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Mental State Examination (MSE)


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Mental State Examination (MSE)

  1. 1. Mental State Examination (MSE) The aim of the MSE is to elicit the patient’s CURRENT psychopathology – no historical details. It collects both Objective and Subjective Information:  Objective – what you observe about the patient DURING the interview o Appearance, Behaviour, Speech, Cognition and Mood  Subjective – the patient’s CURRENT psychological symptoms o Mood, Thoughts, Perception and Insight Appearance:  Demographics o Gender / Apparent Age / Racial Origin  Physique, Hair and Make-up  Clothing Style o E.g. Manic patients – bright / oddly assorted clothes  Cleanliness o Look for signs of self-neglect e.g. Dirty, unkempt, stained or crumpled clothing  Weight Loss o Consider bio-psycho-social causes, for example: Cancer vs. Anorexia vs. Financial Difficulties Behaviour:  Rapport o Attitude: Relaxed/ Co-operative/ Suspicious/ Guarded/ Pre-occupied/ Over Familiar o Eye Contact – Avoidant / Appropriate / Intense  Psychomotor Activity: Agitation vs. Retardation  Movement disorders o Tics = Irregular repeated movements, in a group of muscles e.g. Sideways head o Choreiform Movements = Co-ordinated, brief, involuntary movements e.g. Grimacing o Dystonia = Painful muscle spasm which may lead to contortions  Signs of Impending Violence o Restlessness/ Sweating / Clenched Fists / Pointing Fingers / Raised Voice o Intruding onto the interviewer’s Personal Space Speech:  Physical characteristics only – content comes under ‘Thoughts’  Quantity: o Pressure of Speech: Rapid, ‘can’t get a word in’, lengthy speech – typical of Mania o Poverty of Speech: Minimal Responses e.g. Yes / No – typical of Depression  Quality: o Volume: Loud (Mania) or Quiet (Depressive) o Tone and Fluency o Spontaneity: Prompt Response (Mania) and Slow response (Intoxicated / Depressed) Mood (or Affect)  Change in mood = Commonest symptom of a psychiatric disorder  Should be documented both Subjectively and Objectively: o Subjective Mood  Ask the patient ‘How are you feeling in yourself?’  Document their response without alteration – record any other details in Hx o Objective Mood  Nature of mood during examination, if no mood is noted = ‘Euthymic’
  2. 2.  Constancy of mood – does mood change during the interview?  Congruity of Mood – is the patient’s mood appropriate to context? Thoughts  Deduce what the patient is thinking using: Verbal, Written and Behavioural clues  Abnormalities can occur in 3 different aspects of thought: Stream, Form and Content… Aspect of Thought Description Abnormalities Stream The amount and speed of thoughts  Pressure of thought – unusually rapid, abundant /varied thoughts  Poverty of thought – unusually slow, few or unvaried thoughts  Blocking of thoughts – abrupt and complete emptying of the mind Form The way in which thoughts are linked together  Flight of ideas – one train of thought is not completed before another begins, ideas may be linked by: o Rhyme (aka: ‘Clang Associations’) o Puns – words which sound similar e.g. Mail and Male o Distraction – by something in room / surroundings  Loosening Associations – Complete lack of logical connections in a sequence of thoughts, not even by above links. Also known as: “Knights move” thinking  Preservation – persistent inappropriate repetition of the same sequence of thought e.g. same answer for every varied question. Content What ideas the thoughts contain  Preoccupations – recurring thoughts that can be put out of the mind at will, but result in distress and/or disability.  Morbid thoughts – Hopelessness, Suicidality and Suicidal Intention. Don’t be afraid to ask about self-harm or suicide.  Delusions – a fixed false belief, unaffected by rational argument and unsupported by cultural or educational background. o Ask for explanations regarding unusual statements / events  Obsessions –recurring and persistent thoughts. The patient recognises them as senseless products of their own mind, but cannot get rid of them.  Compulsions – actual actions secondary to obsessions Perceptions  Perception = becoming aware of what is presented to the body through the 5 senses. There are four perception abnormalities: 1. Changes in Perception Intensity e.g. Colours brighter to a patient with mania 2. Changes in Perception Quality e.g. Flowers smelling acrid to a patient with Schizophrenia 3. Illusions = A misperception of a real stimulus  More likely to occur in the presence of: Sensory Impairments / Inattention / Impaired Consciousness / Emotional Arousal.  Ask: “Have you seen anything unusual?” 4. Hallucinations = A perception experienced in the absence of a real stimulus. Ask sensitively: “When their nerves are upset, some people have unusual experiences…” Cognition: There are 6 aspects to assess when assessing higher cortical function: 1. Consciousness = an awareness of self and environment. States include:  Clouding of Consciousness – a state of drowsiness, with incomplete reaction to stimuli and impaired: attention; concentration; memory and thinking.  Stupor – State in which the patient is: mute, immobile and unresponsive. However they may appear conscious as eyes are open and follow objects  Confusion – Muddled thinking, can be: Acute (Delirium) OR Chronic (Dementia)
  3. 3. 2. Orientation = Awareness of person, place and time – Who are you / where are you etc… 3. Attention = Ability to focus on the matter in hand – Serial Sevens (100-7 = 93 etc…) and Concentration = Ability to sustain focus – can also be assessed by Serial Sevens 4. Memory: Assess immediate, recent and long-term memory  Immediate = Digit Span Test, ask patient to repeat a series of digits straight after you  Recent = Remember 3 Random Objects or an Address, recall 5mins later  Long-Term = Recall personal events or well-known public events 5. Language: Assess the patient’s ability to: Name common objects; follow written and verbal instructions and write in sentences. 6. Visio-Spatial Functioning: Ask the patient to draw an old fashioned clock, showing 14:50 Insight  Insight = the extent to which the patient’s view of their illness is congruent to that of their healthcare professional. Usually assessed as: Good / Moderate / Poor.  Assessment of Insight is important in order to: Determine the likelihood of patient co-operation with treatment and aid efforts to change patient’s health beliefs to improve prognosis  Should consider whether the patient is: o Aware their thoughts / behaviours are abnormal and treatment is required o Accepting that the abnormalities are as a result of a Mental Health Illness and that subsequent professional recommendations should be followed. “The Difficult Patient”- Challenges in Assessment  Unresponsive Patients o To confirm whether the patient is mute, ensure you:  Are speaking the appropriate language / provide adequate response time / try a variety of topics / different forms of communication e.g. writing. o If still no response, record general appearance and whether eyes are open and if objects are followed, a full neurological examination may also be necessary. o Warning: Stuporous can suddenly become violent – ensure you are accompanied  Overactive Patients o Use a quiet, confident and concise approach to elicit the most important information  Confused Patients: o Orientate and reassure the patient, explaining the examination in the simplest terms o Test cognitive function early on, in the interview – so that a corroborative history can be sought where necessary. Summary:  MSE sub-titles differ between textbooks, but essentially cover the same thing.  MSE should generally include a contemporaneous assessment of: 1. Appearance 2. Behaviour 3. Speech 4. Mood 5. Thoughts 6. Perception 7. Cognition 8. Insight References:  Metal State Examination Sheet – Provided at Secondary Care, Hellesdon 02/10/2012  Geddes, J. Psychiatry: 4th Edition Oxford University Press; 2012  Semple, D. Oxford Handbook of Psychiatry: 2nd Edition. Oxford University Press; 2009