28th November 2023

Mental State Examination (MSE)

A mental state examination (MSE) is an integral part of a full psychiatric examination. The MSE allows you to observe and assess the patient’s current frame of mind; it aids in giving a snapshot of the manifestation of the underlying state of mind of the patient. The MSE is a structured tool to assess your patient’s cognitive and behavioural functioning under the following domains:

• Appearance.
• Behaviour.
• Speech.
• Mood and affect.
• Thought.
• Perception.
• Cognition.
• Insight and judgement.

Initiating the consultation 

Introduce yourself to the patient and confirm the patient’s name and date of birth. Ensure the environment is comfortable for yourself and the patient. Remember that your MSE begins as soon as you see the patient; the MSE will be done simultaneously when you are carrying out your psychiatric history.

Appearance 

As mentioned within consultation initiation, your assessment and observations begin as soon as you meet the patient. The appearance of your patient can provide clues about their current lifestyle, which may be stemming from their underlying mental illness:

• Demographics – Age, gender, ethnicity, religion.
• Movement and gait – Observe how the patient walks into the room, is their gait uncoordinated/brisk/slow / shuffling / ataxic, and examine their body language, tremors, tics, and abnormal movements (side effects of medication).
• General appearance – Posture, cleanliness (ideas of how a patient is caring for themselves currently), assess for any signs of self-harm, signs of physical injury (violent environment / domestic abuse).
• Weight – Assess for extremes of weight, cachectic.
• Distinguishing features – Tattoos, bruising, scars, track marks, needle sites.
• Stigmata of disease – Jaundice, puffiness, cachectic.
• Clothing – What are they wearing? Are the clothes clean / ripped / dirty? Are these clothes appropriate for the current weather/consultation / general environment?
• Objects – Has the patient brought any objects? Are they holding anything? Observe jewellery.

Behaviour 

The patient’s non-verbal behaviour can be just as important as what they tell you in better understanding their mental state. Keep notes of behaviours you notice; these can be used to link to parts of your psychiatric history in order to build an overall picture.

• Eye contact and body language – Is eye contact maintained, point of fixation, wandering gaze, intense gaze, e.g., fixated with wandering gaze could suggest possible hallucinations in schizophrenia. Is the body language open or closed?
• Rapport and engagement – Do they follow the conversation? Are you able to establish rapport? Are they closed off, reserved, distractible, withdrawn, quiet, eccentric, or preoccupied?
• Attitude – Is the patient cooperative or hostile, open or secretive, evasive or eccentric, distracted or focussed, emotional or apathetic mannerisms, explore gestures, language used and tone of voice, pitch, and intonation.
• Facial expressions – Smiling/grimacing/laughing / anxious/happy/sad/angry/confused/blank.
• Mannerisms – Compulsions/repetitions/tics/tremors / involuntary movements.

Speech

Assessing speech is important in the MSE as it provides valuable information about an individual’s cognitive and psychological functioning. Speech can provide insights into a person’s mood, thought processes, communication abilities, and potential neurological or psychological disorders.

• Rate – Pressure of speech, rapid speech, slow speech, incoherent, fast or slow.
• Quantity – Minimal or absent, excessive, talkative, spontaneous, poverty of speech.
• Tone – Quiet, mild, soft, weak, monotone, tremulous, loud.
• Fluency and rhythm – Coherent, stammering, stuttering, slurring, hesitant, articulate.
• Volume – Quiet or loud.

Mood and affect 

Assessing mood and affect provides important information about a person’s emotional state and overall mental well-being.

Mood – Refers to a person’s predominant emotional state, such as sadness, happiness, or anxiety.

Affect – Refers to the observable expressions of mood, such as facial expressions, tone of voice, and body language.

Affect is momentary (like the weather), while mood is a prolonged emotion (like the climate). Hence, ‘mood is climate, and affect is the weather.’ (Manjunatha et al, 2009)

• Mood
  • ‘How are you / have you been feeling?’
  • ‘How do you feel at this moment in time?’
  • ‘Have you had any periods of feeling low/anxious/depressed?’
  • Consider the following for mood – Consistency/changes in mood / fluctuating mood/extremes of mood
  • Types of mood – Low, depressed (mild/moderate/severe), anxious, irritable, blunted, apathetic, flat, engaged, energetic, happy, content, optimistic, elated – consider these under the broader umbrella terms of positive/negative/neutral.
• Affect
  • Is the patient’s affect appropriate for the current scenario?
  • Assess – Posture, body movements, facial expression, tone of voice – assess patient’s apparent emotion via their affect.
  • Fluctuation – Labile, even, broad, expansive.
  • Range – Fixed, restricted, labile, expansive, normal.
  • Intensity – Blunted, flat, normal, heightened.
  • Congruency – Congruent or incongruent – e.g., patient speaking about distressing and violent events whilst laughing = incongruent.

Thought

Assessing thought allows us to understand how a person thinks and processes information. Thought refers to a person’s internal cognitive processes, such as perception, memory, attention, and reasoning. Additionally, thought content, such as delusions or hallucinations, can provide important information about a person’s perception of reality and potential risk to themselves or others.

When assessing thought, it is useful to consider it under the terms content, form and possessionThe following table provides an outline of questions and content relevant to each domain of thought:

Perception 

In the context of mental state examination, ‘perception’ refers to an individual’s subjective interpretation of their sensory experiences, including what they see, hear, smell, taste, and feel.

• Illusions
  • Misperception of external stimuli or real object, e.g., leaves blowing in the wind, misinterpreted as a goblin.
• Hallucinations
  • Perception that can be auditory or visual in the absence of sensory stimuli
• Auditory hallucinations
  • Who is speaking? – One or several voices?
  • Is the voice male or female?
  • Does the voice sound familiar?
  • Does the voice speak to them or about them?
  • Is the voice speaking in a positive or negative manner?
  • Is the voice telling the patient to do things?
  • Does the voice communicate in simple or complex sentences / laughing or crying/engaging in conversation, or commenting on a patient’s thoughts?
• Visual hallucinations
  • What are they seeing? > figure/shadow/person / is the person familiar?
  • When did this start / how often do they occur?
  • How do they make the patient feel?
  • Do they appear at any specific time of day or location?
• Pseudo-hallucination
  • Presents in the same way as a hallucination, but the patient will be aware that what they are experiencing is not real.
• Hallucination screening questions
  • ‘Do you ever see, hear, smell, taste, or feel things that others can’t?’
  • ‘Did you believe this was real?’ – Assess on a scale of 1-10.
  • ‘Do you ever think your surroundings are not real?’
  • Remember to not challenge the hallucination too intensely as this is what the patient believes to be real; explore it with them to build a broad picture of what they are experiencing before challenging and probing the experience.

– Note visual hallucinations can stem from either psychiatric, infective, or neurological pathology; it is important to consider the following:

• Delirium.
• Lewy body dementia.
• Charles-Bonnet syndrome.
• Migraines.
• Schizophrenia.

– Depersonalisation and derealisation

• Depersonalisation refers to a feeling of detachment or disconnection from one’s self or body. Individuals experiencing depersonalisation may feel as if they are watching themselves from outside their body or feel as if their body is not their own. They may also feel disconnected from their emotions or as if they are in a dream-like state.
• Derealisation refers to a feeling of detachment or disconnection from the external world. Individuals experiencing derealisation may feel as if the world around them is unreal, distorted, or unfamiliar. They may feel as if they are watching the world from behind a veil or as if they are in a movie.
• ‘Do you ever feel like you are not in your own body?’
• ‘Do you ever feel like you’re watching yourself from an outside perspective?’

Cognition 

Cognition refers to an individual’s mental processes involved in acquiring, processing, and using information. Cognition includes various aspects, such as attention, memory, language, perception, and executive functioning.

• Collateral history is of great importance in assessing cognition to understand what the baseline is for your patient.
• Assess the patient’s orientation to time, person and place, as well as their name, address and date of birth.
• Assess the patient’s immediate/recent/long-term memory.
• Note general knowledge will vary depending on education/ethnicity and culture, so questions such as ‘Who is the monarch?’ may not be useful depending on the context.
• Consider using the following formal cognitive assessment tools:
  • Mini-mental state exam (MMSE).
  • Addenbrooke’s cognitive examination III (ACE-III).
  • Abbreviated Mental Test Score (AMTS).
  • Montreal Cognitive Assessment (MoCA).

Insight and judgement 

Insight refers to an individual’s awareness and understanding of their own mental health symptoms and the impact they have on their life.

Judgement refers to an individual’s ability to make sound and appropriate decisions based on their understanding of a situation.

• Insight
  • Can the patient understand their illness?
  • Can the patient understand the environment around them?
  • Can they appreciate what the reality of the situation is?
  • ‘Do you think you have a problem?’
  • ‘Do you feel you need help?’
  • ‘What do you think is causing you to feel this way?’
  • Can be described as poor, fair or good
• Judgement
  • Judgement can be assessed continuously throughout the MSE.
  • ‘What would you do if you could smell smoke in your house?’
    • Poor – Patient would do nothing / stay in the house
    • Good – Patient is aware of the danger and would leave the house and call for help.
    • Impaired – Patient may otherwise have good judgement, but due to acute intoxication, judgement is impaired.

Closing the consultation 

Thank your patient and ask them if they have any concerns or questions

References

• Manjunatha, N., Khess, C. R., & Ram, D. (2009). The conceptualisation of terms: ‘Mood’ and ‘affect’ in academic trainees of mental health. Indian journal of psychiatry, 51(4), 285–288. https://doi.org/10.4103/0019-5545.58295
• Potter, L. (2023) Mental State Examination (MSE) – OSCE guide, Geeky Medics. Available online at: https://geekymedics.com/mental-state-examination/ [Accessed Feb 2023]
• Wilcha, R. and Beehuspoteea, N. (2022) Mental State Examination, Mind The Bleep. Available online at: https://mindthebleep.com/mental-state-examination/ [Accessed March 2023]
• Trzepacz, P.T. and Baker, R.W. (1993) The Psychiatric Mental Status Examination. New York: Oxford University Press.
• El-Hay , M.A.A. (2018) Essentials of Psychiatric Assessment. New York, NY: Routledge.
• Robinson, D.J. (2002) Mental status exam explained. London, ON: Rapid Psychler Press.