Mental Status Examination Presentation.pptx

BENUE STATE UNIVERSITY TEACHING
HOSPITAL, MAKURDI.
DEPARTMENT OF PSYCHIATRY
CLINICAL PSYCHOLOGY UNIT.
A SEMINAR PRESENTATION
ON
MENTAL STATE EXAMINATION (MSE)
BY
SHIAONDO Shadrach Pever

What is Mental Status Examination?
 Mental status examination (MSE) is a component of overall General
Health examinations and may be viewed as the psychological equivalent
of the physical examination.(Note definition of health by WHO).
 The Mental State Examination (MSE) is a structured way of observing
and describing a patient’s current state of mind, under the domains of
Appearance, Attitude, Behaviour, Mood, Affect, Speech, Thought Process,
Thought Content, Perception, Cognition, Insight And Judgement.
 It is especially important in neurologic and psychiatric evaluations.
WHY?

Why Mental Status Examination?
The purpose is to:
 Evaluate, quantitatively and qualitatively, a range of mental functions and
behaviors at a specific point in time.
 The MSE provides important information for diagnosis and for assessment of
the disorder’s development and response to treatment.
 MSE provides a comprehensive cross-sectional description of the patient’s
mental state, which when combined with the biographical and historical
information of the psychiatric history, allows the clinician to make an
accurate diagnosis and formulation of an informed treatment plan.

Key Things To Note About Mental Status
Examination!
1. Is the MSE a separate part of the patient evaluation?
 No. The MSE must be interpreted along with the presenting history,
physical exam, and laboratory and radiologic studies.
 Separate interpretation may lead erroneous diagnosis and conclusions.
 Collateral information from families and friends is also invaluable to
confirm or supply missing data therefore they should be combined with data
obtain from MSE.

Examination!
2. What key factors should be considered along with the MSE?
 To assess properly the patient’s mental status, it is important to have some
understanding of the patient’s social, cultural, and educational background.
 Because what may be abnormal for someone with more intellectual ability
may be normal for someone with less intellectual ability.
 Patients for whom the language that is used during MSE is a second language
may have difficulty understanding various components of the MSE.

3. What are the major components of the MSE.
 Components vary somewhat from author to author. However,
most detailed MSEs include information about:
 Appearance, Cognition, Motor Activity,
 Speech, Affect, Thought Content & Thought Possession
 Perception, Intellect, Judgement and Insight.
Examination!

 The Mini-Mental State Examination (MMSE), the MMSE tests orientation,
immediate and short-term memory, concentration, arithmetic ability, language, and
praxis.
 The Cognitive Capacity Screening Examination (CCSE) tests orientation, serial
subtraction, memory, and similarities. It is less sensitive to delirium or dementia in
the elderly.
 The Neurobehavioral Cognitive Status Examination (NCSE) is especially good for
medically ill patients; it focuses on consciousness, orientation, attention, language,
construction, memory, calculations, and reasoning. It tends to be more sensitive in
detecting impairment because it is more detailed.
Some of the common know MSE are:

Opening the MSE Consultation
Ensure to do the following before beginning the Evaluation:
 Introduce yourself to the patient including your name and role.
 Confirm the patient’s basic biodata details including name and date of
birth etc.
 Ask the patient if they’d be happy to talk with you about their current
issues. Why?
<<<<<<<<<<<Let’s go to the detail of MSE>>>>>>>>

A: Appearance
The appearance of the patient may provide some clues as to their lifestyle, current
mental state and ability to care for themselves.
Observe the patient’s general appearance to identify:
 DISTINGUISHING FEATURES: These may include scars (e.g. self-harm), tattoos
and signs of intravenous drug use.
 WEIGHT: Note if they appear significantly underweight or overweight.
 STIGMATA OF DISEASE: Note any stigmata of disease (e.g. Chicken pox, Jaundice).
 PERSONAL HYGIENE: This can provide insight into the patient’s current ability
to care for themselves.

A: Appearance (Cont.)
 CLOTHING: Note if this is appropriate for the weather/circumstances and if the
clothes have been put on correctly.
 OBJECTS: Look around to see if the patient has brought any objects with them
and note what they are. Inquire to know the what the objects are used for.

B: Behaviour
A patient’s behaviours may provide insights into their current mental state.
Look out for issues such as:
Engagement and rapport
 Note if the patient appears engaged in the consultation and if you are able to
develop a rapport with them.
 Note if the patient appear distracted or if they appear to be engaging with
hallucinations (e.g. replying to auditory hallucinations in schizophrenia).
Eye contact
 Observe the patient’s level of eye contact and note if this appears reduced or
excessive(be mindful cultural variations).
Facial expression
 Observe the patient’s facial expression (e.g. relaxed, angry, disengaged).

B: Behaviour (Cont.)
Body language
 Observe the patient’s body language which may appear threatening (e.g. standing
up close to you) or withdrawn (e.g. curled up or hands covering their face).
 Note any evidence of exaggerated gesticulation or unusual mannerisms.
Psychomotor activity: Observe for any evidence of psychomotor
abnormalities:
 Psychomotor retardation: associated with a paucity of movement and delayed
responses to questions.
 Restlessness: the patient may continuously fidget, pace and refuse to sit still.
Abnormal movements or postures: Note any abnormal movements or
postures:
 Involuntary movements
 Tremors
 Lip-smacking
 Akathisias
 Rocking
 Tics

C: Speech
Patient’s speech can be assess to identify abnormalities which may indicate
underlying mental health issues.
Rate of speech
Pay attention to the patient’s rate of speech:
 Pressure of speech: a tendency to speak rapidly, motivated by an urgency that
may not be apparent to the listener.
 Slow speech: may occur due to psychomotor retardation which is typically
associate with major depression.
Quantity of speech
 Note the quantity of the patient’s speech:
 Minimal or absent speech: associated with depression.
 Excessive speech: associated with mania and schizophrenia.

C: Speech (Cont.)
Tone of speech
 Note the tone of the patient’s speech such as:
 Monotonous speech: associated with conditions such as depression,
schizophrenia and autism.
 Tremulous speech(shaking): associated with anxiety.
Volume of speech:
Note the volume of the patient’s speech including fluency and rhythm of speech
for abnormalities such as:
 Stammering or stuttering
 Slurred/unclear speech: may occur in major depression due to psychomotor
retardation.

D: Mood and Affect
Mood and Affect both relate to emotion, however, they are fundamentally
different.
 AFFECT: This represents an immediately expressed and observed
emotion (e.g. the patient’s facial expression or overall
demeanour/behaviour).
 MOOD: This represents a patient’s predominant subjective internal state
at any one time as described by them.
NOTE: In general Affect is what you observe in the patient Why Mood is
what the patient tells you that s/he has been emotionally passing through.

D: Mood and Affect (Cont.)
Mood: A patient’s mood can be explored by asking questions such as:
 “How are you feeling?”
 “What is your current mood?”
 “Have you been feeling low/depressed/anxious lately?”
Examples of mood states
 Low mood
 Anxious
 Angry
 Enraged
 Euphoric
 Guilty
 Apathetic/Indifferentiated Mood

Affect: To assess affect you need to observe the patient’s facial expressions and
overall demeanour/behaviour.
Apparent/present emotion: Observe the apparent emotion reflected by the
patient’s affect, examples may include:
 Sadness
 Anger
 Hostility
 Euphoria

Range and mobility of affect: Refer to the variability observed in the patient’s affect
during the assessment. Abnormalities may include:
 Fixed affect: the patient’s affect remains the same throughout the interview,
regardless of the topic.
 Restricted affect: the patient’s affect changes slightly throughout the
interview, but doesn’t demonstrate the normal range of emotional expression that
would be expected.
 Labile affect: characterised by exaggerated changes in emotion which may or
may not relate to external triggers. Patients typically feel like they have no control
over their emotions.

Intensity of affect: A patient’s intensity of affect may be described as:
 Heightened: associated with mania and some personality disorders.
 Blunted or flat: associated with schizophrenia, depression and post-traumatic
stress disorder.
Congruency of affect: Tells if the patient’s affect appears in keeping with the
content of their thoughts (known as congruency). A patient sharing distressing
thoughts whilst demonstrating a flat affect or laughing would be described as
showing incongruent affect.
NOTE: Incongruent affect is typically associated with schizophrenia. WHY?

E: Thought
Thought represent the thinking abilities of a patient, which can be described in
terms of form, content and possession.
Thought form: Thought form refers to the processing and organisation of
thoughts. Common things to look out for to identify abnormalities of thought
form include:
 Speed of thoughts: Patient’s may demonstrate abnormally fast (i.e.
racing) or abnormally slow thought processing.
 Flow and coherence of thoughts: In healthy individuals, thoughts
flow at a steady pace and in a logical order. However, in several mental health
conditions, the flow and coherence of thoughts can become distorted.

E: Thought (Cont.)
Abnormalities of thought flow and coherence include:
 Loose associations: Moving rapidly from one topic to another with no
apparent connection between the topics.
 Circumstantial thoughts: These are thoughts which include lots of
irrelevant and unnecessary details.
 Tangential thoughts: Digressions from the main conversation subject,
introducing thoughts that seem unrelated, oblique, and irrelevant.

E: Thought (Cont.)
 Flight of ideas: there is an accelerated tempo of speech often referred to as
‘pressure of speech.
 Thought blocking: sudden cessation of thought, typically mid-sentence,
with the patient being unable to recover what was previously said.
 Perseveration: refers to the repetition of a particular response (such as a
word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a
patient is asked what their name is and they then continue to repeat their name
as the answer to all further questions).
 Neologisms: words a patient has made-up which are unintelligible to
another person.

E: Thought (Cont.)
Thought content: This refers to what the patient has been thinking about.
Some abnormalities of thought content can include:
 Delusions: A firm, fixed belief based on inadequate grounds, these may
include persecutory delusions, Grandiosity etc.
 Obsessions: Thoughts, images or impulses that occur repeatedly and feel
out of the person’s control. The patient is aware these obsessions are
irrational, but the thoughts continue to enter their head.
 Compulsions: Repetitive behaviours that the patient feels compelled to
perform despite recognising the irrationality of the behaviour. WHY?

E: Thought (Cont.)
 Overvalued ideas: A private, abnormal belief that is neither delusional
nor obsessional in nature, but which is preoccupying to the extent of
dominating the sufferer’s life (e.g. the perception of being overweight in a
patient with anorexia nervosa), not same as delusion.
 Suicidal thoughts and Homicidal/violent thoughts.
NOTE: Some examples of questions which can be used to screen for thought
content abnormalities include:
 “What’s been on your mind recently?”
 “Are you worried about anything?”

E: Thought (Cont.)
Thought possession deals with the ownership of a patient thought. Abnormalities of
thought possession include:
 Thought insertion: A belief that thoughts can be inserted into the patient’s
mind.
 Thought withdrawal: A belief that thoughts can be removed from the
patient’s mind.
 Thought broadcasting: A belief that others can hear the patient’s thoughts.
NOTE: Some examples of questions which can be used to screen for thought
possession abnormalities include:
 “Do you think people can put ideas in your head, without your control?”

F: Perception(Cont.)
Perception involves the organisation, identification and interpretation of sensory
information to understand the world around us. Abnormalities of perception are a
feature of several mental health conditions. Abnormalities of perception include:
 Hallucinations: A sensory perception without any external stimulation of the
relevant sense that the patient believes is real (e.g. the patient hears voices but no
sound is present).
 Pseudo-hallucinations: The same as a hallucination but the patient is
aware that it is not real.
 Illusions: The misinterpretation of an external stimulus (e.g. mistaking a
shadow for a person).

F: Perception(Cont.)
 Depersonalisation: The patient feels that they are no longer their ‘true’ self
and are someone different or strange.
 Derealisation: A sense that the world around them is not a true reality.
NOTE: Some examples of questions which can be used to screen for perceptual
abnormalities include:
 “Do you ever see, hear, smell, feel or taste things that are not really there?”
 “Did you think this was real at the time?”
 “Do you still believe it was real?”
 “Do you ever feel like you’ve changed or that you don’t recognise the person you currently are?”
 “Do you ever feel like the world around you isn’t real?”

G: Cognition
Cognition: Cognition refers to “the mental action or process of acquiring
knowledge and understanding through thought, experience, and the senses”.
Cognition can be impaired as a result of mental health conditions and their
treatments.
 Throughout the process of performing a mental state examination, you will
develop a vague idea of the patient’s cognitive performance including:
 Orientation: Explore to known whether patients are orientated in self,
objects, time, place and person.
 Attention Span: Explore what their attention span and concentration levels
are like what their short-term memory is like.

G: Cognition(Cont.)
A formal assessment of cognition can be achieved through a variety of different
validated clinical tests including:
 Mental State Exams (MSE)
 Abbreviated Mental Test Score (AMTS)

H: Insight and Judgement
Insight: Insight, in a mental state examination context, refers to the ability of a
patient to understand that they have a mental health problem and that what
they’re experiencing is abnormal and seek treatment to alleviate the disordered
behaviour.
 Several mental health conditions can result in patients losing insight into their
problem.
 Patients develop insight into their mental health problem progressive as such
some patient insight may varies as others may: *Lack insight *Partial insight
* Have Full insight.
 Having insight into ones health condition can lead to developing good health
seeking behaviour and adherence to treatment.

H: Insight and Judgement(Cont.)
NOTE: Some examples of questions which can be used to assess insight include:
 “What do you think the cause of the problem is?”
 “Do you think you have a problem at the moment?”
 “Do you feel you need help with your problem?”
LACK OF INSIGHT IS ONE OF THE GLOBAL BURDEN THAT IS AFFECTING
PROPER MANAGEMENT OF MENTAL HEALTH DISORDERS?
TRUE or FALSE
WHY?

Dimensions of insight
The following are the three dimensions of insight:
 Psychical Insight: This is the mental recognition of illness, it is divided into
(Clinical, Cognitive, and Metacognitive).
 Clinical Psychical Insight: The awareness of symptoms and their consequences
and label them as symptoms of mental illness.
 Cognitive Psychical Insight: The ability of patient to recognise that his or her
cognitive deficit are as a result of mental illness.
 Metacognitive Psychical Insight: The ability of a patient to recognise and

 Somaesthetic Insight: The awareness and representation of bodily and
physical deficits(motor, sensory, Somatosensory) malfunctioning to effect of
mental illness.
 Emotional Insight: The patient ability to understand that his or her present
emotions are been guided by a psychiatric illness. Its very vital for the
acceptance of a mental illness.
NOTE: All the dimension of insight grow with psychoeducation.
Levels of Insight: According to David (1990), insight grow through the
following level: Awareness of Mental Illness; Ability to label symptoms as
abnormal experience; and Ability to seek treatment.

Judgement: Judgement refers to the ability to make considered decisions or
come to a sensible conclusion when presented with information. Judgement can
become impaired in several mental health conditions leading to poor decision
making.
 You can also specifically assess judgement by presenting the patient a scenario
such as:
 “What would you do if you could smell smoke in your house?”
 Sensible judgement in this situation would involve leaving the house immediately
wherever possible and calling the fire department. A patient with impaired
judgement may suggest ignoring it.

Conclusion:
 The importance of Mental State Examination in mental health practice can not
be overemphasized as it provide prior information into the mental wellbeing and
capacity of patients and their abilities.
 It is important for Clinicians to assess their patients and clients Mental State
through MSE before going into an in-depth Clinical Assessment.
 Clinicians should always avoid making diagnosis from only information obtained
during MSE.
 Clinicians should always ensure that information obtained during MSE are
merged them with clinical assessment information in order to arrived at an
informed diagnosis.

THANKS FOR YOUR
ATTENTION AND INTERST.
Yours
pever, Shiaondo shadrach

References
 Murray, R., Hill, P., & McGuffin, P. (1997). The essentials of postgraduate
psychiatry. Cambridge University Press.
 Lewis P. (nd). Mental State Examination (MSE) – OSCE Guide. https
://geekymedics.com/mental-state-examination/
 Zimmerman M: (1994). Interviewing Guide for Evaluating DSM-IV Psychiatric
Disorders and the Mental Examination. Philadelphia, Psychiatric Press Products,
121–122.

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