This article aims to increase general knowledge on and awareness of the Mental State Examination (MSE) and provide guidance on how a clinician outside of the specialty of mental health might apply aspects of the MSE in a basic form, as part of a holistic assessment.
Origins of the MSE
Concepts closely related to what is now known as the MSE in current day practice have been used in psychiatry for decades (Kareem and Ashby, 2000). The use of the MSE when considering an individual's mental health needs highlights the importance of considering both the subjective narrative of the person experiencing a change in their health, as well as the objective clinician observations (Evans et al, 2019). Furthermore, it is vital that when supporting an individual with their mental health and wellbeing, efforts are made by the clinician/clinical team to seek out the views and thoughts of carers and/or loved ones. Working in partnership with loved ones/carers contributes to the support an individual receives (Evans et al, 2019), and can promote recovery (Waller et al, 2019). In the context of an MSE, gathering information from loved ones/carers before or after the MSE can support the diagnostic process by providing collateral information on areas such as the pre-morbid personality and clarifying an individuals' hopes, dreams and views (to name a few parameters). Such information adds to the assessment process and can help clinicians distinguish what may or may not be a manifestation of an altered mental status.
What is the MSE used for?
The MSE is a tool used to establish a depiction of the mental state of an individual at the time of the assessment (Burton et al, 2010). Similar to the ABCDE tool for assessment of a deteriorating patient (Reuscitation Council UK, 2015), the choice to use the MSE to assess an individual's mental state at a certain point in time is particularly useful because of its systematic approach (Martin, 1990). It offers a level of consistency and a helpful framework when documenting clinical interactions, which in a healthcare setting is key for continuity of care.
Moreover, an MSE can be conducted at any stage of an individual's recovery journey, to provide a clinical ‘snapshot’ of the presentation of an individual at any given moment; whether as part of an initial assessment, during a crisis period, or during a period of stability (Burton et al, 2010). Therefore, a completed MSE can illustrate consistent recovery or the development of a period of relapse for an individual, as it allows the team involved in an individual's care to review and compare the most recent examination with previous ones as a means of evaluating where the individual is on their recovery journey. Lastly, it offers a duality when it comes to assessing an individual's mental state, as considerations are given to what can be observed by a clinician, as well as what is reported and experienced by an individual, which is fundamental when it comes to person-centred care (Health Foundation, 2016).
What does the MSE entail?
The nine domains of the MSE seek to assess varying aspects from an individual's behaviour or appearance to their cognition, all with the view of understanding their mental state at that point in time.
The nine domains that are assessed when an MSE is being conducted are:
Appearance
Behaviour
Speech
Mood and Affect
Thought (form and content)
Perception
Cognition
Insight
Judgement.
These are the common components that make up the MSE, but is key to note that not all guidance and literature will present the areas being assessed during an MSE in exactly the same order as that presented here. Some authors offer check lists (Whittard, 2020), mnemonics (Evans et al, 2019) or advice on the importance of pre-agreed formats (Kareem and Ashby, 2000) for how the MSE should be recorded in clinical notes.
When it comes to conducting an MSE, there are numerous observations and presentations that can be assessed by a clinician. This is because an alteration in mental health can vary its manifestation from individual to individual. However despite this, the use of the MSE is beneficial as helps to tease out the manifestations of a declining mental state in a structured manner (Evans et al, 2020). With this in mind, the following are parameters to consider when conducting an MSE.
Conducting an MSE
Assess the individuals' appearance. The clinician should use their observation skills to note down what the person is wearing, how they might look, if there are any specific physical nuances to note for a particular reason such as risk (eg evidence of self-harm, or identification purposes) (Norris et al, 2016). Also, make sure to note the individual's grooming or hygiene (eg does the individual appear dishevelled?). It is key to provide context for what a clinician might note down in relation to someone's appearance. A rudimentary example, which can be indicative of an altered mental status, is being aware of thermoregulation and an individual's observed presentation. If a person is wearing three jackets despite it being warm outside, this might be indicative of an altered state connected to schizophrenia. One explanation is the possible connection between a dysregulation of body temperature, both at baseline as well as during a period of decline, for those living with schizophrenia (Chong and Castle, 2004). However, further contextual information and physical examinations should be sought to rule out or confirm the clinical rationale.
Assess the individual's behaviour. Focus on the individual's level of activity, arousal levels, eye contact and their gait (Soltan and Girguis, 2017). It is important to note down any abnormal movements; for example a person might have repetitive movements, which may indicate an underlying issue such as obsessive compulsive disorder (OCD) (National Institute of Mental Health, 2020). It is key not only to note down what a clinician observes, but also to engage the individual in a conversation to ascertain further details. A discussion with the individual on what is observed not only provides context, but could possibly clarify if a presentation is behavioural because of the situation, or if it indicates an underlying need; for example, an individual may be shaking their leg or shuffling their feet because they are nervous, or it may be a result of a motor function disturbance due to side effects of a medication (Caroff et al, 2011) they are taking, or an underlying undiagnosed neurological issue like Parkinson's (Mazzoni et al, 2012).
Assess speech. The clinician should focus on the production of speech at this point, and not with the content of what is being spoken (Burton et al, 2010). Parameters such as the speed, rate, volume, fluency and flow of speech are important to note as these may indicate an altered state. Within mental health, an example would be when pressure of speech with an increased rate is observed in an individual experiencing a manic episode, within the context of bipolar disorder (World Health Organization, 2018). Another example of the way an individual's speech may indicate a different altered state is if they present with aphasia, which may be indicative of dementia (World Health Organization, 2018).
Assess mood and affect. It is important to note the clinical presentation, as well as obtaining the individual's narrative. Mood is concerned with developing an understanding for the individual's internal emotional state, and it is good practice to quote the individual directly during the assessment (Norris et al, 2016). The affect component asks for the clinician to describe the apparent emotional state of the individual in front of them, therefore using their clinical judgement when noting this down. Key areas to be mindful of when assessing an individual's affect is to note how they appear overtly, the appropriateness of their presentation, the presented range, and if the affect observed matches with their subjectively reported mood (Burton et al, 2010).
Assess the individual's thought process. This section asks for the following to be assessed: the speed in which thoughts are formulated and expressed, the flow of the thoughts being expressed, and the coherence of the thoughts being formed and expressed (Snyderman and Rovner, 2009). A clinician would seek to find out, for example, if the speed of formulation is normal, accelerated or slow. Or if the coherence of an individual's thoughts is linear, incoherent, or perhaps tangential. In addition, it is important to assess the content of the individual's thoughts, and to try to directly quote an individual's description of their own thoughts. Delusions, overvalued ideas, obsessions, phobias, preoccupations, abnormal beliefs and any views relating to thought possession (insertion, withdrawal or broadcasting) are key areas of exploration in this section (Snyderman and Rovner, 2009). Lastly, it is essential to elicit information about suicidal, homicidal and paranoid ideations, as these are linked to increased risk to the individual and/or others (Royal College of Psychiatrists, 2016).
Assess perception. This requires looking to assess any abnormalities or disturbances related to the individual's sensory information such as hallucinations; auditory, visual, gustatory, tactile or olfactory (Soltan and Girguis, 2017). It is important to seek to understand if the disturbances are of internal or external in nature; does the individual feel/think the auditory hallucinations or voices come from an external location, or do they believe they are coming from inside their own head/mind. Depending on what is expressed, it may indicate variations in the levels of distress an individual may feel, how much insight into their condition they have and their ability to cope with said disturbances depending on whether they are experiencing an internal or external stimuli (Docherty et al, 2015).
Complete a basic cognitive examination. This consists of testing the individual's orientation to time, place and person, their attention and levels of concentration, and lastly their short-term memory (Norris et al, 2016). For short-term memory testing, ask an individual to remember three words chosen at random and inform them that they will be asked to repeat those three words at the end of the session (Norris et al, 2016). For testing concentration levels ask the individual to spell the word ‘world’ backwards (Norris et al, 2016). For orientation to time, place and person, ask the individual to give their full name and date of birth (orientation to person), then ask them where you currently are, such as the locality, building, floor that they are in (orientation to place), and lastly ask them to answer questions relating to orientation to time such as: What season/month/year/date/day of the week it is currently? (Norris et al, 2016). To conclude testing in this domain, ask the individual to repeat the three words they were asked to remember earlier (note that they do not need to be repeated back in the exact order).
Asesss insight. This is an area where the clinician seeks to find out the individual's understanding of their current state, by means of obtaining an explanatory account from them about their condition and possible avenues for support (Burton et al, 2010). When assessing insight, it is key to think of it on a scale from ‘good’ to ‘poor’ levels of insight, and to note down quotes from the individual during the examination. An example of ‘fair’ insight would be an individual who is experiencing distressing auditory hallucinations, which are commanding them to act on something in particular, but the individual is able to express knowing the voices they hear are not real, and that they would like/need support. Using the same initial presentation, an example of ‘poor’ insight may be that on this occasion, the individual is acting on what they are being commanded to do by their auditory hallucinations, and is not able to consider the possibility that the voices they are experiencing are not real.
Assess judgement. This assessment is looking to gage the individual's ability to make sound decisions in relation to specific areas concerning the presenting situation (Martin, 1990); such as, for example, adherence to medication, the ability to seek support when needed, or an understanding of relevant risk. It may be appropriate to assess an individual's judgement by assessing their general problem-solving capacity; this could be done by asking ‘what would you do if the bin over there spontaneously caught fire?’ (ensuring there is a bin in the room). A response that is aligned to an appropriate, realistic outcome displays good judgement.
In what settings can an MSE be carried out and by whom?
Within psychiatry or mental health care, the MSE is carried out in a variety of settings from inpatient, community, emergency and/or rehabilitation settings. When a registered mental health nurse, psychiatrist or other clinicians working within the field of psychiatry conduct an MSE, the outcome of the examination forms part of a working diagnosis (Hersen and Turner, 2003), and should only be used as part of a holistic assessment. A good, holistic assessment should be underpinned by the evaluation of the biological, psychological and social perspectives of an individual's presentation, therefore ensuring that consideration is given to both their physical and mental health on assessment (Norman and Ryrie, 2017).
Outside of the clinicians working within the speciality of psychiatry, there is scope for non-mental health clinicians to use the MSE in their own assessments of individuals who they suspect may be experiencing a decline in their mental state, and/or those with known mental health difficulties. Where non-mental health specialty clinicians choose to use the MSE to support their assessment, considerations to their own sphere of competence should be given to ensure that if there is a lack of confidence in assessing a particular domain/s, it is not assessed, as an inaccurate assessment can affect the patient journey and the care being offered (Nursing and Midwifery Council, 2018). Furthermore, the basic application of a MSE by a non-mental health clinician does not substitute that of a colleague within mental health, as experience and in-depth knowledge relating to mental health conditions creates greater exploration when conducting a MSE (Burton et al, 2010).
At its most basic, non-mental health clinicians can use the MSE to obtain an individual's narrative of what is happening for them, which has led to a presentation to services. With this information, a basic MSE can then be used to inform and support clinicians working in other, non-mental health specialities, such as emergency medicine or community nursing, to make informed decisions of what needs to happen next, and who else needs to be involved in the provision of care to best support the individual. Where preferred, clinicians outside of psychiatry can also use templates or tools that exist as ‘quick reference guides’ as opposed to the nine domains discussed in this article. Three examples of summarised methods that can be used as opposed to a full MSE in the first instance are: Whittard (2020), who offers a checklist format of the MSE; Evans et al (2019) who describe the use of mnemonic BATOMI as a means of assessing an individuals' mental state; and the Public Psychiatric Emergency Assessment Tool (Wright and McGlen, 2012), which is portrayed as helpful in settings where care provision needs to be prompt and timely, such as accident and emergency settings. However, it is key to note that the use of the ‘quick format’ structures/tools mentioned contain a summarised version of the nine domains explored in this article, therefore inherently present with their own limitations.
Procedure for conducting an MSE
Before the examination, the assessing clinician needs to ensure they have a basic understanding of mental health conditions, as this provides context for how an individual may be affected, or present during an examination (Burton et al, 2010).
At the start of an encounter, the assessing clinician should introduce themselves to the individual and inform them of the purpose of the interaction. It is key that a clinician is equipped with effective communication skills (both verbal and non-verbal) in advance of the assessment, as a means of managing any escalating situations that may arise (Price and Baker, 2012).
Efforts should be made to build a therapeutic relationship through the creation of an environment that promotes engagement through partnership. Only through this process of engagement may the individual feel comfortable enough to openly discuss all manner of topics relating to their health (Norman and Ryrie, 2017).
Ensure to use both a formal and an informal interview (Norman and Ryrie, 2017) approach to gather the individual's narrative and assess as many of the domains as possible. Use a variety of questioning techniques, such as asking open-ended questions for the most part, or closed questions when needed for clarity when exploring areas such as risk (Davies, 1997). For engagement with individuals who are experiencing alterations in their mental health and wellbeing, trust is key, as intimate issues are being explored. Therefore, one must remember that when conducting an MSE the purpose of the examination is to try to open communication channels, and not solely to gather information (Norman and Ryrie, 2017).
Summarise key areas or information gathered, and inform the individual of the plan moving forward, as this is key in maintaining the therapeutic rapport that is being developed (Norman and Ryrie, 2017).
Summary
The MSE is a key assessment tool in understanding an individual's mental state at a particular point in time. It provides a systematic framework for clinicians to assess an individual's mental and behavioural presentation and plan next steps in the provision of care. A degree of understanding of mental health conditions is needed prior to undertaking a MSE, however, should a non-mental health clinician feel unable to complete an MSE, consideration should be given to seeking out an individual's narrative as a starting point. This, paired with the development of a trusting therapeutic relationship, is fundamental in an individual feeling safe and supported when presenting to general health care services, before a mental health clinician joins the multidisciplinary team supporting them.
LEARNING OUTCOMES
Understand the importance of listening to an individual's narrative, as this is the starting point to a Mental State Examination (MSE)
Know that having a basic understanding of how to conduct an MSE will aid clinicians outside of the speciality of mental mealth to ensure they are holistic in the care they provide
Understand that communication and trust are key when developing a therapeutic relationship with an individual who is experiencing difficulties with their mental health
Understand that joint working between general and mental health clinicians is key in supporting the holistic needs of the populations accessing health and support in primarily non-mental health environments.
