Protected: Appendices

The MAAS Mental Health Interview comprises 90 content items and 26 process items across nine scales. Content items describe what the physician explores; process items describe how. The two dimensions are scored independently: process skills predict patient satisfaction; content skills predict diagnostic accuracy (Kraan & Crijnen, 1987).

Items marked Core are assessed in every consultation. Items marked Module are triggered by clinical findings. Full explanations and scoring guidance for each item are available at www.maas-mi.eu/mental-health.

Scale 1: Exploring Reasons for Encounter (12 items)

Scale 2: History-Taking (15 items)

Scale 3: Examination of Experience (8 items)

Scale 4: Psychiatric Examination (24 items)

Scale 5: Socio-Emotional Context (14 items)

Scale 6: Presenting Solutions (17 items)

Scale A: Structuring (8 items)

Scale B: Interpersonal Skills (11 items)

Scale C: Communication Skills (7 items)

The MAAS Mental Health Interview was developed by Crijnen and Kraan (1981–2026). Full item explanations, scoring criteria, and clinical probes are available at www.maas-mi.eu/mental-health.

This appendix collects the clinical probes — direct sentences the physician can use — for the Examination of Experience (Scale 3) and the Psychiatric Examination (Scale 4). The chapters teach the why; these panels provide the how.

These are starting points, not scripts. Adapt them to the patient, the moment, and the clinical context. Follow the patient’s own words rather than imposing your vocabulary.

Part I: Scale 3 — Examination of Experience

3.1 Attunement

Opening — The World as a Whole

“How does the world feel to you right now?”

“When you wake up in the morning and look around — does everything feel normal, familiar, real? Or has something shifted?”

“If you had to describe the ‘atmosphere’ of your life right now — how things feel in general — what would you say?”

Reality and Familiarity

“Does the world feel real to you — solid, reliable, there?”

“Do familiar places still feel familiar? Or do things sometimes look the same but feel different?”

“Is there a sense of unreality — as if you’re in a dream, or watching a movie of your life?”

Significance

“Do things still matter to you — your work, your relationships, things you used to care about?”

“Has everything gone flat? Not that you’re sad about something, but that nothing has any weight?”

“Is there a sense of indifference — not choosing not to care, but being unable to?”

Possibility

“Does the future feel open to you — like things could happen, change, get better?”

“Or does it feel closed off — like nothing is going to change, like there’s no way forward?”

“When you think about tomorrow, next week, next month — does it feel real?”

Belonging and Trust

“Do you feel like you belong in the world — that this is your life, your place?”

“Or is there a sense of being on the outside, looking in?”

“Does the world feel safe and predictable, or has something become uncertain or threatening?”

Affective Coloring

“Is there a feeling that sits behind everything — a heaviness, a dread, an emptiness — that colors everything you experience?”

“Not an emotion about something specific, but a kind of atmosphere that’s always there?”

When the Patient Struggles to Articulate

“These things are hard to put into words. You don’t need to have a clear description — just tell me what it’s like.”

“Some people say the world feels ‘flat’ or ‘empty’ or ‘unreal’ or ‘off.’ Does any of that fit?”

“Is there something that’s changed that you can feel but can’t quite name?”

Comparison

“How did things feel before this started? Can you remember a time when the world felt normal?”

“Has it always been this way, or is this a change?”

“Did it come on gradually or suddenly? Was there anything happening at the time?”

3.2 Sense of Self

Opening — General Self-Experience

“How is your sense of who you are right now?”

“Do you feel like yourself — the same person you’ve always been?”

“Has something about how you experience being you changed?”

Minimal Self / Ipseity

“Do your thoughts and feelings feel like they belong to you?”

“Is there a solid sense of ‘I’ — of being the person having these experiences?”

“When you think or feel something, does it feel like you thinking and feeling? Or is there something strange about that?”

“Some people describe feeling like they’re fading, or that the ‘I’ has become uncertain. Does that resonate?”

Continuity

“Do you feel like the same person you were a year ago? Five years ago?”

“Is there a thread that connects you across time, or does it feel broken?”

“Can you connect your present self to your memories — does your past feel like it belongs to you?”

Coherence

“Do different parts of you — your thoughts, feelings, actions — fit together?”

“Or do you sometimes feel like you’re made up of pieces that don’t quite connect?”

“Is there one ‘you,’ or does it sometimes feel like there are several?”

Narrative Identity

“If someone asked you who you are, what would you say?”

“Do you know what matters to you — your values, what you stand for?”

“Has your sense of who you are become unclear or unstable?”

Boundaries

“Is it clear to you where you end and the world begins?”

“Are your thoughts clearly yours — private, contained — or does the boundary sometimes feel unclear?”

“Do you ever feel like you’re merging with your environment, or that the distinction between inside and outside has become uncertain?”

Comparison

“Was there a time when you felt more solid, more like yourself? What was that like?”

“When did this change start? Was there anything happening at the time?”

3.3 Sense of Agency

Section developed in collaboration with Iván Vial and Anna Pritzkau (Heidelberg)

“I Can” / “I Cannot”

“Do you feel capable of doing the things you need to do — everyday things like getting up, getting dressed, making decisions?”

“When you think about something you need to do, does it feel possible, or does it feel like there’s a wall between you and doing it?”

“Is it that you don’t want to, or that you somehow can’t — even though there’s nothing physically stopping you?”

Drive and Energy

“Do you recognize the energy and drive to achieve things in your life?”

“Are there impulses or urges that feel too strong — things you find hard to resist?”

“Or is it the opposite — a shortage of energy, as if your engine has stopped?”

Inhibition

“Can you hold back when you need to? Or do you sometimes act on impulses before you’ve had time to think?”

“Are your intentions often disturbed by interfering urges?”

Will and Decision

“Can you make decisions, or do you find yourself stuck — unable to start or to stop?”

“Do you delay or postpone things, not from laziness but from a kind of paralysis?”

“Is there a feeling of ambivalence — pulled in opposite directions at the same time?”

Authorship and Autonomy

“When you do something, does it feel like you are doing it — or like something is happening through you?”

“Do your actions ever feel mechanical, as if your body is going through motions without you?”

“Have you ever felt that your actions were decided by something beyond your control — voices, thoughts that don’t feel like yours, external forces?”

Perplexity

“Are there moments when you simply don’t know what to do — not that you can’t choose, but that doing anything at all seems impossible?”

“In situations where you’d normally know what to do, do you sometimes feel completely lost?”

Comparison

“Were you able to do these things before? What changed?”

“Has this always been difficult for you, or is this new?”

3.4 Embodiment

Section developed in collaboration with Daniel Vespermann (Heidelberg)

Ownership and Bodily Agency

“Does your body feel like it belongs to you, or does it sometimes feel foreign?”

“Do you feel in control of your body as a whole and its parts?”

“Do you sometimes feel that you cannot perform routine bodily actions the way you would like to?”

Transparency

“Is your body usually in the background, or are you constantly aware of it?”

“Are you sometimes overly aware of your body — having to attend to how it feels as a whole, or how individual parts or regions feel?”

“Do you need to pay increased attention to routine bodily actions, like getting up, walking, or reaching for things?”

Aliveness

“Does your body feel alive and responsive — vital, sensitive, flexible?”

“Or does it feel heavy, numb, or disconnected from what you want to do?”

“Do you experience your body as something that responds to your intentions, or does it feel sluggish or uncooperative?”

Body Image

“How do you feel about your physical appearance to others?”

“Are you constantly preoccupied with how you appear?”

“Do you have a strong wish to shape or change your physical appearance?”

Note: If body control or weight preoccupation emerges, proceed to 4.21 (eating and body control).

Body-Self Integration

“Do your thoughts, desires, or intentions match how your body feels and acts?”

“Does it ever seem as if your thoughts and your body are separated — as if your mind and body are two different things that exist independently?”

“Do you feel like you fully inhabit your body, or is there a gap between ‘you’ and your physical self?”

Follow-Up Probes

“Does your body ever feel like it’s not quite yours?”

“Are you constantly aware of bodily processes — heartbeat, breathing, physical sensations — in a way that you find distressing?”

Comparison

“How did you experience your body before this started? What’s different now?”

“Has your body and the way you act with your body always felt this way, or is this new?”

3.5 Intentional Arc

Pull and Solicitation

“Do things call out to you — activities, projects, people — or has that pull disappeared?”

“When you look around your life, does anything stand out as wanting your attention? Or has everything become equally flat?”

“Is there something that you lean toward naturally, or does everything require a conscious decision to do?”

Anticipation

“Do you look forward to things? Not just know they’re coming, but actually anticipate them?”

“When you think about something you used to enjoy — does the thought still carry any excitement, or is it neutral?”

“Does the future feel like it’s pulling you forward, or is it just… there?”

Absorption

“Can you get absorbed in something — lose yourself in an activity, a conversation, a book?”

“Or are you always at a distance from what you’re doing, never quite in it?”

“When was the last time you were truly engrossed in something?”

Salience

“Do things stand out as interesting or important? Or has everything become equally indifferent?”

“The opposite can happen too — does everything feel equally urgent, equally demanding of your attention?”

Momentum

“When you finish one thing, does the next thing come naturally? Or does each step require a new decision, new effort?”

“Does your day have a flow, or is it a series of separate things you have to push yourself through?”

Connection

“Do you feel connected to your life — that this is your life and you’re in it? Or are you going through the motions?”

“What gets you up in the morning? Is it engagement, or obligation?”

Comparison

“What did it feel like before — when you were engaged? Can you describe that?”

“When did the pull disappear? Was it gradual or sudden?”

“Has there always been a part of this for you — difficulty engaging — or is it entirely new?”

3.6 Sense of Time

Flow and Pace

“Does time flow at its usual pace, or has something changed?”

“Does an hour feel like an hour? Or does it drag, or race?”

“Is time moving too slowly, too fast, or in fits and starts?”

Continuity

“Does time feel continuous — one moment flowing into the next?”

“Or are there gaps — periods where time seems to disappear?”

“Do you sometimes ‘come to’ and realize you’ve lost track of time — not being distracted, but actually missing chunks?”

Implicit Time — Bodily Rhythms

“How are your rhythms — sleep, appetite, energy through the day?”

“Do you feel in step with the day — morning, afternoon, evening feel different? Or has it all blurred together?”

“Do you feel like you’re moving through time at the same pace as everyone else, or have you fallen out of sync?”

Past

“How connected do you feel to your past? Do your memories feel like they belong to you?”

“Is your past something you can visit and return from? Or does it pull you in and trap you?”

“For some people, the past feels like another life. Is that how it is for you?”

Future

“Can you imagine your future? Does it feel real?”

“When you think about next week, next month — does it feel possible and reachable?”

“Or has the future gone blank — as if there’s nothing ahead?”

Present

“Can you be in the present moment? Or are you always pulled somewhere else — to the past, to worries about the future?”

“When you’re here now, talking to me — are you really here?”

When the Patient Struggles

“Time is one of those things that’s hard to describe until something changes. Has anything about how you experience time felt different?”

“Some people say time ‘thickens’ or ‘goes molasses.’ Others say it ‘fragments.’ Does any of that fit?”

Comparison

“How did time feel before this started? Can you describe the difference?”

“When did time start feeling different? Was it sudden or gradual?”

3.7 Sense of Space

Home and Safety

“Do you have a place that feels like home — somewhere safe, where you can let down your guard?”

“Does your home still feel like home? Or has something changed about how it feels?”

“Is there anywhere you feel truly safe?”

Proximity

“How do you feel about being physically close to people?”

“Has your sense of personal space changed — do you need more distance than before?”

“Are there people you can tolerate close to you, and others you can’t?”

Familiarity and Uncanniness

“Do familiar places still feel familiar? Or do they sometimes feel strange — recognizable but somehow different?”

“Have you had the experience of being somewhere you know well and feeling like you don’t belong there?”

Expansion and Contraction

“Does your world feel big enough? Or has it shrunk?”

“How far from home can you comfortably go?”

“Is there a sense that the world is getting smaller — fewer places you can go, fewer spaces that feel okay?”

Presence and Groundedness

“When you’re in a room, do you feel grounded — like you’re really here?”

“Or do you sometimes feel displaced — physically here but experientially somewhere else?”

“Do you feel like the space you’re in has room for you?”

Body in Space

“How does your body feel in different spaces — relaxed in some, tense in others?”

“Do you notice your body responding to spaces — do certain places make you tense up, or feel at ease?”

“Do you feel exposed in some spaces? Contained in others?”

Scanning and Vigilance

“Do you find yourself scanning the room — checking exits, watching for threats?”

“Do you always position yourself in a particular way — back to the wall, near the door?”

“Can you relax in a space, or are you always on alert?”

Comparison

“How did spaces feel before? Were you comfortable in more places?”

“When did your relationship with space change? Was it gradual or sudden?”

3.8 Intercorporeality

Section developed in collaboration with Iván Vial (Heidelberg, with Thomas Fuchs)

Bodily Sensations During Interaction

“Do you notice physical sensations when you’re with other people — warmth, coldness, tension, relaxation?”

“Does your body respond differently with different people — more relaxed with some, more tense with others?”

“Do you sometimes feel physically uncomfortable around others without knowing why?”

Movement Impulses

“Do you notice urges to move toward or away from people?”

“Do you find yourself avoiding eye contact or wanting to shrink away?”

“When you’re in a group, do you want to stay or leave?”

Gaze

“How do you experience being looked at? Does it feel neutral, intrusive, threatening?”

“Do you feel that people are scrutinizing you, judging you, or seeing through you?”

“Is eye contact something you can maintain comfortably, or does it feel forced or overwhelming?”

Resonance and Synchrony

“Do you pick up on other people’s feelings — their mood, their tension, their comfort?”

“Does conversation feel natural — the back-and-forth, the rhythm — or is it effortful?”

“Do you sometimes feel like you’re performing a role rather than just being with someone?”

Boundaries and Transitivism

“Is it clear to you where you end and the other person begins — emotionally?”

“Do you ever feel invaded by someone else’s presence or emotions?”

“Do you sometimes feel that others know what you’re feeling or thinking without you telling them?”

Expression and Awareness

“Are you aware of how you come across to others — your facial expressions, gestures, posture?”

“Do you sometimes feel unable to express what you’re actually feeling?”

“How do other people seem to respond to you? Do you feel understood, or is there a gap?”

Bidirectional Perspective

“Have you had experiences where you felt really connected and understood by someone?”

“Have you had experiences where you felt completely misunderstood, no matter what you tried?”

“How do others describe their experience of being with you?”

Comparison

“Has it always been this way for you, or did something change?”

“If it changed, when did that happen? Was there anything going on at that time?”

Part II: Scale 4 — Psychiatric Examination

4.1 Consciousness

Subjective Experience

“How clear-headed do you feel right now?”

“Do you sometimes feel foggy or unclear in your thinking?”

“Are there moments when you feel mentally absent or disconnected from what’s happening around you?”

Orientation Check

“Do you have difficulty keeping track of what day it is?”

“Do you sometimes lose the thread of a conversation?”

Onset

“Did this come on suddenly, or has it been gradual?”

“Was there anything that preceded this — a change in sleep, medication, substance use, an illness?”

Progression

“Has the fogginess been constant, or does it come and go?”

“Is it worse at certain times of day?”

“Has it gotten worse over time?”

Functional Impact

“Does this interfere with your daily life — at home, at work, in relationships?”

“Have you withdrawn from activities or become less attentive to tasks?”

Comparison Questions

“When did you first notice the fogginess or confusion? Was it sudden or gradual?”

“Has your clarity of thinking always been like this, or is this new?”

Based on the review by Chunyen: three-domain structure (subjective experience, behavioral indicators, cognitive disturbances), onset/progression assessment.

4.7 Obsessions

Opening — Content and Form

“Do you have thoughts that come into your mind that you don’t want? What form do they take — words, pictures, feelings, or doubts?”

“Many people with these kinds of thoughts have thoughts about things that feel completely wrong to them — things they would never do. Has anything like that come up for you?”

Doubt

“Do you find yourself going over the same question again and again — ‘Did I lock the door?’ ‘Did I hurt someone?’ — even when you know the answer?”

“Is there a nagging feeling that something isn’t right, even when you can see that it is?”

Internal Voice

“Do these thoughts sometimes take the form of a voice in your head — not an outside voice, but your own thoughts sounding like a running commentary?”

“Do these feel like your own thoughts, or do they come from somewhere else?”

Intrusive Images

“Do you get disturbing mental pictures that flash into your mind — things you don’t want to see?”

“Are the images accompanied by other sensations — sounds, physical feelings?”

Sensory Phenomena

“Do you experience a physical sensation — a tension or nagging feeling — that drives you to act?”

“Is there a feeling in your body that something isn’t ‘just right’ — not a thought, but a physical experience?”

Self-Appraisal

“Do you worry that these thoughts say something about who you really are?”

“Do you feel that having the thought means you might act on it?”

Incompleteness

“Is there a sense that things are not complete — not done well enough, not right enough — that drives you to repeat?”

Comparison Questions

“When did these thoughts first start? Was there anything happening at the time?”

“Have they changed over time — different content, different intensity?”

“Was there a time when your mind felt clear of these thoughts?”

Based on the review by Braasch: four obsessional forms (doubt, voice, image, sensory), seven content categories, incompleteness principle, self-appraisal dimension.

4.8 Compulsions

Opening — Response and Function

“Do you feel you have to do certain things in response to these thoughts? What happens if you don’t do them?”

Reactive Compulsions

“When the thought comes, what do you do? Is there something you feel you have to do to make it stop or to feel safe?”

“Do you wash, check, count, pray, or repeat things in response to the thought?”

Preventative Compulsions

“Do you also avoid certain situations or actions to prevent the anxiety from starting?”

“Are there things you do before leaving the house, or before starting something, to make sure nothing goes wrong?”

Covert (Mental) Compulsions

“Do you do things in your head — like counting or praying — as well as physical actions?”

“Are there mental rituals you perform that others can’t see?”

Repetition and Termination

“When you perform the action, do you sometimes have to do it again — because it wasn’t done well enough, or you can’t remember doing it correctly?”

“How do you know when an episode is over — have you completed the action, has the intrusive experience subsided, or do you feel relief?”

Functional Impact

“How many hours per day do you spend on these behaviors?”

“Does it interfere with work, relationships, or getting through the day?”

Comparison Questions

“When did the rituals start? Did they come at the same time as the thoughts, or later?”

“Have the rituals changed over time — more elaborate, more time-consuming?”

“Was there a time when you could resist the urge to perform them?”

Based on the review by Braasch: reactive vs. preventative distinction, overt vs. covert forms, repetition criteria, termination patterns, time-based severity assessment.

4.9 OCD Dynamics

Episode Arc

“When does the urge start? When does it stop? Who decides to stop — you, or does it just fade?”

“Which comes first — the thought, the feeling, or the need to act?”

Agency

“Can you resist the urge, even briefly? What happens if you try?”

“How do you know when it’s enough? Is there a feeling you’re waiting for before you can stop?”

Mutual Reinforcement

“Does doing the compulsion make the thoughts come back more?”

“After you complete the ritual, how long before the urge returns?”

Course Over Time

“When did this first start? Has it gotten worse over time?”

“Could you share this with anyone — parents, partner, friends — or was it a secret?”

“Does stress make it worse?”

Family Accommodation

“Have the people around you changed their behavior because of your rituals? Do they help you check, or avoid things that trigger you?”

“Has anyone in your household changed their routines to accommodate what you need to do?”

Comparison Questions

“When did the pattern first start — childhood, adolescence, later?”

“Has the cycle changed over time — faster, more elaborate, harder to stop?”

“Was there a time when you felt more in control of these episodes?”

Based on the OCD dynamics framework: episode arc (onset, peak, termination), agency assessment, mutual reinforcement principle, course trajectory, family accommodation (Dutch anxiety guideline).

4.16 Self-Disorders

Opening — Self-Disorders

“Do you ever feel like you’re not quite there — as if your sense of ‘I’ is fading or becoming uncertain?”

“Do your thoughts always feel like they belong to you, or do some feel foreign — like they’re yours but not really yours?”

“Are there things you normally do without thinking — walking, talking, reading — that now require conscious effort, as if you have to think about how to do them?”

Exploring Self-Presence

“When you say ‘I’ — when you refer to yourself — does that feel solid, or is there something uncertain about it?”

“Is there a sense of being present in your experience, or do you sometimes feel like you’re watching from a distance?”

“Do you feel like a person with thoughts and feelings, or do the thoughts and feelings just seem to happen?”

Exploring Boundaries

“Do you always know where you end and the world begins?”

“Are your thoughts private — clearly yours — or does it sometimes feel like the boundary between your mind and the outside isn’t clear?”

Exploring Thought Disturbances as Self-Disorder

“Do thoughts sometimes overwhelm you — rushing in, too many at once — but they’re still your own thoughts?”

“Do your thoughts sometimes just stop, without warning? Not that you lost your train of thought, but that thinking itself stopped?”

“Do you have thoughts that don’t feel like they fit with who you are — thoughts you don’t recognize as yours, even though nobody put them there?”

“Do you ever seem to hear your own thoughts — not a voice, but your thinking becoming almost audible?”

Transition to First Rank Symptoms

“You said your thoughts don’t always feel like yours. Do they ever feel like they come from outside — from someone or something else?”

“Has anyone or anything ever put thoughts into your head, or taken thoughts away?”

“Can other people hear what you’re thinking, or know your thoughts without you telling them?”

“Do you ever feel that your actions, feelings, or impulses are being controlled by something outside yourself?”

Delusional Perception

“Have you ever had an ordinary experience — seeing something, hearing something — that suddenly felt like it had a special meaning, meant specifically for you?”

“Has an everyday event ever felt like a sign or a message?”

Comparison Questions

“When did you first notice something different about your sense of ‘I’?”

“Has it always been this way, or did it start at a specific time?”

“Has it changed — gotten better or worse — over time?”

Based on the review by Julie Nordgaard (Copenhagen): self-disorder → FRS developmental progression, delusional perception (Wahnwahrnehmung), thought pressure and pseudo-obsessions as self-disorder phenomena, EASE interview framework.

The Assessment Probes are part of the MAAS Mental Health Interview (Crijnen and Kraan, 1981–2026). Scale 3 probes developed in consultation with Iván Vial, Anna Pritzkau, and Daniel Vespermann (Heidelberg). Scale 4 probes developed in consultation with Braasch (OCD) and Julie Nordgaard (self-disorders). See Chapter 3 and Chapter 4 for the teaching framework. See Appendix I for phenomenological terms.

Appendix C: Distinction Tables

Advance Reader Copy — For Review Purposes Only (Crijnen & Kraan, 2026)

Clinical reasoning in mental health often depends on distinguishing between experiences that sound similar but point in different diagnostic directions. These tables collect the key distinctions taught across the chapters. Each contrast changes what you do next. Two-way distinctions use two columns; three-way distinctions use three.

Scale 3: Examination of Experience

Scale 4: Psychiatric Examination — Three-Way Distinctions

Scale 4: Psychiatric Examination — Two-Way Distinctions

Scale 5: Socio-Emotional Context

Cross-Scale Distinctions

These distinctions are taught in context across Chapters 3, 4, and 5. This appendix collects them for reference. For phenomenological terms, see Appendix I.

Scale 3 (Examination of Experience) and Scale 4 (Psychiatric Examination) are designed to work together. Scale 3 explores how the patient experiences the world; Scale 4 examines what specific alterations are present. Findings in one scale guide exploration in the other. This matrix shows every connection.

From Scale 3 to Scale 4: What Triggers What

From Scale 4 to Scale 3: What Enriches Understanding

Clinical Principle

Scale 3 and Scale 4 are not sequential checkpoints but two lenses on the same clinical reality. Scale 3 hears the patient’s experience in their words; Scale 4 translates it into the shared language of psychiatry. Neither alone is sufficient. A psychiatric examination without phenomenological context documents findings without understanding them. A phenomenological examination without psychiatric follow-through may miss treatable pathology.

See Chapter 3 for phenomenological examination teaching, Chapter 4 for psychiatric examination teaching, and Appendix H for the distinction tables that help differentiate similar-sounding findings.

These cards summarize the assessment sequence and key decision points. They are designed for use during training — a quick reminder of what comes next, not a substitute for the clinical reasoning taught in the chapters.

Card 1: Assessment Sequence

Card 2: Scale 3 → Scale 4 Triggers

Card 3: The Tiered Model

Card 4: Risk Assessment Essentials (5.14)

• Ask directly: “Have you had thoughts of ending your life?”
• Map the trajectory: When did ideation start? Escalating, stable, or diminishing?
• Assess the pathway (IMV model): Defeat → Entrapment → Ideation → Intent. Listen for entrapment: “There’s no way out.”
• Identify moderators: Burdensomeness, thwarted belonging, access to means, impulsivity
• Identify protectors: Connection to others, reasons for living, future orientation
• Safety plan if indicated: Warning signs, coping strategies, contacts, means restriction, crisis numbers
• When uncertain: Consult — supervisor, senior colleague, or crisis team. Always appropriate.

Card 5: Process Skills at a Glance

These cards are training aids. Clinical reasoning — taught in Chapters 1–9 — cannot be reduced to a card.

The Mental State Examination documents the patient’s mental state at the time of assessment. This template provides a structured format for recording findings. Write in prose, not bullet points — the narrative form forces clinical reasoning. Always document risk, even when findings are unremarkable.

Template

1. Appearance and Behavior

Physical presentation (4.22): dress, grooming, psychomotor activity, cooperation, eye contact. Note discrepancies between what is observed and what the patient reports.

[Document here]

2. Consciousness, Attention, and Orientation (4.1–4.3)

Level of alertness. Ability to sustain and shift attention. Orientation to time, place, person, and situation. Note fluctuations observed during the interview.

[Document here]

3. Mood and Affect (4.4–4.6)

Mood: the patient’s subjective report (“In your own words, how has your mood been?”). Affect: what you observe — range, reactivity, congruence with stated mood, stability. Note the quality, not just the label.

[Document here]

4. Anxiety (4.5)

Present/absent. If present: situational, generalized, or somatic. Panic features. Avoidance behavior. Observed autonomic signs.

[Document here]

5. Thought Form (4.11)

Rate, flow, and coherence of speech as a window into thought process. Note circumstantiality, tangentiality, loosening of associations, thought blocking, poverty of thought. Quote verbatim when illustrative.

[Document here]

6. Thought Content (4.12)

Preoccupations, overvalued ideas, obsessions (4.7), phobias. If delusions are present, document under Section 8 below.

[Document here]

7. Perception (4.13)

Hallucinations (modality, content, frequency, relationship to mood). Illusions. Depersonalization/derealization (4.10). Triggered by Scale 3 findings or clinical observation.

[Document here]

8. Psychosis Features (4.13–4.16) — if triggered

Delusional mood/atmosphere (4.14). Delusions (4.15): type, systematization, conviction, impact on behavior. Self-disorders (4.16): if indicated by Scale 3 findings. First rank symptoms if present.

[Document here]

9. Cognition (4.17–4.18)

Memory: registration, short-term, long-term — assessed through conversation and, if indicated, informal testing. Intellectual function: vocabulary, abstraction, fund of knowledge as observed. Note whether formal testing is needed.

[Document here]

10. Trauma and Dissociation (4.19–4.20) — if triggered

Trauma exposure screened. If positive: PTSD symptom domains (re-experiencing, avoidance, negative alterations, hyperarousal). Dissociative features if observed or reported. Note: screen, do not process.

[Document here]

11. Insight and Judgment (4.23–4.24)

Insight: awareness of illness, attribution of symptoms, acceptance of treatment need — assess each component separately. Judgment: decision-making capacity in current state. Both are dimensional, not binary.

[Document here]

12. Risk Assessment (always document)

Suicidal ideation: present/absent. If present: passive vs. active, frequency, plan, intent, means, protective factors, trajectory (escalating/stable/diminishing). Refer to Scale 5.14 and the IMV model (Appendix D). Self-harm. Risk to others. Vulnerability. Immediate safety plan if indicated.

[Document here]

Documentation Principles

• Write in prose — a coherent narrative, not a checklist
• Distinguish observation from self-report: “The patient reports feeling calm; affect was anxious with psychomotor agitation”
• Quote the patient’s own words when clinically significant
• Document discrepancies — they are informative, not errors
• Always document risk, even if unremarkable: “Denies suicidal ideation; no self-harm. Protective factors include…”
• Note what was not assessed and why: “Formal memory testing deferred; patient fatigued. To complete next session.”
• The MSE is a snapshot — date and time it. State may change

See Chapter 4 for the teaching framework. See Appendix G for clinical probes organized by item.

This appendix provides a structured approach to suicide risk assessment based on the Integrated Motivational-Volitional (IMV) model (O’Connor & Kirtley, 2018). It complements Scale 5.14 and the safety planning guidance in Scale 6.5.

The IMV Model

The IMV model describes the pathway from background vulnerability to suicidal behavior in three phases:

Phase 1: Pre-Motivational

Background factors that increase vulnerability — not causes, but the soil in which suicidal ideation may grow.

• Diathesis: early adversity, personality factors, cognitive vulnerabilities
• Life events: losses, humiliations, defeats
• These factors are explored in Scales 1, 2, and 5 (items 1.8, 2.10, 5.12, 5.13)

Phase 2: Motivational — From Defeat to Ideation

The central pathway: Defeat → Entrapment → Suicidal Ideation

• Defeat: the sense of having lost — failed, been humiliated, unable to cope. Listen for: “I’ve failed at everything,” “I can’t do this anymore”
• Entrapment: the feeling that there is no escape from the pain of defeat. This is the key motivational variable. Listen for: “There’s no way out,” “Nothing will ever change,” “I’m stuck”
• Moderators of the defeat-entrapment pathway: social support (5.2), problem-solving ability, coping resources (1.11)

Threat-to-self moderators (between entrapment and ideation):

• Perceived burdensomeness (1.7): “Everyone would be better off without me”
• Thwarted belonging (5.1, 5.2): disconnection, isolation, not mattering
• Future orientation (5.6): when the future collapses, the exit narrows

Phase 3: Volitional — From Ideation to Action

Not all ideation leads to action. Volitional moderators determine who acts:

• Access to means: always assess; means restriction saves lives
• Impulsivity: trait and state — substance use increases state impulsivity
• Exposure to suicidal behavior: family, peers, media
• Planning: specificity of plan, timeline, preparatory behavior
• Previous attempts: the strongest predictor of future attempts

Assessment Framework

Step 1: Ask Directly

“Have you had thoughts that life isn’t worth living?”
“Have you thought about ending your life?”
“Have you thought about how you might do it?”

Asking does not increase risk — many patients find it helpful to be asked directly.

Step 2: Map the Trajectory

• When did ideation begin? What triggered it?
• Frequency: how often? Duration: how long do episodes last?
• Trajectory: escalating, stable, or diminishing?
• What makes it worse? What makes it better?

Step 3: Assess the Motivational Pathway

• Defeat: what losses or failures does the patient describe?
• Entrapment: does the patient feel trapped? Can they see alternatives?
• Burdensomeness: does the patient feel they are a burden to others?
• Belonging: does the patient feel connected to anyone?

Step 4: Assess Volitional Factors

• Plan: is there a specific plan? How detailed?
• Intent: does the patient intend to act on thoughts?
• Means: does the patient have access to means? Can access be restricted?
• Preparation: any preparatory behavior (giving away possessions, saying goodbye)?
• Previous attempts: when, method, what happened, what changed?

Step 5: Identify Protective Factors

• Connection to others: “Who would be affected?”
• Reasons for living: “What keeps you going?”
• Future orientation: “Is there anything you’re looking forward to?”
• Help-seeking: “Would you reach out if things got worse?”
• Treatment engagement: the consultation itself may be a protective factor

Step 6: Formulate and Act

• Formulate in terms of the pathway: what drives ideation, what moderates it, what protects
• Do not assign a risk score — formulate a clinical understanding
• Safety plan if indicated (see Scale 6.5): warning signs, coping strategies, social contacts, professional contacts, means restriction, crisis numbers
• Document fully — including what was asked, what the patient said, and what was decided
• When uncertain: consult. Supervisor, senior colleague, or crisis team. This is always appropriate.

The Time Heuristic

Map suicidal ideation across three timeframes to understand trajectory:

• Lifetime: Any previous suicidal thoughts or attempts? When? What happened?
• Recent weeks/months: Has ideation been present? How frequently? What is the trend?
• Right now: Are you having suicidal thoughts at this moment? How strong?

The trajectory matters more than the snapshot. Escalating ideation with increasing entrapment requires immediate action. Stable, longstanding passive ideation in the context of strong protective factors requires a different response.

Reference

O’Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philosophical Transactions of the Royal Society B. 2018;373(1754):20170268.

See Scale 5.14 for item-level guidance. See Scale 6.5 for safety planning. See Chapter 5, Section V for the teaching framework.

Culture shapes how distress is experienced, expressed, explained, and treated. This appendix provides a framework for integrating cultural considerations into the MAAS Mental Health Interview. It does not add items — cultural awareness is embedded throughout all nine scales.

The Cultural Formulation Framework

Adapted from the DSM-5 Cultural Formulation Interview (CFI; Lewis-Fernández et al., 2016), the framework addresses four domains:

1. Cultural Identity

How does the patient define themselves culturally, ethnically, linguistically, and spiritually? Identity is intersectional — a patient may navigate multiple cultural worlds simultaneously. Migration history, generational status, and acculturation stress may be relevant.

“How would you describe your cultural background? Are there traditions or beliefs that are important to you?”

2. Cultural Conceptualization of Distress

How does the patient understand what is happening to them? Cultural explanatory models shape what is reported, what is withheld, and what treatment is accepted.

• Idioms of distress: Culturally specific ways of expressing suffering — somatic complaints (headache, chest pressure, “heat in the body”) may be the primary language of emotional distress in many cultures
• Explanatory models: Spiritual causes (jinn, evil eye, karma), social causes (family shame, community rejection), biomedical causes — these are not mutually exclusive
• Help-seeking patterns: Traditional healers, religious leaders, community elders may be the first and preferred source of help. Integrating these resources rather than competing with them improves engagement

“What do you think is causing this? Have you spoken to anyone else about it — family, religious leader, traditional healer?”

3. Cultural Factors in the Clinical Relationship

The physician-patient relationship is always shaped by cultural dynamics:

• Authority expectations: deference, formality, gendered interactions
• Disclosure norms: what is shared, with whom, and how quickly
• Family involvement: collectivist cultures may expect family participation in the consultation and in decisions
• Language: working through interpreters changes the encounter fundamentally — allow extra time, brief the interpreter, check understanding directly with the patient
• Physician’s own cultural position: your assumptions about normality, pathology, and appropriate behavior are culturally shaped too

4. Cultural Factors in Vulnerability and Resilience

• Migration and displacement: loss of home, language, status, social network
• Discrimination and structural inequality: not a background factor but a current stressor
• Intergenerational trauma: historical trauma transmitted through families and communities
• Cultural strengths: community belonging, spiritual practice, cultural identity as protective factors

Cultural Considerations by Scale

Practical Principles

• Cultural awareness is not a checklist — it is an orientation of curiosity and humility
• Ask rather than assume: “Is there anything about your background or beliefs that would help me understand your situation better?”
• The patient is the expert on their own culture — you are learning from them
• Cultural competence is not knowing about every culture — it is knowing that your perspective is one of many
• Avoid both cultural blindness (“I treat everyone the same”) and cultural stereotyping (“In your culture, people usually…”)
• When in doubt, name it: “I want to make sure I’m understanding you correctly. Can you tell me more about what this means to you?”

Reference

Lewis-Fernández R, Aggarwal NK, Hinton L, Hinton DE, Kirmayer LJ, eds. DSM-5 Handbook on the Cultural Formulation Interview. American Psychiatric Publishing; 2016.

Cultural considerations are integrated throughout all nine chapters. This appendix provides the framework; the chapters show how it applies in practice.

This glossary defines terms from phenomenological psychopathology as they are used in the MAAS Mental Health Interview. The definitions prioritize clinical utility over philosophical precision — they describe what the physician needs to understand to use the concept, not its full intellectual history.

Agency (Scale 3.3)

The felt sense of being the author of one’s actions — the feeling of “I can” or “I cannot.” Not motivation (wanting to act) but the sense that one’s actions originate from oneself and belong to oneself. Diminished in depression (can’t initiate), disturbed in schizophrenia (actions may feel alien).

Alexithymia (Scale 2.1; Chapter 7)

Difficulty identifying and verbalizing one’s own feelings. Present in over 40% of patients with anxiety, depression, and psychotic disorders. Not evasion or low intelligence — the patient genuinely lacks the internal vocabulary for emotional experience. Affects the interview: the clinician must provide scaffolding through the body (“Do you notice anything in your body?”) or through contrasts (“Is it more like sadness, or more like absence?”).

Attunement (Befindlichkeit; Scale 3.1)

The background mood or “finding-oneself” that colors all experience before any specific emotion appears. Not how the patient feels about something specific, but how the world as a whole feels to them. In depression, the world may feel heavy, flat, or distant; in anxiety, threatening or fragile.

Concretization (Scale C.2; Chapter 7)

The clinical skill of helping a patient make a vague or general statement specific and precise. In phenomenological interviewing, this means moving from “I feel disconnected” to specifying: disconnected from what? From the body, the world, other people, or the sense of self?

Depersonalization (Scale 3.2, 4.10)

The experience that oneself has become unreal, detached, or unfamiliar. “Watching myself from outside,” “my body doesn’t feel like mine.” A dissociative phenomenon, not a psychotic one — the patient knows the experience is altered. Distinct from self-disorder, where the basic structure of selfhood is changed.

Derealization (Scale 3.1, 4.10)

The experience that the external world has become unreal, unfamiliar, or dreamlike. Objects look the same but feel different. Distinct from depersonalization (which concerns the self rather than the world), though both often co-occur.

Desynchronization (Scale 3.6; Chapters 2, 3)

Fuchs’ concept: the body falling out of step with shared social time. In depression, the body’s rhythms — sleep, appetite, energy — decouple from the social world. The depressed patient cannot keep pace with the day; the manic patient races ahead of it. Desynchronization explains why disrupted sleep, lost appetite, and inability to maintain routine are not just symptoms but expressions of a temporal disturbance.

Embodiment (Scale 3.4)

The lived experience of having and being a body. Normally transparent — we act through the body without attending to it. In illness, the body becomes conspicuous: heavy in depression, alien in depersonalization, a source of distress in eating disorders, a site of somatic distress in anxiety.

Erklären / Verstehen (Chapter 6; Chapter 9)

Jaspers’ foundational distinction. Erklären (explaining) grasps through causal mechanisms, biology, diagnostic categories. Verstehen (understanding) grasps from within the patient’s experience — meaningful connections that make sense of why this person suffers in this way. Both are needed; the order matters. The patient must feel understood (Verstehen) before they can receive explanation (Erklären). A formulation that explains without understanding does not land.

Intentional arc (arc intentionnel; Scale 3.5)

The momentum of engagement that integrates perception, emotion, and action into a coherent directedness toward the world. When intact, activities pull us forward; when collapsed, everything requires effortful will. Not the same as anhedonia (loss of pleasure) — a patient may feel pleasure if forced into an activity but never be drawn toward one.

Intercorporeality (Scale 3.8)

The bodily dimension of being with others — the pre-reflective resonance, synchrony, and attunement that occurs between bodies in social interaction. Felt as ease, warmth, tension, or disconnection. The physician’s own bodily experience of the encounter (the “praecox feeling”) is a form of intercorporeal data.

Ipseity (Scale 3.2, 4.16)

The most basic, pre-reflective sense of being a self — the “mineness” of experience. Not identity, self-esteem, or personality, but the silent, taken-for-granted sense that experiences are happening to “me.” Disturbed in schizophrenia-spectrum conditions (self-disorders). The EASE interview (Parnas et al., 2005) assesses this systematically.

Praecox feeling (Scale 3.8)

The clinician’s intuitive sense that something is off in the encounter — a subtle unease, a feeling of not being able to reach the patient despite cooperative behavior. Originally described by Rümke (1941) as a diagnostic tool for schizophrenia. Now understood as an intercorporeal signal: the clinician’s body registers a disturbance in intersubjective resonance before the mind can name it.

Self-disorder (Scale 4.16)

A disturbance of the basic structure of selfhood — not low self-esteem or identity confusion, but an alteration in the pre-reflective sense of being a self. Experiences include: diminished sense of existing, loss of the boundary between self and world, feeling transparent to others, thoughts that don’t feel like one’s own. Considered a core feature of schizophrenia-spectrum conditions (Sass & Parnas, 2003).

Spatiality (Scale 3.7)

The lived experience of space — not geography, but how space feels. Spaces can feel safe, threatening, expansive, or constricting. In agoraphobia, open space threatens; in psychosis, familiar spaces may feel uncanny or charged with significance. “Home” carries different weight for displaced persons.

Stimmung (Scale 3.1; Chapter 3)

Heidegger’s term for background attunement — the mood we are always already in before any specific emotion arises. Not an emotion about something specific, but the way the world as a whole feels. Related to Ratcliffe’s “existential feelings.” In clinical use: the background against which all experience is colored. Altered in depression (world feels heavy), derealization (world feels unreal), and delusional mood (world feels charged).

Temporality (Scale 3.6)

The lived experience of time — not clock time but how time flows in experience. In depression, time may feel frozen or unbearably slow; in mania, accelerated; in trauma, fragmented with intrusive past and collapsed future. The loss of temporal flow (“stuck in the present”) is clinically significant.

Transparency (Chapter 3)

The phenomenological principle that in health, the structures of experience are invisible — we see through them rather than at them. The body is transparent (we act through it), time flows unnoticed, space recedes into background. In illness, these structures become conspicuous. The way they become visible is diagnostically informative.

Transitivism (Scale 3.8, 4.16)

A disturbance of self-other boundaries in which the patient feels that their experience is somehow shared with, influenced by, or transferred to the other — or vice versa. “When you look at me, I feel your thoughts entering my head.” Distinguished from empathy or emotional contagion by its involuntary, disturbing quality.

Wahnstimmung (Scale 3.1; Scale 4.14)

Delusional mood or delusional atmosphere. The world feels charged with personal significance — something important is happening, but the patient cannot say what. Not anxiety (which fears something specific) but a pervasive sense that reality itself has shifted. Precedes the formation of specific delusions. When present, proceed to 4.14.

Wahnwahrnehmung (Scale 4.14, 4.16)

Delusional perception. An ordinary perception that immediately acquires personal, delusional significance without any logical connection: the traffic light turns red and the patient “knows” they are chosen. A first rank symptom (Schneider) that marks the crystallization point between delusional atmosphere and formed delusion. Clinically: “Was there a moment when things suddenly made sense to you?”

Key References

• Fuchs T, Schlimme JE. Embodiment and psychopathology: A phenomenological perspective. Current Opinion in Psychiatry. 2009;22(6):570–575.
• Jaspers K. Allgemeine Psychopathologie. Berlin: Springer; 1913.
• Parnas J, Møller P, Kircher T, et al. EASE: Examination of Anomalous Self-Experience. Psychopathology. 2005;38(5):236–258.
• Ratcliffe M. Feelings of Being: Phenomenology, Psychiatry and the Sense of Reality. Oxford University Press; 2008.
• Sass LA, Parnas J. Schizophrenia, consciousness, and the self. Schizophrenia Bulletin. 2003;29(3):427–444.
• Stanghellini G. Lost in Dialogue: Anthropology, Psychopathology, and Care. Oxford University Press; 2016.

See Chapter 3 for the teaching framework. See Appendix B (Assessment Probes) for clinical probes.