Mental state examination (MSE)

This is an objective assessment of the patient’s mental function at a specific point in time.

The MSE includes

Appearance

• Physical state: For example, how old does the patient look? Do they appear unwell? Are they sweating? Are they slim or obese?
• Dress: Are their clothes clean? Are they appropriately clothed? (for example, are they wearing shorts and t-shirt when it is cold outside?)
• Self-care: Are they bodily clean and appropriately groomed? Is there any evidence of self-harm or injury?
• Are clothes brightly coloured or black and dowdy in colour?

Behaviour

• Does the patient have any tics, tremors, acute dystonia, Parkinsonism?
• Is their behaviour appropriate?
  • Are they anxious, agitated, aggressive, defensive or distracted?
  • Are they suspicious, pacing or having conversations with people not present?
  • Do they make good eye contact? Are they withdrawn?
  • Can you build a good rapport with them?

Mood and affect

• Mood is the patient’s sustained, subjectively experienced emotional state over a period of time
• Ask the patient how they feel; this is the subjective assessment of mood – from the patient’s view point. The objective mood assessment is done by the doctor. For example, the patient may describe their mood as “a pit of doom” – subjective assessment – while objectively their mood is “low”. Include both in your notes.
• Affect refers to the patient’s transient flow of emotion in response to a particular event or stimulus (For example, smiling at something funny or crying at a sad memory). Assessment may include comment on the patient’s facial expression, posture, emotional response and speech patterns.
  • There are two elements to affect
    • Congruity of the observed affect. For example, the patient who describes themselves subjectively as “on top of the world”, but is objectively withdrawn and low in mood would be described as having an incongruous affect. Subjective assessment is not reflected by the objective assessment
    • The emotional range, which may be:
      • Normal
      • Flat/blunted; the reduction in the normal emotional expression, evidenced, for example by a flat, monotone voice.

 Speech

• There are two aspects of speech to consider:
  • Quality and flow of speech. Volume, dysarthria (difficulties with the articulation of words and sentences) or stuttering, for example.
  • Rate of production of speech. Is it pressured, which can suggest mania, or very slow with long pauses, which might indicate depression.

Thoughts

• Thought form
  • This is disordered thinking which includes circumstantial and tangential thinking, loosening of associations (‘knights-move’ thinking), flight of ideas, thought blocking and irrelevant answers.
• Thought content (delusions and overvalued ideas)
  • These are diagnostically classified as:
    • Primary or secondary
    • Mood congruent or mood incongruent
    • Bizarre or non-bizarre

Perception

• Is ascertained through the history with further questioning. People are usually able to distinguish what is real and what is not. When this is not the case, it is a disorder of perception. When patient’s admit they have problems with perception it is important to clarify
  • Whether these abnormal perceptions are genuine hallucinations, pseudo hallucinations, illusions or intrusive thoughts
  • Are these visual, auditory, olfactory, gustatory or somatic?
  • When discussing auditory hallucinations, try to find out if they are:
    • First person: audible thoughts and thought echo
    • Second person: critical, persecutory, complementary or command hallucinations
    • Third person: voices arguing, voices discussing the patient or giving a running commentary.

Cognition

• It is important to assess a patient’s orientation to place and time.

Insight

• Does the patient believe they are unwell?
• Do they believe they have a mental health problem?
• Do they think they need treatment?
• Do they think they need to be admitted?

Risk assessment (This will be discussed in a later section)

Some people find the mnemonic ASEPTIC helpful:

Appearance and Behaviour

Speech

Effect (mood and affect)

Perception

Thoughts

Insight

Cognition

The extent to which you complete a full psychiatric history in the ED will vary depending on circumstances.

It is not always possible or even appropriate for a full psychiatric assessment to be made by a doctor in the ED. What is important is to ensure a thorough history is taken, and physical examination is conducted as appropriate. Key questions, which should be explored in the initial assessment in the ED, include:

1. What is the presenting complaint?
2. Why has the patient presented now?
3. What does the patient want? (advice, treatment or admission)
4. Do they have a past psychiatric history?
5. Is what they are asking reasonable?

This will include a risk assessment; any patient stating an intention to self-harm should have a psychosocial assessment by a member of a mental health team before leaving the hospital.