Mental State

Appearance

✅ Grooming & Hygiene: Well-groomed, dishevelled, malodorous, unkempt.
💡 Observing grooming and hygiene provides insight into the client’s self-care and overall mental state.
✅ Eye Contact: Avoidant, intense, normal, darting.
💡 Eye contact patterns can indicate levels of comfort, anxiety, or social engagement.
✅ Motor Activity: Agitated, restless, tremors, psychomotor retardation.
💡 Variations in motor activity may reflect underlying agitation, anxiety, or side effects of medications.
✅ Facial Expression: Neutral, tearful, tense, inappropriate affect.
💡 Facial expressions offer clues about the client’s emotional state and can signal distress or incongruence.

Example: “Client appears dishevelled with poor hygiene, avoids eye contact, and is withdrawn.”

✅ Engagement: Cooperative, guarded, withdrawn, distracted.
💡 The level of engagement indicates the client’s willingness to interact and participate in the assessment process.
✅ Notable Behaviours: Repetitive movements, tics, self-harm evidence.
💡 Notable behaviours such as repetitive movements or signs of self-harm can signal distress or underlying psychiatric conditions.
✅ Speech Rate: Slow, normal, rapid, pressured.
💡 Changes in speech rate may reflect emotional arousal, anxiety, or cognitive processing difficulties.
✅ Speech Tone & Volume: Monotone, normal, loud, whispered.
💡 Variations in tone and volume provide clues about the client’s affect and emotional expressiveness.
✅ Fluency & Coherence: Hesitant, stuttering, slurred, disorganised speech.
💡 Assessing speech fluency and coherence can help identify cognitive impairments or effects of substance use.

Example: “Speech is pressured and rapid, making interruptions difficult.”

✅ Thought Process: Logical, tangential, circumstantial, flight of ideas, loose associations.
💡 Evaluating thought process helps determine how well the client organizes and communicates their ideas.
✅ Thought Content: Delusions, paranoia, obsessive thoughts, suicidal/homicidal ideation.
💡 Assessing thought content is crucial for identifying potential psychotic features or severe distress.
✅ Perceptions: Hallucinations (auditory, visual, tactile, olfactory), illusions.
💡 Perceptual disturbances can signal significant psychiatric conditions requiring immediate attention.
✅ Memory & Orientation: Awareness of time, place, person.
💡 Checking memory and orientation helps gauge the client’s cognitive function and alertness.

Example: “Client expresses paranoid delusions, stating that ‘people are watching me through the walls.’”

✅ Insight (Awareness of Condition): Full, partial, poor, denial of illness.
💡 Insight assessment reveals how aware the client is of their mental health condition, which is vital for treatment engagement.
✅ Judgement (Decision-Making & Consequences): Appropriate, impaired, reckless.
💡 Evaluating judgement helps in understanding the client’s capacity to make safe decisions and foresee consequences.
✅ Self-Awareness: Recognises impact of illness, engagement in treatment.
💡 Self-awareness is critical for acknowledging problems and actively participating in the recovery process.
✅ Risk-Taking Behaviours: Financial, social, personal safety risks.
💡 Identifying risk-taking behaviours assists in planning interventions to minimize further harm.

Example: “Client has poor insight, stating they ‘do not have a problem’ despite frequent overdoses.”

✅ Mood (Self-Reported): Neutral, sad, anxious, irritable, euphoric.
💡 Self-reported mood provides essential insight into how the client perceives their emotional state.
✅ Affect (Observed Emotion): Blunted, flat, labile, inappropriate.
💡 Observed affect offers objective data on the client’s emotional expression, which may differ from their self-report.
✅ Congruency: Mood and affect matching/mismatching.
💡 Assessing congruency between mood and affect helps determine the authenticity of the client’s emotional expression.
✅ Range: Full, restricted, heightened.
💡 Evaluating the emotional range helps in understanding whether the client experiences a wide spectrum of emotions or a limited set.

Example: “Client reports feeling ‘fine’ but appears visibly tearful and has a flat affect.”