Mental State Examination

Unlike other examinations, the MSE is undertaken during the history taking, and involves closely observing the patient for certain signs of psychiatric/mental conditions.

ASEPTIC- (a bit ironic since in most psychiatric conditions there is no ‘pathology’)

• Appearance and Behaviour:
  • Appearance
    • Is the patient wearing markedly formal, florid/vivid or sexually inappropriate clothing? (mania)
    • Is the patient poorly dressed (e.g. mismatched buttons, old clothes)? (dementia/depression)
    • How does the patient sit?
  • Behaviour
    • Patient’s behaviour during the interview
      • Distractable (mania) / tearful (depression) / lethargic (severe depression) / anxious (anxiety disorder)
      • Eye contact
      • Appropriateness
      • Is the patient distracted by hallucinations/delusions?
    • Level of activity
      • Hyperactive/fidgety (mania/anxiety)
      • Psychomotor retardation (severe depression) / slow (depression)
• Speech
  • Any at all? (absence of speech may be a feature of depression- check that the patient is still responsive and check coughing for control of vocal cords)
  • Quantity
    • Brief answers/ monosylabic (depression)
    • Prolonged, pressured speech (where it is hard to get a word in) (mania)
  • Rate (NB different from quantity)
    • Increased in mania/hypomania/ anxiety/panic etc
    • Decreased in depression
  • Quality
    • Volume
    • Stuttering/stumbling/slurring
  • Tone and Rhythm
    • Monotonic may be found in depression
    • Loss of general tonality is often found in chronic psychoses
  • Appropriateness
  • Are there cognitive difficulties e.g. dysphasia (word-finding/comprehension difficulties)?
• Emotion (Mood and affect)
  • A simple way of differentiating the two is that mood is an internal quality that can only be learnt about by the patient telling you (indirectly or directly).  Affect, in contrast, is the way in which the patient’s emotions appear to the outside world.  I.e. how do they show their emotion?
  • Mood
    • Do they describe feelings of depression, excitedness, joy, anxiety, none of the above etc? (euthymic/dysthymic; anhedonia?; euphoric etc)
    • How do they describe their lives, thoughts?
      • Have they had thoughts of suicide/self harm?
  • Affect
    • How do they react when talking about normally ‘good’ things e.g. children, hobbies, partners, happy memories etc
      • Is there no reaction at all (flat affect) or just minimal response (blunted affect)?  (often with severe depression and commonly with SZD)
    • Is this connected with their mood/thoughts etc (congruent- mood disorder / incongruent- psychoses)?
    • Are there dramatic changes in affect throughout the interview (labile affect)?
• Perception
  • Hallucinations
    • Auditory vs Visual vs Other
  • Delusions
    • Delusions of perception
      • Does one random event have to have a completely unrelated consequence?
    • Delusions of grandeur
    • Nihilistic delusions
    • Paranoid delusions etc etc
• Thought
  • Content and form can similarly be divided as what the patient is telling you and how the patient is telling you.  Thought is a process involving belief, memory, perception and more.  It can be hard to assess this, but an idea of what it normal helps:

One thought normally will give rise to a number of other related thoughts and so on and so on, in a goal-driven direction to complete a task (whether this is a conversation, and practical activity, learning/studying etc).  Normally, the ‘train of thought’ allows people to do this.  In thought disorder there is an inability to do this and patients are unable to do this.  This usually manifests as a change in rate of thought and the associations of thought.

• Accelerated tempo of thought
  • e.g. flight of ideas- each new thought triggers a number of associations that come too fast to describe (usually in mania)
• Decelerated tempo of thought
  • e.g. psychomotor retardation (depression)
• Abnormal thought disorder
  • e.g. thought broadcasting, withdrawal, insertion, deletion, control etc NB ALSO COME UNDER DELUSIONS
  • Knight’s move thinking (derailment of the train of thought)
  • Snapping off (sudden ending of chain of thought)
  • Fusion of thoughts (two or more thoughts come together to form another idea that is not usually related to the train of thought)
  • Flight of ideas (rapid changes loosely connected- often by single word associations)
• Insight
  • Does the patient know this is normal/abnormal for them and/or the rest of the world?
• Cognition
  • Assessment using the MMSE may or may not be appropriate, but should always be thought of as a possibility, especially in older patients