🗽
MBBS MEDICINE NOTES FOR MCQMED ///
😡
Psychiatry List/
MSE
Search

MSE

–General appearance and behaviour and apparent age
–Speech
–Mood
–Thoughts
–Perceptions
–Cognitive functions
–insight
(see comments of page)
 
While taking/presenting
  • key communication skills - active listening, summarising, sign posting
  • never describe in stigmatising or patronising ways such as "good", "odd" or "attention seeking". Do not use subjective terms like "fairly"
     

    Appearance

    The appearance of the patient may provide some clues as to their lifestyle, current mental state and ability to care for themselves.
    Observe the patient’s general appearance:
    • Demographics
    • Distinguishing features: these may include scars (e.g. self-harm), tattoos and signs of intravenous drug use.
    • Weight and apparent age: note if they appear significantly underweight or overweight. apparent age vs stated age
    • Stigmata of disease: note any stigmata of disease (e.g. jaundice), pain
    • Personal hygiene: this can provide insight into the patient’s current ability to care for themselves. (if they need prompting or if they require physical help, find it difficult)
    • Clothing: note if this is appropriate for the weather/circumstances and if the clothes have been put on correctly. any emblems or logo of significance, clothes that reflect mood? clean and wearable?
    • Objects: look around to see if the patient has brought any objects with them and note what they are.
    • Gait & Posture
    • Alcohol and substances (signs of use or withdrawal)
    Dishevelled, eccentric clothing, appears stated age, well groomed, etc

    Behaviour

    A patient’s behaviours may provide insights into their current mental state.

    Engagement and rapport

    Note if the patient appears engaged (attitude) in the consultation and if you are able to develop a rapport with them. eg cooperative, hostile, open, secretive, evasive, suspicious, apathetic, distracted, focused, defensive, over familiar, over confident, over bearing, indifferent
    Note if they appear distracted or if they appear to be engaging with hallucinations (e.g. replying to auditory hallucinations in schizophrenia).

    Eye contact

    Observe the patient’s level of eye contact and note if this appears reduced or excessive.

    Facial expression

    Observe the patient’s facial expression (e.g. relaxed, angry, disengaged).

    Body language

    Observe the patient’s body language which may appear threatening (e.g. standing up close to you) or withdrawn (e.g. curled up or hands covering their face). Posture - open, closed, engaged, poor distracted
    Note any evidence of exaggerated gesticulation or unusual mannerisms. (or later on)

    Psychomotor activity

    Observe for any evidence of psychomotor abnormalities:
    • Psychomotor retardation: associated with a paucity of movement and delayed responses to questions.
    • Restlessness: the patient may continuously fidget, pace and refuse to sit still, foot tapping

    Abnormal movements or postures

    Note any abnormal movements or postures:
    • Involuntary movements, disinhibited behavior (disregard for social conventions) or impulsive behavior
    • mannerisms - unusual repetitions, compulsions, rituals
    • Tremors
    • Tics
    • Lip-smacking
    • Akathisias
    • Rocking
    • RESPONSE TO NON VERBAL STIMULI (as in psychosis)
    • GESTURES
     
    agitated, avoiding eye contact, responding to internal voices etc

    Speech

    Assess the patient’s speech to identify abnormalities which may indicate underlying mental health issues.

    Rate of speech

    Pay attention to the patient’s rate of speech:
    • Pressure of speech: a tendency to speak rapidly, motivated by an urgency that may not be apparent to the listener (often a manifestation of thought abnormalities such as flight of ideas, which is described later in the article).
    • Slow speech: may occur due to psychomotor retardation which is typically associated with major depression.

    Quantity of speech

    Note the quantity of the patient’s speech:
    • Minimal or absent speech: associated with depression. Puacity of content? short monosyllabic answers? poverty of speech?
    • Excessive speech: associated with mania and schizophrenia. Talkative, spontaneous, expansive,

    Tone of speech/ prosody

    Note the tone of the patient’s speech:
    • Dull Monotonous speech: associated with conditions such as depression, schizophrenia and autism.
    • Tremulous speech: associated with anxiety.
    • Loud / whispered / normal prosody

    Volume of speech

    Note the volume of the patient’s speech.
    Note the fluency and rhythm of the patient’s speech for abnormalities:

    Fluency and rhythm of speech

    • Stammering or stuttering, hesitant, aphasic?
    • Slurred speech: may occur in major depression due to psychomotor retardation.
    • clear?
    "spontaneous, cohesive, relevant", echolalia (repetition of another person's words, palilalia (repetition of subject's own words), neologism

    Mood and affect

    Mood and affect both relate to emotion, however, they are fundamentally different.
    Affect represents an immediately expressed and observed emotion (e.g. the patient’s facial expression or overall demeanour).
    Mood represents a patient’s predominant subjective internal state at any one time as described by them often a paraphase of what they say
    Affect is what you observe and mood is what the patient tells you.

    Mood

    A patient’s mood can be explored by asking questions such as:
    • “How are you feeling?”
    • “What is your current mood?”
    • “Have you been feeling low/depressed/anxious lately?”

    Examples of mood states

    • Low mood
    • Depressed
    • Anxious
    • Angry
    • Enraged
    • Happy
    • Euphoric
    • Guilty
    • Apathetic

    Affect

    To assess affect you need to observe the patient’s facial expressions and overall demeanour. TRAIL - type, range, appropriateness, intensity, and lability

    Apparent emotion/QUALITY

    Observe the apparent emotion reflected by the patient’s affect, examples may include:
    • Sadness, dysthymic, depression
    • Anger, irritability, hospitality
    • Anxious
    • Euphoria, elated
    • euthymic,

    Range and mobility of affect

    Range and mobility of affect refer to the variability observed in the patient’s affect during the assessment. Abnormalities may include:
    • 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 doesn’t demonstrate the normal range of emotional expression that would be expected.
    • Labile affect: characterised by exaggerated changes in emotion which may or may not relate to external triggers. Patients typically feel like they have no control over their emotions.

    Intensity of affect

    A patient’s intensity of affect may be described as:
    • Heightened: associated with mania and some personality disorders.
    • Blunted or flat: associated with schizophrenia, depression and post-traumatic stress disorder.

    Congruency of affect

    Note if the patient’s affect appears in keeping with the content of their thoughts (known as congruency). A patient sharing distressing thoughts whilst demonstrating a flat affect or laughing would be described as showing incongruent affect. Incongruent affect is typically associated with schizophrenia.
     
    where to include suicidal thoughts or homicidal alienation?

    Thought

    Thought can be described in terms of form stream, content and possession.

    Thought form

    Thought form refers to the processing and organisation of thoughts.

    Speed of thoughts

    Patient’s may demonstrate abnormally fast (i.e. racing) or abnormally slow thought processing. Stream of thoughts = thought blocking. pressure of thoughts, poverty of thoughts

    Phenomenology of thought form (formal thought disorder)

    In healthy individuals, thoughts flow at a steady pace and in a logical order. However, in several mental health conditions, the flow and coherence of thoughts can become distorted.
    Abnormalities of thought flow and coherence include:
    • Loose associations: moving rapidly from one topic to another with no apparent connection between the topics. "loosening of associations", derailment, knight's move
    • Circumstantial thoughts: these are thoughts which include lots of irrelevant and unnecessary details.
    • Tangential thoughts: digressions from the main conversation subject, introducing thoughts that seem unrelated, oblique, and irrelevant.
    • Clang associations: sound of word rather than meaning gives the direction to subsequent associations, punning
    • Flight of ideas: there is an accelerated tempo of speech often referred to as ‘pressure of speech’. In addition to the increased rate of delivery, the language employed is characterised by a wealth of associations, many of which seem to be evoked by more or less accidental connections… the excited speech wanders off the point following the arbitrary connections, and the coherent progression of ideas tends to become obscured.
    • Poverty of thought
    • Thought blocking: sudden cessation of thought, typically mid-sentence, with the patient being unable to recover what was previously said.
    • Perseveration: refers to the repetition of a particular response (such as a word, phrase or gesture) despite the absence/removal of the stimulus (e.g. a patient is asked what their name is and they then continue to repeat their name as the answer to all further questions).
    • Neologisms: words a patient has made-up which are unintelligible to another person.
    • Mutism, echolalia, vebigeration (meaningless repetition of words/phrases), word salad (incoherent mixture of words and phrases)

    Thought content

    Abnormalities of thought content can include:
    • Delusions: a firm, fixed belief based on inadequate grounds, not amenable to a rational argument or evidence to the contrary and not in sync with regional and cultural norms. These may include persecutory delusions, in which the patient erroneously believes another individual or group is trying to harm them or ideas of reference, in which the individual incorrectly believes specific events relate to them.
    • Obsessions: thoughts, images or impulses that occur repeatedly and feel out of the person’s control. The patient is aware these obsessions are irrational, but the thoughts continue to enter their head. Preoccupation, worry, ruminations, hypochondrial or other morbid ideas
    • Compulsions: repetitive behaviours that the patient feels compelled to perform despite recognising the irrationality of the behaviour.
    • Overvalued ideas: a solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life (e.g. the perception of being overweight in a patient with anorexia nervosa).
    • Suicidal thoughts - active or passive
    • Homicidal/violent thoughts
    Some examples of questions which can be used to screen for thought content abnormalities include:
    • “What’s 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 do you harm?”
    • “Do you ever feel that specific events in the world are related to you in some way?”
    • “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 felt your life was not worth living?”
    • “Have you ever attempted to end your life?”
    • “Do you ever think about harming others?”

    Thought possession

    Abnormalities of thought possession include:
    • Thought insertion: a belief that thoughts can be inserted into the patient’s mind.
    • Thought withdrawal: a belief that thoughts can be removed from the patient’s mind.
    • Thought broadcasting: a belief that others can hear the patient’s thoughts.
    Some examples of questions which can be used to screen for thought possession abnormalities include:
    • “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 what you’re thinking?”

    Perception

    Perception involves the organisation, identification and interpretation of sensory information to understand the world around us. Abnormalities of perception are a feature of several mental health conditions.
    Abnormalities of perception include:
    • Hallucinations: a 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). Divided based on complexity (elementary - refers to experiences such as whistles, bangs, flashes or complex - refers to voices, music, seeing faces and scenes) and sensory modality involved (auditory, visual, olfactory, gustatory, somatic - superficial or visceral)
    • Pseudo-hallucinations: the same as a hallucination but the patient is aware that it is not real.
    • Illusions: the misinterpretation of an external stimulus (e.g. mistaking a shadow for a person).
    • Depersonalisation: the patient feels that they are no longer their ‘true’ self and are someone different or strange.
    • Derealisation: a sense that the world around them is not a true reality.
    Some examples of questions which can be used to screen for perceptual abnormalities include:
    • “Do you ever see, hear, smell, feel or taste things that are not really there?”
    • “Did you think this was real at the time?”
    • “Do you still believe it 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 around you isn’t real?”

    Cognition

    Cognition refers to “the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses”. Cognition can be impaired as a result of mental health conditions and their treatments.
    Throughout the process of performing a mental state examination, you will develop a vague idea of the patient’s cognitive performance including:
    • whether they are orientated in time, place and person
    • clouding of consciousness - drowsiness, lethargic, confused, vigilant alert, stupor -mute, immobile, unresponsive
    • what their attention span and concentration levels are like (serial 7 test, counting backwards days of the week)
    • what their short-term memory is like (registration and long term memory) via five item list, asking past presidents
    • visuospatial functioning (draw a clock showing 11:10)
    • overall intelligence based on vocab, grammar, memory, executive function, and inferred level of education
    A formal assessment of cognition can be achieved through a variety of different validated clinical tests including:
    • Mini-mental state exam (MMSE), MOCA
    • Abbreviated mental test score (AMTS)
    • Addenbrooke’s cognitive examination III (ACE-III)
    "formally assessed or not formally assessed but within normal limits, impaired"

    Insight and judgement

    Insight

    Insight, in a mental state examination context, refers to the ability of a patient to understand that they have a mental health problem and that what they’re experiencing is abnormal. Several mental health conditions can result in patients losing insight into their problem.
    According to David, the concept of insight comprises three components characterized by: 1) recognition of the disease itself (that he has a disease and that it is a mental disease), 2) the ability to recognize symptoms, and 3) compliance with treatment.
    Some examples of questions which can be used to assess insight include:
    • “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?”
    Intellectual insight? emotional insight?

    Judgement

    Judgement refers to the ability to make considered decisions or come to a sensible conclusion when presented with information. Judgement can become impaired in several mental health conditions leading to poor decision making.
    You may get some idea of the patient’s judgement abilities as you move through the mental state examination, but you can also specifically assess judgement by presenting the patient a scenario such as:
    • “What would you do if you could smell smoke in your house?”
    Sensible judgement in this situation would involve leaving the house immediately wherever possible and calling the fire department. A patient with impaired judgement may suggest ignoring it.
     
    RISK ASSESSMENT
    notion image
    Â