Mental state examination
(MSE)
Prepared by:
* Mr. Bassim Bakeer
Supervised by:
* Dr. Abed Alkareem
Radwan.
Purpose: the purpose of mental state examination is to
reach a tentative diagnosis. It is the diagnosis of general
cerebral functions. It is designed to detect abnormal
functions. An experienced nurse can complete all the MSE.
Important information about the patient can be taken from
first sight as the patient seen entering the room, sitting or
talking. The first observation is made to the level of
consciousness.
General appearance: is a good indicator of the patients over all
mental
build.
functioning. It includes the weight, height and general body
Nutritional status: poor nutrition can result from medical or
psychiatric disorders. In anorexia nervosa the patient is emaciated but still
thinks she is fat. Overweight can point to over eating as in affective
disorders with hyperphagia.
Hygiene and dress: self care and cleanliness reflects the patients
awareness and activity level. In depression the patient loses interest on his
appearance and hygiene. In mania the patient dresses in colorful and
flamboyant manner. She may use too much makeup and mismatched dress.
Schizophrenics may use strange items for dress e.g. antennas, bags to
protect them from the control of space people.
Eye contact: people usually maintain eye contact when they speak, and
track the movement and gestures of the interviewer. Abnormal eye
movement can be diagnostic. Wandering eyes show distractibility, visual
hallucinations, mania or organic states. Avoidance of eye contact may be
due to hostility, shyness, or anxiety. If the patient is suspicious he tracks
your movements and look to every gesture.
Psychomotor behavior:
Psychomotor activity can be reduced in depression and catatonic
schizophrenia or increase in mania.
Posture: the way the patient sits, walks and
behaves.
Facial expression: the facial expression of the patient e.g. sad
face in depression.
Activity level: the level of activity of the patient. Restlessness in
anxiety, agitation in some depressed patients, excitement in
mania.
Abnormal movements: can be voluntary or involuntary,
voluntary abnormal movements such as the mannerisms of the
schizophrenia or bizarre movements also seen in
schizophrenia.
Involuntary movements such as hand tremor in
Mood and affect:
Mood: is defined as the pervasive and sustained emotion that colors
the persons perception of the world. In depression the patient is
depressed he sees the world through dark glasses. On the other hand
in mania he is euphoric or elated he feels superior and able to do
great things. In anxiety the patient is tense and expecting the
worst.
Affect: it is the external expression of the patients emotional
responsiveness. It is what the examiner observes in the patients
facial expression and expressive behavior in response to internal or
external stimuli. Affect is evaluated for its intensity, duration,
appropriateness to the situation, range of affective expression and
control. In schizophrenia the affect is blunted (flat) or restricted, it
may be inappropriate to the situation. In mania it is expansive and
out of control. Hysterical patients show labile affect that changes
from extreme happiness to extreme sadness in
minutes.
Speech:
Amount of speech: increased in mania and anxiety states were
the patient is talkative, a manic may experience a pressure to
speak continuously, a depressed patient speaks very little and
brief.
Speed: anxious patient speaks rapidly, depressed one speaks
slowly.
Articulation: speech can be slurred (dysarthria) as in organic
brain disorders or intoxication with alcohol or hypnotic.
Rhythm: in depression speech is monotonous.
Thought:
Thought is divided into process and content.
Thought process:
Process is the way patient puts thoughts together and associates
between them. Thought process may be rapid and the patient feels
pressure of thoughts, this may go on to form flight of ideas as in mania,
or it may be slow as in depression. In schizophrenia there is loss of
association between thoughts or poverty of thoughts were they could be
empty or vague. Blocking is the interruption of thought process as if
they were withdrawn from the patients head as in
schizophrenia.
Thought content:
The interviewer should evaluate the content of thoughts for
abnormalities.
Delusions: these are false fixed beliefs held by the patient and not shared by
persons in his culture. They indicate that the patient is psychotic e.g. delusions of
persecution, reference or grandiosity.
Overvalued ideas: unreasonable sustained false beliefs held less firmly
than delusions.
Phobias: unreasonable fear of exposure to specific objects or situations e.g.
agoraphobia, claustrophobia.
Obsessions: irresistible recurrent thought or feeling that cannot be eliminated
by logical effort and associated with anxiety.
Compulsions: meaningless acts that the patient feels compelled to perform.
Counting, washing……
Hypochondria: exaggerated concern over ones health based on false
interpretation of physical signs and not supported by realistic pathology.
Perception: interpretation of events. Some types of hallucination
appears in some clients according to the senses. We have to be sure
that patient has no organic problems especially in the condition of
visual
hallucination.
They are divided into five types:
1- visual 2- auditory 3- olfactory 4- tactile 5- taste
Sensorium and cognition:
Level of consciousness: the patient awareness of and
responsiveness to his internal and external environments. It can be
clouded in organic states and
intoxication.
Orientation: patients awareness of his time, place and person. This
usually disturbed in organic brain
syndromes.
Concentration: the ability to keep ones attention on a certain task.
See if the patient can subtract 7 from 100 and notice his effort and
time taken to perform this task. Concentration is impaired in mania
were the patient is distractible by minor stimuli and in anxiety
states.
Memory: the ability to recall information. It is divided into:
Immediate retention: ask the patient to repeat 6 digits in the
same order (within seconds to less than a
minute)
Short term memory: tell the patient three items and ask him to
repeat them after 5 to 10
minutes.
Long term memory: ask the patient what he did
yesterday.
Remote memory: ask the patient about information in his
childhood,
school…..
Abstract thinking: this is the ability to deal with concepts. Ask the
patient to explain a known proverb or the similarity between two
things. Answers may be concrete as if the patient says that an
orange and an apple are both round. Or abstract if he says that they
are both fruit. Abstract thinking is impaired in schizophrenia and
organic brain
syndrome.
Intelligence and information: if impairment is suspected, you can
ask the patient to perform simple tasks as calculations, for example
ask him what remains of a 100$ if he buys a shirt with 35$ and a
pants with 64$. If he finds difficult ask easier questions. The
patients fund of information should be relevant to his educational
and social background. Ask about important dates persons, or…..
Insight and judgment:
Insight: is the degree of the patients awareness that he is ill. The
patient may deny completely that he has any problem, here insight
is totally lost. Some patients realize that there is a problem but
explain it to be a result of somatic or social cause. This is partial
insight.
Judgment: is the ability to choose appropriate goals and
appropriate means to reach them. Ask the patient what he would do
if he smelled smoke in his house or found a closed addressed letter
in the street.
Impulse control:
Is the patient ability to control his sexual, aggressive and other
impulses.
Some patients cannot resist impulses to explore your office they
look in books and turn things e.g. mania.
Impulse control can be assessed from the patients
history.
Reliability:
How reliable is the information gathered about the patient. Did he
report his condition accurately or was there any difficulty due to
mental retardation, dementia or impaired consciousness. Is there a
need for further investigations.
Summary:
Major positive and negative data from the history and MSE are
summarized. A provisional diagnosis is suggested and a differential
diagnosis is given. Investigations and tests
The End:
Thank you