Mental State Examination

The mental state examination (MSE) is an observational assessment of a patient’s appearance, behaviours and cognitive state. It has seven domains that need to be assessed in order to complete a full examination. When completed correctly, the mental state examination should allow the reader to obtain an exact picture of the patient in their mind.

Overview

The purpose of the mental state examination is to identify a range of mental health conditions, whilst critically analysing the severity of the condition and the risk posed. Combining information from the mental state examination with both the biological and social history, clinicians are able to form an accurate diagnosis and management plan.

This article will outline the structure of the mental state examination. Next, it will demonstrate an example of a completed, written mental state examination report, focusing on a lady with depression. It will then provide a table, documenting common mental state findings in key psychiatric conditions, including anxiety, mania and schizophrenia.

Components to be assessed in a full mental state examination

1. Appearance and behaviour
Aim:
How does the patient look? And how do they interact?

Note:
• Weight
• Self-neglect
• Appropriateness of clothing
• Signs of previous/current mental health issues (e.g. self-harm scars)

Also note:
• Rapport
• Response to unseen stimuli
• Eye contact
• Facial expression
• Body language
• Movement (psychomotor abnormalities)

2. Speech
Aim:
How does the patient sound when talking?

Note:
• Rate
• Rhythm
• Volume (how much do they speak within the conversation)
• Tone
• Content

3. Mood
Aim
How does the patient feel? And how do you think they feel?

Note:
• Subjective opinion (patient opinion)
• Objective opinion (observed emotion, also known as the affect)

Assess risk of self-harm and suicide.

4. Thought
Aim:
Does the patient have a normal thought pattern?

Note:
• Thought form (speed, flow – circumstantiality, tangentiality, flight of ideas, neologisms)
• Delusions
• Obsessions
• Compulsions
• Violence

5. Perception
Aim:
Can you identify any sensory hallucinations?

Note:
• Hallucinations (patient believes they are real)
• Pseudo-hallucinations
• Illusions

6. Cognition
Aim:
Are they orientated to time, place and person?

Note:
• Orientation
• Attention and short-term memory.

Formal cognitive assessments may include: SMMSE, MOCA, ACE-III

7. Insight
Aim:
Is the patient aware they have a problem?

Note:
• Beliefs
• Willingness to accept help

Case Study: Mrs X’s depression

Appearance and behaviour

Mrs X, a 56-year-old female, was sitting in her chair when I arrived at the clinic room. She was bent forwards, resting her head on her left arm, with her eyes closed and sighing.  She was dressed in a jumper and jeans, appropriate for today’s weather. However, there were obvious stains noted on her clothes. Mrs X appeared as a thin individual, but not significantly underweight. She had dirt marks, located under her chin, and similarly, her fingernails were dirty. I was unable to see any visible signs of self-harm or stigmata of other mental health issues.

Mrs X was difficult to establish rapport with and engaged in conversation with great difficulty. She made very little eye contact through the consultation, choosing to focus her eyes downwards or towards the window, and her body language was closed, often facing inwards and choosing to keep her head rested on her arm. She did not smile throughout the consultation and had limited facial expression. There were no movement abnormalities, including no psychomotor retardation, and she did not respond to unseen stimuli.

Speech

Mrs X did not readily engage in speech. She had a slow rate of speech, with a monotonous tone to her voice. She did not show excitement, despite talking about her grandchildren or husband whom she said supported her well. She often paused in her speech, saying she forgot the words but stated her memory is normally fine. The content of the speech was appropriate for the consultation, however, there was a limited volume – often choosing to reply “yes or no” to questions and not attempting to answer more open questions.

Mood

Subjectively, Mrs X exclaimed she felt “depressed” and was unsure of the reason why. Objectively, Mrs X appeared sad with very limited eye contact or facial expression. Her affect was congruent to her mood. She denied any thoughts of self-harm or suicide, stating she “loved her family too much to do something like that.” She reported that she has been sleeping less, often waking at 3 am and unable to get back to sleep. Her husband also noticed she has lost weight (approximately 2 dress sizes over 4 months) and she states that she has not been eating as much, often only having breakfast in the morning. She states she has “nothing to look forward to in the future.”

Thought

Mrs X had reported no evidence of formal thought disorder.

Perception

Mrs X reported no forms of hallucinations across all sensory modalities (auditory, visual, olfactory and tactile.)

Cognition

Mrs X was orientated to time, place and person. Through the conversation, I note that Mrs X would often look towards the window and lose what was being said in the conversation, meaning that we would often have to restart.

Insight

On asking if Mrs X thought she was depressed, Mrs X agreed. She reported that she was wanting to receive help to improve her mood and was hoping to be treated with medication as opposed to therapy.

Common mental state examination findings to key psychiatric conditions

DomainAnxietyManiaSchizophrenia
Appearance and behaviour• Wide range of appearances
• Often well-kept appearance, however, may show self-neglect if anxiety is debilitating
• May have poor eye contact or psychomotor agitation
• Express avoidance behaviour
• Often dressed inappropriately e.g. bright colours, very little clothing
• Appear energetic, excited, talkative, and frequently hyperactive – which may turn to aggression
• Psychomotor agitation
• Wide range of appearances
• Response to unseen stimuli, may be catatonic or withdrawn, look for side effects of antipsychotics (akathisia, dystonia, Parkinsonism)
Speech• Often normal
• Those with severe anxiety may experience difficulty speaking or have a vocal tremor
• Pressured speech (rate is fast, increased quantity)• Neologisms
• Incoherence of speech
• Lack of unprompted speech (alogia)
• Poverty of content
Mood• Anxious or frustrated
• May have somatic complaints (insomnia, abdominal pain) or may be withdrawn
• Some will have a blunted affect, with guarding, whereas others will have higher emotional expression
• Euphoric
• Intense excitement and happiness with the possibility to change to irritability
• May appear withdrawn with reduced emotional responsiveness or have excessive inappropriate emotions, e.g. rage, happiness or anxiety
Thought• Perseverations and ruminations (continuous worry about past/future events) – may be related to specific phobia, social environment or generalised• Flight of ideas (sudden abrupt changes of topics within the speech)
• Grandiose delusions with high levels of self-confidence
• Often delusions are mood-congruent
• Evidence of tangential speech
• Evidence of tangential speech and Clang associations
• Often have paranoid delusions with ideas of reference or evidence of thought disorder (control, broadcasting, removal)
Perception• Often not affected• May experience hallucinations or paranoia• Auditory hallucinations are very common
Cognition• Intact orientation but reduced
concentration and attention
• Intact orientation but reduced concentration and attention• Intact orientation but impaired attention
Insight• Often have good insight into the condition• Often very little insight, shown by impaired judgement (excess gambling, poor financial management, sexual indiscretion)• Often very little insight
Common findings for key psychiatric conditions

Further reading and references

  1. Bullet Psych
  2. The BMJ – How to approach the mental state examination
  3. Geeky medics – Mental State Examination (MSE) – OSCE Guide
  4. Oxford Handbook of Psychiatry. Semple D, Smyth R.  Oxford University Press, 2011
  5. Fish’s Clinical Psychopathology. Casey P, Kelly B. Royal College of Psychiatrists, 2019

Written by Dr Robyn Wilcha (FY1)
Reviewed by Dr Nirja Beehuspoteea (ST5 Old Age Psychiatry)
Edited by: Mudassar Khan (Y4 Medical Student)

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