Appearance and behaviour are assessed from the moment the patient enters the room. This domain provides your first clinical impression and often contains clues about the diagnosis before a single question is asked.

What to Assess and Describe

• General appearance: age, sex, build, apparent vs stated age (looking older than stated age may suggest self-neglect or chronic illness)
• Dress and grooming: appropriately dressed for the weather and occasion? Evidence of self-neglect (unkempt, malodorous, soiled clothing)?
• Psychomotor activity: agitation (unable to sit still, pacing), retardation (slowed movement and speech), or normal
• Eye contact: sustained, poor, avoidant, or intense/staring
• Posture and gait: slumped, rigid, guarded
• Rapport: did the patient engage easily? Were they cooperative, suspicious, hostile, or withdrawn?

How to Present This in the OSCE

Normal finding: The patient is a well-kempt woman who appears consistent with her stated age of 35. She is appropriately dressed, maintains good eye contact, and is cooperative throughout the interview. Psychomotor activity is within normal limits.

Abnormal finding – depression: The patient appears older than his stated age of 42. He is dishevelled with poor grooming and evidence of self-neglect. Psychomotor retardation is evident – he moves slowly, takes time to respond, and sits with a slumped posture. Eye contact is poor.

Abnormal finding – mania: The patient is wearing brightly coloured clothing, appears younger than her stated age of 38, and is highly animated. She is unable to sit still and makes intense, prolonged eye contact. She appears distractible and begins rearranging objects on the desk without prompting.

⚠️ Common Mistake: Do not say ‘the patient looks depressed’ – this is a conclusion, not an observation. Describe what you see: posture, grooming, eye contact, psychomotor activity. Let the examiner draw conclusions from your precise description.

Speech is assessed throughout the interview. You are not asking about speech – you are listening to it. Report on rate, volume, tone, fluency, and spontaneity.

Key Speech Descriptors

Normal speech: Speech is of normal rate, rhythm, and volume. It is spontaneous and fluent, with no abnormalities of form.

Pressured speech – mania: Speech is rapid, pressured, and difficult to interrupt. The patient speaks over my questions and jumps between topics quickly.

Poverty of speech – depression: Speech is reduced in volume and rate. There is notable latency before responses, and answers are often monosyllabic.

💡 Examiner Tip: Always comment on speech even if it is normal – silence on any MSE domain implies you forgot to assess it.

Mood and affect are often confused by IMGs – and examiners know it. Understanding the distinction is essential.

Mood vs Affect – The Critical Distinction

Affect Descriptors

• Flat: virtually no emotional expression, even when discussing emotional topics
• Blunted: reduced range and intensity of emotional expression
• Restricted: narrowed emotional range but not absent
• Labile: rapidly shifting emotional expression without apparent cause
• Elevated / Euphoric: abnormally high, expansive mood – seen in mania
• Dysphoric: an unpleasant, uncomfortable emotional state – not quite ‘sad’ but distressed
• Euthymic: normal range of mood – use this term when mood is appropriate and within normal limits

Congruence – The Often-Missed Mark

Congruence refers to whether the affect matches the mood and the content of speech. Always comment on it.

• Congruent: affect matches mood (e.g. flat affect with depressed mood = congruent)
• Incongruent: affect does not match (e.g. laughing while describing a traumatic event – seen in schizophrenia)

Presenting mood & affect: Mood is low in the patient’s own words – she describes feeling ‘completely empty’. Affect is flat and restricted, with minimal variation throughout the interview and tearfulness when discussing her family. Affect is congruent with stated mood.

💡 Examiner Tip: Always present mood first (subjective), then affect (objective), then congruence. This is the expected order in Australian psychiatric practice.

Perception refers to how the patient experiences the world through their senses. Abnormalities of perception include hallucinations, illusions, depersonalisation, and derealisation.

Types of Perceptual Disturbance

Types of Auditory Hallucinations – Important for Schizophrenia

• Second-person voices: voices addressing the patient directly (‘You are worthless’) – more common in severe depression
• Third-person voices: voices talking about the patient (‘He is a spy’) – highly suggestive of schizophrenia
• Running commentary: a voice providing a continuous commentary on the patient’s actions – first-rank symptom of schizophrenia
• Command hallucinations: voices telling the patient to do something – assess URGENTLY if commands are to harm self or others

How to Ask About Perceptual Disturbance

Opening question: Sometimes when people are going through very difficult times, they can have unusual experiences. Have you noticed anything like that?

Hallucinations: Have you ever heard voices or sounds when there is no one around and nothing to explain them?

Visual hallucinations: Have you seen anything that others around you could not see?

Command hallucinations: Do the voices ever tell you to do things? What kinds of things? Have you ever felt compelled to follow what they say?

Depersonalisation: Have you ever felt as though you were watching yourself from outside your own body, or that you were somehow detached from yourself?

🚨 SAFETY ALERT: If the patient reports command hallucinations telling them to harm themselves or others, this requires immediate risk assessment. Do not continue with routine MSE – address safety first.

Thought is assessed in two distinct components: form (how thoughts are structured and expressed) and content (what the thoughts are about). Both must be assessed and presented separately.

Thought Form – Common Abnormalities

Thought Content – Delusions

A delusion is a fixed, false belief that is not consistent with the patient’s cultural or religious background, held with full conviction, and not amenable to rational argument.

First-Rank Symptoms of Schizophrenia – Know These

Schneider’s first-rank symptoms are highly specific to schizophrenia. Knowing these marks you as a candidate with advanced psychiatric knowledge:

• Thought insertion: belief that thoughts are being placed into one’s mind by an external force
• Thought withdrawal: belief that thoughts are being removed from one’s mind
• Thought broadcasting: belief that one’s thoughts are being transmitted to others
• Passivity experiences: belief that one’s actions, feelings, or impulses are controlled by an external force
• Third-person auditory hallucinations: voices discussing the patient in the third person
• Running commentary: a voice providing a continuous commentary on the patient’s actions
• Delusional perception: a normal perception is given a bizarre, self-referential meaning

How to Ask About Thought Content

Persecutory delusions: Have you had the feeling that people are watching you, following you, or trying to harm you in some way?

Grandiose delusions: Have you felt as though you have special powers, a special mission, or that you are someone important?

Thought interference: Have you had the experience of thoughts entering your mind that feel as though they don’t belong to you? Or the feeling that your thoughts are being taken away or broadcast to others?

Ideas of reference: Have you noticed that things around you – like the television, radio, or strangers – seem to be sending you special messages or referring to you personally?

💡 Examiner Tip: When a patient describes a possible delusion, explore it gently without agreeing or challenging. Say: ‘That sounds like a very difficult experience. Can you tell me more about it?’ Challenging a delusion will shut the conversation down and cost you marks.

Cognitive assessment evaluates orientation, attention, memory, and higher-order functions. In the AMC OSCE, this domain is particularly relevant in presentations of delirium, dementia, and depression with cognitive symptoms. The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) are the two standardised tools most commonly referenced.

Components of Cognitive Assessment

Delirium vs Dementia – The Key Distinction

💡 Examiner Tip: Always look for a reversible cause in delirium: infection (UTI, pneumonia), metabolic (electrolyte disturbance, hypoglycaemia), medication (opioids, benzodiazepines, anticholinergics), pain, urinary retention, constipation, or alcohol withdrawal.

Presenting cognition – normal: The patient is fully oriented to time, place, and person. Attention is intact on serial 7s. She recalls all three objects at five minutes. Language, visuospatial function, and executive reasoning appear intact. There is no evidence of cognitive impairment.

Presenting cognition – impaired: The patient is disoriented to time – he believes it is 2019 and cannot state the day of the week. Attention is markedly impaired – he is unable to complete serial 7s beyond the first subtraction. He recalls zero of three objects at five minutes. These findings are consistent with significant cognitive impairment and warrant formal assessment with the MMSE or MoCA.

Insight refers to the patient’s awareness that they are experiencing a mental illness and that they need help. Judgement refers to their ability to make sound decisions in everyday life. Both are distinct but related – and both must be assessed in every MSE.

Grading Insight

How to Assess Insight and Judgement

Assessing insight: “What do you think is causing the experiences you’ve been having?” “Do you think you might need any help or support at the moment?”

Assessing judgement: “If you smelled smoke in a cinema, what would you do?” – or assess through collateral history of recent decisions

Presenting insight: The patient demonstrates partial insight – she acknowledges feeling unwell but attributes her symptoms entirely to work stress and declines the idea that medication could help.

💡 Examiner Tip: Insight is not binary – always describe the degree. ‘Insight is partial’ is far more useful to an examiner than simply ‘insight is absent’.

⚠️ Common Mistake: Do not confuse a patient disagreeing with you with having absent insight. A patient who understands they are unwell but prefers a different treatment approach may still have full insight.

Risk assessment is not just part of the MSE – in the AMC OSCE it is a standalone competency that carries significant weight. In any psychiatric station, failure to adequately assess suicide risk is a critical error that can result in a failing mark.

🚨 SAFETY ALERT: In the AMC OSCE, any patient presenting with depression, psychosis, substance use, or a history of self-harm MUST have a thorough suicide risk assessment. Do not skip this domain.

The Components of a Suicide Risk Assessment

How to Ask About Suicide – The Step-Wise Approach

Many IMGs avoid asking about suicide directly for fear of ‘planting the idea’. This is a myth – research consistently shows that asking about suicide does not increase risk. In Australia, direct and compassionate questioning is considered best practice.

Opening gently: When people are going through very difficult times, they sometimes have thoughts of not wanting to be here any more. Have you had any thoughts like that?

Exploring passive ideation: Have you had thoughts of wishing you were dead, or that you would not wake up in the morning?

Exploring active ideation: Have you had thoughts of actually ending your life – of acting on those feelings?

Exploring plan: Have you thought about how you might do it?

Exploring access to means: Do you have access to [the method they described] at home?

Exploring intent and timeframe: Have you made any plans about when or where this might happen?

Exploring protective factors: What has stopped you from acting on these thoughts? Is there anything – or anyone – that feels like a reason to stay?

Exploring hopelessness: When you think about the future, what do you see? Does it feel like things could get better?

Risk Stratification – What to Do with the Information

🚨 SAFETY ALERT: In Australia, if a patient is at imminent risk of suicide and refuses voluntary treatment, doctors have a duty of care to initiate an involuntary psychiatric assessment under the relevant state Mental Health Act. In the OSCE, stating this clearly demonstrates that you understand your legal obligations in Australian psychiatric practice.

The Safety Plan

For lower-risk patients, a safety plan is an evidence-based intervention that should be offered at the end of a risk assessment. Mention it in the OSCE:

1. Identify warning signs that a crisis may be building
2. Internal coping strategies – what the patient can do by themselves to feel better
3. Social contacts who can provide distraction and support
4. People the patient can ask for help
5. Professionals to contact in a crisis: GP, mental health team, emergency department
6. Crisis lines: Lifeline (13 11 14), Beyond Blue (1300 22 4636), Suicide Call Back Service (1300 659 467)
7. Making the environment safe – removing access to means

💡 Examiner Tip: Mentioning Lifeline (13 11 14) and Beyond Blue by name in the OSCE demonstrates knowledge of Australian mental health resources – a mark many IMGs miss.