The whole interview is a mental status exam: watch how the patient acts, what they say and do not say, and how they interact with you, on top of the content. Some of the most useful findings are subtle, like a PTSD patient who says they are depressed but does not look it, or dissociation that passes for hesitation, and the skill grows by carefully comparing many people.
How we use it
Do a mental status exam throughout: observe how the patient acts, what they say and what they do not say, on top of the literal information. Then observe how they interact with you.
“You should be doing a mental status exam, right? You observe the patient and how they act, what they say and what they don't say, in addition to the literal information that they're telling you. On top of that, you observe how they interact with you”
15:06Assessment of Personality: Practical Assessment in a Short TimeframeMay 2025 Ask how a theoretically healthy person would act in this situation, then how this patient is acting. If there is a significant divergence, look for the medical explanations.
“Ask yourself if a completely theoretically mentally healthy person presented in this situation, how would they be acting right now? OK, and then how is this patient acting? Is there a significant divergence? If so, what are the medical explanations for that”
42:30Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025 With experience you learn to tell someone whose memory is being activated and turned into a story live from someone presenting a prepared story, consciously or not.
“You do this long enough, you begin to recognize the difference between somebody who is simply having their memory activated and converting that into a story to you live versus somebody who is prepared and wants to present consciously or unconsciously”
44:52How to Do a Psychiatric Intake | The Art and Science of the First HourSep 2025 We draw a sharp line between video and phone visits. The quality, content and process of care changed considerably when moving to telephone only.
“i personally draw a very distinct difference between video based and non-video based you know i had an experience practicing during the pandemic that the quality and content and process changed considerably when moving to telephone only”
46:48Why the Therapeutic Alliance Matters in Psychiatry: Recognizing and Repairing Ruptures with Dr. Catherine EubanksNov 2025
Findings worth catching
People with PTSD often tell you they are depressed, stuck in negative emotions and not doing what they used to, but they do not look depressed. A classical, more biological depression, in episodes of at least two weeks, looks different even when life is going OK. Not 100 percent reliable, but one of the more reliable ways to tell them apart.
“people with PTSD, they show up, they tell you they're depressed, they tell you they're stuck in negative emotions. They tell you they're not doing the same things they used to do. They don't look depressed a lot of the time, okay”
24:15Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 Also said in 2 more episodes
“one of the more reliable, though of course it's not 100% reliable, ways to tell the difference is that people with PTSD, they show up, they tell you they're depressed, they tell you they're stuck in negative emotions, they tell you they're not doing the same things they used to do, they don't look depressed a lot of the time”
23:12Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 “someone with a classical, more biological depression... You know, the kind that can happen to people in episodes lasting at least two weeks in a row. And even if their life is pretty much going OK. They look different”
24:44Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 Dissociation runs from a small disconnection to a full state where the face goes blank and the person seems not present. Freezing can be so subtle it reads as hesitation, thinking, or not wanting to answer, so you have to be attentive.
“some freezing and dissociation can be so subtle that some people might read it as hesitation or just kind of thinking to themselves for some period or not being interested in answering certain questions. You got to be pretty attentive sometimes to catch this kind of thing”
41:19Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 Also said in 1 more episode
“there's a huge spectrum of dissociation from, as you said, just a disconnected... Some small thing disconnected to experiencing someone in a full dissociative state where their mind goes... You can see their face goes blank. It's almost as if they're not present”
38:41Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 When someone's micro-expressions do not match the other person's in conversation, it points to a breakdown in rapidly grasping what the other person is feeling.
“when a person doesn't have the micro expressions that match another person during a conversation, it's some kind of a breakdown of the ability of that person to fully and very rapidly comprehend what is going on in the other person emotionally”
14:41You Can See Everything Psychological Analysis by Clinical & Forensic PsychiatristsOct 2026
Building the skill
Carefully observe different types of patients and compare them to each other.
“I would encourage that clinicians carefully observe different types of patients and compare them to each other”
44:20Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025 Even within depression, a melancholic, more biological episode looks very different from depression that comes from trauma or personality.
“Someone with a melancholic, traditional, more biological, depressive episode, they're going to act very differently than someone whose depression comes from things like trauma or personality”
47:53Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025
It also comes up on
- Collateral informationIf the patient may be hiding symptoms, talk about things that seem unrelated and rely on your mental status exam rather than on what the patient tells you.
- ECTMemory: 30 to 40 percent of people in their index series have a better mini mental status exam score by the sixth treatment, despite the seizures and anesthesia.
- MalingeringTo detect dissimulation, hold a prolonged conversation that has little to do with evaluating specific symptoms. Talk about things that seem unrelated, and rely on your mental status exam rather than on what the patient says.
From these episodes
- You Can See Everything Psychological Analysis by Clinical & Forensic PsychiatristsOct 2026 · 1 point
- Trauma and PTSD: How the DSM Criteria Actually Help Us Understand What’s Going OnOct 2026 · 2 points
- Why the Therapeutic Alliance Matters in Psychiatry: Recognizing and Repairing Ruptures with Dr. Catherine EubanksNov 2025 · 1 point
- How to Do a Psychiatric Intake | The Art and Science of the First HourSep 2025 · 1 point
- Assessment of Personality: Practical Assessment in a Short TimeframeMay 2025 · 1 point
- Understanding Trauma and PTSD, Diagnosis and Dissociation | Episode 21Apr 2025 · 3 points
- Lessons from Forensic Psychiatry: Insanity Defense, Subtle Patients and CulpabilityApr 2025 · 2 points
- Involuntary Treatment & Agency, Thoughts and Feelings | Episode 19Mar 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.