Perception
What perception means in a mental status exam, the main perceptual disturbances (hallucinations, illusions, depersonalization, derealization) and how to chart them in a note.
Quick Answer
Perception in a mental status exam records whether a person is having perceptual disturbances: experiences of the senses that do not match reality. The main ones are hallucinations (perceiving something with no external source, such as hearing voices), illusions (misperceiving something real, such as a coat looking like a person), and depersonalization or derealization (feeling detached from yourself or your surroundings). A typical normal finding is “denies hallucinations; not observed responding to internal stimuli.” If voices give commands, chart what they say and assess risk.
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Definition
Perception is the part of the mental status exam that covers how a person experiences the world through their senses. Clinicians ask about, and watch for, perceptual disturbances in any sense: hearing (auditory), sight (visual), touch (tactile), smell (olfactory) and taste (gustatory).
Perceptual disturbances can occur in psychotic disorders, mood disorders with psychotic features, PTSD and dissociative disorders, intoxication and withdrawal, delirium, dementia, epilepsy and other medical conditions, and with some medications. Some experiences are common and usually harmless, such as briefly hearing your name called while falling asleep (hypnagogic) or waking up (hypnopompic). Cultural and religious context also matters when deciding whether an experience is unusual.
Perception is different from thought content. Hearing a voice no one else hears is a perceptual disturbance; a fixed false belief, such as believing you are being followed, is a delusion and belongs under thought content.
Common perceptual disturbances
| Term | What it means | Example wording |
|---|---|---|
| Auditory hallucinations | Hearing sounds or voices with no external source | “Hears two male voices commenting on her actions most days; voices outside her head; no commands.” |
| Command hallucinations | Voices that tell the person to do something | “Reports a voice telling him to ‘stay inside’; denies commands to harm self or others.” |
| Visual hallucinations | Seeing things that are not there | “Reports seeing small animals in the corner of the room for the past two days.” |
| Tactile, olfactory or gustatory hallucinations | Feeling, smelling or tasting things with no source | “Reports feeling insects crawling under her skin since stopping alcohol yesterday.” |
| Illusions | Misperceiving something that is really there | “At dusk mistook a coat on a chair for a person; recognized it on a second look.” |
| Depersonalization | Feeling detached from your own body, thoughts or feelings, as if watching yourself | “Describes feeling ‘like I’m watching myself in a film’ during panic attacks.” |
| Derealization | Feeling that surroundings are unreal, dreamlike or distant | “Reports the room looked ‘flat, like a stage set’ for several minutes after the argument.” |
| Responding to internal stimuli | Observed signs that the person may be hallucinating, such as pausing, looking around or talking to no one | “Paused mid-sentence and glanced to the left twice, as if listening; denied hearing anything.” |
When it is an emergency. New visual, tactile or smell hallucinations, especially with confusion, fever, a recent head injury or stopping alcohol or sedatives, can signal delirium, withdrawal or another medical emergency: call 911 or go to the nearest emergency department. Command hallucinations to harm self or others need an immediate risk assessment and emergency plan.
How to chart perception in an MSE or progress note
Record the type of experience, what the person hears or sees, how often, how distressing it is, whether they act on it, and any commands. Separate what they report from what you observe.
Weak documentation: “+AH.”
Stronger documentation: “Reports auditory hallucinations: two voices commenting on his actions, daily, mostly in the evening; distress 4/10, down from 8/10 a month ago. No commands. Observed pausing and glancing to the side twice during session.”
Perception in a SOAP note
Report what the person describes in Subjective and what you observe in Objective. A short fictional example:
Subjective: Fictional adult client, 45, with schizophrenia, outpatient follow-up, session 12. Reports hearing two voices most evenings that comment on what he is doing (“he’s making tea now”); says they are quieter than last month and distress is 4/10, down from 8/10. Uses headphones and humming to cope. Has been taking medication daily per his prescriber’s plan.
Objective: Alert and oriented. Casually dressed, good hygiene. Speech normal. Mood “steady”; affect restricted, congruent. Thought process linear. Perception: paused twice mid-sentence and glanced to his left, then continued; when asked, said the voices had commented briefly. Denied visual, tactile or smell hallucinations. On direct questioning, reports that the voices only comment and give no commands; denies suicidal or homicidal thoughts, intent, plan or preparatory behavior; denies a history of suicide attempts, self-harm or violence. Reports no access to firearms or stockpiled medication. Identifies his brother as someone he can contact if symptoms worsen and says he can follow the crisis plan.
Assessment: Persistent auditory hallucinations without commands; client reports quieter voices and distress reduced from 8/10 to 4/10. Change in frequency has not been established. Medication adherence is self-reported. Therapist assesses acute risk of harm to self or others as low, not absent, based on today’s direct assessment, no reported attempt or violence history, the means assessment, effective coping and identified support. Continued outpatient follow-up with his prescriber and the crisis plan below is appropriate today; reassess if commands, suicidal or violent thoughts, or ability to stay safe change.
Plan: Continue coping strategies; add scheduling evening activities with his brother. With client’s consent, therapist will share the reduced distress rating with his prescriber before next week’s appointment. Client and his brother know to call 911 or go to the nearest emergency department if voices tell him to harm himself or anyone else or he cannot keep himself safe, and to call or text 988 if thoughts of suicide arise.
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Tips for documenting perception
Name the sense and the content: Write which sense is involved and what the person hears or sees, not just “hallucinations present.”
Always ask about commands: If voices give instructions, chart what they say, whether the person feels they must obey, and the risk plan.
Separate report from observation: Chart what the person describes and what you saw, such as appearing to respond to internal stimuli.
Track frequency and distress: Rating how often and how distressing the experiences are shows change over time.
Watch for medical causes: New visual, tactile or smell hallucinations, especially with confusion or after stopping alcohol, can be an emergency: call 911 or go to the nearest emergency department.
Keep perception and belief apart: Hallucinations go under perception; delusions go under thought content.
Common mistakes to avoid
- Shorthand only: “+AH/VH” does not say what was heard or seen, how often or whether there were commands
- Not asking about commands: command hallucinations change the risk picture and must be assessed
- Calling every unusual experience a hallucination: hypnagogic experiences, illusions and culturally normal experiences are different
- Putting delusions under perception: false beliefs belong in thought content
- Missing withdrawal or delirium: new hallucinations with confusion or after stopping alcohol need emergency care, not just a note
Frequently asked questions
What is perception in a mental status exam?
Perception records whether a person is having perceptual disturbances: sensory experiences that do not match reality, such as hallucinations, illusions, depersonalization or derealization. A typical normal finding is “denies hallucinations; not observed responding to internal stimuli.”
What is the difference between a hallucination and an illusion?
A hallucination is a perception with no external source, such as hearing a voice when no one is speaking. An illusion is a misperception of something that is really there, such as mistaking a coat on a chair for a person. Illusions are common and often resolve on a second look.
What is the difference between perception and thought content?
Perception covers sensory experiences, such as hearing voices or seeing things. Thought content covers beliefs and ideas, such as delusions, obsessions or suicidal thoughts. Hearing a voice with no external source saying you are being watched is a hallucination. A fixed false belief that you are being watched, held despite clear evidence against it and not explained by cultural or religious context, may be a delusion. Assess the evidence and context before using that label.
What are command hallucinations and how do you document them?
Command hallucinations are voices that tell the person to do something. Chart what the voices say, how often, whether the person feels they must obey or has acted on them, and your risk assessment and plan. Commands to harm self or others need an immediate risk assessment and emergency plan.
When are hallucinations a medical emergency?
New hallucinations with confusion, fever, a recent head injury, or after stopping alcohol or sedatives can signal delirium, withdrawal or another medical emergency: call 911 or go to the nearest emergency department. So do hallucinations commanding harm when the person cannot stay safe.
Related guides: thought content · dissociation · mental status exam · risk assessment · mental status exam template.
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Further Reading
- DSM-5-TR — The American Psychiatric Association’s diagnostic manual. It describes hallucinations as a core feature of psychotic disorders and covers depersonalization/derealization disorder; it does not prescribe how to write a mental status exam.
- NIMH (National Institute of Mental Health) — Plain-language information on mental health conditions, their symptoms and current research.
- Mental status exam template and examples — How this domain fits with the other parts of a mental status exam, with example wording and a fictional completed MSE.