Mental State Examination

Written by: Verity Bradley from Manchester University,

Introduction

MSE forms part of a full psychiatric assessment alongside history taking. Elements can be performed simultaneously alongside the history, or afterwards in an systematic fashion.

This information should help to enable a judgement to be made regarding the presence and severity of any mental illness. The MSE should be obtained and recorded in a standardized format.

 

Components of the Mental State Exam

  • Appearance
  • Behaviour
  • Speech
  • Mood
  • Perception
  • Thought form
  • Thought content
  • Cognition
  • Insight

MSE

Appearance

  • Apparent age
  • Ethnicity
  • Cleanliness & personal hygiene. Is there any evidence of self-neglect?
  • Attire (is it appropriate for weather, surroundings etc... May be important sign in a manic patient)
  • Any abnormal involuntary movements e.g. tics, grimaces, tremors, stereotypies etc.

Behaviour

  • Appropriateness of behaviour
  • Level of eye contact
  • Rapport
  • Is patient easily distracted? (distractibilty)
  • Any abnormal movements?
  • Restlessness, anxiety
  • Socially inappropriate e.g. embarrassing, over-familiar and sexually forward behaviour (may be seen in manic patients)
  • Aggression, violence etc.....

Speech

  • Volume, rate and tone
  • Quantity and fluency: Are answers unduly brief or monosyllabic or are they inappropriately prolonged? Does the speech appear pressured?
  • 'Flight of ideas' does patient move quickly between subjects
  • New or made up words (neologisms) or any other abnormal use of language?
  • Logicality
  • Abnormal associations
  • Is speech appropriate for the situation e.g. does patient answer questions appropriately, is the content of speech appropriate to the situation?

 

Mood

Mood vs. Affect

Affect: ' The emotional state of the patient at a given moment in time' 

Mood: ' The patient's emotional state over a longer period of time'

Analogy: 'Affect is the weather, where mood is the climate' (Oxford Handbook of Psychiatry.)

  • How has your mood been lately?'
  • Ask about depressed mood e.g. concentration, appetite, feelings of guilt, worry, sleeping patterns, sexual relationships
  • Ask about self-harm e.g feelings about the future, 'have you ever thought that life was not worth living?', thoughts of ending life, any preparations, any previous attempts at self-harm/suicide?
  • Ask about elevated mood.
Concentration, appetite, sleeping patterns and sexual side of relationship are still important to ask about. For example, manic patients often require little sleep and typically have impaired concentration. Also ask 'Is your mood changeable at the moment?' and 'do you think you have any special gifts and talents?'
  • Anxiety and panic symptoms

 

Perception

  • Ask patients about their experience of abnormal perceptions & abnormal beliefs (e.g. hallucinations and delusion)
  • Often difficult to ask about

 

Use questions such as:

  • Start with 'I'd like to ask you a couple of questions about sometimes people have but may find difficult to talk about. I ask everyone these questions'
  • Then use questions such as ' Have you ever had experiences of hearing noises or voices when there was nobody around?' etc...

 

Thought Form & Content

Thought Form

  • Formal thought disorder
  • Accelerated tempo of thought: Flight of ideas
  • Decelerated tempo of thought: psychic retardation (occurs in depressive illness)
  • Goal-directedness
  • Linearity of thought

 

Thought Content

  • Assessing whether or not patient has any abnormal beliefs or ideas
  • Delusions
  • Over-valued ideas
  • Obsessions and compulsions
  • Preoccupations
  • Any thoughts of self harm or harm to others

 

Cognition

Assessment of:

  • Attention & concentration
  • Orientation to time, place & person
  • Level of comprehension
  • Short-term memory

Methods used include:

  • Mini-mental state exam (MMSE)
  • Frontal & parietal lobe functioning tests

Insight

Insight: Is the degree to which an individual believes s/he is unwell. It is impaired in those suffering with psychosis/schizophrenia.

  • It is important to ellicit a patient's insight as it can help determine prognosis and compliance with treatment.
  • Is patient aware that their thoughts, feelings, behaviours are part of an illness?
  • Will patient accept medical advice and treatment? Is s/he receptive to this?

A variety of psychiatric illnesses lead to an impairment of insight e.g:

A young male believes that his auditory hallucinations and sense of being watched are caused by cameras and loudspeakers that have been placed in his house by neighbours.

(This male is suffering from schizophrenia, he has no insight into his illness and is convinced he is being watched).

Summary

Useful Links

 

1) Mental State Exam, USMLE review

http://www.youtube.com/watch?v=dO7QxvHLy9c

2) Ask Dr Clarke - Mental State Examination

http://www.askdoctorclarke.com/content/c261.pdf

3) Newcastle medical school resource. Great for practise for taking MSE

http://www.ncl.ac.uk/nnp/teaching/general/hx_mse/index.html