Knowing how to conduct a mental state examination is an essential component for any clinician working within the mental health space. To help ensure you are equipped with all the right skills to do this accurately, we’ve created the following guide; filled with tips, tricks, examples and templates for mental state examinations.
What is a mental state examination?
A mental state examination or MSE is used to assess and observe a client’s mental state either as part of an initial assessment for the working diagnosis or in a more concise form throughout the treatment process.
There is quite a bit of variation in how the MSE is used in different fields, but it often involves a structured clinical interview and behavioral observations. These can be separated into ten integral aspects, which we’ll cover (with detail) in a moment. A wide range of different healthcare professions utilize mental health examinations, including:
- Social work
- Life coaching
- Psychiatric nursing
Pros and cons of Mental state examination
Here are the ten integral aspects of the MSE and some details I always include to ensure I get a comprehensive assessment completed.
The first thing to consider when conducting an MSE is the client's appearance which can be a beneficial indicator of their mental status. Some things to remember when you make notes on the client's appearance include:
Demographics: Date of birth, gender, and physical sex, ethnicity, and religion
Clothing type: You should be thinking about whether the client is dressed appropriately for the setting and occasion: Are they clean? Do they reflect the affect of the client (i.e., are they wearing all black or are they brightly colored)?
Posture: Does the client present as stable on their feet (postural instability)? Are they slouched forward or sitting with a rigid posture?
Gait: Similar to posture, do they seem stable on their feet (i.e., intoxication)? Does the client appear to be moving abruptly or in an uncoordinated manner, or are they shuffling and hesitant?
Hygiene and self-care: Note the cleanliness of the client. This can be in terms of visual or other sensory cues.
Physical health: While referrals often come through a GP, it is essential to gather a good understanding of the client's physical health. Be sure to ask if they are currently experiencing physical pain, biological symptomatology such as appetite, libido, or change in energy levels.
Substance use: Does the client engage in the use of psychoactive substances? If so, which ones and how often? Another thing to keep an eye out for here is signs of withdrawal such as pallor, perspiration, and tremor.
Like appearance, behavior can provide clinicians with further objective insight into the current mental state the client is experiencing. One important thing to note when commenting on behavior (and the MSE as a whole) is that the MSE should not incorporate language that could stigmatize or patronize the client. Some things to remember within the behavioral section of the MSE include:
Gestures: An essential aspect of non-verbal communication, gestures, or their frequency or appropriateness is crucial to note.
Mannerisms: Similar to gestures, can be indicative of several different disorders. Things to note are the appropriateness of the mannerisms and repetition throughout the MSE.
Facial Expression: What expressions does the client present? Are they congruent with affect and subjective reports?
Eye contact: Does the client make eye contact? If so, do they maintain it?
Level of Arousal: Does the client appear to demonstrate any psychomotor slowing or hyperarousal? Are they distracted and seemingly unaware of their surroundings, or are they behaving in a disinhibited manner?
Observation of a client's speech requires considering several different factors or changes in an individual's speech. For example, neurological conditions such as dementia, stroke, tumors, or traumatic brain injuries can be identified through aphasia (the complete inability to formulate or comprehend speech, depending on the area of the brain affected). Below are some of the details to be sure to note:
Quantity: Is the client struggling to get words out (poverty or paucity), or are they spontaneous and talkative in their speech.
Tone (prosody): Is the speech dull, quiet, or monotonous?
Rhythm: What is the fluency of the speech? Articulate and clear or perhaps slurred and hesitant?
Rate: Like rhythm, speech rate refers to the pace and paucity or pressure of the speech. Note the quantity and the flow of the client's speech.
The clinical definition of mood refers to a sustained emotion, present over a prolonged period, that can significantly impact their subjective perception of the world. In an MSE, mood is considered in two ways;
Subjectively: By asking the client how they feel. Therefore as reported by the client and observed and noted verbatim within the report by the clinician. Some practical questions to ask would include - How have you been feeling recently? Have you been eating and sleeping normally? How are your energy levels?
Objectively: This is how we, as clinicians, observe and describe the client's mood. Note its consistency throughout the session: Do they present as irritable, anxious, apathetic, dysthymia, euthymic, or elated? Is it appropriate and congruent with their affect?
Questions to ask patients about mood:
- How are you feeling?
- Have you been feeling discouraged/low recently?
- Have you been feeling energized/excited/elated recently?
- Have you been feeling angry/frustrated/irritable recently?
Affect is related to mood but is more interested in a client's presentation from moment to moment and assessed by observation alone of many factors aforementioned; voice, movement, posture, and expression. Some helpful descriptors to use in the MSE include:
When you are observing a client’s affect, you want to think about whether it is congruent with their current and perceived mood. Affect is also related to range and mobility; does the client feel or seem as though they have a limited affect?
Assessing a client's thoughts involves consideration of four different aspects of thought:
Form of thought: How the thoughts are linked together and their speed, coherence and flow.
Content of thought: What do the thoughts contain? This could include things such as suicidal ideation, self-harm, obsession, or delusions.
Some examples of questions that can be used to screen for content of thought include:
- What has been on your mind recently?
- Do you ever feel that other people are trying to cause you harm?
- Do you ever think about harming others?
- Have you ever felt that your life wasn’t worth living?
- Are there any thoughts you struggle to get out of your head?
Stream of thought: Is there poverty of thought or blocking occurring in the speed and amount of thoughts?
Possession of thought: Possession refers to the idea that others can manipulate thoughts through insertion, broadcasting, or withdrawal
Examples of thought phenomenology can include:
- Tangentiality or responding to a question in an irrelevant way
- Flight of ideas presenting as a continuous flow of speech that flows from one topic to another with no apparent association or coherent link
- The poverty of thought or a reduction in the number of thoughts
- Compulsions or repetitive behaviors
- Rumination or sustained processing or overvalued ideation on a negative topic
Perception is concerned with the process whereby an individual experiences things through their sensory organs. The different sensory modalities include:
The acronym PERCEPTIONS is, helpfully, an incredibly comprehensive methodology to use when assessing what your client is currently perceiving.
Perception: Have the client's perceptions altered recently? Are they experiencing any delusions, hallucinations, or other perceptual changes?
Encephalitis: Ensure the client is not experiencing abnormalities due to a biological cause.
Reflex hallucinations: Stimuli in one modality causing a hallucination in another modality.
Concentration: Has your client experienced difficulties in concentration or perceptual changes?
Experiences: What are these experiences? Do they insight fear or change the current environment? Do they feel their sensory organs are reliable?
Pseudohallucinations: Are hallucinations that your client might experience that are not hallucinations. They are not perceived to be produced through a sensory organ but rather internally.
Tactile, auditory, visual, gustatory, olfactory hallucinations: What modality are these experienced in? Is it just one or more than one?
Ipseity disturbance: This is the experience whereby your client may feel a diminished sense of self or instead not feel like themselves.
Organic states: Be sure to gain a complete medical history to rule out any organic mental disorders caused by things like Parkinson's or a tumor.
Negative symptoms - symptoms that present as a lack of something, i.e., the 5 A's (Affect, Apathy, Alogia, Avolition, Anhedonia).
Sensory impairment: What is the experience of the impairment? How does it feel? Are they experiencing new perceptions as a result?
An assessment of your client's cognition in the MSE is concerned with their levels of orientation, attention, memory, alertness, and visuospatial functioning. This section will consider their self-awareness, language, mental calculation, drawing, awareness of the environment, and higher cortical functioning.
- Firstly, when looking at cognition, we need to assess the client's ability to orientate themselves. This will involve asking some simple questions such as - Do you know who you are? Who am I? Where are we? What day is it?
- Next, it is essential to consider if the client is experiencing any clouding of their consciousness. What are they thinking, memory, and concentration? Are they experiencing any drowsiness?
- If the client is entirely unresponsive, mute, or mobile, they may be experiencing a stupor. This is associated with extreme impairment.
- Memory is another important thing to assess: immediate, long, and short-term memory using the appropriate tools available.
- The final assessment is visuospatial functioning through tasks such as the spatial relationship among objects. In this situation, it would be possible to employ the clock drawing task, i.e., ask your client to draw a clock with its hands showing 12.30.
One vital aspect to consider in assessing your client's cognition is culture, ethnicity, or language barriers. Westernized assessment tools do require consideration of their irrelevance for clients who have a different heritage.
Insight refers to a client's ability to recognize and appraise their experiences; this aspect is concerned with whether they can have insight into their symptoms, diagnosis, and need for treatment. It is crucial to gauge the client's take on their needs moving forward as it will correlate to their willingness to receive help and their ability to recover. Two words that will help you as a practitioner in this section are:
- Awareness: is your client aware they need treatment and what that is?
- Acceptance: are they willing to accept the symptoms they are experiencing require treatment?
There are six well-known stages of insight that have been delineated:
- Complete denial - self-explanatory
- Periods of awareness of being unwell and requiring assistance but significant denial
- Aware of being unwell but attributing causality to external factors such as physical ailments
- Intellectual insight - the knowledge that they do have a mental illness but are unable to maintain this knowledge in the experience of symptoms and modify behavior to mitigate it
- Emotional insight refers to a complete understanding of the disease and the ability to adjust behavior accordingly
It can be instrumental in identifying what stage the client is within the MSE. This will help you predict the likelihood of compliance and progress within the treatment.
10. Risk Assessment and Clinical Judgment
Last but not least (risk assessment is often considered the most critical step within an MSE) is the time for you to use your knowledge to complete a summary and risk assessment. This is the part of the MSE that a practitioner in the future is most likely to pick up and read, so be sure to incorporate all the crucial details you have gathered about this client.
Additionally, ensure you can:
- Arrange any further tests or assessments required for a client
- Note any concerns alerted throughout the MSE (physical, suicide or self-harm, or risk to others) and ensure you alert the appropriate people
Annnnnnd you're done!
Not quite. Be sure to thank your client for their time and be very clear about how you will move forward. This is when it would be great if you are using a software platform that means you can contact your client through a portal or send out calendar links and reminders to your next meeting!
Common terminologies used in an MSE
10 questions to ask your clients
The exact questions that you ask your clients will depend on a few factors, including what field of mental healthcare you work in. Nevertheless, here are 10 questions that are usually asked during mental state examinations that can be adapted to suit your needs:
- How do you generally feel most of the time?
- What are your strengths? What do you feel like you are particularly good at?
- Are there things you feel guilty about?
- Do you feel like you need help for the problems you’re experiencing?
- What are the obstacles, if any, preventing you from achieving your goals?
- Do you have any difficulties that you want help with?
- Have you had any psychological or other treatment interventions in the past?
- What do you think when you are sad/angry?
- What’s been on your mind recently?
- What benefit/s are you wanting to see from this service?
Books and videos to know more about conducting a mental state examination
We understand how complicated conducting mental state examinations can be. To help ensure you are equipped with all the information required to do this effectively, here are some books and videos to conduct further research:
The Psychiatric Mental Status Examination, written by Paula T. Trzepacz and Robert. W. Baker
This is an excellent resource for both students and seasoned clinicians. The book outlines mental state examinations before diving deeply into each of its different components. Check it out at Amazon.
The Mental Status Examination Handbook, written by Mario F. Mendez
This handbook guides clinicians from any mental health field through the process of conducting mental state examinations. It outlines how referrals, testing procedures and cognitive assessments should be completed, helping you to achieve accurate results. Find the book on Amazon.
Psychiatric Interviewing : The Art of Understanding: A Practical Guide for Psychiatrists, Psychologists, Counselors, Social Workers, Nurses, and Other Mental Health Professionals, with online video modules, written by Shawn Christopher Shea
An in-depth overview of the methods and processes of clinical interviewing. This text is a fantastic insight into the different techniques that clinicians can apply when conducting interviews with their patients across a range of healthcare fields. Have a look here at Book Depository.
Video: The Mental Status Exam
In this video, Allan Clarke explains all of the components of a mental state examination, in relation to mental health and substance use clients. Check it out here on Youtube.
Extra tips for conducting an MSE
No matter how busy your day is, how stressed you are and how many clients you have to see that day remember it could be the worst day of their life. Take a moment to yourself before each session to have a few breaths and ensure you can be completely present for each client.
- Welcome each client warmly and help to put them at ease.
- Be sure to write down your client's words verbatim. If given permission, it can be helpful to record sessions to ensure you don't misinterpret them.
- Considering each client's demographics, what is their age, culture and do you require an interpreter? What else can you do to put them at ease?
- Remember that if you have limited time, always prioritize RISK for every client.
I hope this has been helpful! Good luck conducting these evaluations.