How to conduct a mental state examination (MSE)

A mental state examination or MSE is an essential tool for any clinician working within the mental health space. An 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.  

It's doubtful that anyone visiting this page is entirely new to the concept of an MSE. Therefore, I will jump straight in. I'll note some helpful tips for any MSE at the end of the article, so be sure to stick around until the end.

Here are the ten integral aspects of the MSE and some details I always include to ensure I get a comprehensive assessment completed.  

1. Appearance

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 you make notes on regarding the client's appearance are;

Demographics: date of birth, gender, and physical sex, ethnicity, and religion

Clothing type: some things to think about are if 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 symptomology 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.

2. Behaviour

Like appearance, behavior can provide any clinician with some further objective insight into the current mental state they are experiencing. One important thing to note when commenting on behavior (and the MSE as a whole) is that the MSE is not to incorporate language that could stigmatize or patronize the client. Some things to remember within the behavioral section of the MSE:

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?

3. Speech 

Observation of a client's speech requires considering several different factors and artifacts or changes in an individual's speech could be an excellent way to support a formulation of a presentation. 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, dependant 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. 

Mental health exam

4. Mood 

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, dysthymic, euthymic, or elated? Is it appropriate and congruent with their affect? 

5. Affect 

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; congruence, range, fluctuation, quality, and intensity. 

6. Thoughts 

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. 

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 

7. Perception 

Perception is concerned with the process whereby an individual experiences things through their sensory organs. The different sensory modalities include:

  1. Auditory
  2. Visual
  3. Olfactory
  4. Gustatory
  5. Somatic

The acronym PERCEPTIONS is, ironically, 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? 

MSE exam perception


8. Cognition 

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. 

  1. 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? 
  2. 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? 
  3. If the client is entirely unresponsive, mute, or mobile, they may be experiencing a stupor. This is associated with extreme impairment. 
  4. Memory is another important thing to assess: immediate, long, and short-term memory using the appropriate tools available. 
  5. 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.

9. Insight 

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: 

  1. Awareness: is your client aware they need treatment and what that is?
  2. 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: 

  1. Complete denial - self-explanatory 
  2. Periods of awareness of being unwell and requiring assistance but significant denial
  3. Aware of being unwell but attributing causality to external factors such as physical ailments
  4. 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 
  5. 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 Judgement 

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! 

Remember at the start when I said I would note down some helpful hints to stick around for???

Well, here they are; 

  • 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 put them at ease initially 
  • 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.

Mental state examination completion


 

 


 

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