Mental State Examination Flashcards
What are the components of the MSE?
Appearance and Behaviour Speech Emotions: Mood & Affect Perceptions Thought: Form, Content, Flow Insight Cognition
(“ASEPTIC”)
What is the mnemonic to remember the components of the MSE?
“ASEPTIC”
What do you look at in Appearance part of MSE?
Age, gender, ethnicity
Description of physical appearance
Dress: description related to circumstances
Self care: kempt/unkempt, cleanliness, odour
Anything striking, unusual, out of place
What do you look at in Behaviour part of MSE?
Appearance and Behaviour
Rapport, engagement, hostility
Eye contact: quality and quantity
Appropriateness of interaction
Movements/ postures/mannerisms
Psychomotor retardation or agitation
What do you look at in Speech part of MSE?
Volume
Tone
Rate and Rhythm
Fluidity, word finding difficulties, dysphasia, dysarthria, stutter/ stammer
Spontaneity/paucity/pressure
What is the difference between mood and affect?
Mood vs Affect: Climate vs Weather
What do you look at / find out in Emotion (mood and affect) part of MSE?
Apathy, Anhedonia, Anergia, Feeling sad…
Somatic symptoms
- sleep (EMW), appetite/ weight, diurnal variation
- Concentration, energy, libido, motivation, enjoyment /pleasure
Depressive cognitions:
- guilt/self blame/ rumination/ catastrophizing
- Poor self esteem
- Negative thoughts
- hopes/future plans
Suicide and DSH
What do you look at / find out in Perception part of MSE?
Illusion:
- sensory input that becomes augmented by the mind to become something else
Hallucination:
- sensory perception with no incoming actual stimuli
(auditory, visual, olfactory, gustatory, tactile/somatic)
Timing, associations, frequency
What types of auditory hallucinations might there be?
- 2nd person (“you are no good!”)
- 3rd person (“he/she/they are no good!”)
- Echo
- Running commentary
- Commanding
What do you look at / find out in Thoughts part of MSE?
A description of not only CONTENT of the mind
But also how the content is structured (its FORM) as well as it’s output (FLOW)
5 things that could be the content of thoughts?
- Preoccupations
- Obsessions/compulsions
- Worries/anxieties
- Overvalued ideas
- Delusions
What is a delusion and what types can there be?
“false, unshakeable belief that is out of keeping with the patient’s social and cultural background”
- Paranoid/ persecutory
- Grandiose
- Erotomanic
- Reference
- Control
- Religious
- Nihilistic
What different “Forms” can thoughts take?
Form: describes coherency and structure/organisation of information
- Incoherence ie word salad, aka schizaphasia
- Illogicality (non-sequitur – knights move)
- Derailment (loosening of association)
- Tangentiality (off point and irrelevant)
- Circumstantiality (finally gets there!)
- Thought block
- Thought paucity/poverty
- neologisms
- clanging
- stilted speech
What do you consider in thought “Flow”?
Rapidity of though thought process – seen in mania – loose association, as well as crowding of thoughts/ideas
Flight of ideas,
crowding, retardation, perseveration of thought
This is often lumped into the thought form.
What types of insight can there be?
Cognitive insight: eg “I have diagnosis X” often someone told them this…
Emotional insight: “my mental health means X to me”
Describes attitudes to treatment, and self-awareness of symptoms,
What do you look at / find out in Cognition part of MSE?
- Orientation: Time, Place, Person, Situation
- Attention
- Concentration
- ?Frontal lobe testing
- Memory: episodic, semantic,
- MMSE, MOCA,RUDAS, ACE-III
- Frontal lobe tests (not well covered in MMSE)
Who came up with “First Rank Symptoms”
Kurt Schneider
What are Kurt Sneider’s First Rank Symptoms?
3x3 +2
Thought:
- thought insertion,
- broadcast
- withdrawal
Made/Passivity
- made: impulse
- act
- or emotion
Auditory
- audible thought echo
- 3rd person hallucination
- running commentary
+2
- delusional perception
- somatic passivity
What 4 things did Eugen Bleuler come up with?
Autism,
Affect blunting,
Association loosening,
Ambivalence
What 4 things did Donald Cameron come up with?
Interpenetration
Metonymy
Asyndesis
Overinclusion
What do you think about when considering risk in MSE?
- Risk to self (suicidality and inadvertent harm)
- Thoughts of death, Wishing for death, Suicide thoughts, Suicide plans, Suicide attempts, Impulsivity,
- Psychotic delusions: can fly, is a god?, Manic risk taking?
- Risk To others: paranoia, aggression, impulsivity, Othello/morbid jelousy, weapons?
- Risk from others: vulnerability, saying rude things (attacked)
Example MSE 1
Young, sad looking African gentleman. Dressed appropriately. Appears slow in his movements, and in in his speech. Melody was present in voice. His affect was somewhat limited and reflected a depressed mood.
Mood reported as depressed and appeared as such. Hopelessness, apathy, anhedonia and anergia. Poor sleep and appetite reported also.
Thought: mainly coherent, and no evidence of paranoid or psychotic processes. He did describe some strong beliefs about hospitals – that they had “killed his mum and son” however I am not convinced this of a delusional nature- but rather accusation from frustration against perceived failure by the system.
Perception: spoke of hearing his inner voice telling to kill himself. This appears not to be true hallucination but will need further clarification on the ward.
Cognition: appeared generally orientated – somewhat slowed down thought processes – however may also be due to recent events and being tired.
Insight – partial insight into the severity of his state – likely he is ambivalent so his emotional insight is poor, while his cognitive insight perhaps slightly better when told he is depressed.
Risk: by my judgment he is of high risk of completed suicide on basis of already making attempt today despite engaging in services. He will likely fluctuate in his ability to retain hope, and see purpose for continued living, and is very likely to have further episodes of suicidal attempt going forward if not treated. The risk is all the more likely to increase in the intial phases of treatment by mechanisms described above.
Example MSE 2
Dishevelled man initially naked but dresses. Dirty track suite trousers and dirty feet.
Appears otherwise adequately nourished. Not malodourous. No evidence of intoxication.
EC was adequate. Emotional contact was jovial but demanding. Formal contact was broken intermittently by what I can only think is thought disorder.
Speech ranged from normal tone and volume to him nearly yelling – for no apparent reason, although still continuing on with the same answer/sentence.
Mood: appeared euthymic – reported as such.
Thought: there appears periods of thought block, and distraction. He reports paranoia with persecutory ideation of cameras, NHS, and likely other agents. He spoke of “pedos” and wanting to get away from the country without being able to articulate a clear plan. His sentence structure is a times impossible to follow with incoherence and only vaguely linked terms. At times he completely drops answers.
Perception: admits to AH of derogatory nature. Seen freely responding to these when alone.
Cognition: grossly orientated to time place and person – although disagrees with the situation.
insight: little to no insight into his current state, or the effects of his MH on his presentation.
Risk: he is likely vulnerable and will not fair well on his own in his present state. I do not believe he will be able to follow through with any plans or intentions due to the thought disorder at present.
He has not reported any intentions of harm to self. He could be attacked if he were in Hackney shouting racist slurs.
How do you conduct and MSE?
As a conversation, not a checklist.
