Mental Status Examination Introduction

MSE forms part of a full psychiatric assessment alongside history taking. Elements can be performed simultaneously alongside the history, or afterwards in an systematic fashion. This information should help to enable a judgement to be made regarding the presence and severity of any mental illness. The MSE should be obtained and recorded in a standardized format.

Components of the Mental State Exam

ppearance !ehaviour Speech Mood "erception Thought form Thought content #ognition $nsight MSE

Appearance

pparent age Ethnicity #leanliness % personal hygiene. $s there any evidence of self&neglect' ttire (is it appropriate for weather, surroundings etc... May be important sign in a manic patient) ny abnormal involuntary movements e.g. tics, grimaces, tremors, stereotypies etc.

Behaviour

ppropriateness of behaviour *evel of eye contact +apport $s patient easily distracted' (distractibilty) ny abnormal movements' +estlessness, an,iety Socially inappropriate e.g. embarrassing, over&familiar and se,ually forward behaviour (may be seen in manic patients)

ggression, violence etc.....

s well as noting what a person is actually doing during the e,amination, 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 e,pression body language and gestures posture eye contact response to the assessment itself rapport and social engagement level of arousal (e.g. calm, agitated) an,ious or aggressive behaviour psychomotor activity and movement (e.g. hyperactivity, hypoactivity) unusual features (e.g. tremors, or slowed, repetitive, or involuntary movements)

Speech

.olume, rate and tone /uantity and fluency0 re answers unduly brief or monosyllabic or are they inappropriately prolonged' 1oes the speech appear pressured' -2light of ideas- does patient move 3uickly between subjects 4ew or made up words (neologisms) or any other abnormal use of language' *ogicality bnormal associations $s speech appropriate for the situation e.g. does patient answer 3uestions appropriately, is the content of speech appropriate to the situation'

Mood Mood vs. Affect

Affect: - The emotional state of the patient at a given moment in timeMood: - The patient-s emotional state over a longer period of timenalogy0 - ffect is the weather, where mood is the climate- (5,ford 6andbook of "sychiatry.)

6ow has your mood been lately'sk about depressed mood e.g. concentration, appetite, feelings of guilt, worry, sleeping patterns, se,ual relationships

sk about self&harm e.g feelings about the future, -have you ever thought that life was not worth living'-, thoughts of ending life, any preparations, any previous attempts at self& harm7suicide' sk about elevated mood.#oncentration, appetite, sleeping patterns and se,ual side of relationship are still important to ask about. 2or e,ample, manic patients often re3uire little sleep and typically have impaired concentration. lso ask -$s your mood changeable at the moment'- and -do you think you have any special gifts and talents'n,iety and panic symptoms

Affect:

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

Mood:

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

Perception

sk patients about their e,perience of abnormal perceptions % abnormal beliefs (e.g. hallucinations and delusion) 5ften difficult to ask about

Use questions such as:

Start with -$-d like to ask you a couple of 3uestions about sometimes people have but may find difficult to talk about. $ ask everyone these 3uestionsThen use 3uestions such as - 6ave you ever had e,periences of hearing noises or voices when there was nobody around'- etc...

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 89 and :: years), cases of severe an,iety, and mood disorders. $t is also important in trauma or substance abuse. "erceptual 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 e,perience 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 and7or distress associated with the hallucinations

hou!ht "orm # Content hou!ht "orm

2ormal thought disorder ccelerated tempo of thought0 2light of ideas 1ecelerated tempo of thought0 psychic retardation (occurs in depressive illness) <oal&directedness *inearity of thought

hou!ht Content

ssessing whether or not patient has any abnormal beliefs or ideas 1elusions 5ver&valued ideas 5bsessions and compulsions "reoccupations ny thoughts of self harm or harm to others 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 anore,ia 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) an,iety (generalised, i.e. heightened an,iety with no specific referent= or specific, e.g. phobias)

Co!nition
Assessment of:

ttention % concentration 5rientation to time, place % person *evel of comprehension Short&term memory

Methods used include:

Mini&mental state e,am (MMSE) 2rontal % parietal lobe functioning tests

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, into,icated, stuporose) orientation to reality (often e,pressed in regard to time7place7person & e.g. awareness of the time7day7date, 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 >-s from 8??) general knowledge language (e.g. naming objects, following instructions) ability to deal with abstract concepts (e.g. describing conceptual similarity between two things).

Insi!ht
Insi!ht: $s the degree to which an individual believes s7he is unwell. $t is impaired in those suffering with psychosis7schizophrenia.

$t is important to ellicit a patient-s insight as it can help determine prognosis and compliance with treatment. $s patient aware that their thoughts, feelings, behaviours are part of an illness' @ill patient accept medical advice and treatment' $s s7he receptive to this' variety of psychiatric illnesses lead to an impairment of insight e.g0

young male believes that his auditory hallucinations and sense of being watched are caused by cameras and loudspeakers that have been placed in his house by neighbours. (This male is suffering from schizophrenia, he has no insight into his illness and is convinced he is being watched).

$nsight 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 e,ploring recent decision&making or by posing a practical dilemma (e.g. what should you do if you see smoke coming out of a house')

Summar$