Mental State Examination APPEREANCE AND BEHAVIOUR Appearance Personal hygiene Are there any signs of self-neglect? Clothing Are they depressed appropriately for the weather and circumstances ? Are the clothes put on correctly? Physical signs of underlying difficulties Are there any signs of self-harm scars or signs of IV drug use> Stigmata of disease? E.g. jaundice Weight Very underweight or very overweight? Object Did they bring any objects with them? Behaviour Engagement and rapport Is the patient engaged? Are they able to build up a rapport? Do they appear to be distracted? Do they appear to be responding to hallucinations. Eye contact Reduced Intense Staring Facial expressions Relaxed, fearful, angry etc. Are they able to respond appropriately? E.g. do they laugh when difficult topics come up? E.g. do they become tearful when difficult topics come up? Body language Threatening e.g. standing close to you Withdrawn e.g. curled up or hands covering the head Note any evidence of exaggerated gesticulations or unusual mannerisms Are there any signs of paranoia? Does the patient appear to be on the edge, fearful, glancing around the room? Psychomotor activity Observe for any signs of abnormalities Psychomotor retardation Associated with paucity in movement and delayed responses to questions Restlessness Continuously fidget, pace and refuses to sit still Abnormal movements or postures Note any abnormalities or postures Involuntary movements Tremors Ticks Lip smacking Akathisias Rocking Posturing SPEECH Rate of speech Pressure of speech Rapid speech - Motivated by an urgency that may not be apparent -> may be present in mania Slow speech – may occur due to psychomotor retardation -> may be present in depression Quality of speech Poverty of speech Depression Excessive speech Mania Tone of speech Monotonous depression, psychosis and autism tremulous anxiety V olume of speech quiet depression loud mania Fluency and rhythm of speech stammering or stuttering slurred speech may occur in major depression due to psychomotor retardation MOOD AND AFFECT R elate s to emotions Affect Immediately expresses and observed emotion i.e. what you observe E.g. patient’s facial expression Apparent emotion: For example, sadness, anger, hostility, euphoria. Range and mobility of affect : Variability observed in the patient’s affect during the assessment. Fixed affect: the patient’s affect remains the same throughout the interview, regardless of the topic. Restricted affect: the patient’s affect changes slightly throughout the interview but does not demonstrate the normal range of emotional expression that would be expected. Liable affect: characterised by exaggerated changes in emotion which may or may not relate to external triggers. Patient’s feel that they have no control over their emotions. Intensity of affect : Heightened: associated with mania and some personality disorders. Blunted or flat: associated with schizophrenia, depression and post-traumatic stress disorder. Congruency of affect : Is the patient’s affect appearing in keeping with the content of their thoughts (congruency). A patient sharing distressing thoughts whilst demonstrating a flat affect or laughing would be considered incongruent affect. Incongruent affect -> typically associated with schizophrenia. Mood Patient’s predominant subjective internal state at any one time as described by them i.e. what the patient says. How to ask: How are you feeling today? What is your current mood> Have you been feeling low/depressed/anxious lately? Examples: Low mood Anxious Enraged Euphoric Guilty Apathetic THOUGHTS Through Form Possessing and organisation of thoughts. Speed of thoughts : May be abnormally fast e.g. racing in mania or abnormally slow thought processing. Flow and coherence of thoughts: In a healthy person should flow at a steady pace and in a logical order. Loose associations: moving rapidly from one topic to another with no apparent connection between topics. Circumstantial thoughts: thoughts which includ e lots of irrelevant and unnecessary details but do eventually come back to the point. Tangential thoughts: digressions from the main conversation subject, introducing thoughts that seem unrelate, oblique and irrelevant. Flight of ideas seen with fast and pressured speech, where ideas run into one another making it difficult for the observer to follow the speech. Thought blocking sudden cessation of thought, typically, mid-sentence which the patient unable to remove from what was previously said. Preservation: refers to the repetition of a particular response despite the absence/removal of the stimulus. E.g. when the patient is asked what their name is, and they continue to repeat their name to answer all further questions. Neologisms: words a patient has made up which are intelligible to another person. Word salad: speaking a random string of words without relation to one another. Thought Content Delusions : A firm fixed belied that is based on inadequate grounds and not amendable to rational argument or evidence contrary and not in sync with regional and cultural norms. For example, when the patient believes, someone is trying to harm them or that the news reporter is referring to them. Obsessions: T houghts, images, or impulses that occur repeatedly and feel out of the person’s control. Patient is aware that these obsessions are irrational, but the thoughts continue to enter the head. Compul sions: R epetitive behaviours that the patient feels compelled to perform despite recognising the irrationality of behaviour. Suicidal thoughts Homicidal/violent thoughts. Questions to screen for thought content abnormalities : What has been on your mind recently? Are you worried about anything? Do you sometimes have thoughts that others tell you are false? Do you have any beliefs that aren’t shared by others you know? Do you ever feel that people are out to harm you ? Do you ever feel that specific events in the world relate to you somehow? Are there any thoughts you have a hard time getting out of your head? Do you sometimes feel the need to perform certain behaviours repetitively, despite understanding these are irrational? Do you ever think about ending your life? Have you ever attempted to end your life? Have you ever harmed yourself to cope with difficult emotions? Do you ever think about harming others? Thought Possession Abnormalities Thought insertion: A belief that thoughts can be inserted into the patient’s mind. Thought withdrawal: A belief that thoughts can be removed from a patient’s mind. Thought broadcasting : A belief that others can hear the patient’s thoughts How to ask: Do you think people can put ideas in your head without your control? Have you ever felt like people have removed memories or thoughts from your mind? Do you ever feel like others can hear your thoughts? PERCEPTION Involves organisation, identification and interpretation of sensory information to understand the world. Abnormalities : Hallucinations: Sensory perception without any external stimulation of the relevant sense that the patient believes is real. E.g. the patient hears voices, but no sound is present. Pseudo-hallucinations: Same as hallucinations, but the patient knows is not real Illusions: The misinterpretation of an external stimulus e.g. mistaking a shadow for a person. Derealisation: A sense that the world around them is not true reality. How to ask: Do you ever see, hear, smell or feel or taste things that are not really there ? Do you think this was a real at the time? Do you still believe that was real? Do you ever feel like you’ve changed or that you don’t recognise the person you currently are? Do you ever feel like the world are you isn’t real? COGNITION The mental action or process of acquiring knowledge and understanding through thought, experience and the senses. Is the patient orientated in time, place or person? What are the patient’s span and concentration like? What is the patient’s short-term memory like? Formal assessment can be done through: MMSE AMTS ACE-III MOCA INSIGHT AND JUDGEMENT Insight Ability of a patient to understand that they have a mental health problem and that what they are experiencing is abnormal. How to ask: What do you think the cause of the problem is? Do you think you have a problem at the moment ? Do you feel you need help with your problem? Judgment Ability to make considered decisions or come to a sensible conclusion when presented with information. Can become impaired in mental health conditions leading to poor decision making. Can assess through questions such as: What would you do if you could smell smoke in your house? RISK Risk to self Ask if experiencing any thoughts of harming themselves and if they plan to act on these thoughts . Ask about deliberate self-harm with no suicide intent but as a way of managing overwhelming and difficult emotions of feelings of dissociation. How to ask: Sometimes when people are going through difficult things, they might have thoughts of wanting to harm themselves, is this something you have experienced? Do you have any plans to act on those thoughts? People can sometimes hurt themselves to manage overwhelming emotions or feeling of numbness – is this something you’ve ever done? If so, how do you cope with those feelings? Assess other aspects of risk: Substance misuse, what do they use? Self-neglect: are they eating and drinking? Are they attending to hygiene? Are they attending to their physical health needs? For example, taking medications for physical health conditions. Risk to others Ask if they have any thoughts or have made any plans to harm others. Sometimes when people are going through difficult things, they might have thoughts to harm someone else. Is this something you have experienced? Do you have any plans to act on those thoughts?