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Mental State Examination (MSE) – OSCE Guide

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TheΒ mental state examinationΒ (MSE) is a structured way of assessing a patient’s current state of mind. As with any clinical examination, it is split into several domains:

  • Appearance and behaviour
  • Speech
  • Mood and affect
  • Thoughts
  • Perception
  • Insight and judgement
  • Risk

We’ve produced video demonstrations of how to perform a mental state exam in an OSCE setting.

The Royal College of Psychiatrists defines the purpose of the MSE as providing a “clear, objective snapshot of someone’s mental functioning at a given time-point“. A comprehensive MSE is essential to a psychiatric assessment, helping inform assessment, diagnosis and management.

This mental state examination guide provides a framework for performing a mental state examination.Β 


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

AskΒ the patient if they’d be happy to talk with you about their current issues.

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Appearance and behaviour

Observing a patient’s appearance and behaviour can provide information about their current mental state and risk.

Appearance

Observe the patient’s general appearance:

  • Personal hygiene: are there any signs of self-neglect?
  • Clothing: are they dressed appropriately for the weather/circumstances? Are clothes put on correctly?
  • Physical signs of underlying difficulties: any self-harm scars or signs of intravenous drug use?
  • Stigmata of disease: note any stigmata of disease (e.g. jaundice).
  • Weight: note if they appear significantly underweight or overweight.
  • Objects: look around to see if the patient has brought any objects with them and note what they are.

Behaviour

Engagement and rapport

Note if the patient appears engaged in the consultation and if you can develop a rapport with them.

Note if they appear distracted or appear to be responding to hallucinations (e.g. replying to auditory hallucinations in schizophrenia).

Eye contact

Observe the patient’s level ofΒ eyeΒ contactΒ and note if this appears reduced or intense and staring.

Facial expression

Observe the patient’sΒ facialΒ expression (e.g. relaxed, fearful, angry, disengaged). Note if they respond appropriately (e.g. becoming tearful when discussing difficult topics vs laughing incongruously).Β 

Body language

Observe the patient’sΒ bodyΒ language,Β which may appear threatening (e.g. standing up close to you) or withdrawn (e.g. curled up or hands covering their face).

Note any evidence of exaggerated gesticulation or unusual mannerisms.

Observe for any signs of paranoia. Does the patient appear on edge, fearful or glancing around the room?

Psychomotor activity

Observe for any evidence of psychomotor abnormalities:

  • Psychomotor retardation: associated with a paucity of movement and delayed responses to questions.
  • Restlessness: the patient may continuously fidget, pace and refuse to sit still.

Abnormal movements or postures

Note any abnormal movements or postures:

  • Involuntary movements
  • Tremors
  • Tics
  • Lip-smacking
  • Akathisias
  • Rocking
  • Posturing

Speech

Assess the patient’s speech to identify abnormalities which may indicate underlying mental health issues.

Rate of speech

Pay attention to the patient’s rate of speech:

  • Pressure of speech: a tendency to speak rapidly, motivated by an urgency that may not be apparent to the listener (often a manifestation of thought abnormalities such as flight of ideas, described later in the article). This can be present in mania.
  • Slow speech: may occur due to psychomotor retardation, typically associated with depression.

Quantity of speech

Note the quantity of the patient’s speech:

  • Poverty of speech: associated with depression.
  • Excessive speech: associated with mania.

Tone of speech

Note the tone of the patient’s speech:

  • Monotonous speech: associated with conditions such as depression, psychosis and autism.
  • Tremulous speech: associated with anxiety.

Volume of speech

Note the volume of the patient’s speech:

  • Quiet speech may be seen in depression.
  • Loud speech can be seen in mania.

Fluency and rhythm of speech

Note the fluency and rhythm of the patient’s speech for abnormalities:

  • Stammering or stuttering
  • Slurred speech: may occur in major depression due to psychomotor retardation. It may also be a sign of acute intoxication.
  • Stilted speech: can be a manifestation of thought block (see below).

Mood and affect

Mood and affect both relate to emotion, however, they are fundamentally different.

Affect represents an immediately expressed and observed emotion (e.g. the patient’s facial expression or overall demeanour).

Mood represents a patient’s predominant subjective internal state at any one time as described by them.

Affect is what you observe, and mood is what the patient tells you (as an analogy, mood is the climate whilst affect is the current weather).

Mood

A patient’s mood can be explored by asking questions such as:

  • “How are you feeling?”
  • “What is your current mood?”
  • “Have you been feeling low/depressed/anxious lately?”
Examples of mood states
  • Low mood
  • Anxious
  • Angry
  • Enraged
  • Euphoric
  • Guilty
  • Apathetic

Affect

To assess affect, observe the patient’s facial expressions and overall demeanour.

Apparent emotion

Observe the apparent emotion reflected by the patient’s affect. Examples may include:

  • Sadness
  • Anger
  • Hostility
  • Euphoria

Range and mobility of affect

Range and mobility of affect refer to the variability observed in the patient’s affect during the assessment. Abnormalities may include:

  • Fixed affect: the patient’s affect remains the same throughout the interview, regardless of the topic.
  • Restricted affect: the patient’s affect changes slightly throughout the interview, but doesn’t demonstrate the normal range of emotional expression that would be expected.
  • Labile affect: characterised by exaggerated changes in emotion which may or may not relate to external triggers. Patients typically feel like they have no control over their emotions.

Intensity of affect

A patient’s intensity of affect may be described as:

  • Heightened: associated with mania and some personality disorders.
  • Blunted or flat: associated with schizophrenia, depression and post-traumatic stress disorder.

Congruency of affect

Note if the patient’s affect appears in keeping with the content of their thoughts (known as congruency). A patient sharing distressing thoughts whilst demonstrating a flat affect or laughing would be described as showing incongruent affect. Incongruent affect is typically associated with schizophrenia.


Thought

Thought can be described in terms of form, content and possession.

Thought form

Thought form refers to the processing and organisation of thoughts.

Speed of thoughts

Patients may demonstrate abnormally fast (i.e. racing, as seen in mania) or abnormally slow thought processing.

Flow and coherence of thoughts

In healthy individuals, thoughts flow at a steady pace and in a logical order. However, in several mental health conditions, the flow and coherence of thoughts can become distorted.

Abnormalities of thought flow and coherence include:

  • Loose associations: moving rapidly from one topic to another with no apparent connection between the topics.
  • Circumstantial thoughts: these are thoughts which include lots of irrelevant and unnecessary details but do eventually come back to the point.
  • Tangential thoughts: digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.
  • Flight of ideas: seen with fast, pressured speech. Ideas run into one another, making it difficult for the observer to follow the flow of speech.
  • Thought blocking: sudden cessation of thought, typically mid-sentence, with the patient unable to recover what was previously said.
  • Perseveration: refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is, and they then continue to repeat their name as the answer to all further questions).
  • Neologisms: words a patient has made up which are unintelligible to another person.
  • Word salad: speaking a random string of words without relation to one another.

Thought content

Abnormalities of thought content can include:

  • Delusions: a firm, fixed belief based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms. These may include persecutory delusions, in which the patient erroneously believes another individual or group is trying to harm them or ideas of reference, in which the individual incorrectly believes specific events relate to them (e.g. news reports on the television). Delusions can be mood congruent, such as grandiose delusions (e.g. that they have special powers) in mania.
  • Obsessions: thoughts, images or impulses that occur repeatedly and feel out of the person’s control. The patient is aware these obsessions are irrational, but the thoughts continue to enter their head.
  • Compulsions: repetitive behaviours that the patient feels compelled to perform despite recognising the irrationality of the behaviour.
  • Overvalued ideas: a solitary, abnormal belief that is neither delusional nor obsessional but preoccupying to the extent of dominating the person’s life (e.g. the perception of being overweight in a patient with anorexia nervosa).2
  • Suicidal thoughts
  • Homicidal/violent thoughts

Some examples of questions which can be used to screen for thought content abnormalities include:

  • β€œWhat’s been on your mind recently?”
  • β€œAre you worried about anything?”
  • β€œDo you sometimes have thoughts that others tell you are false?”
  • β€œDo you have any beliefs that aren’t shared by others you know?”
  • β€œDo you ever feel that people are out to harm you?”
  • β€œDo you ever feel that specific events in the world relate to you somehow?”
  • β€œAre there any thoughts you have a hard time getting out of your head?”
  • β€œDo you sometimes feel the need to perform certain behaviours repetitively, despite understanding these are irrational?”
  • β€œDo you ever thinkΒ about ending your life?”
  • β€œHave you ever felt your life was not worth living?”
  • β€œHave you ever attempted to end your life?”
  • β€œHave you ever harmed yourself to cope with difficult emotions”?
  • β€œDo you ever think about harming others?”

Thought possession

Abnormalities of thought possession include:

  • Thought insertion: a belief that thoughts can be inserted into the patient’s mind.
  • Thought withdrawal: a belief that thoughts can be removed from the patient’s mind.
  • Thought broadcasting: a belief that others can hear the patient’s thoughts.

Some examples of questions which can be used to screen for thought possession abnormalities include:

  • β€œDo you think people can put ideas in your head without your control?”
  • β€œHave you ever felt like people have removed memories or thoughts from your mind?”
  • β€œDo you ever feel like others can hear your thoughts?”

Perception

Perception involves the organisation, identification and interpretation of sensory information to understand the world around us. Abnormalities of perception are a feature of several mental health conditions.

Abnormalities of perception include:

  • Hallucinations: a sensory perception without any external stimulation of the relevant sense that the patient believes is real (e.g. the patient hears voices, but no sound is present).
  • Pseudo-hallucinations: the same as a hallucination, but the patient knows it is not real.
  • Illusions: the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).
  • Depersonalisation: the patient feels that they are no longer their β€˜true’ self and are someone different or strange.
  • Derealisation: a sense that the world around them is not a true reality.

Some examples of questions which can be used to screen for perceptual abnormalities include:

  • β€œDo you ever see, hear, smell, feel or taste things that are not really there?”
  • β€œDid you think this was real at the time?”
  • β€œDo you still believe it was real?”
  • β€œDo you ever feel as though you’re not real?”
  • β€œDo you ever feel like you’ve changed or that you don’t recognise the person you currently are?”
  • β€œDo you ever feel like the world around you isn’t real?”

Cognition

Cognition is “the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses”. Cognition can be impaired due to mental health conditions and their treatments.

Throughout the process of performing a mental state examination, you will develop a vague idea of the patient’s cognitive performance, including:

  • whether they are orientated in time, place and person
  • what their attention span and concentration levels are like
  • what their short-term memory is like

A formal assessment of cognition can be achieved through a variety of different validated clinical tests, including:


Insight and judgement

Insight

Insight, in a mental state examination context, refers to the ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal. Several mental health conditions can result in patients losing insight into their problem.

Some examples of questions which can be used to assess insight include:

  • “What do you think the cause of the problem is?”
  • “Do you think you have a problem at the moment?”
  • “Do you feel you need help with your problem?”

Judgement

Judgement refers to the ability to make considered decisions or come to a sensible conclusion when presented with information. Judgement can become impaired in several mental health conditions leading to poor decision making.

You may gain an understanding of the patient’s judgement abilities as you move through the mental state examination. You can also specifically assess judgement by presenting the patient with a scenario such as:

  • “What would you do if you could smellΒ smoke in your house?”

Sensible judgement in this situation would involve leaving the house immediately and calling the fire department. A patient with impaired judgement may suggest ignoring it.


Risk

Assessing risk is an essential part of an MSE. Risk can be subdivided into risk to self and risk to others.

Risk to self

Ask the patient if they are experiencing any thoughts of harming themselves and whether they plan to act on these thoughts. It is also essential to ask about deliberate self-harm, which some patients may undertake, not with suicidal intent but as a way of managing overwhelming and difficult emotions or feelings of dissociation.

Normalising statements can help reduce shame and stigma, helping the patient talk more about this difficult topic:

  • β€œSometimes, when people are going through difficult things, they might have thoughts of wanting to harm themselves – is this something you’ve experienced?”
  • β€œDo you have any plans to act on those thoughts?”
  • β€œPeople can sometimes hurt themselves to manage overwhelming emotions or feelings of numbness– is this something you’ve ever done? If so, how do you cope with these feelings?”

It is also important to assess other aspects of risk to self, such as:

  • Substance misuse: what do they use?
  • Self-neglect: are they eating and drinking? Are they attending to personal hygiene?
  • Are they attending to their physical health needs? (e.g. taking medications for physical health conditions)

Risk to others

Ask the patient if they are having any thoughts or have made any plans to harm others. Again, normalising statements can help elicit this:

  • β€œSometimes, when people are going through difficult things, they might have thoughts to harm someone else. Is this something you’ve experienced?”
  • β€œDo you have any plans to act on those thoughts?”

Closing the consultation

Ask the patient if they have anyΒ questionsΒ orΒ concerns that have not been addressed.

Thank the patientΒ for their time.


Reviewer

Dr Hannah Rodgers

Psychiatry trainee


References

  1. Murray, R., Hill, P., & McGuffin, P. (Eds.). (1997). The essentials of postgraduate psychiatry. Cambridge University Press.
  2. P.J. Mckenna. Disorders with overvalued ideas. Published in December 1984. Available from: [LINK].
  3. Soltan, M., & Girguis, J. (2017). How to approach the mental state examination.Β BMJ: British Medical Journal,Β 357.

 

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