Clinical Practice Guidelines

Mental State Examination

  • Background

    • MSE is a systematic appraisal of the appearance, behaviour, mental functioning and overall demeanor of a person.  In some ways it reflects a "snapshot" of a person's psychological functioning at a given point in time.
    • A MSE is an important component of the assessment of a patient.
    • Most of us intuitively perform many parts of a MSE every time we interact with or observe others.
    • Observations of person's mental state are important in determining a person's capacity to function, and whether psychiatric follow-up is required.
    • Judgements about mental state should always consider the developmental level of the person and age-appropriateness of the noted behaviour(s).
    • If there is any indication of current suicidal or homicidal ideation the person must be referred for risk assessment by a qualified mental health clinician.

     

    Assessment

    A typical MSE includes consideration of the following domains:

    Appearance

    A person's appearance can provide useful clues into their quality of self-care, lifestyle and daily living skills.

    • distinctive features
    • clothing
    • grooming
    • hygiene

    Behaviour

    As well as noting what a person is actually doing during the examination, attention should also be paid to behaviours typically described as non-verbal communication.  These can reveal much about a person's emotional state and attitude.

    • facial expression
    • body language and gestures
    • posture
    • eye contact
    • response to the assessment itself
    • rapport and social engagement
    • level of arousal (e.g. calm, agitated)
    • anxious or aggressive behaviour
    • psychomotor activity and movement (e.g. hyperactivity, hypoactivity)
    • unusual features (e.g. tremors, or slowed, repetitive, or involuntary movements)

    Mood and affect

    It can be useful to conceptualise the relationship between emotional affect and mood as being similar to that between the weather (affect) and the season (mood).  Affect refers to immediate expressions of emotion, while mood refers to emotional experience over a more prolonged period of time.

    Affect:

    • range (e.g. restricted, blunted, flat, expansive)
    • appropriateness (e.g. appropriate, inappropriate, incongruous)
    • stability (e.g. stable, labile)

    Mood:

    • happiness (eg, ecstatic, elevated, lowered, depressed)
    • irritability (e.g. explosive, irritable, calm)
    • stability

     

    Speech

    Speech can be a particularly revealing feature of a person's presentation and should be described behaviourally as well as considering its content (see also section on Thoughts).  Unusual speech is sometimes associated with mood and anxiety problems, schizophrenia, and organic pathology.

    • speech rate (e.g. rapid, pressured, reduced tempo)
    • volume (e.g. loud, normal, soft)
    • tonality (e.g. monotonous, tremulous)
    • quantity (e.g. minimal, voluble)
    • ease of conversation

    Cognition

    This refers to a person's current capacity to process information and is important because it is often sensitive (though in young people usually secondary) to mental health problems.

    • level of consciousness (e.g. alert, drowsy, intoxicated, stuporose)
    • orientation to reality (often expressed in regard to time/place/person - e.g. awareness of the time/day/date, where they are, ability to provide personal details)
    • memory functioning (including immediate or short-term memory, and memory for recent and remote information or events)
    • literacy and arithmetic skills
    • visuospatial processing (e.g. copying a diagram, drawing a bicycle)
    • attention and concentration (e.g. observations about level of distractibility, or performance on a mentally effortful task - e.g. counting backwards by 7's from 100)
    • general knowledge
    • language (e.g. naming objects, following instructions)
    • ability to deal with abstract concepts (e.g. describing conceptual similarity between two things).

     

    Thoughts

    A person's thinking is generally evaluated according to their thought content or nature, and thought form or process.

    Content:

    • delusions (rigidly held false beliefs not consistent with the person's background)
    • overvalued ideas (unreasonable belief, e.g. a person with anorexia believing they are overweight)
    • preoccupations
    • depressive thoughts
    • self-harm, suicidal, aggressive or homicidal ideation
    • obsessions (preoccupying and repetitive thoughts about a feared or catastrophic outcome, often indicated by associated compulsive behaviour)
    • anxiety (generalised, i.e. heightened anxiety with no specific referent; or specific, e.g. phobias)

     

    Process:

    Thought process refers to the formation and coherence of thoughts and is inferred very much through the person's speech and expression of ideas.

    • highly irrelevant comments (loose associations or derailment)
    • frequent changes of topic (flight of ideas or tangential thinking)
    • excessive vagueness (circumstantial thinking)
    • nonsense words (or word salad)
    • pressured or halted speech (thought racing or blocking)

     

    Perception

    Screening for perceptual disturbance is critical for detecting serious mental health problems like psychosis (this is relatively rare in young people, though peak onset is between 19 and 22 years), cases of severe anxiety, and mood disorders.  It is also important in trauma or substance abuse.  Perceptual disturbances are typically marked and may be disturbing or frightening.

    Dissociative symptoms:

    • derealisation (feeling that the world or one's surroundings are not real)
    • depersonalisation (feeling detached from oneself)

    Illusions:

    • the person perceives things as different to usual, but accepts that they are not real, or that
    • things are perceived differently by others

    Hallucinations:

    • probably the most widely known form of perceptual disturbance
    • hallucinations are indistinguishable by the sufferer from reality
    • can affect all sensory modalities, although auditory hallucinations are the most common
    • in children it is common to experience self-talk or commentary as an internal "voice"
    • command hallucinations (voices telling the person to do something) should be investigated
    • important to note the degree of fear and/or distress associated with the hallucinations

     

    Insight & Judgement

    Insight and judgement is particularly important in triaging psychiatric presentations and making decisions about safety.

    Insight:

    • acknowledgement of a possible mental health problem
    • understanding of possible treatment options and ability to comply with these
    • ability to identify potentially pathological events (e.g. hallucinations, suicidal impulses)

    Judgement:

    • refers to a person's problem-solving ability in a more general sense
    • can be evaluated by exploring recent decision-making or by posing a practical dilemma (e.g. what should you do if you see smoke coming out of a house?)

     

    Management

    Unusual or incongruous features noted in a MSE may indicate the need for the involvement of Mental Health services, particularly where there is disturbed perception and/or thought processes.  Consideration of the above domains will help in this determination, and will facilitate the process of seeking a secondary consultation or making a mental health referral.  Please note again that if there is any indication of current suicidal or homicidal ideation the person must be referred for risk assessment by a qualified mental health clinician.