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1. MENTAL STATE
EXAMINATION
Dr Leslie Stephan 2013

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What is mental state examination?
An attempt at an objective assessment
of the current state of the person’s
mind
A cross-sectional assessment of the
person at a particular point in time -
mental state can change quickly
An act of OBSERVATION

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All we can do is infer the state of the
mind by observing the way the person
looks and acts, as well as from what
they say : thus we note what we
see
hear
smell
(we do not taste or touch the person!)

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Standard Elements of the MSE
Appearance
Behaviour
Conversation
Affect
Perception
Cognition
Insight
Judgement
Rapport

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APPEARANCE

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This may give substantial information
about internal psychic functioning:
Facial expression
Posture
Dress
Self-care
Grooming
State of physical health

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Facial Appearance
We are aware of the extreme plasticity of
the human face - we assume that this can
reflect the inner emotional state :
sorrow, rage, fear, boredom, elation etc.
Pilowsky and Katsikitis (1996) have shown
that humans are able to accurately and
reliably interpret emotions from facial
expression

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Posture
The way the person comports their body
may also reflect the emotional state :
an excited person is not stooped
an agitated person is not slouched
Posture can be abnormal or even bizarre
(eg. catatonia)

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Dress
Beware that you do not make a value
judgment: attire may reveal
the ordinary
eccentricity – this does not always
equate to abnormal mental state
the bizarre - may reflect abnormality

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Self-care and Grooming
Impairment in grooming
(poorly washed, soiled nails, matted hair,
(offensive body odour…..
along with other signs of poor self-care
(poor dental care, skin lesions, neglected
wounds…
may indicate……..????

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Physical Health
There can be many observable indicators
of possibly poor physical health:
obesity
poor oral care
weight loss
skin cancers
painful gait
lumps
jaundice……
which may for example reflect neglect
due to mental illness

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BEHAVIOUR

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This is an assessment of the person’s
activity during the course of the interview
and is distinct from mere appearances.

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The motor activity may be :
ordinary !
excessive - hyperactive
deficient - retarded
inappropriate
abnormal

15. Motor Agitation
Restlessness, pacing, “unable to sit still”,
frequently changing posture
Signs of high arousal – sweating, vigilant,
excessive startle response (“jumpy”),
tremulousness
Aggressive posturing, fist clenching,
intimidating stance, loud verbal outbursts
Hand wringing
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Motor Retardation
Paucity of spontaneous movements
Slowed movements
Lack of use of non-verbal gesturing
which may be found in ….????

17. Inappropriate
Behaviour that is beyond the bounds of
usual interpersonal actions:
• Failure to exercise common social cues
• Socially offensive actions
• Disinhibited behaviours
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Abnormal Movements
Tics - involuntary spasmodic movement
Stereotypies - repetitive fixed pattern of purposeless
movement
Mannerisms - ingrained involuntary habit
Echopraxia - imitation of another’s movements
Bizarre – catatonia

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CONVERSATION

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We make an assumption that :
what is spoken and how it is spoken
reflects
what is thought and how it is thought.
content of flow and form of
thought thought

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Flow of Thought
Absence of speech (eg. mutism)
Rate of speech
Paucity of animation in voice
(the ‘prosody’ or musicality of speech)
Delayed verbal responses to questions
(the latency of response)
Quantity of speech ( eg. “yes/no” answers)
Volume of speech

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Form of Thought
Refers to HOW the conversation (by implication thought) is put
together – impairment is referred to as
“FORMAL THOUGHT DISORDER”
Examples:
Looseness of association
#disconnectedness between successive ideational concepts
#may be mild to gross (“word salad”)
#tangentiality, verbigeration, “interpenetration of themes” are
variations of loose associations
#an important sign of active psychosis because it cannot be
readily faked.
Flight of ideas
a continuous flow of speech which continues to digress from the
original topic and fails to come to a conclusion – the person often
needs to be interrupted
Thought blocking – stream of thought suddenly, inexplicably
stops

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Content of Thought
Refers to… what is actually said….the ideas that
occupy the mind :
may be normal or abnormal
identify the most important themes
DELUSIONS are the most abnormal of ideas :
• your duty is to be certain this is the case!
• what is the evidence for its truth
• ascertain how the person formed this belief
their evidence for it
• the conviction with which it is held
OBSESSIONAL ideas
OVER-VALUED ideas
SUICIDAL or HOMICIDAL thoughts

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AFFECT

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Feelings are transient emotional states
that are highly reactive to the internal
and external environment and change
constantly
Affect is the form that feelings take
over a relatively brief period of time
Mood is a more pervasive emotional
state that is more stable over time

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Mood is subjective :
the patient TELLS YOU how they feel
Affect is objective :
judged by the OBSERVER and also deduced
from behaviour…..

27. Affect can be conceptualised along three
domains:
• Quality – the nature of the affect
depressed, anxious, sad, despondent, anguished, elevated……
• Variation – the responsivity of the affect
reactivity - the demonstration of emotional reactions to the interview
content
restricted – a reduction in the range of responses
blunted – a bland affect with little emotional tone
flat - an absence of emotionality
labile – rapidly changing emotional state
• Complementarity – the match of the affect
Inappropriate affect - emotionality not consistent with external stimuli
Incongruous affect - not consistent with content of thoughts
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PERCEPTION

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A MSE is not documenting a past history
of these but whether they are active
during the assessment.

30. Percept Disturbances
Hallucinations
• are the main disorder of perception that we
describe
• their presence
is elicited by asking the patient, or
revealed by observing behaviour
Illusions
TLE perceptual disturbances: déjà vu, jamais vu,
micro/macropsia, synesthesia
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Depersonalisation - a sense of being disconnected
from yourself
Derealisation – a disconnection between the self
and external world
Dissociation: thoughts and emotions can feel
disconnected from self and thus not part of the self :
seen in
extreme anxiety
PTSD
borderline personality disorder
intellectual impairment

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Hallucinations
True hallucinations
experienced as originating outside the head
(eg. are heard “with the ears”)
Pseudo-hallucinations
experienced as originating inside the head
(eg. seen with the “mind’s eye”)

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Auditory hallucinations are most common in schizophrenia -
they may be elementary or complex. There are typical forms :
Two or more people arguing or commenting about the
person in the third person
A running commentary about the person’s behaviour
Command hallucinations – demands a significant risk
assessment - degree of compulsion the person feels to act
upon them
Visual hallucinations can occur in schizophrenia but one
should suspect an organic cause :
(drug intoxication/withdrawal, delirium…)
Hallucinations in other modalities – olfactory, gustatory,
somatic, visceral are almost always organic
(eg. substances, TLE should be seriously considered)

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COGNITIVE TESTING

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An essential part of the mental state examination
Aims to detect the presence of an organic brain
syndrome
Results have to be interpreted in context of….
medication educational level
motivation age
tiredness cultural factors
There are good standardized instruments - some
very simple [Folstein’s MMSE] - which screen for
cognitive function but are not very good at detecting
subtle deficits
Cognitive deficits can be detected during the
interview, as well as elicited through specific testing

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Orientation
Memory
Attention and concentration
Language
Parietal lobe tests
Frontal lobe tests

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Orientation
Screens for a non-specific confusional state
delirium
dementia
transient states (e.g. substances, ECT
(sedation…..
Patient asked to state…..
Time most sensitive to mild confusion
Place
Person usually only impaired in severe
dementia

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Memory
Immediate memory
or registration - ability to hold discrete
information in conscious awareness and
repeat back. Capacity limited, decays
rapidly, impaired by distraction
Short term memory
ability to recall information after distraction
from minutes to hours later. Decays over a
day or two. Requires intact registration.
Long term memory
ability to retrieve information stored from
days to years ago. Does not decay but
retrieval can become impaired

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Memory
Registration
ask the person to repeat
3 objects/sentence immediately giving at
least two attempts
Recall
ask the person to recall
3 objects/sentence after 5 minutes (during
which you distract with other tests)
Retrieve
ask for autobiographical data – where they
spent last Christmas Day, birth-date,
address, where they grew up…..

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Attention and Concentration
Digit span – tests attention span.
Ask person to repeat a set of numbers in
forward order. Then ask person to repeat
new numbers in reverse order. Increase
length of numbers after each try.
Serial tasks – tests concentration (ability to
maintain attention over time).
Taking 7 away from 100 or spelling ‘world’
backwards or reciting months of the year in
reverse order.

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INSIGHT

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The person’s understanding of their experience :
the nature of it
the consequences for them
their response to it
an awareness of possible reasons why the person
is suffering symptoms at this time and connections
between events and consequent experiences
Arguably THE MOST IMPORTANT FEATURE of
the mental state of a person as may represent the
greatest challenge for intervention and is a key
issue in risk assessment
Several levels:
Partial or complete
Variable or permanent
Intellectual or emotional

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Directly enquire from the person :
What do you think has caused all this?
What do the staff tell you about this condition?
Do you agree or disagree with them?
Why do you bother to take any medication?
How will you manage this situation?
How do you feel about how others think of your
problem?
What do you think is the best thing for you now?

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JUDGEMENT

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Ability to make appropriate decisions
Based on :
weighing up of available information
+
anticipating consequences of certain choices
then choosing an appropriate action
Important as impaired judgment is a key issue in
risk assessment
Usually assessed during interview by looking at the
decisions the patient has recently made, or intends
to make, in response to their symptoms or
experiences.

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RAPPORT

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The quality of the relationship formed
between the patient and you the interviewer.
You try to objectively judge the ability of the
patient to engage in the interview process,
to be warm and open in their manner, to
disclose information
(Should) improve as the interview goes on
Some patients (and interviewers!) are
unable to form rapport – an important
mental state sign, as it predicts the capacity
of the person to engage and cooperate with
treatment