Mental State Examination

Overview Of Mental State Examination:

The mental state examination is a structured description of diagnostic signs and symptoms exhibited by the patients during the consultation.

It important to aware of the non-verbal communications, and to consider how things said in addition to what said. [3]

The goal of the mental state examination is to elicit the patient’s current psychopathology, that is their abnormal subjective experiences, and an objective view of their mental state, including abnormal behaviour.

Inevitably, the MSE (i.e. now) merges at the edges with history of the presenting problems (recently).

Behavioural abnormalities that the patient reports as still present, but which cannot observ at interview (e.g. disturbed sleep, overeating, cutting), are part of the history of the presenting illness.

A symptom that has resolved, such as an abnormal belief held last week but not today, should usually form part of the history, but will not report in the MSE.

In contrast, an abnormal belief held last week that still held today will report in both history of the presenting problems and MSE. [1]

Procedure Of Mental State Examination:

How to conduct a mental state examination ?

1. Appearance and behaviour i.e.

• General appearance
• Attitudes towards Examiner
• Facial expression
• Comprehension
• Posture
• Movements
• Social behaviour

2. Speech i.e.:

• Quantity
• Rate
• Spontaneity
• Volume & Tone
• Flow & Rhythm

3. Mood & Affect i.e.:

• Subjective
• Objective: Predominant Mood, Constancy, Congruity

4. Thoughts i.e.:

• Stream
• Form
• Content – Preoccupations, Morbid thoughts, including suicide, Delusions and overvalued ideas, Obsessional symptoms

5. Perceptions i.e.:

• illusions
• Hallucinations
• Distortions

6. Cognition i.e.:

• Consciousness
• Orientation
• Attention
• Concentration
• Memory
• Intelligence
• Abstract Thinking
• Language functioning
• Visuospatial functioning

7. Insight

8. Judgement [1] [2]

Appearance and Behaviour Of Mental State Examination:

Much can be learnt from general appearance, facial expression, posture, voluntary or involuntary movements, and social behaviour.

General appearance:

The important points to be noted are:

• Physique and body habitus (build).
• Physical appearance (approximate height, weight, and appearance),
• Looks comfortable/uncomfortable,
• Physical health,
• Grooming, Hygiene, Self-care,
• Dressing (e.g. adequate, appropriate, any peculiarities),
• Facies (Non-verbal expression of mood),
• Effeminate/Masculine [2]

excited patients may dress incongruously in brightly coloured or oddly assorted clothes.

Signs of self neglect include a dirty unkempt appearance and stained, crumpled clothing. Self-neglect suggests alcoholism, drug addiction, dementia, or schizophrenia.

An appearance of weight loss is as important in psychiatry as it is in general medicine, suggesting physical disorder (e.g. cancer, hyperthyroidism), psychological disorder (e.g. anorexia nervosa, depressive disorder), or social problems such as financial difficulty or homelessness. [1]

Attitude towards examiner:

• Cooperation
• Guardedness
• Evasiveness
• Hostility
• Combativeness
• Haughtiness,
• Attentiveness,
• Appears interested/disinterested/apathetic,
• Any ingratiating behaviour,
• Perplexity [2]

Facial expression:

Mood states are accompanied by characteristic facial expressions and postures.

For example:

• Turning down of the corners of the mouth and vertical furrows in the brow suggest depression.
• Horizontal furrows on the brow, wide palpebral fissures, and dilated pupils suggest anxiety.

An unchanging ‘wooden’ expression may result from a parkinsonian syndrome, either primary or caused by antipsychotic drugs. [1]

Comprehension:

Intact / Impaired (Partially / Fully)

Posture:

• It may also give indications of prevailing mood.
• A depressed patient characteristically sits with shoulders hunched, and with the head and eyes ‘downcast’.
• An anxious patient typically sits upright, with the head erect and the hands gripping the chair. [1]

Movement:

• excited patients are overactive, restless, and move rapidly from place to place and task to task.
• Depressed patients are inactive and move slowly.
• Rarely, a depressed patient becomes completely immobile and mute, a condition known as stupor.
• Anxious or agitated patients are restless, and sometimes tremulous.
• Any involuntary movements should note, including tics, choreiform movements, dystonia, or tardive dyskinesia. [1]

Social Behaviour:

• Increased, decreased, or inappropriate behaviour,
• Eye contact (gaze aversion, staring vacantly, staring at the examiner, hesitant eye contact, or normal eye contact). [2]
• excited patients disinhibit, and may break social conventions, for example by being unduly familiar.
• Some demented and some chaotic patients disinhibit, while others are withdrawn and preoccupy.
• In describing these behaviours, a clear and accurate description of what done or not done is more scientific than subjective terms such as ‘disinhibited’ or ‘bizarre’. [1]

Signs of impending violence:

They include restlessness, sweating, clenched fists or pointed fingers, intrusion into the interviewer’s ‘personal space’, and a raised voice.

Here we define three movement disorders:

• Tics irregular repeat movements involving a group of muscles (e.g. a sideways movement of the head).
• Choreiform movements are brief involuntary movements that coordinate but purposeless, such as grimacing or movements of the arms.
• Dystonia is a muscle spasm, which is often painful and may lead to contortions. [1]

Speech In Mental State Examination:

The physical characteristics of a patient’s speech come under this heading; the ‘form’ and ‘content’ of the thoughts they express through the medium of speech record later under ‘Thoughts’.

Here we describe changes to speech that often seen in patients with depression or mania.

Quantity:

Depressed patients speak less than usual; excited patients speak more. Occasionally a patient does not speak at all (mutism).

Rate:

Depressed patients speak more slowly than usual. excited patients speak faster. Copious rapid speech which is hard to interrupt call pressure of speech.

Spontaneity:

Patients with depression or intoxicated patients may have a long answer latency; they are asked a question, but it can many seconds, or longer, before an answer is forthcoming.

Patients with mania will answer promptly, and often very quickly, if they are able to attend for long enough to the interview.

Volume:

Depressed patients may speak quietly; excited patients may often heard far down the corridor.

Abnormalities of the continuity of speech, including any sudden interruptions, rapid shifts of topic, and lack of logical thread, should record under ‘Thoughts— form’. [1]

Flow and Rhythm of Speech:

• Smooth/hesitant,
• Blocking (sudden),
• Dysprosody,
• Stuttering/Stammering/Cluttering,
• Any accent, Circumstantiality,
• Tangentiality, Verbigeration, Stereotypies (verbal),
• Flight of ideas, Clang associations. [2]

Mood In MSE:

Mood is the pervasive feeling tone which sustain (lasts for some length of time) and colours the total experience of the person.

Affect, on the other hand, is the outward objective expression of the immediate, cross-sectional experience of emotion at a given time.

The assessment of mood includes testing the quality of mood, which assess subjectively (‘how do you feel’) and objectively (by examination).

The other components are stability of mood (over a period of time), reactivity of mood (variation in mood with stimuli), and persistence of mood (length of time the mood lasts).

The affect similarly describe under quality of affect, range of affect (of emotional changes displayed over time), depth or intensity of affect (normal, increased or blunted) and appropriateness of affect (in relation to thought and surrounding environment).

Mood describe as general warmth, euphoria, elation, exaltation and/or ecstasy (seen in severe mania) in mania; anxious and restless in anxiety and depression; sad, irritable, angry and/or despaired in depression; and shallow, blunted, indifferent, restricted, inappropriate and/or labile in schizophrenia. [2]

The patient’s ‘subjective’ mood and the professional’s ‘objective’ assessment of mood should document. Mismatch between the two can useful in the assessment of diagnosis and risk.

Subjective Mood:

• Ask the patient ‘What is your mood just now?’, or ‘Can you tell me how you’re feeling in your spirits?’
• Record the patient’s responses without altering them, so record (for example) ‘Great, never felt better’, or ‘OK, not too bad’, or ‘Awful, terrible, desperate’.
• Often, patients will need some encouragement to report their feelings, and you should sensitive to this need.
• If a depressed mood report, the associated symptoms may include a feeling of being ready to cry, lack of interest and enjoyment, and pessimistic thoughts, including thoughts of suicide.
• When anxiety report, associated symptoms include palpitations, dry mouth, tremor, sweating, and worrying thoughts.
• When elevated mood report, associated symptoms include excessive self confidence, grandiose plans, and an inflated assessment of the person’s own ability.

Objective mood:

The nature, constancy, and congruity of a patient’s observed mood should be described:

1. Nature of mood or moods:

• These might include depression, elation, anger, anxiety, suspicion, or perplexity.
• In this circumstance, many psychiatrists use the term ‘euthymic’, but, as this term is unusual outside psychiatry, we prefer the term ‘unremarkable mood’.
• As described above, mood states accompany by characteristic facial expressions and postures, which can help to identify the mood of a patient who is denying emotion, for example denying that he is angry.

2. Constancy of mood:

• In healthy people, mood varies from day to day and hour to hour—it is normal for mood to fluctuate in reaction to internal circumstances (e.g. what the person is thinking about) and external circumstances (e.g. reminders of a failed relationship, or of recent exam success).
• Alternatively, it may decrease (reduced reactivity, blunting, or flattening), such as in depression, when smiles or laughter do not follow a shift to a positive or amusing topic.
• Irritability is a term which spans two components of the objective assessment of mood: predominant moods (in irritability, this might include tension and anger) and variation in mood (in irritability, this would labile, with anger triggered easily).

3. Congruity of mood:

• Normally, our mood, our thoughts and our perceptions closely associate, and ‘fit’ together logically.
• For example, if we are watching news scenes from a natural disaster, we are seeing scenes of destruction and suffering, we are thinking about how difficult this must for the people involve, and we are likely to feeling subdued, contemplative, and may depressed.
• Equally, an elated person will thinking happy thoughts and perceiving all the good, positive things in the world around them.
• In these cases, there is ‘congruity of mood’, which is normal.
• Very occasionally, such as in schizophrenia, this linkage is lost, and there is ‘incongruity of mood’, so that, for example, a person appears cheerful while describing sad events. [1]

Thoughts In Mental State Examination:

If we want to know what someone is thinking, we can work it out in several ways. The first and most obvious is to listen to what they are saying, either spontaneously or in response to our or someone else’s questions.

The next is to read what they are writing, whether that is on paper, on a computer, or in a text message.

Abnormalities of thought:

Disorders of thinking can of several kinds:

1. Abnormality of the stream of thought (its amount and speed);
2. Abnormality of the form of thought (the ways in which thoughts are linked together);
3. Abnormality of the content of thought (preoccupations, morbid thoughts, delusions, overvalued ideas, obsessional and compulsive symptoms).

1. Abnormalities of the stream of thought:

In disorders of the stream of thought both the amount and the speed of thoughts are changed.

There are three main abnormalities: pressure, poverty and blocking of thought.

1. Pressure of thought:

Thoughts unusually rapid, abundant, and vary. The disorder is characteristic of mania but also occurs in schizophrenia.

2. Poverty of thought:

Thoughts are unusually slow, few, and unvary. The disorder is characteristic of severe depressive disorder but also occurs in schizophrenia.

3. Blocking of thought:

It refers to an experience in which the mind is suddenly empty of thoughts.

Thought blocking is the experience of an abrupt and complete emptying of the mind.

It occurs especially in chaotic patients, who may interpret the experience in a delusional way – believing, for example, that their thoughts have remove by another person (delusion of thought withdrawal).

2. Abnormalities of the form of thought:

There are three main abnormalities of the ways in which thoughts are linked together: flight of ideas, loosening of associations, and perseveration.

1. Flight of ideas:

In this abnormal state, characteristic of mania, thoughts and any accompanying spoken words move quickly from one topic to another, so that one train of thought is not completed before the next begins.

Because topics change so rapidly, the links between one topic and the next may difficult to follow.

Instead the link may through:

• Rhyme, for example when an idea about chairs follow by an idea about pears (rhyming links are sometimes called clang associations);
• Puns, that is two words that have the same sound (e.g. male/ mail);
• Distraction, for example a new topic suggested by something in the interview room.

2. Loosening of associations:

• It is a lack of logical connection between a sequence of thoughts, not explicable by the links described under flight of ideas.
• This lack of logical association is sometimes called knight’s-move thinking (referring to the sudden change of direction of the knight in chess).
• Usually the interviewer alert to the presence of loosening of associations because the patient’s replies are hard to follow.
• When there is loosening of associations, the links between ideas cannot be made more understandable in either of these ways.
• Loosening of associations occurs most often in schizophrenia.
• It is often difficult to distinguish loosening of associations from flight of ideas, and when this happens it is often helpful to tape-record a sample of speech and listen to it carefully.

3. Perseveration:

It is the persistent and inappropriate repetition of the same sequence of thought, as shown in either speech or actions.

It can be demonstrated by asking a series of simple questions; the patient repeats his answer to the first question as his response to all subsequent questions even though these require different answers. [1]

Content of thought:

Any preoccupations;

Obsessions (recurrent, irrational, intrusive, egodystonic, ego-alien ideas);

Contents of Phobias (irrational fears);

Delusions (false, unshakable beliefs) or Overvalued ideas;

Explore for delusions/ideas of persecution, reference, grandeur, love, jealousy (infidelity), guilt, nihilism, poverty, somatic (hypochondriacal) symptoms, hopelessness, helplessness, worthlessness, and suicidal ideation.

Delusions of control, thought insertion, thought withdrawal, and thought broadcasting are Schneiderian first rank symptoms (SFRS).

The presence of neologisms should be recorded here. [2]

Delusions:

Delusions are false, unshakable beliefs, that are firmly held by the patients, even if there are clear cut evidences that they are not at all true, e.g., “they are going to get me” (Persecutory Delusions), “everyone is looking at me”, “they are talking about me on TV” ( Delusions of Reference), “its my fault that there are so many people unemployed” (Grandiose Guilt), “I am dead” (Nihilism). [3]

Obsessional and compulsive symptoms:

Obsessions are recurrent and persistent thoughts, impulses, or images, that enter the mind despite efforts to exclude them, that the person recognizes are senseless, and that the person recognizes as products of their own mind.

The obsessions usually concern matters that the person finds distressing or unpleasant, and often feels ashamed to tell others about.

Themes of obsessional phenomena:

Obsessional thoughts:

• Dirt and contamination, for example the idea that the hands are contaminated with bacteria.
• Aggressive actions, for example the idea that the person may harm another person, or shout angry remarks.
• Orderliness, for example the idea that objects have to be arranged in a special way, or clothes put on in a particular order.
• Disease, for example the idea that the person may have cancer (some ideas of contamination refer to illness, e.g. ideas of contamination with harmful bacteria).
• Sex, usually thoughts or images of practices that the person finds disgusting.
• Religion, for example blasphemous thoughts, or doubts about the fundamentals of belief (e.g. ‘Does God exist?’) or about the adequacy of a religious practice such as confession.

Compulsions:

Checking rituals, which are often concerned with safety (e.g. checking repeatedly that a gas tap has been turned off).

Cleaning rituals, such as repeated hand washing or domestic cleaning.

Counting rituals, such as counting to a particular number or counting in threes.

Dressing rituals, in which the clothes are always set out or put on in a particular way. [1]

Perception In Mental State Examination:

Perception is the process of becoming aware of what is presented to the body through the sense organs (the eyes, the ears, the nose, the tongue, the skin).

You may, for example, go for a walk by a river, and see rowing boats, hear the chatter of the rowers, smell the fresh air, and feel the cool breeze on your face.

These perceptions are experienced as real, and are real.

Abnormalities of Perception:

Abnormalities of perception are of four kind:

1. Changes in the intensity of perception:

In mania, perception seems more intense, and, for example, colours may be particularly bright and vivid, and the sound of a pin dropping can seem loud.

In depressive disorder, perception may be less intense, with colours downgraded so that the world seems drab and grey.

2. Changes in the quality of perception:

In some disorders, especially schizophrenia, perceptions may seem distorted or unpleasant; for example, food tastes unpleasant or flowers smell acrid.

3. Illusions:

An illusion is a misperception of a real external stimulus. Illusions are likely if one or more of the following circumstances is present:

• Sensory impairment, such as at dawn or dusk, or if the person is visually or deaf or hard of hearing;
• Inattention on the sensory modality, such as when a person whose attention is focused on a book may mistakenly identify a sound as a voice;
• Impaired consciousness, such as delirium;
• Emotional arousal, usually fear.

4. Hallucinations:

A hallucination is a perception experienced in the absence of an external stimulus to the corresponding sense organ, for example, hearing a voice when no one is speaking within hearing distance, or seeing bright flashing lights when there is no light source.

A hallucination has two qualities that distinguish it from imagery i.e.:

(i) Firstly, It is experienced as a true perception;

(ii) Secondly, It seems to come from outside the head.

Unless the experience has these two qualities it is not a hallucination.

Although hallucinations are generally regarded as the hallmark of mental disorder, healthy people experience them occasionally, especially when falling asleep (hypnagogic hallucinations) or when waking (hypnopompic hallucinations).

These two kinds of hallucinations are brief and usually of a simple kind, such as a bell ringing or a name being called.

Modalities of Hallucination i.e.:

The hallucinations can be in the auditory, visual, olfactory, gustatory or tactile domains.

Auditory hallucinations:

• It may be experienced as voices, noises, or music.
• Hallucinatory voices may seem to speak words, phrases, or sentences.
• Some address the patient as ‘you’ (second-person hallucinations). Others talk about the patient as they (third-person hallucinations), and these latter are characteristic of schizophrenia.

Visual hallucinations:

• This may be simple, such as flashes of light, or complex, such as the figure of a man.
• Usually they experience as normal in size, but sometimes may seem unusually small or large.
• Visual hallucinations associate particularly with organic mental disorders but can occur in other conditions.

Hallucinations of smell and taste:

• They are uncommon. The taste or smell may seem to be recognizable, but more often it is unlike any smell or flavour that has experienced before, and has an unpleasant quality.

Tactile hallucinations:

• These are also uncommon. They may experience as superficial sensations of being touched, pricked, or strangled.
• Besides this, Sometimes they may experience as sensations just below the skin, which may attribute to insects or other small creatures burrowing through the tissues in this way, a tactile hallucination may associate with a delusional interpretation.

Hallucinations of Deep Sensation:

• They are also uncommon. They may experience as feelings of the viscera being pulled or distended, or as sexual stimulation.
• Again, they may well associate with delusional interpretation. [1]

Cognition In Mental State Examination:

Assessment of the cognitive or higher mental functions is an important part of the MSE.

A significant disturbance of cognitive functions commonly points to the presence of an organic psychiatric disorder. [2]

1. Consciousness:

• In general, Consciousness is awareness of self and the environment.
• Furthermore, Its level varies between the extremes of coma and alertness. Several terms are used for the intervening states of consciousness. [1]
• Any disturbance in the level of consciousness should ideally be rated on Glasgow Coma Scale, where a numeric value is given to the best response in each of the three categories (eye opening, verbal, motor). [2]
• In detail, Clouding of consciousness refers to a state of drowsiness with incomplete reaction to stimuli, impaired attention, concentration, also memory, and slow, muddled thinking.
• Besides this, Stupor refers to a state in which the person is mute, immobile, and unresponsive, but appears conscious because the eyes are open and follow objects.
• Confusion refers to muddled thinking. Lastly, The resulting term, confusional state, can be qualified by the terms ‘acute’ or ‘chronic’, which are alternative terms for delirium and dementia, respectively.

2. Orientation:

• Orientation is assessed by asking about awareness of time, place, and person.
• Disorientation is an important symptom that indicates impairment of consciousness or impairment of new learning.
• Questions begin with the time, day, month, year, and season. In assessing responses to questions about time, the interviewer should remember that many people do not know the exact time of day (although they usually know it to the nearest hour) or the exact date (though they are usually accurate to a few days).
• Orientation in place is assessed by asking the name of the place in which the interview is being held. If the answer is inaccurate, further questions are asked about the kind of place (e.g. home, a hospital ward, or a home for the elderly), and the name of the town.
• Personal orientation is assessed by asking about other people present (e.g. relatives in the home, or the staff in a hospital ward). If patients give wrong answers, they should be asked about their own identity—their name, occupation, and role in life.

3. Attention & Concentration:

• Attention is the ability to focus on the matter in hand, and concentration is the ability to sustain that focus.
• Attention and concentration can impaire in many kinds of psychiatric disorder but especially in anxiety disorder, depressive disorder, mania, schizophrenia, and organic disorder.
• For example, poor concentration may prevent a person from working effectively in an office. While taking the history, the interviewer should look out for evidence of impaired attention and concentration.
• In the mental state examination, specific tests give. It is usual to begin with the ‘serial 7s test’.
• The patient ask to subtract 7 from 100 and then to take 7 from the remainder repeatedly until it is less than 7.
• If so, the patient should ask to do a simpler subtraction, such as taking 3s from 30, or to avoid a mathematical task and say the months of the year in reverse order, or the simpler task of naming the days of the week in reverse order.
• Such tests of attention give before tests of memory because poor attention can lead to poor performance on memory tasks, even when there is no memory deficit.

4. Memory:

Memory problems may come to light during history taking.

During the mental state examination, tests are given to assess immediate, recent, also remote memory.

No ‘memory test’ is wholly satisfactory, and the results should be assessed cautiously and in relation to other information about the patient’s ability to remember. [1]

a. Immediate Retention and Recall (IR and R) i.e.:

Use the digit span test to assess the immediate memory; digit forwards and digit backwards subtests (also used for testing attention; are described under attention).

b. Recent Memory i.e.:

Ask how did the patient come to the room/hospital; what he ate for dinner the day before or for breakfast the same morning.

Give an address to be memorised and ask it to be recalled 15 minutes later or at the end of the interview.

c. Remote Memory i.e.:

• Ask for the date also place of marriage, name and birthdays of children, any other relevant questions from the person’s past.
• Note any amnesia (anterograde/ retrograde), or confabulation, if present. [2]

Anterograde amnesia i.e.:

This occurs after a period of unconsciousness. It is the impairment of memory for events between the ending of complete unconsciousness and the restoration of full consciousness.

Retrograde amnesia i.e.:

This is the loss of memory for events before the onset of unconsciousness.

It occurs after head injury or electroconvulsive therapy (ECT), when patients will be unable to remember events such as waking and showering during the early morning before their treatment.

Confabulation i.e.:

It is the reporting as ‘memories’ of events that did not take place at the time in question. Additionally, It occurs in some patients with severe disorders of recent memory. [1]

5. Intelligence:

Intelligence is the ability to think logically, act rationally, and deal effectively with environment.

Ask questions about general information, keeping in mind the patient’s educational and social background, his experiences and interests, for example, ask about the current and the past prime ministers and presidents of India, the capital of India, and the name of the various states.

Test for reading and writing; Use simple tests of calculation.

6. Abstract thinking:

Abstract thinking is characterised by the ability to:

• Assume a mental set voluntarily,
• Shift voluntarily from one aspect of a situation to another,
• Keep in mind simultaneously the various aspects of a situation,
• Grasp the essentials of a ‘whole’ (for example, situation or concept), and
• To break a ‘whole’ into its parts. Abstract thinking testing assesses patient’s concept formation.

The methods used are:

• Proverb Testing: The meaning of simple proverbs (usually three) should be asked.
• Similarities (and also the differences) between familiar objects should be asked, such as: table/ chair; banana/orange; dog/lion; eye/ear. [2]

Language Functioning:

Language functions can be tested in simple ways. These include the following.

Naming i.e.:

• The patient is asked to name common objects, such as those in the interview room, e.g. pen, chair, window.
• It should be straightforward for a patient to name such objects, unless they have a severe deficit, but more obscure objects may pick up more subtle deficits.
• For example, rather than pointing to his shirt, the interviewer might point to his cuff, or cufflink.

Verbal instruction i.e.:

• The patient is asked to carry out a command, which may have several components, such as ‘Take this piece of paper, fold it, and place it on the table’ .

Written instruction i.e.:

• The interviewer writes a simple command on a piece of paper (e.g. ‘Stand up’), shows it to the patient, and says ‘Do what it says’ .

Writing a sentence i.e.:

• The interviewer hands the patient a pen and a piece of paper, and says ‘Please write a sentence’.

Visuospatial Functioning:

This can test informally or formally.

• Informally, a patient’s carers (whether relatives or healthcare staff such as nurses) can ask to observe the patient’s ability to find their way around, such as from their bed to the toilet and back again.

More formally, a patient can ask to:

• Copy simple line figures, such as a star, a cube, and the front of a simple house, with windows and doors, as a simple test of visuospatial functioning;
• Recall those simple line figures several minutes later, following distractor tasks (such as some of the language tasks described above), as a simple test of visuospatial memory;
• Draw an old-fashioned clock face, with the time showing (for example) ‘quarter to three’.
• This requires quite complex visuospatial skills, such as remembering that the ‘12’ goes at the top of the clock, and spacing the numbers appropriately; the circle must drawn first, followed by the numbers, and then the hands. [1]

Insight In Mental State Examination:

Insight is the degree of awareness and understanding that the patient has regarding his illness.

Ask the patient’s attitude towards his present state; whether there is an illness or not; if yes, which kind of illness (physical, psychiatric or both); any treatment need; is there hope for recovery; what is the cause of illness.

Depending on the patient’s responses, insight can grade on a six-point scale:

1. Complete denial of illness.
2. Slight awareness of being sick and needing help, but denying it at the same time.
3. Awareness of being sick, but it attribute to external or physical factors.
4. Awareness of being sick, due to something unknown in self.
5. Intellectual Insight: Awareness of being ill and that the symptoms/failures in social adjustment are due to own particular irrational feelings/thoughts; yet does not apply this knowledge to the current/future experiences.
6. True Emotional Insight: It is different from intellectual insight in that the awareness leads to significant basic changes in the future behaviour. [2]

Judgement In Mental State Examination:

Judgement is the ability to assess a situation correctly and act appropriately within that situation. Both social and test judgement assess.

i. Social judgement observe during the hospital stay and during the interview session. It includes an evaluation of ‘personal judgement’.

ii. Test judgement assess by asking the patient what he would do in certain test situations, such as ‘a house on fire’, or ‘a man lying on the road’, or ‘a sealed, stamped, addressed envelope lying on a street’.

Judgement rate as Good/Intact/Normal or Poor/ Impaired/Abnormal. [2]

Frequently Asked Questions

What is Mental State Examination?

Mental status examination(MSE) is a standardised format in which the clinician records the psychiatric signs and symptoms present at the time of the interview.

What is the procedure of Mental State Examination?

• Appearance and behaviour
• Speech
• Mood & Affect
• Thoughts
• Perceptions
• Cognition
• Insight
• Judgement

What is the meaning of Perception?

Perception is the process of becoming aware of what is presented to the body through the sense organs.

What is insight?

Insight is the degree of awareness and understanding that the patient has regarding his illness.