Mental Status Examination (MSE) - Study Notes

Objectives

• To develop a comprehensive understanding of why we conduct a Mental State Examination (MSE), including its role in initial assessment, diagnosis, treatment planning, and monitoring progress.

• To develop an understanding of various internal and external factors that may influence your Mental State Examination, such as cultural background, physical health, medication, environmental distractions, and observer bias.

• To develop a detailed understanding of the systematic components of the Mental State Examination, ensuring all key areas of mental functioning are covered.

What is a Mental State Examination (MSE)?

• Used as a systematic snapshot in mental health to objectively assess and document an individual's current mental state at a specific point in time.

• Crucial for identifying and documenting observable signs and reported symptoms of mental illness, aiding in differential diagnosis.

• Provides a baseline for the person's mental state, which is essential for tracking changes.

• Repeated MSE over a period of time offers a longitudinal perspective, invaluable for indicating improvement or deterioration of mental state in response to treatment or illness progression.

• Based on a comprehensive triangulation of information: direct observations and reported symptoms obtained from the individual, collateral history (information from family, friends, or other healthcare professionals), and the clinician's honed clinical observation skills.

MSE Environment and Engagement

• Be aware of your room / surroundings: Ensure the setting is conducive to a sensitive and thorough assessment. This includes evaluating lighting, noise levels, and overall atmosphere.

• No interruptions: Minimize distractions from phones, colleagues, or other external factors to maintain focus and respect the individual's privacy.

• Comfortable: Ensure both the interviewer and the individual are physically and psychologically at ease. This might involve comfortable seating and appropriate room temperature.

• Private: Conduct the MSE in a confidential space to foster trust and encourage open communication, adhering to ethical and legal guidelines for patient privacy.

• Safe: Assess the physical safety of the environment for both the individual and the clinician. This includes considering potential risks from the individual's behaviour or the physical setting.

• Others included?: Determine, with the individual's consent, if family members or support persons should be present, considering their potential contribution to collateral history and the individual's comfort.

• Engagement with consumer: Establish rapport and a therapeutic alliance. This is fundamental for obtaining accurate and comprehensive information.

• Conversation: Utilize open-ended questions and active listening to encourage the individual to share their experiences and feelings naturally.

• Communication skills: Employ effective verbal and non-verbal communication techniques to facilitate understanding and build trust.

  • Verbal: Use clear, concise language, avoid jargon, and adapt communication style to the individual's cognitive and emotional state.

  • Non-verbal: Pay attention to and appropriately use body language, eye contact, and facial expressions to convey empathy and attentiveness.

MSE Components

• Appearance: Observation of physical presentation including dress, hygiene, grooming, body habitus, distinguishing features, and signs of self-neglect or self-harm.

• Behaviour: Observation of motor activity (e.g., psychomotor agitation/retardation, tics, tremors), posture, gait, eye contact, and overall demeanour (e.g., cooperative, withdrawn, hostile).

• Speech: Assessment of quantity (e.g., poverty of speech, pressured speech), rate (e.g., slow, rapid), volume (e.g., whispered, loud), tone, articulation, and fluency. Note any unusual qualities such as stammering or slurring.

• Mood: The individual's sustained, subjective emotional state over time, as reported by them (e.g., depressed, anxious, irritable, euphoric, euthymic). This is often elicited by asking, "How have you been feeling?"

• Affect: The observable, objective expression of emotion, which can be congruent or incongruent with mood. Described by range (e.g., restricted, full, constricted), intensity (e.g., blunt, flat, exaggerated), appropriateness, and lability.

Thought

• Form and stream: Refers to how thoughts are connected and flow. This includes assessing:

  • Rate: Flight of ideas, slow, rapid.

  • Continuity: Thought blocking, perseveration, circumstantiality, tangentiality.

  • Logic: Loosening of associations, incoherence (word salad).

• Content: Refers to what the individual is thinking about. This includes:

  • Delusions: Fixed, false beliefs not amenable to reason or cultural explanation (e.g., persecutory, grandiose, somatic, ideas of reference).

  • Obsessions: Recurrent, intrusive thoughts or impulses.

  • Compulsions: Repetitive behaviours or mental acts performed to reduce anxiety.

  • Preoccupations: Excessive concerns about specific topics (e.g., illness, finances).

  • Phobias: Intense, irrational fears.

  • Suicidal/Homicidal ideation: Thoughts of harming self or others.

Safety – Risk Assessment

• Need to assess all potential risks to self and others thoroughly, including historical data, current stressors, and protective factors.

• Homicidal: Evaluate any thoughts, plans, or intent to harm others. Inquire about specific targets, means, and recent acts of aggression.

• Aggression: Assess for impulsivity, history of violence, current triggers, and potential for harm to staff, other patients, or property.

• Suicide: A detailed assessment of suicidal risk is paramount, as outlined below.

Suicidal Ideation / Plan / Intent / Means

• Suicidal Ideation: Thoughts of ending one's life. Inquire about frequency, duration, and specific content of these thoughts.

• Suicidal Plan: The specific method or strategy the individual has considered or formulated to commit suicide. Details include method, time, and location.

• Intent: The individual's determination or desire to act on suicidal thoughts and plans. This reflects the seriousness of their current risk.

• Access to means: Availability and accessibility of methods to carry out the suicidal plan (e.g., medications, weapons, high places).

• Protective factors: Identify factors that mitigate risk, such as family support, reasons for living, religious beliefs, future plans, and engagement with treatment.

Safety Planning

• A collaborative, concrete, and prioritized written plan of action to be used when experiencing a suicidal crisis. It should include:

  • Early warning signs: Identification of thoughts, images, moods, situations, or behaviours that signal an impending crisis.

  • Coping strategies: Internal strategies to distract from or manage suicidal thoughts (e.g., listening to music, exercise, mindfulness).

  • People to call – Family, Friends, Supports: A list of individuals who can provide support, including their names and contact numbers.

  • Professionals to call – include numbers: A list of mental health professionals, crisis lines, or emergency services with their contact information.

  • Goals / reasons to live: Articulation of personal motivations for staying alive (e.g., family, pets, future aspirations, personal values).

  • Ensuring your environment is safe: Steps to remove or restrict access to lethal means (e.g., giving weapons to a trusted person, safeguarding medications).

  • Where to go if not safe: Identification of safe places or services to access if the home environment feels unsafe (e.g., emergency department, crisis centre).

Perception

• Refers to the interpretation of sensory experiences. Abnormalities include:

  • Auditory: Hearing sounds or voices that are not present (e.g., command hallucinations, running commentary).

  • Visual: Seeing things that are not present (e.g., people, objects, patterns).

  • Tactile: Feeling sensations on the skin that are not present (e.g., bugs crawling).

  • Gustatory: Tasting things that are not present or unusual tastes.

  • Olfactory: Smelling odours that are not present or unusual smells.

  • Also consider illusions (misinterpretations of real external stimuli) and depersonalization/derealization.

Cognition

• Assessment of intellectual functions, including:

  • Orientation: Awareness of person, place, time, and situation.

  • Attention and Concentration: Ability to focus and sustain attention.

  • Memory: Immediate, recent, and remote memory (e.g., registration, retention, recall).

  • Executive Functioning: Planning, abstract thinking, problem-solving, flexibility, and judgment.

  • General Knowledge: Assessed through questions about current events or general facts.

Insight

• The individual's understanding of their own mental illness or psychological problems. It involves:

  • Recognition of having a problem or illness.

  • Attribution of symptoms to the illness.

  • Understanding of the need for treatment.

  • Awareness of potential consequences.

  • Degrees of insight can range from complete denial to full awareness.

Judgement

• The ability to make sound decisions and engage in appropriate, safe, and constructive actions based on an understanding of consequences. This is assessed by:

  • Observing past behaviours and decisions.

  • Evaluating responses to hypothetical scenarios (e.g., "What would you do if you found a stamped, addressed envelope on the ground?").

  • Considering the impact of the illness on daily functioning and decision-making (e.g., financial management, social interactions).

Why are we completing an MSE?

• What do we do with the information?: The information gathered during an MSE is used to formulate a comprehensive understanding of the client's current mental health status. It forms the foundation for diagnosis, risk assessment, and legal considerations.

• How does it inform practice?: It directly guides the development of individualized care plans, selection of therapeutic interventions, medication management decisions, and determination of the least restrictive environment for care. It's a dynamic tool, influencing ongoing treatment adjustments.

Mental State Examination and Mental Health Nursing

• This section links the MSE directly to nursing practice as a fundamental assessment tool for registered nurses. It informs client-centred care and decision-making by:

  • Guiding care planning: Nurses use MSE findings to identify priority areas for intervention, set measurable goals, and develop strategies tailored to the individual's needs.

  • Ensuring patient safety: Regular MSEs allow nurses to continuously monitor and reassess risk factors (e.g., suicidality, aggression) and implement immediate safety measures.

  • Facilitating communication: The MSE provides a standardized language for interdisciplinary team members to communicate effectively about a client's mental state and progress.

  • Evaluating treatment effectiveness: Changes observed in successive MSEs help nurses and the team evaluate whether interventions are effective and adjust the care plan as necessary.

  • Advocacy: Enables nurses to advocate for appropriate resources and levels of care based on a precise understanding of the client's presentation.