Two critical elements of the mental status assessment are thought process and thought content. You can weave an evaluation of an individual’s thoughts throughout the general patient interview.
 

Thought Process (Bickley et al., 2021)

Thought process describes “how” people think. It is the logic, organization, coherence, and relevance of the patient’s thought as it leads to a goal. Note any of the following speech patterns that suggests abnormal thought process.
 

Thought Process
Abnormality	Description	Associated Conditions
Blocking	Abrupt disruption of speech midsentence or before the idea is finished; patient “loses their thought”	Marked in schizophrenia.
Circumstantiality	Mild thought disorder; speech with too much detail, indirect, slow to reach the point	Appears in people with obsessions.
Clanging	Words chosen based on sound instead of meaning (i.e., rhyming and punning)	Occurs in schizophrenia and manic episodes.
Confabulation	Responds to questions with fake facts or events to fill in gaps from memory loss	Observed in Korsakoff syndrome from alcoholism.
Derailment (loosening of associations)	Extraneous speech and changing topics that are loosely connected or unrelated	Observed in schizophrenia, manic episodes, and other psychotic disorders.
Echolalia	Repeating others’ words and phrases	Occurs in manic episodes and schizophrenia.
Flight of Ideas	Continuous flow of increased speech with quick changes of topic; changes are based on associations, play on words, or distracting stimuli, but ideas are not well connected	Frequently observed in manic episodes.
Incoherence	Incomprehensible and irrational speech, without meaningful connections, abrupt changes in topic; disordered grammar or word use	Observed in severe psychotic episodes (common in schizophrenia)
Neologisms	Fictional, made-up, or distorted words	Observed in schizophrenia, psychotic disorders, and aphasia.
Perseveration	Continual repetition of words or ideas	Occurs in schizophrenia and other psychotic disorders.

 

Thought Content (Bickley et al., 2021)

Thought content describes “what” the patient thinks about, including insight and judgment.  When evaluating thought content, allow the patient to take the lead instead of asking direct questions. Note any of the following patterns that suggest abnormal thought content.
 

Thought Content
Abnormality	Description	Associated Conditions
Anxiety	Apprehension, worry, distress, and/or physical symptoms of tension	Anxiety disorders
Compulsion	Repetitive behaviors the patient performs in response to an obsession with the goal to reduce anxiety; the behaviors are excessive	Anxiety disorders
Delusions	Distorted personal beliefs that do not change even with conflicting proof; delusions include: Persecutory - torment Grandiose - pompous Jealous - envious Erotomanic – belief that another person is in love with the individual Somatic – bodily functions or sensations Unspecified – delusions with no particular persecutory or grandiouse component; belief that external events, objects, or people have a personal significance (i.e., commands from the radio or television)	Psychotic disorders Delirium Severe mood disorders Dementia
Depersonalization	Feeling that one’s self or identity is different, changed, unreal, lost or detached from one’s mind or body	Psychotic disorders
Derealization	Feeling that the environment is strange, unreal, or remote	Psychotic disorders
Obsession	Persistent thoughts, images, or urges that feel invasive and undesireable; the patient attempts to ignore or suppress the feeling with other thoughts or behaviors (i.e., compulsive behavior)	Anxiety disorders
Phobias	Persistent irrational fears	Anxiety disorders

 

General Guidelines for an Effective Mental Health Interview (Lippincott Procedures, 2022)

Use these strategies when interviewing the patient to help evaluate thought process and content.

• Start the interview with broad, empathetic statements.
• Talk about normal behaviors before discussing abnormal ones.
• Phrase questions with sensitivity to minimize the patient’s anxiety.
• Ask the patient to clarify vague statements.
• Help the patient focus on the issues.

References:
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.
 
Hinkle, J. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15^th ed.). Wolters Kluwer Health.  https://wolterskluwer.vitalsource.com/books/9781975161057
 
Lippincott Procedures. (2022, February 18). Psychiatric nursing assessment. https://procedures.lww.com/lnp/view.do?pId=858982&hits=assessment,evaluate,mental,assessments,health

 

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