Mental State Examination

The mental state examination or mental status examination (MSE) is used when assessing patients from a mental health point of view. Equal importance must be give to the mental state exam as a student would give for doing a CVS exam for a patient with chest pain. This examination is a key tool in the psychiatric assessment of a patient. The MSE gives the clinician a momentary window into the patient’s psychological state at a given time. Much of the assessment is done by observation. In order to undertake a complete mental state exam a student must also ask direct questions that encourages the patient to open up about their thoughts. Apart from being an important tool for diagnosing patients, the MSE also helps risk assess patients, therefore the suicide risk section is a vital part of the examination.

Introduction

1. Wash hands

Wash your hands using the Ayliffe technique

2. Introduce yourself

Introduce yourself and give your name and grade

 “Hi, my name is Han Solo and I am a 4th year medical student”

3. Check patient details

Clarify patient's identity by confirming their name and asking for their DOB

4. Explain what exactly what you will be doing, and how long the interview will take and that you will maintain patient confidentiality.

5. Gain verbal consent

 “Would this be ok with you?”

 

The general demeanor of the patient. This gives you a clue about the patient’s self hygiene and current state of mind.

  • Hygiene - Are they unkempt? evidence of neglect?
  • Clothing - Unusually bright coloured/multi-coloured (? mania)

  • Physical appearance - Evidence of malnutrition, withdrawn body posture?

  • Distinct marks - Self harm or needle track marks

An assessment of what the person is doing during the consultation.

  • Body language - Are they withdrawn? Restless?

  • Eye contact

  • Facial expression - flat, apathy

  • Arousal and movement - hyperactive/ hypoactive

  • Rapport - co-operative, engaged?

  • Additional movements - tremor, tardive dyskinesia, tics

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It's often difficult to differentiate between a patient’s mood and affect. The easiest way to make a distinction is to think of the patient’s mood is what they tell you they are feeling, and affect is your observation of the apparent emotions externally shown by the patient.

  • Mood - subjective, the patient’s words. Cover biological aspects if low mood e.g sleep, appetite, memory.

  • Affect - objective, ? flat affect

Are the two congruous or incongruous?

“How has your mood been lately?”

It's often difficult to differentiate between a patient’s mood and affect. The easiest way to make a distinction is to think of the patient’s mood is what they tell you they are feeling, and affect is your observation of the apparent emotions externally shown by the patient.

  • Mood - subjective, the patient’s words. Cover biological aspects if low mood e.g sleep, appetite, memory.

  • Affect - objective, ? flat affect

Are the two congruous or incongruous?

“How has your mood been lately?”

The patient’s speech can often be important in helping the clinician make a diagnosis. Special considerations for the content of the speech will be covered in the “Thought” section.

  • Rate - increased, pressured speech, poverty of speech

  • Tone

  • Quantity - minimal or over expressive to questions

  • Quality - quiet/loud, rhythm

A patient's thinking can be subdivided into the thought content and the thought process.

Thought Content

  • Delusions - strongly held beliefs held even in the face of contrary evidence

  • Obsessions/Phobias - obsessive preoccupation with certain thoughts

  • Overvalued ideas - Anorexia nervosa - think they are fat

  • Suicide ideation - self harm or suicidal thoughts

  • Possessions - thought insertion, thought withdrawal

“Are there times when you want to end it all”

“Have you ever acted on these thoughts”

“How far did you go in your plans”

“What is stopping you from acting on them”

Thought Process

  • Speed - slow/fast

  • Tempo - flight of ideas/ poverty of thought

  • Pressured - thought blocking

Perception is how we process sensory information and form an understanding of our environment. It is an important aspect of the mental state exam, as it allows detection of perception disturbances in severe mental health conditions. One of schneider’s first rank symptoms suggestive of schizophrenia.

  • Hallucinations - false sensory perception in the absence of stimuli. One of schneider’s first rank symptoms suggestive of schizophrenia.

  • Any sensory modality, auditory and visual most common
  • Nature of hallucination - third person (?schizophrenia), second person
  • Note distress caused by hallucination to patient

“Do you see or hear things that may not be there”

  • Illusion - distortions of reality.

    • Patient can be aware of disparity between what they and others perceive

Looks at how the patient is able to process information at their current state.

  • Alertness - drowsy, stupor

  • Orientation - time, place & person

  • Processing ability tested by a separate exam known as the Mini Mental State Examination

“ I will now ask you a few questions that may seem a bit daft but it helps us see how you are processing information.

The patient’s understanding of their current mental health problems. Important aspect for risk assessing and also evaluating prognosis.

  • Recognition

  • Compliance

  • Identify pathological process (hallucination/delusion)

“What do you think is causing this”

“Do you think you need any treatment”

Patient’s basic capacity to make decisions

  • Discussion through a scenario/life event to assess decision making skills

Assess the patient's suicide risk

  • Ask about thoughts of deliberate self harm (DSH) or suicide
  • If there are thoughts of ending their life - then explore if they have done anything about them: research method, leaving a note, writing a will etc

"Sometimes when people are very low in their mood, they may have dark thoughts of harming themselves or ending their life, have you had any of these thoughts?"

Assess lifestyle risks and previous history

  • Alcohol/Drugs
  • Previous DSH or overdoses 
  • Co-existing mental health problems 
  • Employment/unemployment
  • Family history of mental health problems/ suicide 
  • Family or friends living with patient

Thank the patient

Let the patient know you have finished examining them and thank them for their time. 

“Thank you for your time, that's all the questions I had for now.”

Turn to the examiner and summarise your findings

“Today I have met Jack Smith a 26 year old gentleman, who came to see me regarding his low mood. On general inspection….”