Mental State Examination

The mental state examination is a way of observing and describing a patient’s current state of mind.

– The purpose of the MSE is to get a cross-sectional description of the patient’s mental state

– It is a time-specific snapshot of the patient’s current mental state (allows comparison to before)

– This is combined with the psychiatric history, allowing clinicians to get the overall sense of the patient’s condition

Mental State Exam Acronym = A Brilliant Scientist Makes All Theories Too Perfectly Complicated “In-it”

Appearance

This is a general description of the patient’s general look and appearance. Important to include the following:

– An opening sentence summarising gender build and ethnicity (describe what you see)

– Description of their clothes –> is it appropriate for the setting?

– Are they well kempt or is their evidence of poor personal hygiene?

– Any distinctive features (e.g. adornments or tattoos?)

– Mannerisms –> This includes whether patient was actively hallucinating, neurological signs, catatonic features

Behaviour

This is used to describe the patient’s ability to engage with you. Include the following:

– What was their general manner –> agitated, threatening, tearful

– Eye contact –> did they maintain eye contact with you

– Rapport –> Could they establish a friendly rapport with you?

Speech

The speech is important as it is correlated to mood and also to the patient’s thoughts. Address the following:

– First describe tone (variation in pitch) + rate (speed) + volume (quantity) + whether it is spontaneous:

            – In mania –> patients may display “pressure of speech” (rate and volume are increased)

            – In depression –> tone, rate and volume are usually decreased

            – Normal speech can be described as “spontaneous, logical, relevant and coherent.”

– Then describe if any specific types of abnormal speech:

Mood

This is used to describe the patient’s underlying emotion, which is steady and prevailing:

– First describe subjective mood –> this is how the patient describes their own mood

– Then describe objective mood –> this is your assessment of the patient’s mood

– Can be dysthymic/depressed (low), euthymic (normal) or hyperthermic (elated)

Affect

This is the observed, short-term external demonstration of emotion. Whereas mood is like the generate climate, the affect is used to describe the current transient state which considers responses to external stimuli:

– Normal affect is reactive –> shows appropriate emotional responses to external stimuli and matters

– Abnormal affects include: blunted (lacking emotional response)        

– Labile (excessively changeable)

– Suspicious              

– Incongruous (out of tune with subject matter e.g. laughing about bereavement)

Thought Form

This refers to how the patient structures their thoughts and whether they are connected to each other:

– First summarise whether the patients thought were logical, relevant and coherent

– Explain any abnormalities in thought form:

i) Flight of ideas –> abnormal thoughts where patients leap from one topic to another without links between them

ii) Loosening of associations –> Here there is no discernible link between words or statements.

– Can be Word salad –> This is a complete jumble of word

– Verbigeration –>  sound/words repeated in senseless way

– Knights move thinking –> Unexpected and complete illogical leaps from one topic to another

iii) Thought block –> The patient’s subjective experience of thought is abnormal (e.g. my mind goes blank)

Thought Content

This is used to describe the actual content of the patient’s thoughts and whether they are suicidal. Check for:

Abnormal Beliefs:

– Overvalued ideas –> These are understandable thoughts, but they are pursued by the patient beyond bounds of reason to the point that it causes distress (e.g. an intense belief that they are responsible for a death)

– Ideas of reference –> beliefs that other people are talking about them, but not with delusional intensity

– Delusion –> A false belief out of keeping with the patient’s sociocultural background held with unshakeable conviction even in the face of contradictory evidence

– Negative Cognitions –> Specific worries, phobias, obsessions or ruminations

– Depersonalisation – feeling as if they are not real (i.e. they are watching themselves through glass)

– Derealisation – feeling as it the world is not real (e.g. the world is made of cardboard)

– Suicidal ideation –> always check for thoughts, plans and intents for suicide/self-harm

Perception

This section address whether the patient experiencing phenomena which are not present. Address the following:

– Do they experience illusions –> These are misinterpretations of normal perceptions (e.g. mistaking a rope for a snake)

– These do occur sometimes in healthy people but are more frequent in psychotic illness

– Do they experience hallucinations –> These are perceptions which occur in the absence of an external stimulus

– They are experienced as coming from the outside world, rather than a product of their own mind

– They can occur in any sensory modality but auditory and visual are the most common

– Some auditory ones seen in healthy people when falling asleep (hypnagogic) + waking (hypnopompic)

– Do they experience pseudo hallucinations –> These are internal perceptions with preserved insight

– The patient accepts they might not be external real voices e.g. “I hear a voice in my head saying I’m wrong.”

Cognition

This involves testing the 5 basic aspects of brain function to see if the patient has functional impairment. If any of these are impaired, then do a formal assessment using either MMSE or ACE-R. Check for:

i) Level of consciousness –> is the patient alert and responsive?

ii) Orientation –> is the patient aware of the time (day, date, time), place and who they are?

iii) Attention and concentration –> can the patient count backwards in 3s/7s or spell WORLD backwards?

iv) Memory –> Can the patient repeat a list of >3 objects or an address immediately and after 5 minutes?

v) Executive functioning –> Can the patient understand proverbs or do approximation (height of landmark)

Insight

This section is about the patient’s understanding of their condition and its cause as well as their willingness to accept treatment. Here is it important to address the following:

– Does the patient realise they are ill –> does he acknowledge his symptoms are abnormal and aware of severity?

– Do they think they need treatment –> are they willing to accept any type of treatment?

– Which setting should they be in in their opinion –> are they happy to be treated in hospital?