Appearance and behaviour
The first domain of the examination, the only one fully available when someone will not speak to you, and the one where loaded language does most damage.
Appearance and behaviour is the first domain of the mental state examination and the one most often written carelessly, usually because it seems obvious. It is also the only domain available in full when someone will not or cannot speak to you, which makes it disproportionately valuable in exactly the assessments that are hardest.
It is also where loaded language does most damage, because it is where clinicians most often reach for a word that characterises a person rather than describing an event.
What to observe before anyone speaks
The examination starts when you first see the person, not when the interview begins. Some of the most useful observations come from the waiting area, the corridor, or the camera in a place of safety.
- How are they occupying themselves? Sitting still, pacing, talking to staff, lying under a blanket?
- What have they brought with them, and does it fit the circumstances?
- Who is with them, and how do they interact?
- Do they look at you when you approach, and how?
- Is anything about their physical state immediately apparent — injury, intoxication, apparent weight loss, a limp?
What a person does when they think nobody is watching frequently differs from what they do in the interview, and both belong in the note. Someone practising boxing moves in a corridor and then sitting calmly through an interview has shown you two things, and only recording the second loses half the picture.
Grooming, self-care and clothing
The useful entries here are specific. "Poorly kempt" is a judgement; the observations that support it are the finding.
| Instead of | Record |
|---|---|
| Poor self-care | Unwashed hair, a strong body odour, untreated skin wounds |
| Dishevelled | Unkempt hair, stained clothing, several days' beard growth |
| Inappropriately dressed | Wearing a heavy winter coat and three jumpers in warm weather |
| Bizarre appearance | Wearing a hospital gown over outdoor clothing, with a hand-lettered badge |
Clothing that is unsuitable for the weather is a genuinely useful observation because it points in several directions at once: disorganisation, self-neglect, homelessness, or a delusional explanation the person may offer if asked. It is worth asking.
Meticulous presentation is a finding too, and is more often missed. Someone immaculately turned out in circumstances where that took considerable effort is telling you something, whether about elevated mood, obsessionality, or how much this assessment matters to them.
Psychomotor activity
Two directions, and both need describing rather than labelling.
Psychomotor retardation
A global slowing of movement, speech and reaction. The observations that constitute it: slowed movement, few spontaneous gestures, long pauses before answering, a delay between question and any response at all.
Restlessness and increased activity
Pacing, fidgeting, hand-wringing, difficulty remaining seated, repeatedly standing and sitting. Record what the person actually did.
The word compresses several different states — distress, restlessness, akathisia, fear, anger — into one label that points nowhere. Someone pacing because they are frightened and someone pacing because of akathisia need entirely different responses, and the label conceals which you are looking at. Describe the movement and, where you can, what preceded it.
Abnormal movements worth naming
These have specific meanings and specific implications, so the technical term is appropriate where it applies.
| Finding | What it looks like | Why it matters |
|---|---|---|
| Tremor | Rhythmic involuntary shaking, often of the hands | Lithium toxicity, withdrawal, anxiety, medication side effect |
| Akathisia | Inner restlessness with an irresistible urge to move; rocking or shifting the legs while seated | Antipsychotic side effect; distressing and frequently mistaken for agitation |
| Tardive dyskinesia | Involuntary repetitive movements, often of the face, lips or tongue | Associated with long-term antipsychotic treatment |
| Dystonia | Sustained muscle contraction producing abnormal posture | Can be acute and requires urgent attention |
| Stereotypy | Repetitive purposeless movement | Seen in psychosis, learning disability and autism |
| Responding to unseen stimuli | Glancing at an empty corner, muttering, pausing as if listening | Suggests perceptual disturbance the person may not report |
Akathisia deserves particular attention because it is so often misread. A person who cannot sit still because of an antipsychotic, and who is then described as agitated, may receive more of the medication causing it. Distinguishing it costs one question: "Is it a feeling inside that makes you need to move, or are you moving because you are worried about something?"
Engagement and rapport
How the person related to you is a finding, and it is best recorded as behaviour rather than character.
- Guarded — reluctant to expand on answers, watchful of the room, checking the door.
- Withdrawn — minimal spontaneous engagement, brief answers, little eye contact.
- Overfamiliar — disinhibited social approach beyond what the situation invites: first names immediately, personal questions of the assessor, standing very close.
- Distractible — attention repeatedly drawn away by sounds or movement.
- Irritable — short responses, visible frustration; record what prompted it.
Overfamiliarity is worth naming specifically because it is a genuine finding with diagnostic weight, particularly in mania and in frontal presentations, and because it is easily written up as rudeness instead.
Change across the interview
Perhaps the most underused observation in this domain. A person is not a fixed state for the half-hour you spend with them.
Record whether they settled, escalated, became tearful at a particular subject, or disengaged after a specific question. The trigger matters as much as the change.
He was calm and cooperative for the first ten minutes and settled further as the interview progressed. He stood up abruptly when his family were mentioned and sat down again when asked. He became tearful when discharge was discussed and recovered within a minute.
Also record anything that may have altered the picture. Medication given shortly beforehand, several hours in a police vehicle, or a long wait without food all bear on what you observed and belong in the note.
The language trap in this domain
Appearance and behaviour is where the descriptors identified in the research on bias in health records cluster most heavily — aggressive, agitated, combative, uncooperative, hostile. The Health Affairs analysis of over 40,000 notes found Black patients had 2.54 times the odds of at least one such descriptor appearing in their record.
The remedy is the same thing that makes the domain clinically better: describe the event rather than characterising the person.
Aggressive and hostile throughout. Uncooperative with the assessment.
He raised his voice twice and stood up abruptly when his family were mentioned, sitting down when asked. He did not wish to answer questions about his housing.
The second version is what a reader needs. It shows that a specific subject was the trigger, that he responded to a request, and precisely which area he declined to discuss — three things the first version destroys.
Worked example
He was dishevelled, with unkempt hair and stained clothing, and was dressed unsuitably for the weather in a heavy coat and several layers. Eye contact was intermittent. He was restless throughout, pacing and unable to remain seated, though no abnormal involuntary movements were observed. He was calm, overfamiliar on introduction, and settled as the interview progressed. He had received promethazine thirty minutes before review, which may have contributed. He was seen practising boxing movements in the corridor before the interview began.
A reader who was not there can now picture him, knows what may have altered the presentation, and has both the corridor observation and the interview behaviour recorded separately.
Common questions
What should I include in the appearance and behaviour section of an MSE?
Grooming and self-care, clothing and its suitability for the setting and weather, physical signs, eye contact, psychomotor activity, any abnormal movements, and how the person engaged with you. Record observations rather than judgements, and note any change across the interview along with what prompted it.
How do I distinguish akathisia from agitation?
Akathisia is an inner restlessness, usually caused by antipsychotic medication, producing an irresistible urge to move — often rocking or shifting the legs while seated. Asking whether the feeling comes from inside and compels movement, or whether they are moving because something is worrying them, usually separates the two. Missing it risks increasing the medication causing it.
Should I record observations made before the interview started?
Yes, and they are often among the most useful. What someone does in a waiting area or corridor, when they do not feel observed, may differ from their presentation in the interview. Record both, separately, and note which was which.
Is 'agitated' acceptable in a clinical note?
It is widely used but compresses distress, restlessness, akathisia, fear and anger into one label that points nowhere. Describing the movement, and where possible what preceded it, is more accurate and tells the reader which of those they are dealing with.
What is overfamiliarity and why record it?
Disinhibited social approach beyond what the situation would normally invite: using first names immediately, asking personal questions of the assessor, standing very close. It carries diagnostic weight, particularly in mania and frontal presentations, and is easily mistaken for rudeness if not named.