Nursing Assignment: Mental Status Examination (MSE)
Nursing Assignment: Mental Status Examination (MSE)
• Overview of assessment
• Mental Status Examination (MSE)
• The assessment of risk
• The utility of assessment tools
• Creating a Clinical Formulation
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Purpose of a Detailed History
• To assist with decisions about diagnosis.Nursing Assignment: Mental Status Examination (MSE)
• To increase understanding of the factors that are contributing to the person’s symptoms or concerns.
• To determine the most appropriate treatment and individual recovery plan for each person.
Conceptual Model of Assessment
A thorough assessment involves three areas of information in the psychiatric interview, while at the same time developing rapport and a therapeutic relationship:
1. Cross-sectional and longitudinal histories (e.g. family history, psychiatric history, substance use).
2. Behavioural observations (including MSE).
3. Assessment tools – rating scales.
Goals of Initial Assessment
• Establishing a therapeutic relationship.
• Obtaining basic information about the person.
• Arriving at tentative ideas about the person’s experience – what is happening and their triggers.
• Developing a plan.
• Decreasing the person’s anxieties about therapy and treatment.
• Building hope by communicating that the person is understood and can recover.
Safety First
We need to feel safe when interviewing a person that we do not know.
• Conduct the interview in a private room that has two exits (preferably).
• Place your seating arrangements next to a quick exit away from the person.
• Have a discrete alarm system that works.
• Inform the team of your whereabouts beforehand.
• If in doubt, leave the door open, or ask a team member to co-interview.
Building Rapport and Therapeutic engagement
The person being interviewed also needs to feel safe.
• Involve the person in the process by engaging their active participation.
• Establish the beginnings of a therapeutic alliance – make it a collaborative inquiry.
• Develop trust and rapport – using open, sensitive, discrete reflection.
• Recognise that the person is the expert on their own experience.
Identifying the Concern Obtain a brief description of the concern in the person’s own words.
Ask the following • What is the nature of the concern(s)? • Why and how has the person presented at this time? • What events have led to the person’s presentation?
Identify recent events and stressors • Note both positive and negative stressors. • Note life changing events. • Any ongoing stressors?
Family History
• Marital history.
• Current relationships.
• Quality of relationships with significant others.
• Children: – Ages, mental and physical health.
• Custody, visitation rights, etc.
• Birth family – parents:
• Age, health, occupation, personality, family history of mental illness.
Psychiatric History • Previous mental health concerns and issues.
• Where treated, how long and outcomes.
• What kind of treatment?
• Response to treatment – what worked in the past; what didn’t.
• Length of time before illness.
• Involuntary admissions, if any, etc.
• How the person came to obtain treatment.
• Level of support from carers and family, etc.
Purpose of the MSE
• To obtain a comprehensive cross-sectional description of the person’s mental state which, when combined with the biographical and historical information of the psychiatric history, allows us to make a more accurate diagnostic formulation to enable coherent treatment planning.
• To identify the person’s strengths and ‘areas needing support’ in order to promote resilience in their recovery journey.Nursing Assignment: Mental Status Examination (MSE)
• To develop a clinical formulation (as nurses).
• To have baseline information against which we compare further MSEs.
1. Appearance and Behaviour.
2. Speech – rate, quantity and volume.
3. Mood and affect
4. Thought – form and content.
5. Perception.
6. Sensorium and Cognition – LOC, orientation, intelligence and memory.
7. Insight and judgment.
Components of the MSE
An initial brief description of how the person looks – build, height, complexion, eye colour, hair colour, and any distinguishing features.
• General – manner of dress (and appropriateness), make-up, tattoos, scars. • Age and gender. • Self-care – grooming, hygiene, nutrition, dental care. • Posture. • Stature and physical characteristics. • Recent injury – self-harm, trauma. • Substance use – intoxication, withdrawal, recent/current use. • Physical disorder/disability.
Appearance
• Psychomotor activity – agitation and hyperactivity, retardation.
• Abnormal movements – e.g. tics.
• Bizarre behaviour – rituals, grimacing etc.
• Medication and treatment side effects.
• Eye contact.
• Ability to form rapport with you.
• Attitude and level of cooperation during the interview.
Behaviour
• Describe the quality and the types of actions:
• Reduction in the level of movement (psychomotor retardation).
• Increases in the overall level of movement (psychomotor agitation). Slowed movement (bradykinesia).
• Decreased movement (hypokinesia).
• Absence of movement (akinesia).
• Tremors, tics, etc.
Psychomotor Activity
• Record the person’s facial expressions and attitude toward the interviewer – whether the
person appeared interested or bored during the interview.
• Record the person’s level of cooperation – whether they are hostile and defensive or friendly
and cooperative – note if they are guarded, uncomfortable or relaxed, and whether the
information is trustworthy and reliable.
• This description is based solely on the interviewer’s subjective observations.
Attitude to Interview – Cooperation
We know what a person’s thoughts are by what the person says.
Physical aspects of thoughts and speech can be described in terms of:
• Quantity – amount of speech, aphasia, mutism, incessant, refusal to speak.
• Rate – rapid, slow, slurred, monotonous, normal.
• Tempo and rhythm – melody of speech, include dysarthrias and dysphasia.
• Volume – loud, soft, quiet, etc.
Speech
• Looseness of association (irrelevance). • Flight of ideas (change topics). • Magical thinking (attributing experience to external forces). • Racing (rapid thoughts). • Tangential (departure from topic with no return). • Circumstantial (being vague, i.e. ‘beating around the bush’). • Word salad (nonsensical responses, i.e. jabberwocky). • Derailment (extreme irrelevance). • Neologism (creating new words). • Clanging (rhyming words).
Patterns of Speech and Thought
• Poverty of thought or speech (limited content). • Pressure of speech (extremely accelerated speech). • Thought blocking (speech is halted). • Mutism (no response, but with awareness). • Perseveration (continuing a response, i.e. ‘gets stuck’). • Echolalia (meaningless repetition (echo) of all or part of a sentence). • Verbigeration (senseless repetition of a word or phrase).
Patterns of Speech and Thought
• Mood is the subjective experience of the person at a particular time. It is a pervasive emotional state. Ask the person how he/she is feeling.
• Affect is the expression of the mood that can be observed by the interviewer. That is, affect is an objective, observable appraisal of how the person appears to be feeling.
Mood and Affect
• Establish the length of a particular mood, if the mood has been reactive or not, and if the mood has been stable or unstable (ask the person).
Might be described as
• ‘happy’
• ‘sad’
• ‘good’
Mood
• Affect is defined in the following terms:
• Expansive (contagious).
• Euthymic (normal).
• Restricted or constricted (limited variation).
• Blunted (severe reduction in intensity).
• Flat (no variation).
• Labile (up and down variations).
• Congruency of affect – refers to whether the affect is appropriate to what is discussed.
• Anhedonia – the loss of feelings of pleasure.Nursing Assignment: Mental Status Examination (MSE)
Affect
Affect
Might be described as: • Depressed. • Dysphoric. • Anxious. • Irritable. • Neutral. • Euthymic.
Affect
Thought form • Thought form refers to the logical connections between thoughts and their relevance to
the main thread of conversation.
• Irrelevant detail, repeated words and phrases, interrupted thinking (thought blocking) and loose, illogical connections between thoughts, may be signs of a thought disorder.
Thought Form and Content
Focus of the ideas expressed
• Obsessions (repetitive and intrusive thoughts, images, or impulses).
• Phobias (excessive and irrational fears).
• Preoccupations (e.g. with illness or symptoms).
• Delusions (examine types in next section).
• Themes (religious, persecutory, etc).
• Risk of harm (self or others), antisocial thoughts, fantasies and urges.
Thought Content
Nursing Assignment: Mental Status Examination (MSE)
Perception refers to the person’s awareness of their inner (subjective – the lived experience) and outer worlds (objective – the world in which we all live).
• Perceptual deception
• Illusions (misrepresentation of an external sensory experience).
• Hallucinations (an apparent perception in the absence of an external stimulus).
Perception
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Hallucinations
• Hearing things that aren’t there (auditory).
• Seeing (visual).
• Feeling (tactile).
• Tasting (gustatory).
• Smelling (olfactory).
• The most frequent hallucinations are auditory (e.g. hearing voices calling, commanding, commenting, insulting, or criticising).
• Command hallucinations.
Hallucinations
• It is important to ask specifically about command hallucinations .
• Clarify what the person will do in response to these command hallucinations.
• Many people also experience ruminating thoughts – these are generated inside the person’s head.
• Many people can identify the source of their auditory hallucinations.
Hallucinations
Delusions are false beliefs that are accepted without question.
• Delusions are not held by others of the same age, cultural, ethnic or educational background.
• They remain impervious to reasoning even when presented with obvious proof or objective evidence to the contrary (e.g. that he/she is God).
Perception – Delusions
• Persecutory or paranoid (others are deliberately trying to wrong, harm, or conspire against another).
• Grandiose (an exaggerated sense of one’s own importance, power, or significance – common in Bipolar Disorder: Manic phase).
• Somatic (physical sensations or medical problems).
• Reference (belief that otherwise innocuous events or actions refer specifically to the individual).
• Control, influence and passivity (belief that one’s thoughts, feelings, impulses, and actions are controlled by an external agency or force).
Types of Delusions
• Nihilistic (belief that the self or part of the self, or others, or the world, does not exist).
• Jealousy (unreasonable belief that a partner is unfaithful).
• Religious (false belief that the person has a special link with God – exclude intense cultural beliefs).
Types of Delusions
Depersonalisation
• The uncanny sense that one does not feel real, or feel like oneself – can be experienced by anyone – usually transient in nature.
Derealisation
• The sense that the world does not seem real – often transient, experienced by ‘normal’ people.
• Heightened or dulled perception.
• Déjà vu – feeling of familiarity to situations that are novel.
Other Perceptual Disturbances
1. Attention and concentration.
2. Memory – short term and long term: Immediate recall, recent, and remote.
3. Language.
4. Visual and spatial skills.
5. Reasoning (executive functions).
• Abstract thinking – the ability to deal with more than one idea at a time.
• Insight and judgment.
Cognitive Functioning
Orientation
• To time (day, date, month, year). It’s normal to be a day off the date.
• To place (currently where, what town, country, etc).
• To person (1st and 3rd person – self-identity and role of others).
Orientation and Consciousness
Attention
• Ability to direct mental energy when fully alert.
• Can be tested by counting by 2s to 20. This task is easy and can be used for people with poor arithmetic skills.Nursing Assignment: Mental Status Examination (MSE)
Concentration
• Sustained focus of attention for a period of time.
• Can be tested by serial 7s subtractions.
• Is also assessed by the capacity to listen throughout the interview.
Attention and Concentration
Levels of consciousness
• Alertness – characterised by full awareness.
• Clouding – characterised by a lack of clear-mindedness with disturbance in thought and attitude.
• Somnolence – characterised by drowsiness.
• Stupor – characterised by response to pain.
• Coma – characterised by unresponsiveness.
• Impaired consciousness usually implies an Organic Disorder – e.g. delirium, dementia.
Consciousness and Sensorium
• Immediate (registration, short term, working memory) – teach an address and after 5 minutes, ask for recall.
• Recent memory (24 hours recall) – ask about current affairs and news the person would know; what they had for breakfast (assuming you know the correct answer).
• Remote (long term memory) – ask for dates of birth or events which occurred long back in their history and that can be confirmed (e.g. wedding date).
Memory
• Involves the ability to deal with concepts, recognise similarities and common characteristics,
interpret more than one idea at a time and generalise from particulars. The opposite is to be
‘concrete’ in your thinking.
• Abstract thinking can vary in degree between individuals – there is no set degree.
• Can be assessed by asking the person to interpret proverbs with which they are familiar (e.g.
‘two heads are better than one’; ‘actions speak louder than words’; ‘don’t judge a book by its
cover’. Proverbs need to be culturally appropriate (and many young people have not heard of
old proverbs).
Abstract Thinking
• Test the person’s knowledge by asking some obvious questions such as who is the
current Prime Minister or the capital of Australia (and/or other countries).
• Need to consider the person’s educational and other training background in evaluating
the answers.
General Knowledge
Intelligence is assessed on the information the person provides throughout the interview: • Assimilating factual knowledge. • Logic and problem-solving skills. • Abstraction, generalisation, symbolism.
• Estimate as:
• Below average Average Above average
Intelligence
• Insight – the ability to recognise the situation and have some understanding of one’s illness.
• The presence of psychosis (if delusions and hallucinations are present) can reduce insight.
• Judgment – involves both cognitive decision (insight) and action (behaviour ) (e.g. what would you do if you found a stamped, addressed letter on the path?).
Insight and Judgment
Impulsivity
• This involves estimating the degree of the person’s impulse control – does the person do things without thinking or planning (e.g. taking a small boat to NZ).
Risk factors
• It is critical to ask if a person is suicidal, or if they ever have had suicidal ideation.
• Discussing suicide will not make people more likely to think about it, but may save their life.
Impulsivity and Risk Factors
• Also inquire about past acts of self-harm or violence.
• If the reply is positive for these thoughts or acts – inquire about specific plans, suicide notes, family history, and impulse control issues.
• Ask how the person views suicide to determine if a suicidal gesture or act is considered acceptable or unacceptable.
• Also consider their protective factors (e.g. children, a partner/close family, religious ideals).
Suicidal Ideation
• For homicidal ideation, ask the person if they have any thoughts of wanting to hurt anyone, or wishing someone was dead.
• If the reply is positive, ask about any specific plans to injure someone and how they plan to control these feelings if they occur again.
• Also inquire about past acts of violence, or legal issues – assault, GBH, etc.
Homicidal Ideation
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Risk of absconding
• Ambivalence about treatment – may not be willing to accept treatment.
• Past history of absconding.
Sexual vulnerability risk
• Past sexual abuse and exploitation.
• Lack of awareness of personal boundaries and inability to state own needs in relationships.
• Inability to recognise predatory behaviour or a violent environment.
• Significant substance use history.
• Intellectual disability.
Other Risk Factors
Additional Assessment Tools
• There are many assessment tools to help provide additional assessment information.
• The Kessler Psychological Distress Scale (K-10) is used routinely in primary care settings https://www.tac.vic.gov.au/files-to-move/media/upload/k10_english.pdf
• The AUDIT (Alcohol Use Disorders Identification Test) is used to determine if there is an alcohol use problem and it will point to the severity of the problem
• Complete the AUDIT at http://auditscreen.org/~auditscreen/cmsb/uploads/audit-english-version- new_001.pdf.Nursing Assignment: Mental Status Examination (MSE)
Clinical Formulation
• The formulation is a way to organise the information collected so far
• It helps the nurse to work collaboratively with the person to find out what has been happening/what has happened; what it means to them; and what we can do to help to relieve distress
• We use the 5Ps to organise the Clinical Formulation
The 5Ps
1. Presenting factors: what are the key issues leading to presentation at this time?
2. Precipitating factors: what has happened recently to cause difficulties leading to presentation?
3. Predisposing factors: what are the historical events/vulnerabilities that have led to the development of mental health concerns?
4. Perpetuating factors: what might interfere with current coping capacity?
5. Protective factors: what are the person’s supports/strengths/capacities that will enable recovery?
References
O’Brien, A., & Allman, M. (2017). Assessment in mental health nursing, chapter 23, In K. Evans., D. Nizette., & A. O’Brien. Psychiatric and mental health nursing (4th ed.), Chatswood, NSW: Elsevier Australia.Nursing Assignment: Mental Status Examination (MSE)