11/13/24, 8\:11 PM Guide | Mental state exam (MSE)

Mental state exam (MSE)

Table of contents
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Introduction

The mental state examination (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 a
Thoughts
Perception
Insight and judgement
Risk
The Royal College of Psychiatrists de
m e n t a l f u n c t i o n i n g a t a g i v e n t i m e- p o i n t "
. 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.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
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Ask the patient if they'd be happy to talk with you about their current issues.

Appearance & 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 di
Stigmata of disease\: note any stigmata of disease (e.g. jaundice).
Weight\: note if they appear signi
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 of eye contact and note if this appears reduced or intense and staring.
Facial expression
Observe the patient’s facial expression (e.g. relaxed, fearful, angry, disengaged). Note if they respond appropriately (e.g.
becoming tearful when discussing di
Body language
Observe the patient’s body language, which may appear threatening (e.g. standing up close to you) or withdrawn (e.g. curled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
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
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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
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
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 & a

Mood and a
A
Mood represents a patient's predominant subjective internal state at any one time as described by them.
A
current weather).

Mood

A patient's mood can be explored by asking questions such as\:
" H o w a r e y o u f e e l i n g ?"
" W h a t i s y o u r c u r r e n t m o o d ?"
" H a v e y o u b e e n f e e l i n g l o w / d e p r e s s e d / a n x i o u s l a t e l y ?"
Examples of mood states
Low mood
Anxious
Angry
Enraged
Euphoric
Guilty
Apathetic
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A

To assess a
Apparent emotion
Observe the apparent emotion re
Sadness
Anger
Hostility
Euphoria
Range and mobility of a
Range and mobility of a
include\:
Fixed a
Restricted a
emotional expression that would be expected.
Labile a
typically feel like they have no control over their emotions.
Intensity of a
A patient's intensity of a
Heightened\: associated with mania and some personality disorders.
Blunted or schizophrenia, depression and post-traumatic stress disorder.
Congruency of a
Note if the patient's a
distressing thoughts whilst demonstrating a
Incongruent aschizophrenia.

Thought

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

Thought form

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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

Abnormalities of thought
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 di

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
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 speci
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\:
“ W h a t’ s b e e n o n y o u r m i n d r e c e n t l y ?”
“ A r e y o u w o r r i e d a b o u t a n y t h i n g ?”
“ D o y o u s o m e t i m e s h a v e t h o u g h t s t h a t o t h e r s t e l l y o u a r e f a l s e ?”
“ D o y o u h a v e a n y b e l i e f s t h a t a r e n’ t s h a r e d b y o t h e r s y o u k n o w ?”
“ D o y o u e v e r f e e l t h a t p e o p l e a r e o u t t o h a r m y o u ?”
“ D o y o u e v e r f e e l t h a t s p e c i
“ A r e t h e r e a n y t h o u g h t s y o u h a v e a h a r d t i m e ge t t i n g o u t o f y o u r h e a d ?”
“ D o y o u s o m e t i m e s f e e l t h e n e e d t o p e r f o r m c e r t a i n b e h a v i o u r s r e p e t i t i v e l y , “ D o y o u e v e r t h i n k a b o u t e n d i n g y o u r l i f e ?”
“ H a v e y o u e v e r f e l t y o u r l i f e w a s n o t w o r t h l i v i n g ?”
“ H a v e y o u e v e r a t t e m p t e d t o e n d y o u r l i f e ?”
“ H a v e y o u e v e r h a r m e d y o u r s e l f t o c o p e w i t h d i
“ D o y o u e v e r t h i n k a b o u t h a r m i n g o t h e r s ?”
d e s p i t e u n d e r s t a n d i n g t h e s e a r e i r r a t i o n a l ?”
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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\:
“ D o y o u t h i n k p e o p l e c a n p u t i d e a s i n y o u r h e a d w i t h o u t y o u r c o n t r o l ?”
“ H a v e y o u e v e r f e l t l i k e p e o p l e h a v e r e m o v e d m e m o r i e s o r t h o u g h t s f r o m y o u r m i n d ?”
“ D o y o u e v e r f e e l l i k e o t h e r s c a n h e a r y o u r t h o u g h t s ?”

Perception

Perception involves the organisation, identi
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 ‘true’ self and are someone di
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\:
“ D o y o u e v e r s e e , h e a r , s m e l l , f e e l o r t a s t e t h i n gs t h a t a r e n o t r e a l l y t h e r e ?”
“ D i d y o u t h i n k t h i s w a s r e a l a t t h e t i m e ?”
“ D o y o u s t i l l b e l i e v e i t w a s r e a l ?”
“ D o y o u e v e r f e e l a s t h o u g h y o u’ r e n o t r e a l ?”
“ D o y o u e v e r f e e l l i k e y o u’ v e c h a n g e d o r t h a t y o u d o n’ t r e c o gn i s e t h e p e r s o n y o u c u r r e n t l y a r e ?”
“ D o y o u e v e r f e e l l i k e t h e w o r l d a r o u n d y o u i s n’ t r e a l ?”

Cognition

Cognition is " t h e m e n t a l a c t i o n o r p r o c e s s o f a c q u i r i n g k n o w l e d ge a n d u n d e r s t a n d i n g t h r o u gh t h o u gh t , s e n s e s"
. Cognition can be impaired due to mental health conditions and their treatments.
e x p e r i e n c e , a n d t h e
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 di
Mini-mental state exam (MMSE)
Abbreviated mental test score (AMTS)
Addenbrooke's cognitive examination III (ACE-III)
Montreal Cognitive Assessment (MOCA)

Insight & judgement

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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\:
" W h a t d o y o u t h i n k t h e c a u s e o f t h e p r o b l e m i s ?"
" D o y o u t h i n k y o u h a v e a p r o b l e m a t t h e m o m e n t ?"
" D o y o u f e e l y o u n e e d h e l p w i t h y o u r p r o b l e m ?"

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 speci
" W h a t w o u l d y o u d o i f y o u c o u l d s m e l l s m o k e i n y o u r h o u s e ?"
Sensible judgement in this situation would involve leaving the house immediately and calling the
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 di
Normalising statements can help reduce shame and stigma, helping the patient talk more about this di
“ S o m e t i m e s , w h e n p e o p l e a r e g o i n g t h r o u g h d i
“ D o y o u h a v e a n y p l a n s t o a c t o n t h o s e t h o u g h t s ?”
t h e y m i g h t h a v e t h o u g h t s o f w a n t i n g t o h a r m t h e m s e l v e s – i s
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“ P e o p l e c a n s o m e t i m e s h u r t t h e m s e l v e s t o m a n a ge o v e r w h e l m i n g e m o t i o n s o r f e e l i n g s o f n u m b n e s s– i s t h i s s o m e t h i n g
y o u’ v e e v e r d o n e ? I f s o , h o w d o y o u c o p e w i t h t h e s e f e e l i n gs ?”
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\:
“ S o m e t i m e s , w h e n p e o p l e a r e g o i n g t h r o u g h d i
“ D o y o u h a v e a n y p l a n s t o a c t o n t h o s e t h o u g h t s ?”
t h e y m i g h t h a v e t h o u g h t s t o h a r m s o m e o n e e l s e . I s t h i s

Closing the consultation

Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.

Reviewer

Dr Hannah Rodgers
Psychiatry trainee

References

1. Murray, R., Hill, P., & McGu
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. B M J \: B r i t i s h M e d i c a l J o u r n a l , 3 5 7 .
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Source\: geekymedics.com
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