MENTALSTATE EXAMINATION (MSE)
*PURPOSE:Toreach a tentative diagnosis.Itis the diagnosis of general cerebral functions.Designedto detect abnormal functions.Anexperienced nurse can complete all theMSE.Importantinformationcanbe taken from first sight(when enteringthe room, sitting ortalking. Also,level of consciousnesscan be observed.
1. GENERALAPPEARANCE:Goodindicator ofpts.over all mental functioning. It includesweight, height and general body built.NutritionalStatus:Poornutrition can result from medical or psychiatric disorders.Inanorexia nervosapt.is emaciated but still thinks she isfat.Overweightcan point to over eating as in affective disorders withhyperphagia.
B. Hygiene and dress:Self care and cleanliness reflects pt.'s awareness and activity level.Indepression:pt. loses interest in his appearance and hygiene.Inmania:pt. dresses in colorful and flamboyant manner. She may use too much makeup and mismatched dress.Inschizophrenia: 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 theyspeak&trackmovement &gesturesofinterviewer.Abnormal eye movements can bediagnostic:-Wandering eyes show distractibility, visual hallucinations, mania or organic states.-Avoidance of eye contact may be due to hostility, shyness, or anxiety.-If pt. issuspicious,he tracks your movements and looks to every gesture.
2. PSYCHOMOTOR BEHAVIOR:Psychomotor activity:Reducedin depression&catatonic schizophrenia or increase inmania.B. Posture:Thewaypt.sits, walks, and behaves.C. FacialExpression:Sadface in depression, mask face of Parkinsonism.
D.Activity level:Restlessnessin anxiety.Agitationin some depressedpatients.Excitementin mania.E.Abnormal movements:Voluntary:suchas the mannerisms of the schizophrenia or bizarre movements also seen inschizophrenia.Involuntary:suchas hand tremor in anxiety.
3. MOODAND AFFECT:Mood:Thepervasive and sustained emotion that colors the person's perception of the world.In depression:pt. seesthe world through dark glasses.In mania:pt.is euphoric orelated,feels superior and able to do great things.In anxiety:pt. feels afraidof theunknown.Patientis tense and expecting the worst.
B. Affect:Externalexpression ofemotionalresponsiveness.What is observedinpt.'sfacial expression &expressive behavior in response to internal or external stimuli.Evaluatedfor its intensity, duration, appropriateness tosituation, range of affective expression, and control.In schizophrenia: blunted(flat), restricted,orinappropriate tosituation.In mania: expansiveand out of control.In hysterical pts.:labileaffect that changes from extreme happiness to extreme sadness in minutes.
4. SPEECH:Amountof Speech:increasedin mania and anxiety states were theptistalkative.Pt. withmaniamay experience a pressure to speakcontinuously.Pt. withdepression speaksvery little and brief.B. Speed:Anxious pt.speaksrapidly.Depressed pt.speaks slowly.
C. Articulation:Speechcan be slurred (dysarthria) as in organic brain disorders or intoxication with alcohol or hypnotic.D. Rhythm:In depression speech is monotonous.
5. THOUGHT:A. ThoughtProcess:Thewaypt.puts thoughts together and associates between them.In mania:rapid and pt.feels pressure of thoughts,andmaygo on to form flight ofideas.In depression:slowIn schizophrenia: lossof association between thoughts or poverty of thoughts were they could be empty or vague.Blocking:interruptionofprocessas if they were withdrawn frompt.'shead as in schizophrenia.
B. ThoughtContent:Delusions:-Fixedfalse beliefs heldby pt.and not shared by persons in his culture.-Theyindicate thatpt.is psychotic e.g. delusions of persecution, reference or grandiosity.
Overvaluedideas:-Unreasonablesustained false beliefs held less firmly than delusions.Phobias:-Unreasonablefear of exposure to specific objects or situations e.g. agoraphobia, claustrophobia.
Obsessions:-Irresistiblerecurrent thought or feeling that can not be eliminated by logical effort and associated with anxiety.Compulsions:-Meaninglessacts thatpt.feels compelled toperform as counting, washing…
Hypochondria:-Exaggeratedconcern over one’s health based on false interpretation of physical signs and not supported by realistic pathology.
6. PERCEPTION:Interpretationof events.Sometypes ofhallucinationappear in some clients according to the senses.Wehave 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.Levelof Consciousness:Pt.awareness of and responsiveness to his internal and external environments.Itcan be clouded in organic states and intoxication.Inpsychiatric disorders as in dissociative hysteria or fugue states.B.Orientation:Pt.'sawareness of his time, place and person.Usuallydisturbed 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.Impairedin mania were thept.is distractible by minor stimuli and in anxiety states.
D. Memory:Ability to recall information.Itis divided into:-Immediate:askpt.to repeat 6 digits in the same order (within seconds to less than a minute).-Shortterm:tellpt.three items and ask him to repeat them after 5 to 10 minutes.-Longterm:askpt.what he did yesterday.-Remote:askpt.about information in his childhood, school…
E. Abstractthinking:Abilityto deal with concepts.Ask pt.to explain a known proverb or the similarity between two things.Answersmay beconcreteas if the patient says that an orange and apple are bothround,Orabstractif he says that they are both fruit.Abstract thinking is impaired in schizophrenia and organic brain syndrome.
F. Intelligenceand information:Ifimpairment is suspected,ask pt.to perform simple tasks as calculations,Askhim what remains of a 100 $ if he buys a shirt with 35 $ and a pants with 64 $.Ifhe finds difficult ask easier questions.Pt.'sfund of information should be relevant to his educational& socialbackground.Askabout important dates, persons, or…
8. INSIGHT AND JUDGMENT:A.Insight:Degree of pt.'sawareness that he is ill.Pt.may deny completely that he has anyproblem (insightis totallylost).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.Askpt. 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.Somepatients can not resist impulses to explore youroffice;they look in books and turn things e.g. mania.Impulsecontrol can be assessed from the patient’s history.
10. RELIABILITY:How reliable is the information gathered about thepatient?Didhe report his condition accurately or was there any difficulty due to mental retardation, dementia or impairedconsciousness?Isthere a need for furtherinvestigations?
11. SUMMARY:Majorpositive and negative data from the history and MSE are summarized.Aprovisional diagnosis is suggested and a differential diagnosis is given.Investigationsand tests needed are listed.