Mental state examination

  • See Also

    Acute behavioural disturbance: Acute management 
    Acute Behavioural Disturbance: Assessment and verbal de-escalation 
    Acute behavioural disturbance: code grey 

    Key Points

    1. A Mental State Examination (MSE) is a part of every mental health assessment.
    2. Interpretation of the MSE must keep in mind the patient’s age and developmental level.
    3. If there is any indication of current suicidal or homicidal ideation in the child or adolescent they must be referred for further assessment by a mental health clinician.

    Background

    • The MSE is used to gain an understanding of the patient’s psychological functioning at a particular point in time in order to direct care appropriately.
    • You will find you perform many parts of the MSE intuitively every time you interact with or observe others. 

    The Mental State Examination

    Component What to assess
    Appearance & Behaviour Physical appearance Gender; ethnicity; body habitus; apparent age; cleanliness and grooming, hair/clothing style, cosmetics and jewellery; syndromic features.
    Manner of relating to clinician and parents Ease of separation from each parent; reactions to meeting the clinician (e.g. eagerness to please, defiance, overfamiliar); eye contact; facial expression. Note presence of hallucinatory behaviours (e.g. talking to self; laughing incongruently).
    Activity level Psychomotor slowing or agitation, sustained or episodic, goal-oriented or erratic; coordination, unusual postures or motor patterns (e.g. tics, stereotypies, odd mannerisms, tremors).
    Speech Spontaneous and talkative to mute. Fluency, rate, volume, tone.
    Mood Predominant emotion over days/weeks (e.g. euthymic, apathetic, angry, dysphoric, apprehensive, euphoric). Use 0-10 scale (0: extremely sad & wishing to end life immediately, 10: extremely happy).
    Affect Current observed emotional state. Describe type, range (constricted to labile), reactivity (blunted or flat to reactive), & appropriateness.
    Thought Stream (i.e. speed) Poverty of thought (thought blocking), poverty of content (perseveration), racing thoughts, flight of ideas.
    Form Logical & goal-directed or disordered (e.g. circumstantial, tangential, derailment, looseness of associations, word salad).
    Content Obsessions, delusions (e.g. persecutory, referential, grandiose, somatic, bizarre), phobias, magical thinking, thoughts of harm to self or others.
    Perception Altered bodily experiences (e.g. depersonalization, derealization), passivity phenomenon, illusion, hallucination (e.g. auditory, visual, olfactory, tactile).
    Cognition Level of consciousness Alert, drowsy, delirium, stupor.
    Orientation Awareness to confusion of self, current setting, date & familiar people.
    Attention Need for redirection/repeating, sustained activity, distractibility.
    Memory Immediate (e.g. repeat numbers, names back), short-term (e.g. recall three objects at 2 and 5 minutes), long-term (e.g. recall events of past week).
    Ability Impression of current abilities; concrete to abstract thinking.
    Insight & Judgment Insight Intact, partial or poor insight. Ability to identify potentially pathological events (e.g. hallucinations, suicidal impulses); acknowledgement of a possible mental health problem; locus of control (internal v external).
    Judgment Intact to impaired judgment. Problem solving ability in context of current psychological state (can be explored by recent decision making).

     

    Consider consultation with a mental health clinician when

    • Unusual or incongruous features noted in a Mental State Examination.

    Consultation with a mental health clinician should occur when

    • A situation of immediate risk of harm to self or others by a patient.
    • Risk of imminent departure from the emergency department by a patient known to be at risk of harm to self or others.
    • An acutely psychotic/agitated patient, whose immediate management requires significant sedation which will subsequently impede psychiatric assessment.

    Note: consultation with a mental health clinician is mandatory for a patient being held under a legislative Act.

    Last updated November 2018