MSE

• A mental state examination is a structured way of assessing a patient's current state of mind

  1. Appearance and behaviour
  2. Speech
  3. Mood and affect
  4. Thoughts
  5. Perception
  6. Insight and judgement
  7. Risk
• Appearance:

  • Personal hygiene: are there any signs of self-neglect?
  • Clothing: are they dressed appropriately for the weather/circumstances? Are clothes put on correctly?
  • Physical signs of underlying difficulties: any self-harm scars or signs of intravenous drug use?
  • Stigmata of disease: note any stigmata of disease (e.g. jaundice).
  • Weight: note if they appear significantly underweight or overweight.
  • Objects: look around to see if the patient has brought any objects with them and note what they are.
• Behaviour is split into:

  • Engagement and rapport
  • Eye contact
  • Facial expression
  • Body language
  • Psychomotor activity
  • Abnormal movements or postures
• Behaviour - engagement and rapport:

  • Note if the patient appears engaged in the consultation and if you can develop a rapport with them.
  • Note if they appear distracted or appear to be responding to hallucinations (e.g. replying to auditory hallucinations in schizophrenia).
• Behaviour - eye contact:

  • Observe level of eye contact
  • Reduced
  • Intense and staring
• Behaviour - facial expression:

  • Observe - e.g. relaxed, fearful, disengaged
  • Note if responding appropriately e.g. becoming tearful when discussing difficult topics vs laughing incongruously
• Behaviour - body language:

  • May appear threatening or withdrawn
  • Note any evidence of exaggerated gestures or unusual mannerisms
  • Observe for signs of paranoia e.g. appears on edge, glancing around the room
• Behaviour - psychomotor activity:

  • Psychomotor retardation - lack of/slowing down of movements, delayed responses to questions
  • Restlessness - patient may continuously fidget, pace and refuse to sit still
• Behaviour - abnormal movements or postures:

  • Involuntary movements
  • Tremors
  • Tics
  • Lip-smacking
  • Akathisias - unable to sit still
  • Rocking
  • Posturing - rigid body movements or chronic abnormal positions
• Speech is split into:

  • Rate
  • Quantity
  • Tone
  • Volume
  • Fluency and rhythm
• Speech - rate:

  • Pressure of speech - tendency to speak rapidly, motivated by an urgency that may not be apparent to the listener - can be present in mania
  • Slow - may occur due to psychomotor retardation - typically associated with depression
• Speech - quantity:

  • Poverty of speech (alogia) - depression
  • Excessive - mania
• Speech - tone:

  • Monotonous - associated with depression, psychosis and autism
  • Tremulous - associated with anxiety
• Speech - volume:

  • Quiet speech may be seen in depression
  • Loud speech may be seen in mania
• Speech - fluency and rhythm of speech:

  • Stammering or stuttering
  • Slurred - may occur in major depression due to psychomotor retardation. also sign of acute intoxication
  • Stilted speech - unnatural and formal - can be due to thought block
• Mood vs affect:

  • Both relate to emotional but are fundamentally different
  • Mood represents a patients predominant subjective internal state at any of time as described by them
  • Affect represents an immediately expressed and observed emotion e.g. patients facial expression
• Mood:

  • Can be explored with questions such as: "how are you feeling?" and "what is your current mood?"
  • Examples of mood states:
  • Low mood
  • Anxious
  • Angry
  • Enraged
  • Euphoric
  • Guilty
  • Apathetic - no interest or enthusiasm
• Affect:

  • Apparent emotion e.g. sadness, anger
  • Range and mobility of affect e.g. fixed affect (remains the same), restricted (doesn't demonstrate normal range expected), labile (exaggerated changes in emotion)
  • Intensity - E.g. heightened (mania), blunted or flat (schizophrenia, depression)
  • Congruency - if the patients affect appears in keeping with the content of their thought. Incongruent affect is typically associated with schizophrenia - sharing distressing thoughts whilst demonstrating a flat affect or laughing
• Thought:

  • Can be described in terms of:
  • Form
  • Content
  • Possession
• Thought form:

  • Speed - e.g. racing thoughts in mania
  • Flow and coherence:
  • Loose associations - moving rapidly between topics with no apparent connection
  • Circumstantial - irrelevant details
  • Tangential - digressions from main subject
  • Flight of ideas - fast, pressured speech with ideas running into one another
  • Thought blocking - sudden cessation of thought
  • Perseveration - repetition of a response despite the removal of the stimulus
  • Neologisms - makes up words
  • Word salad - random string of words without relation
• Thought content:

  • Delusions - firm, fixed belief based on inadequate grounds e.g. persecutory delusions and grandiose delusions
  • Obsessions - thoughts, images or impulses that occur repeatedly and feel out of the persons control
  • Compulsions - repetitive behaviours that patient feels compelled to perform
  • Overvalued ideas - solitary, abnormal belief that is neither delusional nor obsessional but preoccupying to the extent of dominating the persons life e.g. perception of being overweight in a patient with anorexia
  • Suicidal thoughts
  • Homicidal thoughts
• Thought possession:

  • Thought insertion - thoughts inserted into patients mind
  • Thought withdrawal - thoughts removed from their mind
  • Thought broadcasting - others can hear their thoughts
• Perception:

  • organisation, identification and interpretation of sensory information
  • Hallucinations
  • Pseudo-hallucinations - same as hallucinations but the patient knows it is not real
  • Illusions - misinterpretation of external stimulus
  • Depersonalisation
  • Derealisation
• Cognition:

  • Should develop a vague idea of the patients cognition throughout the MSE - whether they are orientated, attention span and short term memory
  • A formal assessment can be done via:
  • Mini-mental state exam (MMSE)
  • Abbreviated mental test score (AMTS)
• Insight and judgement:

  • Insight - ability of a patient to understand that they have a mental health problem and what they are experiencing is abnormal
  • Judgement - ability to make considered decisions or come to a sensible conclusion when presented with information e.g. asking "what would you do if you could smell smoke in your house?" - a patient with impaired judgement may suggest ignoring it
• Risk:

  • Risk to self - any thought of harming themselves and whether they plan to act on these thoughts
  • Also ask about other risks to self - substance misuse, self-neglect
  • Risk to others - are they having any thoughts or made any plans to harm others