Mental State Examination Flashcards
What are the stages of a Mental State Examination?
- Appearance and Behaviour
- Speech
- Mood and Affect
- Thoughts
- Perceptions
- Cognition
- Insight
What do we look at in the appearance and behaviour section of the MSE?
• Build and distinctive features
• Clothing – unkempt clothing might indicate depression/paranoid schizophrenia.
• Hygiene – might indicate self-neglect or depression or raw hands – might indicate frequent washing as in OCD.
• Gait and posture:
o Psychomotor activity and movement e.g. hyperactivity (mania) or hypoactivity (depression)
o Facial expression, body language and gestures
o Eye contact and rapport – lack might indicate depression
o Unusual features e.g. tremors, slowed movements, stereotyped movements (purposeless movements) or mannerisms (quasi-purposeful movements).
o Level of arousal – agitated, calm, provocative, abrupt?
What do we look at in the speech section of the MSE?
This is the production of speech rather than the content (which comes under “Thoughts”).
- Rate e.g. rapid/ pressured (mania)
- Rhyme: words linked e.g. hair and bear or punning: 2 words have the same sound e.g. male and mail (seen in mania)
- Tone e.g. monotonous (depression)
- Volume e.g. loud, normal, soft
What do we look at in mood and affect section of the MSE?
Affect refers to immediate observed or objective emotion while mood refers to a more subjective emotion over a prolonged period of time. Affect tends to be what you observe whereas you need to ask about mood.
- Mood: described using the patient’s own words.
- Nature e.g. high, depressed, anxious, angry or low.
- Variability e.g. continuous, relentless, changeable
- Severity e.g. out of range of normal for their personality or within the range of how they generally feel.
- Affect: described by how they convey their emotion and non-verbal cues picked up by interviewer.
- Quality e.g. sad, angry, hostile
- Range e.g. restricted, expansive or labile
- Intensity e.g. blunted, flat, elevated
- Affect may be described as “congruent” (where affect reflects mood) or “incongruent” (where the emotion is inappropriate to the content of the speech)
What do we look at in the thoughts section of the MSE?
All of these sections are covered in more detail in later slides:
You should think about the stream, the content and the form of the patient’s thoughts as gleaned from what you hear of their speech and your supposition or analysis of their thought processes.
Stream: abnormality of the amount and speed of thought
Form: abnormality in the way thoughts are linked. A distinct disorganisation of thought process is known as “formal thought disorder.”
Delusions: a false, unshakeable idea or belief that is firmly held despite evidence to the contrary that is not consistent with the person’s educational, cultural and social background
- Over-valued ideas: an isolated, pre-occupying and strongly held belief that dominates a person’s life or actions.
- Obsessive: recurrent and persistent thoughts, images or impulses that occur despite efforts to exclude them. They are their own thoughts and usually cause distress. (These may be associated with the compulsion to act out certain behaviors such as checking in obsessive compulsive disorder).
Thoughts of self-harm or suicide: these need to be asked about in more detail if present (covered in other flashcard)
What is involved in the perception section of the MSE?
Dissociative symptoms:
• De-realisation - feeling that the world is not real
• De-personalisation - feeling detached from yourself
Illusions:
misinterpretation of real stimulus in the context of emotional state, e.g. misperceiving a shadow on the wall as an intruder
Hallucinations:
these are perceptions without an external stimulus
o Auditory: can be voices, noises or music
▪ 2nd person auditory hallucinations – which voices talk to the patient “You are all-powerful, they can’t hurt you” More common in affective psychosis and personality disorder.
▪ 3 rd person auditory hallucinations – voices talking about the patient. Which may occur in a form of a running commentary – “Now jack is walking across the room. He looks scared. He is heading to the window.” Occurs in paranoid Schizophrenia.
▪ Command hallucinations - voices telling the person to do something “Mary, you must tell the authorities about this or it will all go wrong”
o Visual: can be images or flashes
o Tactile: superficial sensations of being touched.
o Gustatory and olfactory: usually an unpleasant taste or smell.
What is involved in the cognition section of the MSE?
This refers to a person’s current capacity to process information.
• Level of consciousness
• Orientation to time and place
• Memory functioning - including immediate or short-term memory, and memory for recent and remote information or events
• Literacy and arithmetic skills
• Visuospatial processing e.g. copying a diagram
• Attention and concentration e.g. observations about level of distractibility, or performance on a mentally effortful task - e.g. counting backwards by 7’s from 100
• Language e.g. naming objects, following instructions
The Mini Mental State Examination (MMSE) is one way of assessing this. It should however, be considered a screening test only as it is not a comprehensive test of all cognitive functioning, for example, it does not contain any assessment of frontal or executive function.
What is involved in the insight section of the MSE?
Insight is the patient’s awareness and understanding of their mental illness, treatment options, ability to comply with these treatment options and ability to identify symptoms. It can be explored at different levels rather than “present” or “absent”. For example, a patient might recognise the need to see a doctor and be in hospital, but not recognise that the symptoms are related to a mental illness and be unwilling to accept treatment.
What is involved in the stream section of the thoughts analysis in MSE?
Stream: abnormality of the amount and speed of thought
Examples:
• Pressure: unusually rapid, abundant and varied. Occurs in mania.
• Poverty: unusually slowed, few and unvaried. Occurs in severe depression.
• Thought blocking: the mind becomes suddenly empty of thoughts. Occurs in paranoid schizophrenia. (Often gleaned from a sudden ceasation of speech and can be confirmed by asking the patient what has happened.)
What is involved in the form section of the thoughts analysis in MSE?
Form: abnormality in the way thoughts are linked. A distinct disorganisation of thought process is known as “formal thought disorder.”
Examples:
• Flight of ideas: thoughts are moving so quickly that one train of thought is not completed before the next one starts thus the topic might be difficult to follow. Occurs in mania.
• Loosening of associations: lack of logical connection between a sequence of thoughts – can be called “Knight’s move thinking.” Occurs in schizophrenia.
• Perseveration: persistent and inappropriate repetition of the same thought – via speech or actions. (Can be associated with frontal lobe dysfunction.)
What is involved in the delusions section of the thoughts analysis in MSE?
Delusions: a false, unshakeable idea or belief that is firmly held despite evidence to the contrary that is not consistent with the person’s educational, cultural and social background:
- Persecutory: people or organisations are trying to inflict harm
- Delusions of reference: objects, events or people have special significance e.g. a comment on the TV is directed to them alone.
- Grandiose: beliefs of exaggerated self-importance, e.g. that they have special powers or influence.
- Guilt or worthlessness: beliefs that the person has done something shameful based on an innocent error. Occurs in psychotic depression.
- Delusions of control: beliefs that actions, impulses and thoughts are controlled by an outside agency.
- Delusions concerning the possession of thoughts:
- Thought insertion: thoughts have been implanted by an external agency
- Thought withdrawal: thoughts have been taken away
- Thought broadcast: thoughts are known to others via telepathy or the media.
- These symptoms are examples of the so-called “ Schneiderian first rank symptoms of schizophrenia”
- Over-valued ideas: an isolated, pre-occupying and strongly held belief that dominates a person’s life or actions.
- Obsessive: recurrent and persistent thoughts, images or impulses that occur despite efforts to exclude them. They are their own thoughts and usually cause distress. (These may be associated with the compulsion to act out certain behaviors such as checking in obsessive compulsive disorder).
What questions should be asked in the thoughts of suicide section of the thoughts analysis in the MSE?
Thoughts of self-harm or suicide: these need to be asked about in more detail if present. It is helpful to think about a hierarchy of questions e.g.
• It sounds as if you were quite desperate, do you ever wonder if it’s worth going on?
• Have you ever thought about hurting or harming yourself?
• Have you ever done anything about these thoughts?
• What stops you from acting on these thoughts? (protective factors)
• Have you tried to end your life?
• Did you intend to hurt yourself or kill yourself?
• What did you do to ensure that you were not found?
• What did you put in place for those left behind? (Final acts)
• What has stopped you from doing this again? (regrets/ hopelessness)
• How do you feel about the fact that you did not die?
What are over valued ideas and obsessive thoughts in the MSE thoughts section?
- Over-valued ideas: an isolated, pre-occupying and strongly held belief that dominates a person’s life or actions.
- Obsessive: recurrent and persistent thoughts, images or impulses that occur despite efforts to exclude them. They are their own thoughts and usually cause distress. (These may be associated with the compulsion to act out certain behaviors such as checking in obsessive compulsive disorder).
