Mental State Assessment (MSA) is a fundamental skill for nurses, doctors and others working in health care settings. This presentation covers some of the core skills required: looking, listening and asking. Many thanks to Jenni Bryant, @JenCLNinja on Twitter, for sharing her work which provided the structure and much of the content of this presentation.

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Assessing Mental State
“Looking, Listening & Asking”
Paul McNamara
RGN (RAH), RPN (SAMHS), BN (Flin.), MMHN (USQ), Cert IMH (WCHN), CMHN, FACMHN
@meta4RN

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Acknowledgement
This presentation adapted from the work of Jenni Bryant
@JenCLNinja

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Mental State Assessment
Mental state can and does change over a shift,
day or week - important to document changes
Brief MSA on all patients, not just those with a
diagnosed mental illness
Why? An indication of person’s thinking
(cognition), feeling (mood) and behaviour

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Comprehensive Assessment
Composed of two parts
 History
 Mental State Assessment (MSA)
History is static
 medical, psychiatric
 personal (developmental, relationship,
education, employment, social)
MSA changes

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Mental State Assessment
General Description
Mood
Affect
Speech
Thoughts
Perception
Cognition
Insight
Judgement
Plus:
Risk Assessment & Estimation
Substance Use or Abuse

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General Description looking
Level of Consciousness
 drowsy, alert, sleeping, fluctuating
Appearance
 grooming, makeup, posture, clothing, obvious
physical deformities or characteristics
Behaviour
 eye contact, rapport, level of activity, body
language, mannerisms, specific activities

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Mood asking
Subjective:
 How has your mood been lately?
 How do you feel within yourself?
 What has given you happiness, joy
or enjoyment recently?
 Are you a good person?
 Have you been feeling guilty or sad?
 If 10 is as good as you ever feel and
0 is as low as you go, where on the
scale have you been over the last
couple of weeks?
Vegetative:
 Sleep
 Appetite
 Irritability
 Tearfulness
 Energy
 Motivation
 Libido
 Withdrawal

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Affect looking
Objective:
 Facial and bodily
expression of mood
state
 Appropriate to content
 Assess the range,
appropriateness,
intensity and quality of
affect
 Rapid shift from one
emotive response to
another? (lability)
Some Useful Adjectives:
 sad, tearful, angry,
irritable, elated, euphoric,
frightened, despondent,
animated, expansive,
cooperative, ingratiating,
distressed, discouraged,
anxious, hostile, guarded,
anxious, calm, ambivalent,
dysphoric, euthymic,
suspicious, fatuous,
bewildered, perplexed

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Speech listening
 Physical qualities
 Flow: smooth, hesitant, interrupted, staccato, are
responses prompt or delayed?
 Rate: fast (pressured), slow, or unremarkable?
 Volume: soft, loud, unremarkable.
 Tone: flat, monotonous, restricted range, expressive
 Continuity: the capacity to maintain a normal progression
from one stream of thought to the next. Over-inclusive,
poverty, circumstantial, perservation or blocking?
 Form: Assess for abnormalities of form of speech, not
form of thought eg stammer/stutter, dysarthia, expressive
or receptive aphasia.
 Clarity
 Accent

10. Thoughts asking & listening
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 Form
 amount - poverty, flight of ideas, vague
 continuity of ideas - incoherent, blocking,
circumstantial, tangential, irrelevant
 disturbance in meaning or use of language -
neologisms, word salad
 Content - delusions, obsessions, compulsions,
suicidal ideation, phobias, preoccupations

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Perception
looking, listening & asking
 Hallucinations
 false sensory perception
 any of the senses
 occurs in the absence of a stimulus
 auditory, visual, olfactory, tactile, gustatory
 Illusion
 misinterpretation of sensory stimulus

12. Cognition asking & listening
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 Orientation
 time, place, person, situation
 Memory
 Concentration
 Attention
 MMSE
 Clockface [brief frontal lobe assessment]

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MMSE
Mini Mental State Examination
 Screening [ie: not diagnostic] tool for cognitive
impairment - best for mild to moderate
 Does not differentiate between delirium and
dementia
 Used to detect impairment, to follow course of
illness, to monitor treatment response
 Affected by education, intelligence, age,
literacy, culture and inter-rater reliability

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Insight Judgement
 Are they aware that
they are ill and
understand the
effects and
implications?
 Good, partial or
poor?
 Has patient history
of impulsivity?
 Can they accurately
assess a situation &
act appropriately in
response?
 Intact or impaired

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Risk
Risk Estimation:
 Self harm
 Suicide
 Assault [physical, sexual]
 Infanticide
 Homicide
 Absconding
 Medication/Treatment Adherence

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Risk to self asking
 Do you still have “the fighting spirit”?
 Do you ever think “what’s the point in going on?”
 What’s keeping you going… what makes life worth
living?
 Have you thought you would be better off dead?
How strong are these thoughts?
 Have you thought of suicide?
 Have you made a plan? [if “yes”, do they have
access to means?]
 When would you do this?

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Risk to others asking
 You seem pretty angry.
 Are you able to express that anger safely?
 Do you feel like acting on that anger?
 Do you feel like hurting someone?
 Am you safe to be around at the moment?
 Am I safe with you?
 What has made you angry?

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Alcohol, Tobacco & Other Drugs
asking
Opportunistic, Non-Judgmental Assessment
 Rapport established
 Most substance abuse is contextual
 Give “permission” for honest answers
 “Sounds like you’ve had a lot of stress lately. How
have you been coping?”
 “You’ve got a lot of stuff going on at the moment…
are you drinking or smoking more than usual?”
 “In FNQ plenty of people use the bottle shop or a
bit of choof or speed to try to manage stress. How
about you?”

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Alcohol, Tobacco & Other Drugs
asking
 Alcohol
 Tobacco
 Cannabis (choof, gunja, yarndi, weed, dope)
 Amphetamines (speed, goey)
 Methamphetamines (ice, crystal meth)
 MDMA methylenedioxymethamphetamine (ecstasy)
 Opioids (codeine, morphine, methadone, heroin)
 Benzodiazepines (benzos: diazepam, oxazepam,
nitrazepam/moggies, temazepam/normies,
alprazolam/xannies)

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Mental State Assessment
comments or questions?
General Description
Mood
Affect
Speech
Thoughts
Perception
Cognition
Insight
Judgement
Plus:
Risk Assessment & Estimation
Substance Use or Abuse