MENTAL STATE EXAMINATION (MSE)

MENTAL STATE EXAMINATION (MSE) *PURPOSE: • To reach a tentative diagnosis. • It is the diagnosis of general cerebral functions. • Designed to detect abnormal functions. • An experienced nurse can complete all the MSE. • Important information can be taken from first sight (when entering the room, sitting or talking. Also, level of consciousness can be observed.

1. GENERAL APPEARANCE: • Good indicator of pts. overall mental functioning. It includes weight, height and general body built. • Nutritional Status: • Poor nutrition can result from medical or psychiatric disorders. • In anorexia nervosa pt. is emaciated but still thinks she is fat. • Overweight can point to overeating as in affective disorders with hyperphagia.

B. Hygiene and dress: • Self care and cleanliness reflects pt.'s awareness and activity level. • In depression: pt. loses interest in his appearance and hygiene. • In mania: pt. dresses in colorful and flamboyant manner. She may use too much makeup and mismatched dress. • In schizophrenia: pt. may use strange items for dress e.g. antennas, bags to protect them from the control of space people.

C. Eye contact: • People usually maintain eye contact when they speak& track movement & gestures of interviewer. • Abnormal eye movements can be diagnostic: -Wandering eyes show distractibility, visual hallucinations, mania or organic states. -Avoidance of eye contact may be due to hostility, shyness, or anxiety. -If pt. is suspicious, he tracks your movements and looks to every gesture.

2. PSYCHOMOTOR BEHAVIOR: • Psychomotor activity: • Reduced in depression &catatonic schizophrenia or increase in mania. B. Posture: • The way pt. sits, walks, and behaves. C. Facial Expression: • Sad face in depression, mask face of Parkinsonism.

D. Activity level: • Restlessness in anxiety. • Agitation in some depressed patients. • Excitement in mania. E. Abnormal movements: • Voluntary: such as the mannerisms of the schizophrenia or bizarre movements also seen in schizophrenia. • Involuntary: such as hand tremor in anxiety.

3. MOOD AND AFFECT: • Mood: • The pervasive and sustained emotion that colors the person's perception of the world. • In depression: pt. sees the world through dark glasses. • In mania: pt. is euphoric or elated, feels superior and able to do great things. • In anxiety: pt. feels afraid of the unknown. Patient is tense and expecting the worst.

B. Affect: • External expression of emotional responsiveness. • What is observed in pt.'s facial expression &expressive behavior in response to internal or external stimuli. • Evaluated for its intensity, duration, appropriateness to situation, range of affective expression, and control. • In schizophrenia: blunted (flat), restricted, or inappropriate to situation. • In mania: expansive and out of control. • In hysterical pts.: labile affect that changes from extreme happiness to extreme sadness in minutes.

4. SPEECH: • Amount of Speech: • Increased in mania and anxiety states were the pt. is talkative. • Pt. with mania may experience a pressure to speak continuously. • Pt. with depression speaks very little and brief. B. Speed: • Anxious pt. speaks rapidly. • Depressed pt. speaks slowly.

C. Articulation: • Speech can be slurred (dysarthria) as in organic brain disorders or intoxication with alcohol or hypnotic. D. Rhythm: • In depression speech is monotonous.

5. THOUGHT: A. Thought Process: • The way pt. puts thoughts together and associates between them. • In mania: rapid and pt. feels pressure of thoughts, and may go on to form flight of ideas. • In depression: slow • In schizophrenia: loss of association between thoughts or poverty of thoughts were they could be empty or vague. • Blocking: interruption of process as if they were withdrawn from pt.'s head as in schizophrenia.

B. Thought Content: • Delusions: -Fixed false beliefs held by pt. and not shared by persons in his culture. -They indicate that pt. is psychotic e.g. delusions of persecution, reference or grandiosity.

Overvalued ideas: -Unreasonable sustained false beliefs held less firmly than delusions. • Phobias: -Unreasonable fear of exposure to specific objects or situations e.g. agoraphobia, claustrophobia.

Obsessions: -Irresistible recurrent thought or feeling that can not be eliminated by logical effort and associated with anxiety. • Compulsions: -Meaningless acts that pt. feels compelled to perform as counting, washing…

Hypochondria: -Exaggerated concern over one’s health based on false interpretation of physical signs and not supported by realistic pathology.

6. PERCEPTION: • Interpretation of events. • Some types of hallucination appear in some clients according to the senses. • We have to be sure that pt. has no organic problems especially in ?visual hallucination. • Hallucination types:Visual, Auditory, Olfactory, Tactile, and Taste.

7. SENSORIUM AND COGNITION: A. Level of Consciousness: • Pt. awareness of and responsiveness to his internal and external environments. • It can be clouded in organic states and intoxication. • In psychiatric disorders as in dissociative hysteria or fugue states. B. Orientation: • Pt.'s awareness of his time, place and person. • Usually disturbed in organic brain syndromes.

C. Concentration: • Ability to keep one’s attention on a certain task. • See if the patient can subtract 7 from 100 and notice his effort and time taken to perform this task. • Impaired in mania were the pt. is distractible by minor stimuli and in anxiety states.

D. Memory: • Ability to recall information. • It is divided into: -Immediate:ask pt. to repeat 6 digits in the same order (within seconds to less than a minute). -Short term:tell pt. three items and ask him to repeat them after 5 to 10 minutes. -Long term:ask pt. what he did yesterday. -Remote:ask pt. about information in his childhood, school…

E. Abstract thinking: • Ability to deal with concepts. • Ask pt. to explain a known proverb or the similarity between two things. • Answers may be concrete as if the patient says that an orange and apple are both round, • Or abstract if he says that they are both fruit. • Abstract thinking is impaired in schizophrenia and organic brain syndrome.

F. Intelligence and information: • If impairment is suspected, ask pt. to perform simple tasks as calculations, • Ask him what remains of a 100 $ if he buys a shirt with 35 $ and a pants with 64 $. • If he finds this difficult, ask easier questions. • Pt.'s fund of information should be relevant to his educational & social background. • Ask about important dates, persons, or…

8. INSIGHT AND JUDGMENT: A. Insight: • Degree of pt.'s awareness that he is ill. • Pt. may deny completely that he has any problem (insight is totally lost). • Some pts. realize that there is a problem but explain it to be the result of somatic or social cause (partial insight).

B. Judgment: • Ability to choose appropriate goals and appropriate means to reach them. • Ask pt. what he would do if he smelled smoke in his house or found a closed addressed letter in the street.

9. IMPULSE CONTROL: • Is the patient ability to control his sexual, aggressive and other impulses. • Some patients cannot resist impulses to explore your office; they look in books and turn things e.g. mania. • Impulse control can be assessed from the patient’s history.

10. RELIABILITY: • How reliable is the information gathered about the patient? • Did he/she report his/her condition accurately or was there any difficulty due to mental retardation, dementia or impaired consciousness? • Is there a need for further investigations?

11. SUMMARY: • Major positive and negative data from the history and MSE are summarized. • A provisional diagnosis is suggested and a differential diagnosis is given. • Investigations and tests needed are listed.

MENTAL STATE EXAMINATION (MSE)