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Mental state examination (MSE)

- MSE is a systematic appraisal of the appearance, behavior, mental
functioning and overall manner of a person.
- In some ways it reflects a "snapshot" of a person's psychological functioning
at a given point in time.
- A MSE is an important component of the assessment of a patient.
- Most of us intuitively perform many parts of a MSE every time we interact
with or observe others.
- Observations of person's mental state are important in determining a
person's capacity to function, and whether psychiatric follow-up is required.
- Judgements about mental state should always consider the developmental
level of the person and age-appropriateness of the noted behavior(s).
- If there is any indication of current suicidal or homicidal ideation the person
must be referred for risk assessment by a qualified mental health clinician.

A typical MSE includes consideration of the following

domains:

Appearance
A person's appearance can provide useful clues into their quality of self-care,
lifestyle and daily living skills.
- distinctive features
- clothing
- grooming
- hygiene
- Gait

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Behaviour
As well as noting what a person is actually doing during the examination, attention
should also be paid to behaviours typically described as non-verbal
communication.
- facial expression
- body language and gestures
- posture
- eye contact
- response to the assessment itself
- rapport and social engagement
- level of arousal (e.g. calm, agitated)
- anxious or aggressive behaviour
- psychomotor activity and movement (e.g. hyperactivity, hypoactivity)
- unusual features (tremors, or slowed, repetitive, or involuntary movements)
- Mannerisms
- Attitude: Cooperative, hostile, open, secretive, evasive, suspicious,
apathetic, easily distracted, focused, defensive.

Mood and affect

- It can be useful to conceptualize the relationship between emotional affect
and mood as being similar to that between the weather (affect) and the
season (mood).
- Affect refers to immediate expressions of emotion, while mood refers to
emotional experience over a more prolonged period of time.
Affect:
- range (e.g. restricted, blunted, flat, expansive)
- appropriateness (e.g. appropriate, inappropriate, incongruous)
- stability (e.g. stable, labile)
- Quality: Sad, angry, hostile, indifferent, euthymic, dysphoric, detached,
elated, euphoric, anxious, animated, irritable.
Mood:
- happiness (eg, ecstatic, elevated, lowered, depressed)
- irritability (e.g. explosive, irritable, calm)
- stability
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Speech
Speech can be a particularly revealing feature of a person's presentation and
should be described behaviorally as well as considering its content.
Unusual speech is sometimes associated with mood and anxiety problems,
schizophrenia, and organic pathology.
- speech rate (Fast, slow, normal, pressured)
- volume (e.g. loud, normal, soft)
- tonality (e.g. monotonous, tremulous)
- quantity (Talkative, spontaneous, expansive, paucity, poverty)
- Fluency and Rhythm (Slurred, clear, with appropriately placed inflections,
hesitant, with good articulation, aphasic)

Cognition
This refers to a person's current capacity to process information and is important
because it is often sensitive to mental health problems.
- level of consciousness (Vigilant, alert, drowsy, lethargic, stuporous, asleep,
comatose, confused, fluctuating.)
- orientation to reality (often expressed in regard to time/place/person - e.g.
awareness of the time/day/date, where they are, ability to provide personal
details)
- memory functioning (including immediate or short-term memory, and
memory for recent and remote information or events)
- literacy and arithmetic skills
- visuospatial processing (e.g. copying a diagram, drawing a bicycle)
- attention and concentration (e.g. observations about level of distractibility,
or performance on a mentally effortful task - e.g. counting backwards by 7's
from 100)
- general knowledge
- language (e.g. naming objects, following instructions)
- ability to deal with abstract concepts (e.g. describing conceptual similarity
between two things).

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Thoughts
A person's thinking is generally evaluated according to their thought content or
nature, and thought form or process.

Content:
- delusions (rigidly held false beliefs not consistent with the person's
background)
- overvalued ideas (unreasonable belief, e.g. a person with anorexia believing
they are overweight)
- preoccupations
- depressive thoughts
- self-harm, suicidal, aggressive or homicidal ideation
- obsessions (preoccupying and repetitive thoughts about a feared or
catastrophic outcome, often indicated by associated compulsive behaviour)
- anxiety (generalised, i.e. heightened anxiety with no specific referent; or
specific, e.g. phobias)

Process:
Thought process refers to the formation and coherence of thoughts and is inferred
very much through the person's speech and expression of ideas.
- highly irrelevant comments (loose associations or derailment)
- frequent changes of topic (flight of ideas or tangential thinking)
- excessive vagueness (circumstantial thinking)
- nonsense words (or word salad)
- pressured or halted speech (thought racing or blocking)

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Perception
Screening for perceptual disturbance is critical for detecting serious mental health
problems like psychosis, cases of severe anxiety, and mood disorders. It is also
important in trauma or substance abuse. Perceptual disturbances are typically
marked and may be disturbing or frightening.

Dissociative symptoms:
- derealisation (feeling that the world or one's surroundings are not real)
- depersonalisation (feeling detached from oneself)

Illusions:
- the person perceives things as different to usual, but accepts that they are
not real, or that things are perceived differently by others

Hallucinations:
- a sensory perception without any external stimulation of the relevant
sense that the patient believes IS real (e.g. hears voices but no sound
present)
- probably the most widely known form of perceptual disturbance
- hallucinations are indistinguishable by the sufferer from reality
- can affect all sensory modalities, although auditory hallucinations are the
most common
- in children it is common to experience self-talk or commentary as an
internal "voice"
- command hallucinations (voices telling the person to do something) should
be investigated
- important to note the degree of fear and/or distress associated with the
hallucinations

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Insight & Judgement

Insight and judgement is particularly important in triaging psychiatric
presentations and making decisions about safety.

Insight:
- acknowledgement of a possible mental health problem
- understanding of possible treatment options and ability to comply with these
ability to identify potentially pathological events (e.g. hallucinations,
suicidal impulses)
Judgement:
- refers to a person's problem-solving ability in a more general sense can be
evaluated by exploring recent decision-making or by posing a practical
dilemma (e.g. what should you do if you see smoke coming out of a house?)

Intellectual:
A. Information and Vocabulary: Suggested patient instructions:
- “Name the last 5 presidents.”
- “Name 5 of the largest cities in the country.”
- “Name the current president, vice president, governor, and mayor.
B. Vocabulary - Possible descriptors:
- Grade school level, high school level, fluent, consistent with education.
C. Abstraction - Possible questions for patient:
1. Similarities – “How are the following items similar?”
- “an apple and an orange” (round ~concrete, fruit ~abstract)
- “a chair and a table” (made of wood ~concrete, furniture ~abstract)
- “a watch and a ruler” (measurement instruments ~abstract)
2. Proverbs – “How would you describe the meaning of the following sayings?”
- “People living in glass houses should not throw stones.”
- “A bird in the hand is worth two in the bush.”
- “Two heads are better than one.”