information expected to be
known by someone of their age, education, and cultural background.
Example: "Who is the current president or prime minister of this country?"
"Can you name any recent major news event?"

Observation: Difficulty understanding the situation or poor general fund of knowlegde,

providing an illogical response, or needing repeated explanations may indicate impairment in
comprehension, which could result from conditions like dementia, intellectual disabilities, or
acute psychosis.

In everyday life, intelligence is often judged by how quickly people understand concepts,
generate ideas, and perform on academic or practical tasks. Similarly, intelligence assessment
during an interview relies on observations like speed of thinking, abstract reasoning, verbal
ability, and vocabulary, along with personal history, including academic and vocational
achievements.

If a person’s intellectual capacity at the interview seems lower than their history suggests,
clinicians consider conditions like dementia, brain trauma, or medical issues. Reduced
intelligence is also linked to schizophrenia and major depression. If intellectual capacity
appears unexpectedly high, possible explanations include hypomania, stimulant use, or an
engaging personality. Accurate assessment requires caution to avoid misjudgments.

General Fund of Knowledge Questions

For Literate Individuals:

1. "Who is the president or prime minister of this country?"

2. "Can you name the capital of your country?"
3. "How many days are in a year?"
4. "Who is the father of our nation?"
5. "Can you name any country outside your continent?"

For Illiterate Individuals:

1. "Who leads the country or community?"

2. "What are the seasons in a year?"
3. "What time of day does the sun rise?"
4. "What do you do if your animal falls sick?"
5. "Can you name a famous leader from history?"

ABSTRACTION
The ability to deal with concepts.
Abstraction involves the ability to understand the meanings of words beyond the literal
interpretation.
Methods:
1. Proverbs (eg., Don’t cry over spilled milk)
2. Similarities and differences (eg., Orange and apple; Dog and lion)
3. Conceptual series completion (eg., 5,10,15...)

Abstraction in the Mental Status Examination (MSE) is important because it helps assess a
person's cognitive flexibility, higher-level thinking, and ability to understand complex or
generalized concepts. The ability to think abstractly is crucial for problem-solving, making
inferences, and navigating social situations, as it reflects how well someone can move beyond
concrete details. Impaired abstraction can signal cognitive issues, such as thought
disorganization in schizophrenia, cognitive decline in dementia, or rigidity in disorders like
obsessive-compulsive disorder (OCD). Additionally, abstraction provides insights into brain
functioning, particularly in the frontal lobes, and is linked to a person's insight and judgment.
By testing how a person interprets proverbs or identifies similarities between objects, the
MSE can gauge a person's logical reasoning and their capacity for abstract thought, which is
essential for understanding relationships and making decisions.

Interpreted as concrete/abstract/impaired. Inference is made as abstraction present at concrete

level (when literal explanation is given) or concrete and abstract level (when both literal and
abstract explanations are given.
JUDGEMENT

A judgment is a thought that reflects how someone views reality. It reflects how well a
person can assess situations, weigh options, and make reasonable choices based on their
understanding of reality. A person with good judgment can recognize the risks and benefits of
their actions, while poor judgment may involve decisions that are irrational, dangerous, or
inappropriate for the situation.

Three types of judgement:

1. Personal Judgment: The ability to make realistic plans for the future, such as in
education, work, or life.
2. Social Judgment: The ability to explain social events or situations in a realistic way.
Subtle manifestations of behavior that are harmful to the patient and contrary to
acceptable behavior in the culture; does the patient understand the likely outcome of
personal behavior and is patient influenced by that understanding.
3. Test Judgment: How a person responds to a hypothetical situation (like a fire
breakout).

Judgement rated as: good/intact/normal or poor/impaired/abnormal.

Impaired judgment can be seen in various mental health disorders. Some of these disorders
include:

1. Schizophrenia: Impaired judgment is common due to delusions (false beliefs) or

disorganized thinking. A person may make decisions based on hallucinations or
irrational beliefs.
2. Bipolar Disorder: During manic episodes, individuals may have impaired judgment,
engaging in risky behaviors like excessive spending, unprotected sex, or impulsive
decisions due to an inflated sense of self-confidence.
3. Dementia: In disorders like Alzheimer's disease, cognitive decline can lead to poor
decision-making, inability to understand the consequences of actions, and difficulty
recognizing the need for care or safety.
4. Depression: Individuals with severe depression may have impaired judgment,
especially when it comes to making decisions about their well-being, such as
neglecting personal care or avoiding important responsibilities due to low energy or
negative thinking.
5. Substance Use Disorders: Substance abuse can significantly impair judgment, as
individuals may make dangerous choices (e.g., driving under the influence, risky
sexual behavior) due to the effects of drugs or alcohol on decision-making.
6. Personality Disorders:
o Antisocial Personality Disorder: Individuals may make reckless or harmful
decisions without regard for others' safety or rights.
o Borderline Personality Disorder: Impulsivity and emotional instability can
lead to poor judgment, such as engaging in self-destructive behaviors or
making hasty decisions in relationships.
7. Obsessive-Compulsive Disorder (OCD): People with OCD may have impaired
judgment due to compulsive behaviors, where they engage in repetitive actions (like
checking or cleaning) that they believe are necessary to prevent harm, even when the
actions are not logically needed.
 8. Post-Traumatic Stress Disorder (PTSD): Impaired judgment can occur due to
hyperarousal or flashbacks, leading to impulsive decisions, such as avoiding situations
or people that might be triggering, even if it is not the best course of action.
9. Intellectual Disabilities: Impaired judgment is a feature of intellectual disabilities,
where individuals may have difficulty understanding complex situations or
consequences, leading to poor decision-making.
10. Neurocognitive Disorders (e.g., brain injuries or strokes): Brain injuries or strokes
can affect the areas of the brain responsible for reasoning and decision-making,
leading to impaired judgment.

Insight and Judgement are interrelated - The ability to form an opinion or judgment
depends on the amount of insight a person has. A person with good insight has a clear
understanding of the situation or context, which helps in making better judgments. Without
proper insight, decisions may be made impulsively or without full awareness of the
consequences.

INSIGHT
Definition- Awareness of one’s own mental condition.
These levels help us understand how well a person recognizes and understands their mental
health condition. These levels of insight are important because they can significantly
influence how a person engages with their treatment and manages their condition.

Example - Do you think you have a problem? Do you need treatment? What are your plans
for the future?

Mental illnesses can change how a person sees the world and handles situations. Assessing
insight helps determine how aware a patient is of these changes and how they adapt. Insight
is complex, involving the person's understanding of their own health, abilities, and worth. It
also involves how they relate their internal state to others and the outside world. In short,
insight requires both self-awareness and awareness of the external world. Insight composed
of 3 distinct, overlapping dimensions, namely the recognition of morbid psychological
change, labelling of this change as deriving from mental illness and understanding that this
change requires treatment.

Grade 1 - Complete Denial: The person doesn’t recognize any mental health issues and
believes there is nothing wrong, even if it’s apparent to others.

Grade 2 - Slight Awareness: The person senses that something is not right but doesn’t
attribute it to a mental health condition. They might think external factors are to blame.

Grade 3 - Awareness of Being Ill but Denial of Specifics: The person acknowledges having a
mental health problem but rejects the specific diagnosis given by their healthcare provider.

Grade 4 - Intellectual Insight: The person understands they have a mental health condition
and can discuss it, but this understanding is purely intellectual. They don’t apply this
knowledge to their own life or behavior.
Grade 5 - True Emotional Insight: The person not only understands their condition
intellectually but also feels it emotionally. They recognize how their illness impacts their life
and take responsibility for managing it.

Grade 6 - Integrated Insight: The highest level of insight, where the person fully accepts their
condition and actively works on their treatment. They incorporate their understanding into
daily life and decision-making, leading to better management of their illness.

Various mental health disorders can impair insight, meaning individuals with these conditions
may have difficulty recognizing or understanding their symptoms, their impact, or the need
for treatment. Some disorders that often involve issues with insight include:

1. Schizophrenia: Individuals with schizophrenia may struggle to recognize the

symptoms of their illness, such as delusions or hallucinations, and may not understand
the need for treatment.
2. Bipolar Disorder: In manic episodes, individuals may lack insight into the severity of
their condition, overestimating their abilities or engaging in risky behavior without
recognizing the consequences.
3. Dementia: As cognitive function declines, individuals with dementia may not be
aware of their memory loss, confusion, or other cognitive impairments.
4. Depression: In some cases, people with depression may not fully recognize the depth
of their depression or how it affects their behavior, emotions, and relationships.
5. Anxiety Disorders: Individuals with anxiety disorders, such as obsessive-compulsive
disorder (OCD), may not fully realize the irrationality of their fears or compulsive
behaviors.
6. Personality Disorders: Certain personality disorders, such as narcissistic personality
disorder or borderline personality disorder, may involve a lack of insight into one's
own behaviors or how they affect others.
7. Substance Use Disorders: People with substance use disorders often have limited
insight into the extent of their addiction, its impact on their life, and the need for
treatment.
8. Psychotic Disorders: Any disorder involving psychosis (e.g., schizophrenia or
schizoaffective disorder) can involve a significant lack of insight into the person's
mental state or symptoms.

Factors affecting insight:

 Cultural factors
 General intelligence and knowledge
 Stigma
 Symptomatology
 Personality traits
 Predominant defense mechanism

Possible questions for patient:

 What brings you here today?

 What seems to be the problem?
 What do you think is causing your problem?
 How do you understand your problem?
 Are you aware of phenomenon others have observed? o If so, do you recognize the
phenomenon as abnormal?
 If so, do you consider that they are caused by mental illness?
 If so, do you think you need treatment?