Mental State Examination

Mental State Examination A session on examination and assessment of the Mental Health Status By Christopher Skinner

Mental State Examination In this session the learner will learn how to assess the Mental Status. The steps in the Mental Health Examination. The referral pathway resulting from the status report that you make.

Mental State Examination Once learnt, the MSE is relatively easy to apply. The steps are based on observation of different manifestations of the client’s presentation.

Mental State Examination Appearance: What does the client look like to the observer using your senses? Dress Manner Smell Eye Contact Suspicious, Hypervigilant? Tremulous, Scared, Frightened, Angry, Combative, Threatening or Jealous? Body Language and Posture

Mental State Examination Behaviour What is the behaviour like? How does the client relate to you? Are they co-operative or not? Are they listening to you when you ask questions? Are they friendly or distant? Are there complaints about the client’s behaviour? Is the client agitated or restless?

Affect Is the client happy or sad? Are they angry? Are they withdrawn or expansive? Are they extrovert or introvert? Are they jealous?

Mood How would you describe the mood? Happy or Sad – How does the client tell you that they feel? Are they angry, embarrassed, down or blue? Are they threatening to self harm or suicide?

Cognition refers to the thinking of the client tells us whether thought is ordered or disordered, coherent or incoherent, clear or confused, normal or abnormal. This is examined by asking the patient a series of questions

Questions What is the day, the date? Where are you? Who is the Prime Minister of Australia? What did you have for breakfast? What is your name? What is worrying you? How did you come to be here?

Answers Normal answers to the questions indicate normal cognition. Difficulty in answering the questions or bizarre answers indicate faults in cognition or disordered thinking.

Examples What is the day, date? Most people can answer this – however, if confused, the client may answer these simple questions with inaccurate information.

Examples Where are you? Most people can tell you where they are. Incorrect answers indicate confusion.

Examples Who is the Prime Minister of Australia? Most people will answer Kevin Rudd, but people who are confused or delusional will give alternative answers. New Australians and some alternative life stylers may not be able to answer this question

Examples Similarly, questions about breakfast and who are you will demonstrate whether the client is confused or unable to recall basic information.

Examples What is worrying you? The client may answer this – the information provided may give clues as to whether the client has insight or not. Answers may provide clues as to what is ailing the client. May point to suicidal ideation.

Serial Sevens Serial sevens is a simple mathematical exercise, starting with 100, ask the client to take away seven each time, so the answers are 93, 86, 79 and so on. Clients who are unable to do this may have a cognitive disorder, or be very poor at mental arithmetic. Most clients can do this.

Cognition Disordered thinking is common in the Psychoses – there is a lack of touch with reality. Confused thinking shows a clouded sensorium as in Delirium, and diseases such as Alzheimer's and Wernicke's encephalopathy. There may also be organic or infectious causes, such as Urinary Tract Infection, Diabetes, Organic Brain Syndrome.

Insight Mentally Ill clients suffering from acute psychosis often lack insight into the fact that they are mentally ill, and may deny that there is anything wrong, when it is clear to casual observers that their behaviour is abnormal.

Judgement Clients who are severely depressed may be suicidal and may show evidence of poor judgement. Similarly, Manic clients may show poor judgement about aspects of self control, they may plan projects for which they do not have the pre-requisite resources, either emotional, financial or health wise.

Plan Asking the client what is their plan may demonstrate disordered thinking, or expose ideas of self harm/suicide. Your plan will depend on your observations of the MSE (Mental Status Examination).

Summary Appearance Behaviour Affect Mood Insight Judgement Plan Referral

Referral Where the client raises feelings of unease in you, as the observer, by demonstrating thought disorder or abnormality, then you need to refer the client either to their case manager, the Psychiatrist, or for first aid, via the ambulance or police.

Ambulance and or Police? Where the client threatens self harm or suicide, says they want to die, or threatens to harm or kill others, then you need to refer them to the emergency services, which may be Police (where they threaten to do harm to others) or Ambulance (where they threaten harm to themselves, or talk of suicide) In Australia the emergency number is “000”

The Mental Health Act enables people to be admitted to hospital for Psychiatric assessment and treatment where they are deemed to be a danger to themselves or others – i.e. where they threaten to harm themselves or others, or harm their reputation.

Mental Health Act Two medical officers, one a Psychiatrist, need to assess the admitted patient to determine whether they have a mental illness or disorder. If not, the admitted patient should not be kept in hospital against their will. (Least Restrictive principle)

The Key It is better to be safe than sorry. You are not disempowering someone by reporting them to emergency services when they threaten harm to themselves or others. If you make a mistake, you have only embarrassed yourself as you acted in good faith.