Mental status examination (MSE)

Mental status examination (MSE)

Introduction

The mental status examination and psychosocial assessment are essential parts of every nursing assessment as well as the assessment of client's physical health. It is the first standered of psychiatric nursing practice. The  MSE helps the nurse to collect objective data about the client's appearance, behaviour, attitude, speech, mood and affect, perception, thought, sensorium, insight and reliability.

The completion of the MSE sometimes involves several interviews because the client is not always immediately responsive to all parts of the examination during the acute phase of illness. The MSE can be administered on a daily basis for an acutely ill client,

Definition

Mental status examination is an assessment of general motor behavior, thought, emotional functioning along with evaluation of insight and judgment of the patient's present status.

Purposes

·         The MSE is a core skill of psychiatrists and nurses and is a key part of the initial psychiatric assessmeng,  of a patient in psychiatric hospital setting.

·         It is a systematic collection of data based on observation of the patient's behaviour while the patient is in the clinician's view during the interview.

·         Obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of interview.

·         Information on the client's insight, judgment capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting.

·         It is carried in the manner of an informal enquiry, using a combination of open and closed questions, supplemented by structured tests to assess cognition.

·         The MSE can also be considered part of the comprehensive physical examination performed by physicians and nurses although it may be performed in a cursory and abbreviated way in non-mental health settings.

Guidelines

·         Data collected through the mental status examination represents the psychological status of only a shorter period.

·         Both subjective and objective data should be given due consideration.

·         While doing mental status examination person's educational and cultural background should be kept in mind for accurate interpretation.

·         After each component inference should be noted

Components of mental status examination     

1.       Identification data

1)Date and time

2)Venue

3)Language of interview

4)Time taken for interview

2.       General appearance and behaviour

The points to be noted are:

Body build and physical appearance (approximate height, weight, and appearance)

                                i.            Looks comfortable/uncomfortable

                              ii.            Physical health

                            iii.            Grooming

                             iv.            Hygiene

                               v.            Self-care

                             vi.            Dressing (adequate, appropriate)

Attitude towards the examiner

                           vii.            Cooperation/guardedness/evasiveness/hostility

                         viii.            Attentiveness

                             ix.            Shows interest/appears disinterested     

Comprehension

                               x.            Intact/impaired (partially/ftlly).

Gait andposture

                             xi.            Normal or abnormal (way of sitting, standing walking, lying),

Motor activity

                           xii.             Increased/decreased

                         xiii.            Excitement/stupor

                         xiv.            Abnormal involuntary movements (AIM's) tics, tremors

                           xv.            Restlessness/akathisia

                         xvi.            Catatonic signs (mannerisms, stereotypes, posturing, waxy flexibility, negativism, ambitendency, automatic obedience, echopraxia, psychological pillow, forced grasping)

                       xvii.            Conversion and dissociative signs (pseudoseizures, possession states).

                     xviii.            Social withdrawal, autism.

Social manner

                         xix.            Increased, decreased, or inappropriate.

Rapport

                           xx.            Whether a working empathic relationship can be established with the patient, should  mentioned.

Hallucinatory behaviour: Smiling or crying without reason, muttering talking to self (non-social speech) anc odd gesturing in response to auditory or visual hallucinations.

3.       Mood and affect: In addition to non-verbal mood observed and described under general appearance ana behaviour, the patient is asked about present 'mood.' This is recorded as subjective affect while the observed emotional change is described as objective affect.

The appropriateness of mood in relation to thought and surrounding environment is commented upon next.

Mood is described as general warmth, euphoria, elation, exaltation and ecstasy in mania; anxious and restless in anxiety and depression; sad, irritable, angry and despaired in depression; shallow, blunted, indifferen restricted, inappropriate and labile in schizophrenia. Anhedonia may occur in both schizophrenia and depression.

4.       Speech: Speech can be examined under the following headings:

Rate and quantity ofspeech

                                i.            Whether speech is present or absent (mutism).

                              ii.            If present, whether it is spontaneous.

                            iii.            Productivity is increased or decreased.

                             iv.            Rate is rapid or slow.

                               v.            Pressure of speech or poverty of speech.

Volume and tone of speech

                             vi.            Increased/decreased.

Flow and rhythm ofspeech

                           vii.            Smooth/hesitant.

                         viii.            Dysprosody.

                             ix.            Blocking (sudden).

                               x.            Circumstantiality.

                             xi.            Tangentiality, loosening of associations.

                           xii.            Verbigeration, stereotypies (verbal).

                         xiii.            Flight of ideas, clang associations.

5.       Perception: Perception is assessed under the following headings:

Hallucinations: The presence of hallucinations should be noted. Whether hallucinations are auditory , visual, olfactory, gustatory or tactile should be asked.

Auditory hallucinations are the commonest in psychiatric disorders (non-organic). It should bc further enquired what was heard, how many voices were heard, in which part of the day, male or female voices, how interpreted and whether second person or third person hallucinations (i.e., whether the voices are addressing the patient or  are discussing him in third person).

Illusions and misinterpretations: Whether visual, auditory, or in other sensory fields; whether occur in clear consciousness or not.

Depersonalization and derealization.

Somatic passivity phenomenon: Strange sensations imposed by somebody.

Others: Autoscopy, abnormal vestibular sensations, sense of presence should be noted here.

6.       Thought: In clinical examination, thought is assessed by the content of speech, under the following  headings:

Stream of thought: 'Stream of thought' overlaps with examination of 'speech.' Spontaneity, productivity  flight of ideas, poverty of content of speech, thought block should be mentioned here.

Continuity of thought is assessed, Whether the thought processes are relevant to the questions asked. Any loosening of associations, tangentiability, circumstantiality, illogical thinking, perseveration, and verbigeration ts noted.

Content of thought: Obsessions and contents of phobias; ideas and delusions of persecution, reference, grandeur, love, jealousy (infidelity), guilt, nihilism, poverty, hypochondriacal symptoms, hopelessness, helplessness, worthlessness, and suicide should be explored.

Delusions of control, thought insertion, thought withdrawal, thought broadcasting are Schneiderian first rank symptoms (SFRS). The presence of neologisms should be recorded here.

7.       Sensorium and cognition: Cognitive or higher mental functions are an important part of the MSE. Their significant disturbance commonly points to an organic psychiatric disorder,

Alertness and level of consciousness:

The terms describe the level of consciousness are confused, clouding of consciousness, stupor and coma.

Orientation :

Check the orientation to time, place and person.

Person -What is your name?

Place- where are you today?

Time- What is today's date?

Person with organic disorder may give grossly inaccurate answers but patient's with schizophrenic disorder may say that they are someone else or somewhere in the world or reveal personalized orientation to the world.

Consciousness: Conscious/confusion/clouding/delirium/stupor/coma. Any disturbance of consciotsness should be rated on Glasgow Coma Scale.

Orientation: Whether the patient is well oriented to time (time, date, day, month, year, season, time spent in hospital), place (where is he, location, where does he stay) and person (his own name, can he identify beople around him and their role in setting).

Memory

Immediate (within 5 minutes): Show five unrelated objects, ask the patient to name them. After naming hide it from patient's vision. Ask afterwards to remember and tell those names. Or tell an address and ask the patient to tell after five minutes.

·         Give a five digit number which is not in sequence, e.g. 72918

·         Tell an address to the patient, ask him to tell it after 5 minutes.

Recent (within past few days): What had you for last night dinner? Who visited you yesterday?

Recent past: (Within 6 months): Asking patients to recall important news events from the past few months checks recent past memory

·         Which festival did you celebrated last month?  

·         When did you go to temple last?

·         Which friend have you visited last month?

Remote (more than 6 months): Remote memory can be tested by asking patients for information about thcir childhood that can be verified later.

·         In which year have you passed SSLC?

·         In which year have you started working?

·         What was your primary school teacher's name?

Inference: After confirming with the informant if the answers are correct, we can interpret the findings as each memory as good, average, and poor.

Attention: Attention is the ability to focus on a particular stimulus. Is the attention easily aroused and  sustained. Ask the patient to repeat digits forwards and backwards.

Concentration: Concentration is the ability to sustain attention over a period of time. Can the patient concentrate; Ease of distractibility; Ask to serial sevens from hundred (100-7 test), or serial threes from forty (40-3 test), or to count backwards from 20, or enumerate the names of the months (or days of the week) in the reverse order. Note down the answers and the time take perform the tests.

Abstractability: Abstract thinking testing assesses patient's concept formation. The methods used are:

·         Proverb testing: The methods used to assess the abstractability are proverb testing (at least 3 proverbs should be asked, Asking the meaning of simple proverbs,

·         Similarities (and also the differences) between familiar objects, like: table and chair; banana and orange; dog and lion; eye and ear.

The answers may be overly concrete or abstract. Appropriateness of answers is judged. Concretization of  responses or inappropriate answers may occur in schizophrenia.

General information: Ask questions about general information, keeping in mind the patient's educational and social background, his experiences and interests, e.g., ask about the current and the past prime ministers and presidents of India, the capital of India, and the name of the various states,

Calculations: Assess both written and verbal calculations. Give simple tests of calculation.

Intelligence: Intelligence is the ability to think logically, act rationally, and deal effectively with the environment. It include the test to assess the patient's vocabulary, general information and ability to conceptualize. The person's educational level and any learning difficulties should be careftllly evaluated.

8.       Impulse control

It can be observed by the client's general behaviour during the interview.

9.       Judgement     

Judgement can be evaluated by exploring patient's involvement in activities, relationship and vocational choices.

·         Test judgement- it is assessed by giving a hypothetized life situation to the patient

·         Personal judgement- it is assessed by asking about personal plans, aims etc.

·         Social judgement- assessed by observing the client's interactions with others in the ward.

10.   Judgement is rated as Good/lntactmormal or Poor/lmpaired/Abnormal.

11.   Insight: Insight is rated on a 6-point scale from one to six

·         Grade1-Complete denial of illness.

·         Grade2-Slight awareness of being sick and needing help, but denying it at the same time.

·         Grade3-Awareness of being sick, but attributes it to external or physical factors.

·         Grade4-Awareness of being- sick, due to something unknown in self.

·         Grade5-Intellectual insight: Awareness of being ill and that the symptoms/ failures in social adjustment are due to own particular irrational feelings/ thoughts; yet does not apply this knowledge to the current/future experiences.

·         Grade6-True emotional insight: It is different from intellectual insight in that the awareness leads to in significant basic changes in the future behaviour an personality.

Ask the patient's attitude towards his present state; whether thqre is an illness or not; if yes, which kind of illness (physical, psychiatric or both); is any treatment needed; is there hope of recovery; what is the cause of illness. Depending on the patient's responses, grade the insight.

Documentation of MSE

It can be the reported important in various ways should suchas in a descriptive way or in a concise manner.Regardless of the format the important findings should documented and verbatism resposes by the the patient should be recorded whenever they add important information and support the nurse’s assessment.

Conclusion

Information obtained during MSE is used along with other objective and subjective data. The MSE will not reflect how the patient was in the past and will be in future. It is an evaluation of patient's current state.



Mnemonic:

Mental State Examination

ASEPTIC

·                 Appearance / Behaviour

·                 Speech

·                 Emotion (mood and affect)

·                 Perception (hallucinations, illusions)

·                 Though (content, form)

·                 Insight

·                 Cognition (AMT, MMSE)