Mental Status Examination (MSE) Maggie Walker 2013 PDF

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Summary

The mental status examination (MSE) is perhaps the most essential part of the clinical assessment process in psychiatric practice and care. It is a structured way of observing and describing a consumer's current state of mind, using certain “domains”. These are Mood and Affect, Perceptions and Hallu...

Description

Mental Status Examination and Assessment 1 The mental status examination (MSE) is perhaps the most essential part of the clinical assessment process in psychiatric practice and care. It is a structured way of observing and describing a consumer's current state of mind, using certain “domains”. These are Mood and Affect, Perceptions and Hallucinations, Thought Process and Content, Suicidal and Homicidal Ideation, Cognition (this includes memory and concentration), Insight and Judgement, Appearance, Behaviour, Rapport, Speech. The MSE was designed to enable the clinician to obtain a comprehensive understanding and therefore description of the consumer's mental state. It is combined with historical and biographical information. This enables the clinician to make a diagnosis and formulation which is essential for accurate and thorough treatment planning. The MSE also highlights areas of possible differential diagnosis. This is absolutely necessary to avoid misdiagnosis; many physical conditions can present psychiatrically and vice versa, and many medications can precipitate psychiatric illness. Information is collected through the processes of direct interviewing and observation of the consumer. Specific questions are asked about current symptoms and their history as well as the consumer’s psychiatric and medical history. It is essential to collect information regarding family history and the consumers’ social situation. At times formalised psychological tests are undertaken as an adjunct to the MSE. The information is often unable to be gathered at one interview and there is a need to collect more information as the consumers’ journey continues. The MSE is not the same as a mini-mental state examination (MMSE). It is frequently confused with the MMSE which is a brief screening test for dementia. The MSE is the core skill of any mental health professional. Those not directly working in the mental health field still require and understanding of the MSE due to differential diagnostic issues. The purpose of the MSE is to obtain evidence of signs and symptoms of mental disorder or illness. It is essential to assess the consumer’s danger to themself and others. In Australia risk to reputation is also assessed. Information about the consumer's insight, judgment, and capacity for abstract reasoning is used to guide decisions regarding treatment and the treatment setting. Open and closed questions are used as well as specific structured tests to help assess cognition. Information should be written down using standardised headings. The outcome of the MSE is used alongside the other information, in order to generate a formulation of the mental disorder/illness, make a diagnosis and formulate a comprehensive and holistic treatment plan.

The Domains Domains – in all domains consideration has to be given as to the patient’s gender, gender orientation, culture, sub-culture, religious, spiritual and cultural beliefs. Also consideration must be given to differences between the interviewer and the patient e.g. culture, religion, gender etc. And any bias each party may have.

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Mental Status Examination and Assessment 2 Mood and Affect. Trzepacz and Baker (1993) describe mood as a person's predominant internal state at any one time. They described affect as the external and dynamic manifestations of a person's internal emotional state. Others have described the two states differently. The Trzepacz and Baker definitions are used for the MSE. Therefore mood is the current subjective state of the consumer as described by the consumer. Affect is the interviewer’s inference of the consumer's emotional state based on objective observation. There is question and debate as to whether or not the interviewer can comment upon the mood state as well e.g: Mood - X reports that his mood is good and he has not problems but his presentation is incongruent with his reporting as he presents with depressed mood. Affect - flat and incongruent with reported mood state. Mood is primarily described using the patient's own words. It can also be described in psychiatric terms by the interviewer e.g. euthymic, dysphoric, dysthymic, depressed, expansive, euphoric, elevated, hypomanic, manic, angry, anxious, apathetic, labile, expansive. A person who is unable to experience any pleasure what-so-ever has anhedonia. Alexithymia is a term used to describe when consumers have an inability to identify and describe their emotions; these consumers may also have difficulty in distinguishing, empathising with and understanding the emotions of others. It is a personality construct not a symptom of illness. When assessing mood state it is a very good idea to use a numerical scale to assist in assessment, this can help the patient to more accurately describe or rate their mood and can be used as a reference for improvement, deterioration and history of mood. 0

5

10

0 = the worst the patient could possibly feel and wants to die 10 = the best the patient can feel in a normal mood state >10 = Elevation of mood, hypomania, mania

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11

12

13

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Mental Status Examination and Assessment 3 Affect is the apparent emotion, observed by the interviewer, as conveyed by the consumer's nonverbal behaviour e.g. euthymic, dysphonic, dysthymic, depressed, anxious, sad, tearful, flat, labile, restricted, blunted, elevated, hypomanic, manic. The interviewer should also comment upon: 

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Range or intensity: full (normal), labile, restricted, blunted, exaggerated, flat, dramatic, expansive, exaggerated, overly-reactive, heightened. An expansive, overly reactive or heightened affect could suggest elevation, hypo-mania or mania. An overly dramatic or exaggerated affect might suggest the presence of a personality disorder. Appropriate or inappropriate i.e. it is appropriate to be sad at the death of a friend etc. Congruent: matches the mood Incongruent: doesn’t match the mood state i.e. the consumer presents as labile but reports that they are well, this is incongruent. If a consumer shows a happy mood state following bad news this is usually described as incongruent; be careful not to judge. A consumer may not be affected by the death of a parent, if for example, their upbringing was dysfunctional and that relationship was terminated a long time ago. Stability: stable vs. labile Reactivity sometimes called mobility This is the way the consumers affect changes during interview or conversation. Terms as reactive, fixed, immobile or labile can be used. The person may show a full range of affect; this means they show a wide range of emotional expression. Conversely the affect may be described as being restricted.

The following while not true “DOMAINS” should be enquired about as they are very relevant to diagnosis and care: Anxiety is a symptom that is often not specifically asked about but it is a debilitating and under diagnosed issue, hence its inclusion here. Anxiety can be a part of another illness e.g. depression or anxiety as a result of distressing delusions or auditory hallucinations. It can also be a disorder in its own right. Its exact nature may not become recognisable until a later stage. Again a continuum is useful for assessment. 0

5

10

0 = the absence of anxiety; 10 = anxiety at its most extreme with feelings of panic What is also important to note is: did the anxiety occur before the presenting illness, is it made worse by the presenting illness or did it occur with the presenting illness and does it’s picture mirror that of the presenting illness or is the presentation different in any way.

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Mental Status Examination and Assessment 4 Sleep, enquire about and observe for:           

Usual pattern for the consumer, hours etc, do they wake refreshed? Changes to usual pattern. How long has this been going on? What makes sleep worse or better? Can’t drop off to sleep Broken sleep Middle insomnia Early morning wakening Fear of sleep and why Dreams or nightmares Does the consumer wake refreshed?

Energy, enquire about and observe for:      

Energy levels What is normal for the consumer How does the consumer differ from their normal How long has this been going on? What makes this worse or better? The presence of psychomotor agitation or retardation can be included here or under the domain of behaviour

ADL’s, enquire about and observe for:  Hygiene & grooming  Food and fluid intake  Voiding

Perceptions and Hallucinations Perceptions. A perception is not a hallucination it is a sensory experience. They are: • •

•

Illusions - like a mirage in the desert or heat shimmering on a hot summer road. Hypnopompic hallucinosis (dropping off to sleep) or hypnogogig hallucinosis (waking up) these are perceptual disturbances such as hearing someone say your name, hearing a door shut or seeing things briefly and fleetingly etc. These are quite common and occur when the brain is dropping off to or waking up from sleep Alcoholic hallucinosis, where the consumer is withdrawing from alcohol and usually see’s vague things or faces of people he or she knows, the faces usually occur when they close their eyes, these occur as a result of organic brain changes.

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Mental Status Examination and Assessment 5 •

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Pseudo-hallucinations which are e.g. when the consumer complains of voices in their head but the voice comes from inside the patients head or ear not from outside the patients head or ear. Sounds heard from the outside are hallucinatory. Pseudo-hallucinations are regarded as a non-psychotic symptom. People who have personality disorders or issues with fantasy or untruth may experience pseudo-hallucinations. Déjà vu when the consumer’s sense of time is distorted. Depersonalization when the consumer’s sense of self is distorted. Derealisation is where the consumer has a distorted sense of reality.

Hallucinations. These are sensory perceptions without external stimuli. The experience for the patient is real. Hallucinations can be auditory, visual, tactile (touch), olfactory (smell) or gustatory (taste). Auditory and then visual are the most common. Auditory hallucinations are typical of a psychotic illness. The patient hears a voice or voices either: talking to them directly; talking about them in the third person or they hear a cacophony of voices. The voices are usually threatening or insulting. They can also be command in nature telling the consumer to commit suicide or hurt other people and accurate assessment is therefore essential. Duration of presence, periods of absence, intensity, volume, how distracting the voices are, whether or not the consumer can ignore them, what gender are they, does the consumer recognise the voices, the content of what they are saying and insight into the voices should all be considered. Some consumers always hear voices to some degree but live with them and cope and this is their personal wellness level. Auditory pseudohallucinations are common in dissociative disorders and personality disorders. Visual hallucinations are not as common as auditory hallucinations. They are, by in large, vague e.g. a movement out of the side of the consumers vision, shadows, faces seen in the patterns on walls, flooring, bushes and trees etc. The subject matter of the visual hallucinations is most usually related to the auditory hallucinations and they do not exist independently. Vivid or clear visual hallucinations generally suggest an organic condition e.g. epilepsy, brain injury, toxicity due to infection, high fever, tumour, or, toxicity as a result of drug use and/or drug/alcohol withdrawal. Their presence may also be suggestive of a personality disorder or untruth. Visual effects of hallucinogenic drugs can be more correctly described as visual illusions or visual pseudohallucinations as they are distortions of sensory experiences. Tactile hallucinations are generally uncommon and are usually seen if the consumer has an organic issue e.g. alcohol withdrawal. However they can and do happen to people who have severe anxiety, here the consumer often feels as if they have something crawling under their skin. As with any symptom it is important to fully investigate i.e. does your consumer have another reason for this symptom e.g. an organic issue within the brain, scabies, body lice. Olfactory and gustatory hallucinations are again generally uncommon and can indicate that the consumer has an organic issue e.g. epilepsy.

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Mental Status Examination and Assessment 6

Thought Process Isuues with Though Process fall into 2 areas Form and Disorder (Formal Thought Disorder, FTD): refers to a serious problem with thinking and feeling where there is an interruption or disorganization of thought processing. Thought Form and Disorder is assessed by what the consumer describes and/or from what the interviewer notices in the consumer’s speech. It refers to the quantity, flow and rate of the consumers thinking as well as whether or not the consumers’ thinking is logical and coherent. Thought Form Logical/illogical/irrelevant/incoherent Tangential - the consumers speech in relation to a subject or question doesn’t streamline

during discussion, instead they veer off onto subjects that have some relation to the topic; this can be a sign of psychosis or an ego defence mechanism. Loose associations Derailment - this is where the thinking completely slips off one track and onto another and

there is no relation between one topic and the other Racing thoughts – as it sounds it is where the consumer experiences their thoughts racing around in their head. Flight of ideas - this is typical of mania, here the thinking is so rapid the consumers speech appears incoherent, this indicates the flow or rate of thought. Circumstantial thinking - the speech of the consumer is long winded and has a lot of irrelevant

and/or excessive detail but they usually eventually get to the point. It’s like the consumer goes around in a big, long circle to give an explanation to a simple question or in discussion of a topic. Retarded or inhibited thinking is a slowed pattern of thinking. Thought blocking - the thinking stops in the head mid way through a thought process and the

consumer cannot retrieve the thought. Concrete thinking - literal and linear thinking where the consumer cannot use or understand

metaphors or abstract speech or reasoning

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Mental Status Examination and Assessment 7 Echolalia – the repetition of another person's words Palilalia - the is repetition of the consumer’s own words Neologisms - these are made-up words which have a specific meaning to the person using them.

Thought Disorder AKA Formal Thought Disorder Poverty of speech/thought – this is where there is an overall reduction in the quantity of thought. It is one of the negative symptoms of schizophrenia it can also be a feature of severe depression or dementia. Thought blocking - the thinking stops in the head mid way through a thought process and the

consumer cannot retrieve the thought. Thought broadcasting Thought insertion Thought perseveration - this is a pattern of thinking where the consumer keeps returning to the same limited set of ideas. Ideas of reference – the consumer finds relevance in insignificant and/or external events,

remarks etc in that these things happen to them for a reason or have a special meaning Illogical Tangential Derailment Perseveration – where the consumer keeps on returning to the same set of ideas

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Mental Status Examination and Assessment 8 Content Thought Content: refers to delusions, overvalued ideas, obsessions, phobias, somatic beliefs/behaviours any preoccupations. Suicidal ideation and thoughts to harm others are also examples of thought content but are covered under a separate heading. The interviewer assesses: • • • • •

Intensity: this is how noticeable or prominent or pronounced the thought content is. The emotions associated with the thoughts. How logical etc they are. Are the thoughts experienced as the patient’s own and under their control or does the consumer experience being controlled by something outside of them The degree of how much belief is associated with the thoughts should also be ascertained to work out if the thinking is truly delusional or if the thinking falls into the category of being an over-valued idea. This is a spectrum or continuum of thinking, see below. Trying to ascertain if any of the thinking can be disputed or challenged is an important factor in the diagnostic picture.

“normal” thinking

over valued idea

delusional ideation

A delusion is a fixed false belief that cannot be disputed, recent research points to the usefulness of CBT in treating some consumers’ delusional belief systems. One could argue that this is effective in the milder range of the delusional spectrum. To be delusional a thought has to be out of keeping with the patient's educational, cultural, religious, spiritual, familial or social background. The patient's delusions can be described as: Persecutory, Paranoid or Grandiose. There are also Delusions of Infidelity and Erotomania, delusions of infidelity and erotomania are the most dangerous of all delusions. Delusions of reference, delusional jealousy and delusions of misidentification can also occur. Delusions are described as mood-congruent i.e. the content is in keeping with the mood or incongruent if they are not in keeping with the mood. Congruent delusions are typical of manic or depressive psychoses; mood-incongruent delusions are more reflective of schizophrenia. Delusions of control or passivity where the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency are typical of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of depressive psychoses. An overvalued idea is a false belief that is held with conviction but not with delusional intensity. Hypochondria is an overvalued idea that the patient has about themselves that they are suffering from an illness. Body dysmorphia is an overvalued idea the patient has that a part of their body is abnormal, they will see a distorted image in the mirror when they look at themselves; people with anorexia nervosa are often dysmorphic about being overweight. Maggie Walker 2013

Mental Status Examination and Assessment 9 An obsession is an unwanted, unpleasant and/or intrusive thought that the patient cannot stop from happening by just their will alone. The patient is aware of these thoughts and that they are originating from within their own mind and that these thoughts are irrational and unhelpful but they have little or no ability to stop them. These thoughts and their associated behaviour are often compulsive in nature. A person can also experience obsessional doubts about themselves and decisions that they have made, worry obsessively that they have forgotten to do something e.g. lock the house, switch off the electricity or that they have made a bad or poor or wrong decision. In obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions. A phobia is an abject fear or dread of an object or situation that is usually extreme. In addition the reality is that the object or situation does not pose any real threat. A phobia is different from a delusion because the patient is aware that their fear is irrational. A patient’s phobia is specific to them and personalised to situations that they dread. The phobia is rarely observed at interview and mostly reported on by the patient. It can be accompanied by panic symptomology and/or avoidance behaviou...