Mental State Examination (MSE)

The aim of the MSE is to elicit the patient’s CURRENT psychopathology – no historical details.

It collects both Objective and Subjective Information:

 Objective – what you observe about the patient DURING the interview
o Appearance, Behaviour, Speech, Cognition and Mood
 Subjective – the patient’s CURRENT psychological symptoms
o Mood, Thoughts, Perception and Insight

Appearance:
 Demographics
o Gender / Apparent Age / Racial Origin
 Physique, Hair and Make-up
 Clothing Style
o E.g. Manic patients – bright / oddly assorted clothes
 Cleanliness
o Look for signs of self-neglect e.g. Dirty, unkempt,
stained or crumpled clothing
 Weight Loss
o Consider bio-psycho-social causes, for example:
Cancer vs. Anorexia vs. Financial Difficulties

Behaviour:
 Rapport
o Attitude: Relaxed/ Co-operative/ Suspicious/ Guarded/ Pre-occupied/ Over Familiar
o Eye Contact – Avoidant / Appropriate / Intense
 Psychomotor Activity: Agitation vs. Retardation
 Movement disorders
o Tics = Irregular repeated movements, in a group of muscles e.g. Sideways head
o Choreiform Movements = Co-ordinated, brief, involuntary movements e.g. Grimacing
o Dystonia = Painful muscle spasm which may lead to contortions
 Signs of Impending Violence
o Restlessness/ Sweating / Clenched Fists / Pointing Fingers / Raised Voice
o Intruding onto the interviewer’s Personal Space

Speech:
 Physical characteristics only – content comes under ‘Thoughts’
 Quantity:
o Pressure of Speech: Rapid, ‘can’t get a word in’, lengthy speech – typical of Mania
o Poverty of Speech: Minimal Responses e.g. Yes / No – typical of Depression
 Quality:
o Volume: Loud (Mania) or Quiet (Depressive)
o Tone and Fluency
o Spontaneity: Prompt Response (Mania) and Slow response (Intoxicated / Depressed)

Mood (or Affect)

 Change in mood = Commonest symptom of a psychiatric disorder
 Should be documented both Subjectively and Objectively:
o Subjective Mood
 Ask the patient ‘How are you feeling in yourself?’
 Document their response without alteration – record any other details in Hx
o Objective Mood
 Nature of mood during examination, if no mood is noted = ‘Euthymic’
  Constancy of mood – does mood change during the interview?
 Congruity of Mood – is the patient’s mood appropriate to context?

Thoughts
 Deduce what the patient is thinking using: Verbal, Written and Behavioural clues
 Abnormalities can occur in 3 different aspects of thought: Stream, Form and Content…

Aspect of Description Abnormalities

Thought
Stream The amount  Pressure of thought – unusually rapid, abundant /varied thoughts
and speed  Poverty of thought – unusually slow, few or unvaried thoughts
of thoughts  Blocking of thoughts – abrupt and complete emptying of the mind
Form The way in  Flight of ideas – one train of thought is not completed before
which another begins, ideas may be linked by:
thoughts are o Rhyme (aka: ‘Clang Associations’)
linked o Puns – words which sound similar e.g. Mail and Male
together o Distraction – by something in room / surroundings
 Loosening Associations – Complete lack of logical connections
in a sequence of thoughts, not even by above links. Also known as:
“Knights move” thinking
 Preservation – persistent inappropriate repetition of the same
sequence of thought e.g. same answer for every varied question.
Content What ideas  Preoccupations – recurring thoughts that can be put out of the
the thoughts mind at will, but result in distress and/or disability.
contain  Morbid thoughts – Hopelessness, Suicidality and Suicidal
Intention. Don’t be afraid to ask about self-harm or suicide.
 Delusions – a fixed false belief, unaffected by rational argument
and unsupported by cultural or educational background.
o Ask for explanations regarding unusual statements / events
 Obsessions –recurring and persistent thoughts. The patient
recognises them as senseless products of their own mind, but
cannot get rid of them.
 Compulsions – actual actions secondary to obsessions

Perceptions
 Perception = becoming aware of what is presented to the body through the 5 senses. There
are four perception abnormalities:
1. Changes in Perception Intensity e.g. Colours brighter to a patient with mania
2. Changes in Perception Quality e.g. Flowers smelling acrid to a patient with Schizophrenia
3. Illusions = A misperception of a real stimulus
 More likely to occur in the presence of: Sensory Impairments /
Inattention / Impaired Consciousness / Emotional Arousal.
 Ask: “Have you seen anything unusual?”
4. Hallucinations = A perception experienced in the absence of a
real stimulus. Ask sensitively: “When their nerves are upset, some
people have unusual experiences…”

Cognition: There are 6 aspects to assess when assessing higher cortical function:
1. Consciousness = an awareness of self and environment. States include:
 Clouding of Consciousness – a state of drowsiness, with incomplete reaction to stimuli
and impaired: attention; concentration; memory and thinking.
 Stupor – State in which the patient is: mute, immobile and unresponsive. However
they may appear conscious as eyes are open and follow objects
 Confusion – Muddled thinking, can be: Acute (Delirium) OR Chronic (Dementia)
2. Orientation = Awareness of person, place and time – Who are you / where are you etc…
3. Attention = Ability to focus on the matter in hand – Serial Sevens (100-7 = 93 etc…) and
Concentration = Ability to sustain focus – can also be assessed by Serial Sevens
4. Memory: Assess immediate, recent and long-term memory
 Immediate = Digit Span Test, ask patient to repeat a series of digits straight after you
 Recent = Remember 3 Random Objects or an Address, recall 5mins later
 Long-Term = Recall personal events or well-known public events
5. Language: Assess the patient’s ability to: Name common objects; follow written and verbal
instructions and write in sentences.
6. Visio-Spatial Functioning: Ask the patient to draw an old fashioned clock, showing 14:50

Insight
 Insight = the extent to which the patient’s view of their illness is congruent to that of
their healthcare professional. Usually assessed as: Good / Moderate / Poor.
 Assessment of Insight is important in order to: Determine the likelihood of patient co-operation
with treatment and aid efforts to change patient’s health beliefs to improve prognosis
 Should consider whether the patient is:
o Aware their thoughts / behaviours are abnormal and treatment is required
o Accepting that the abnormalities are as a result of a Mental Health Illness and that
subsequent professional recommendations should be followed.

“The Difficult Patient”- Challenges in Assessment

 Unresponsive Patients
o To confirm whether the patient is mute, ensure you:
 Are speaking the appropriate language / provide adequate response time / try
a variety of topics / different forms of communication e.g. writing.
o If still no response, record general appearance and whether eyes are open and if
objects are followed, a full neurological examination may also be necessary.
o Warning: Stuporous can suddenly become violent – ensure you are accompanied
 Overactive Patients
o Use a quiet, confident and concise approach to elicit the most important information
 Confused Patients:
o Orientate and reassure the patient, explaining the examination in the simplest terms
o Test cognitive function early on, in the interview – so that a corroborative history
can be sought where necessary.

Summary:
 MSE sub-titles differ between textbooks, but
essentially cover the same thing.
 MSE should generally include a contemporaneous
assessment of:
1. Appearance
2. Behaviour
3. Speech
4. Mood
5. Thoughts
6. Perception
7. Cognition
8. Insight

References:
 Metal State Examination Sheet – Provided at Secondary Care, Hellesdon 02/10/2012
 Geddes, J. Psychiatry: 4th Edition Oxford University Press; 2012
 Semple, D. Oxford Handbook of Psychiatry: 2nd Edition. Oxford University Press; 2009