mentalstateexamination
Overview

The Mental State Examination (MSE) is a structured, comprehensive assessment to evaluate a patient presenting with mental health symptoms.

Just like we would perform a cardiovascular examination in a patient presenting with chest pain, we use the MSE in a patient presenting with mental health symptoms.

The MSE can be easily remembered using the acronym ASEPTIC: 

  • Appearance & Behaviour
  • Speech
  • Emotion: Mood & Affect
  • Perception
  • Thought
  • Insight & Judgement
  • Cognition

It’s always important to conduct at Risk Assessment after the Mental State Examination. 

Appearance & Behaviour

A stands for Appearance & Behaviour

Appearance refers to a basic description of the patient and can include:

  • what they are wearing
  • levels of personal hygiene
  • body habitus
  • physical signs of disease / harm

Behaviour refers to:

  • how well the patient engages during the consultation
  • their levels of eye contact
  • facial expressions
  • body language
  • abnormal movements such as tremors / tics / involuntary movements / posturing

A patient with depression, may have poor self-care and hygiene, avoid eye contact and have psychomotor retardation (or slow movements / delayed responses to questions).

A patient with mania, may be wearing an extravagant outfit, be hyperactive, maintain intense unrelenting eye contact and have psychomotor agitation. 

Speech

S stands for speech.

The assessment of a patient’s speech can be further broken down into:

  • Rate
    • Slow
    • Pressured (rapid speech which is difficult to interpret) 
  • Quantity
    • Mute
    • Poverty of speech 
    • Excessive
  • Tone
    • Monotonous
    • Tremulous
  • Volume
    • Quiet
    • Loud
  • Rhythm
    • Stammering
    • Stuttering
    • Slurring
    • Stilting

A patient with depression may have slow, quiet, monotonous and poverty of speech.

A patient with mania may have pressured, loud and confident speech that is difficult to interrupt

Emotion: Mood & Affect

E stands for Emotion which includes Mood and Affect. 

MOOD

Mood is subjective and refers to the patient’s own assessment of their current emotional state.

This can simply be assessed by asking the patient “How are you feeling?”

Patient’s may describe their mood as low, anxious, angry, enraged, euphoric or apathetic. 

AFFECT

Conversely, affect is objective and refers to what the examiner observers during the consultation.

Affect includes:

  • Patient’s apparent emotion
  • Reactivity of their emotional state
    • Fixed
    • Restricted
    • Labile
  • Intensity
    • Flat (no emotion) 
    • Blunted  (less emotion)
    • Exaggerated (heightened emotion)
    • Normal

It is always important to assess whether mood and affect are congruent i.e. does the patient’s report mood match their affect. If there is a discrepancy between mood and affect, we say they are incongruent.

Someone with depression may have a low mood with a blunted affect. 

Someone who is manic may have an elevated mood with a labile affect. 

Someone with schizophrenia may appear happy when describing upsetting events. This would be an incongruent mood and affect.

Perception

P stands for Perception

It refers to assessing the sensory information of the world around us.

There are different types of perceptual abnormalities: 

HALLUCINATION

A hallucination is when someone sees, hears, feels, smells, or tastes something that isn’t really there. It feels completely real to the person, even though there’s no external source.

For example, a patient with auditory hallucinations may hear voices but there is no sound present.

Hallucinations can happen in conditions like schizophrenia, psychosis, or drug use. 

PSEUDO-HALLUCINATION

A pseudo-hallucination is just like a hallucination but the individual recognizes that it is not real.

ILLUSION

An illusion is a misinterpretation of a real external stimulus. Unlike hallucinations (where there is no real stimulus), illusions occur when something is actually present, but the brain perceives it incorrectly.

For example, someone with psychosis may hear the sound of the wind and thinking that someone is whispering. 

DEPERSONALISATION

Depersonalization is a feeling of being detached or disconnected from yourself, as if you’re watching yourself from the outside.

This can be seen in post-traumatic stress disorder (or PTSD).

DEREALISATION

Derealisation is a sense that the world around them is not a true reality.

Thought

T stands for THOUGHT

This includes: 

THOUGHT CONTENT

Thought content refers to the actual substance of the patient’s thoughts. This can be assessed by asking the patient “what’s been on your mind recently”. 

  • Delusions (fixed, false beliefs) 
  • Obsessions
  • Overvalued ideas 
  • Suicidal or homicidal thoughts

THOUGHT FORM

Thought form refers to how a patient moves from one thought to another. In healthy individuals thought form should logical and at a steady pace.

Abnormalities of thought flow and coherence include:

  • Loose associations where a patient moves rapidly from one topic to another with no apparent connect between the topics
  • Circumstantial thoughts include lots of unnecessary and irrelevant detail but eventually come back to the point
  • Tangential thoughts include digressions from the main conversation subject
  • Flight of ideas refers to fast pressured speech when ideas run into one another, making it difficult for the observer to follow
  • Thought blocking refers to a sudden cessation of thought, typically mid-sentence, with the patient unable to recover what they previously said
  • Perseveration refers to the repetition of a particular response e.g. the patient keeps repeating their name in response to all questions
  • Neologisms is when a patient has made up words which are unintelligible
  • Word salad is when a patient speaks a random string of words without relation to one another

THOUGHT POSSESSION

  • Thought insertion – a belief that thoughts can be inserted into the patient’s mind
  • Thought withdrawal – a belief that thought’s can be removed from the patient’s mind
  • Thought broadcasting – a belief that others can hear the patient’s thoughts

For example, a patient with schizophrenia may have delusions, loose associations, flight of ideas, thought insertion, withdrawal and broadcasting.

“I know that the government is putting thoughts in my head. I didn’t think of this idea to run for president — it’s like they’re controlling my mind and putting these ideas there, making me think I’m the only one who can save the world.”

Insight & Judgement

I stands for Insight and Judgement

INSIGHT

Insight refers to the patient’s ability to understand their condition. 

It can be described as intact, partial or impaired.

JUDGEMENT

Judgement refers to the patient’s ability to make decisions or solve problems in their current psychological state. 

For example, you may ask them “what would you do if you could smell smoke in your house?” and assess their response as intact or impaired.

Cognition

C stands for COGNITION

This should include an assessment of the patient’s:

  • Level of consciousness – are they alert or drowsy?
  • Oriented to person, time and place
  • Memory (short and long term)
  • Concentration
  • Formal assessment
    • Mini mental state examination (MMSE)
    • Montreal Cognitive Assessment (MOCA)
Risk Assessment

A risk assessment should be undertaken in all patients presenting with a mental health condition. 

Risk can be broken down into:

RISK TO SELF

  • Suicide risk including thoughts, plans and actions
  • Self harm risk
  • Vulnerability including substance abuse, homelessness, isolation 

RISK TO OTHERS

  • Violence or Aggression including anger, hostility or threats of violence