section of the mse report. it would describe a patient's suicidal thoughts, depressed cognition, delusions, overvalued ideas, obsessions, phobias and preoccupations. one should separate the thought content into pathological thought, versus non-pathological thought. importantly one should specify suicidal thoughts as either intrusive, unwanted, and not able to translate in the capacity to act on these thoughts (mens rea), versus suicidal thoughts that may lead to the act of suicide (actus reus). abnormalities of thought content are established by exploring individuals' thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts. delusions a delusion has three essential qualities: it can be defined as "a false, unshakeable idea or belief (1) which is out of keeping with the patient's educational, cultural and social background (2) ... held with extraordinary conviction and subjective certainty (3)", and is a core feature of psychotic disorders. for instance an alliance to a particular political party, or sports team would not be considered a delusion in some societies. the patient's delusions may be described within the segue pm mnemonic as somatic, erotomanic delusions, grandiose delusions, unspecified delusions, envious delusions (c.f. delusional jealousy), persecutory or paranoid delusions, or multifactorial delusions. there are several other forms of delusions, these include descriptions such as: delusions of reference, or delusional misidentification, or delusional memories (i.e., i was a goat last year) among others. delusional symptoms can be reported as on a continuum from: full symptoms (with no insight), partial symptoms (where they may start questioning these delusions), nil symptoms (where symptoms are resolved), or after complete treatment there are still delusional symptoms or ideas that could develop into delusions you can characterize this as residual symptoms. delusions can suggest several diseases such as schizophrenia, schizophreniform disorder, brief psychotic disorder, mania, depression with psychotic features, or delusional disorders. one can differentiate delusional disorders from schizophrenia for example by the age of onset for delusional disorders being older with a more complete and unaffected personality, where the delusion may only partially impact their life and be fairly encapsulated off from the rest of their formed personality. i.e. believing that a spider lives in their hair, but this belief not affecting their work, relationships, or education. whereas schizophrenia typically arises earlier in life with a disintegration of personality and a failure to cope with work, relationships, or education. other features differentiate diseases with delusions as well. delusions may be described as mood-congruent (the delusional content in keeping with the mood), typical of manic or depressive psychosis, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. examples of this include experiences of thought withdrawal, thought insertion, thought broadcasting, and somatic passivity. schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses. overvalued ideas an overvalued idea is an emotionally charged belief that may be held with sufficient conviction to make believer emotionally charged or aggressive but that fails to possess all three characteristics of delusion—most importantly, incongruity with cultural norms. therefore, any strong, fixed, false, but culturally normative belief can be considered an "overvalued idea". hypochondriasis is an overvalued idea that one has an illness, dysmorphophobia that a part of one's body is abnormal, and anorexia nervosa that one is overweight or fat. obsessions an obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. obsessions are typically intrusive thoughts of violence, injury, dirt or sex, or obsessive ruminations on intellectual themes. a person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. in obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes). phobias a phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a delusion in that the patient is aware that the fear is irrational. a phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview. preoccupations preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. clinically significant preoccupations would include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the cognitive distortions of anxiety and depression. suicidal thoughts the mse contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life. the most important questions to ask are: do you have suicidal feeling now; have you ever attempted suicide (highly correlated with future suicide attempts); do you have plans to commit suicide in the future; and, do you have any deadlines where you may commit suicide (i.e. numerology calculation, doomsday belief, mother's day, anniversary, christmas) perceptions a perception in this context is any sensory experience, and the three broad types of perceptual disturbance are hallucinations, pseudohallucinations and illusions. a hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). an illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. a pseudohallucination is experienced in internal or subjective space (for example as "voices in my head") and is regarded as akin to fantasy. other sensory abnormalities include a distortion of the patient's sense of time, for example déjà vu, or a distortion of the sense of self (depersonalization) or sense of reality (derealization). hallucinations can occur in any of the five senses, although auditory and visual hallucinations are encountered more frequently than tactile (touch), olfactory (smell) or gustatory (taste) hallucinations. auditory hallucinations are typical of psychoses: third-person hallucinations (i.e. voices talking about the patient) and hearing one's thoughts spoken aloud (gedankenlautwerden or écho de la pensée) are among the schneiderian first rank symptoms indicative of schizophrenia, whereas second-person hallucinations (voices talking to the patient) threatening or insulting or telling them to commit suicide, may be a feature of psychotic depression or schizophrenia. visual hallucinations are generally suggestive of organic conditions such as epilepsy, drug intoxication or drug withdrawal. many of the visual effects of hallucinogenic drugs are more correctly described as visual illusions or visual pseudohallucinations, as they are distortions of sensory experiences, and are not experienced as existing in objective reality. auditory pseudohallucinations are suggestive of dissociative disorders. déjà vu, derealization and depersonalization are associated with temporal lobe epilepsy and dissociative disorders. cognition this section of the mse covers the patient's level of alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. unlike other sections of the mse, use is made of structured tests in addition to unstructured observation. alertness is a global observation of level of consciousness i.e. awareness of, and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporous. orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). attention and concentration are assessed by several tests, commonly serial sevens test subtracting 7 from 100 and subtracting 7 from the difference 5 times. alternatively: spelling a five-letter word backwards, saying the months or days of the week in reverse order, serial threes (subtract three from twenty five times), and by testing digit span. memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter f, in one minute"). the mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the mse. mild impairment of attention and concentration may occur in any mental illness where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of brain functioning such as delirium, dementia or intoxication. specific language abnormalities may be associated with pathology in wernicke's area or broca's area of the brain. in korsakoff's syndrome there is dramatic memory impairment with relative preservation of other cognitive functions. visuospatial or constructional abnormalities here may be associated with parietal lobe pathology, and abnormalities in executive functioning tests may indicate frontal lobe pathology. this kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal neuropsychological testing. the mse may include a brief neuropsychiatric examination in some situations. frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-rock"). the posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles. the parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed. a cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. pathology in the basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. a lesion in the posterior fossa can be detected by asking the patient to roll his or her eyes upwards (parinaud's syndrome). focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use, head injuries, tumors or other brain disorders. insight the person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. in this context, insight can be said to have three components: recognition that one has a mental illness, compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. as insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively. impaired insight is characteristic of psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to consent to treatment. judgment judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. one should frame judgement to the functions or domains that are normal vs impaired. (i.e. poor judgement