1. MENTAL STATE EXAMINATION
Fahad Alosaimi MBBS, SSC-Psych
Consultation liaison psychiatrist
King Saud University

2. The mental status examination( MSE)
MSE is a cross-sectional, systemic documentation of the quality of mental functioning at the time of interview.
It serves as a baseline for future comparison and to follow the progress of the patient.

3. Outlines of MSE Appearance , Behaviour & Attitude (Cooperativeness)
Speech
Mood & Affect
Thoughts
Perceptions
Cognitive functions
Consciousness level
orientation(time, place, person)
attention
concentration
Memory
Language and reading.
Visuospatial ability
Abstract thinking
Judgment & Insight

4. MSE
Appearance:
include body build, self-care, clothes ,grooming, hair,nails, facial expressions, and any unusual features (e.g. weight loss).
Behaviour:
*both the quantitative and qualitative aspects.
*Note level of activity, posture, eye to eye contact and unusual movements (tics, grimacing, tremor, disinhibited behaviour, hallucinatory gestures,…etc)
Attitude:
*Note the patient’s attitude( verbal& non verbal) during the interview (interested, bored, cooperative, uncooperative, sarcastic, guarded or aggressive).
General Description
Appearance. In this category, the psychiatrist describes the patient's appearance and overall physical impression, as reflected by posture, poise, clothing, and grooming. If the patient appears particularly bizarre, the clinician may ask, "Has anyone ever commented on how you look?" "How would you describe how you look?" "Can you help me understand some of the choices you make in how you look?"
Examples of items in the appearance category include body type, posture, poise, clothes, grooming, hair, and nails. Common terms used to describe appearance are healthy, sickly, ill at ease, poised, old looking, young looking, disheveled, childlike, and bizarre. Signs of anxiety are noted: moist hands, perspiring forehead, tense posture, wide eyes.
Overt Behavior and Psychomotor Activity. This category refers to both the quantitative and qualitative aspects of the patient's motor behavior. Included are mannerisms, tics, gestures, twitches, stereotyped behavior, echopraxia, hyperactivity, agitation, combativeness, flexibility, rigidity, gait, and agility. Restlessness, wringing of hands, pacing, and other physical manifestations are described. Psychomotor retardation or generalized slowing down of body movements should be noted. Any aimless, purposeless activity should be described.
Attitude Toward Examiner. The patient's attitude toward the examiner can be described as cooperative, friendly, attentive, interested, frank, seductive, defensive, contemptuous, perplexed, apathetic, hostile, playful, ingratiating, evasive, or guarded; any number of other adjectives can be used. The level of rapport established should be recorded.

5. Impression?!

6. Impression?!

7. Impression?!

8. Impression?!

9. MSE *Listen to and describe how the patient speaks, noting: Speech:
* Speech can be described in terms of its quantity, rate of production, and quality.
*Listen to and describe how the patient speaks, noting:
Coherence
spontaneity
Volume, flow & tone
continuity
speech impairments (stuttering, dysarthria…)
This part of the report describes the physical characteristics of speech. Speech can be described in terms of its quantity, rate of production, and quality. The patient may be described as talkative, garrulous, voluble, and taciturn, unspontaneous, or normally responsive to cues from the interviewer. Speech may be rapid or slow, pressured, hesitant, emotional, dramatic, monotonous, loud, whispered, slurred, staccato, or mumbled. Impairments of speech, such as stuttering, are included in this section. Unusual rhythms (termed dysprosody) and any accent that may be present should be noted. Is the patient's speech spontaneous or not?

10. MSE (AFFECT) *Note any affect abnormalities in:
Its nature (e.g. anxiety, depression, elation…),
Its variability (constricted affect, labile affect..),
Its appropriateness whether the affect is to the thought content.

11. Mood
Affect
The long term feeling state through which all experience are filtered.
the emotional background
Last days to weeks.
Changes spontaneously, not related to internal or external stimuli.
Symptom (ask patient)
the visible and audible manifestations of the patents emotional response to external and internal events .
The emotional foreground
Momentary , seconds to hours.
Changes according to interanl & extrnalstimuli,
observed by others (sign)(Current emotional state)

12. Thought Forms (process) contents
the way in which a person puts together ideas and associations.
Examples:
goal-directed thinking
Loosening of associations or derailment
Flight of ideas
Tangentiality
Circumstantiality
Word salad or incoherence
Neologisms
Clang associations (rhyming)
Punning(double meaning)
Thought blocking
Vague thought
what a person is actually thinking about.
Delusions
Preoccupations
Obsessions and compulsions
Phobias
Suicidal or homicidal ideas
Ideas of reference and influence
Poverty of content
Thought Content. Disturbances in content of thought include delusions, preoccupations (which may involve the patient's illness), obsessions ("Do you have ideas that are intrusive and repetitive?"), compulsions ("Are there things you do over and over, in a repetitive manner?" "Are there things you must do in a particular way or order?" "If you do not do them that way, must you repeat them?" "Do you know why you do things that way?"), phobias, plans, intentions, recurrent ideas about suicide or homicide, hypochondriacal symptoms, and specific antisocial urges.
A 32-year-old woman with a mild viral syndrome picked up a carton of milk in the supermarket and then returned it to its shelf, after deciding not to buy it. Over the next few days, she spent increasing amounts of time thinking about the act. She could not stop herself from thinking that the mother of a young child picked up the same container, contracted the patient's virus, and gave it to her child, who may then have become ill and died as a result of a fulminant infection. Despite knowing that this sequence of events was extremely unlikely, the woman could not stop replaying the scenario in her mind.
Does the patient have thoughts of doing harm to himself or herself? Is there a plan? A major category of disturbances of thought content involves delusions. Delusions—fixed, false beliefs out of keeping with the patient's cultural background—may be mood congruent (in keeping with a depressed or elated mood) or mood incongruent. The content of any delusional system should be described, and the psychiatrist should attempt to evaluate its organization and the patient's conviction as to its validity. The manner in which it affects the patient's life is appropriately described in the history of the present illness. Delusions may be bizarre and may involve beliefs about external control. Delusions may have themes that are persecutory or paranoid, grandiose, jealous, somatic, guilty, nihilistic, or erotic. Ideas of reference and of influence should also be described. Examples of ideas of reference include a person's belief that the television or radio is speaking to or about him or her. Examples of ideas of influence are beliefs about another person or force controlling some aspect of a person's behavior.
Thought Process (Form of Thinking). The patient may have either an overabundance or a poverty of ideas. There may be rapid thinking, which, if carried to the extreme, is called a flight of ideas. A patient may exhibit slow or hesitant thinking. Thought may be vague or empty. Do the patient's replies really answer the questions asked, and does the patient have the capacity for goal-directed thinking? Are the responses relevant or irrelevant? Is there a clear cause-and-effect relation in the patient's explanations? Does the patient have loose associations (for example, do the ideas expressed appear to be unrelated and idiosyncratically connected)? Disturbances of the continuity of thought include statements that are tangential, circumstantial, rambling, evasive, and perseverative.
Blocking is an interruption of the train of thought before an idea has been completed; the patient may indicate an inability to recall what was being said or intended to be said. Circumstantiality indicates the loss of capacity for goal-directed thinking; in the process of explaining an idea, the patient brings in many irrelevant details and parenthetical comments but eventually does get back to the original point. Tangentiality is a disturbance in which the patient loses the thread of the conversation and pursues tangential thoughts stimulated by various external or internal irrelevant stimuli and never returns to the original point. Thought process impairments may be reflected by incoherent or incomprehensible connections of thoughts (word salad), clang associations (association by rhyming), punning (association by double meaning), and neologisms (new words created by the patient through the combination or condensation of other words).

13. MSE Assess : Perception:
perceptual disturbances may be experienced in reference to the self or the environment.
Assess :
Which sensory system (e.g. auditory, visual..etc.)
Type:
*hallucinations, illusions , depersonalization, derealization.
*third person hallucinations Vs second person hallucinations).
The circumstances (timing) of the occurrence of any hallucinatory experience
Ask the patient about his reaction to hallucinations
Perception
Perceptual disturbances, such as hallucinations and illusions, may be experienced in reference to the self or the environment. The sensory system involved (for example, auditory, visual, olfactory, or tactile) and the content of the illusion or the hallucinatory experience should be described. The circumstances of the occurrence of any hallucinatory experience are important; hypnagogic hallucinations (occurring as a person falls asleep) and hypnopompic hallucinations (occurring as a person awakens) are of much less serious significance than are other types of hallucinations. Hallucinations may also occur in particular times of stress for individual patients. Feelings of depersonalization and derealization (extreme feelings of detachment from the self or the environment) are other examples of perceptual disturbance. Formication, the feeling of bugs crawling on or under the skin, is seen in cocainism.
Examples of questions used to elicit the experience of hallucinations include the following: Have you ever heard voices or other sounds that no one else could hear or when no one else was around? Have you experienced any strange sensations in your body that others do not seem to experience? Have you ever had visions or seen things that other people do not seem to see?
A young man with schizophrenia heard an insistent voice repeatedly telling him to stop his antipsychotic mediation. After resisting the command for many weeks, the patient felt that he could no longer fight the voice, and he discontinued treatment. Two months later, he was hospitalized involuntarily and near cardiovascular collapse. He later said that, once he stopped the medication, the voice further insisted that he should stop eating and drinking in order to be pure.
A terrified 37-year-old man in acute delirium tremens glanced agitatedly about the room. He pointed out the window and said: "My God, the Spanish armada is on the lawn. They're about to attack." He experienced the hallucination as real, and it persisted intermittently for 3 days before abating. Subsequently, the patient had no memory of the experience.

14. MSE Abstract Thinking:
It is the ability to deal with concepts and to make appropriate inference.
It can be tested by :
similarities: ask the patient to tell you the similarity between 2 things (e.g. car and train), and the difference between 2 things (e.g. book and notebook),
proverbs: ask the patient to interpret one or two proverbs (e.g. people in glass houses should not throw stones) the patient may give a concrete answer (e.g. stones will break the glass).

15. MMSE Orientation (score 1 if correct)
Name this hospital or building. _______
What city are you in now? _______
What year is it? _______
What month is it? _______
What is the date today? _______
What state are you in? _______
What county is this? _______
What floor of the building are you on? _______
What day of the week is it? _______
What season of the year is it? _______
Registration (Score 1 for each object correctly repeated)
Name three objects and have the patient repeat them. _______
Score number repeated by the patient.
Name the three objects several more times if needed for the patient to repeat correctly (record trials _______ ).
Attention and calculation
Subtract 7 from 100 in serial fashion to 65. Maximum score = 5 _______
Recall (score 1 for each object recalled)
Do you recall the three objects named before? _______

16. MMSE Language tests Construction
Confrontation naming: watch, pen = 2 _______
Repetition: "No ifs, ands, or buts" = 1 _______
Comprehension: Pick up the paper in your right hand, fold it in half, and set it on the floor = 3
Read and perform the command "close your eyes" = 1 _______
Write any sentence (subject, verb, object) = 1 _______
Construction
Copy the design below = _______
Total MMSE questionnaire score (maximum = 30) _______ _______

17. MSE Visuospatial Ability: (When brain pathology is suspected)
Ask the patient to copy a figure such as interlocking pentagons.
Language and Reading: (When brain pathology is suspected)
nominal aphasia: name two objects (e.g. a pen and a watch ).
expressive aphasia: repeat after you certain words.
receptive aphasia: carry out a verbal command.
reading comprehension: read a sentence with written command (e.g. close your eyes).
Visuospatial Ability: (When brain pathology is suspected)
Ask the patient to copy a figure such as interlocking pentagons.
Language and Reading: (When brain pathology is suspected)
To test for nominal aphasia, ask the patient to name two objects (e.g. a pen and a watch ).
To test for expressive aphasia, ask the patient to repeat after you certain words.
To test for receptive aphasia (auditory functions), ask the patient to carry out a verbal command.
To test for reading comprehension, ask the patient to read a sentence with written command (e.g. close your eyes).

18. MSE Judgment: Insight:
the patient’s predicted response and behaviour in imaginary situation.
From recent history.
Insight:
the degree of awareness and understanding the patient has that he or she is mentally ill.
The patient’s compliance with psychiatric treatment largely depends on his insight.

19. levels of insight Complete denial of illness.
Slight awareness of being sick and needing help but denying it at the same time.
Awareness of being sick but blaming it on others, on external factors, or on organic factors.
Awareness that illness is due to something unknown in the patient.
Intellectual insight: admission that the patient is ill and that symptoms or failures in social adjustment are due to the patient's own particular irrational feelings or disturbances without applying this knowledge to future experiences.
True emotional insight: emotional awareness of the motives and feelings within the patient and the important people in his or her life, which can lead to basic changes in behavior.

20. Website :

21. Thank you