….

the MSE

Gurvinder Kalra
Staff Psychiatrist
Flynn Adult Inpatient Psychiatric Unit
LRH MHS
Traralgon, Victoria
Questions…
What have you noticed, so far:
 What happens when a psychiatrist first sees a

patient?

 What structure do they follow?

 How does the patient respond?

 Why does the psychiatrist do what they do?

What we do in psychiatry…

 Assessment in psychiatry:
 History (Pt + Collaterals)
 Mental State Examination
 Risk Ax

 Using clinical observation to evaluate a person’s

mental state and to begin considering
appropriate treatment
 Your role…..
 To conduct patient interviews

 To conduct MSEs
 Complete process
 Recognise significant findings

 To present on patient’s status to various

audiences
 MHRB
 Colleagues
 Ward rounds
 Patient documentation
 Legal documentation
Psychiatric Interview
Essential framework

History
 Identification
 HOPI (including negative Hx)
 Past psychiatric history
 Past medical history
 Family history
 Personal history (longitudinal development including
current life situation, hobbies)
 Forensic history
 Premorbid personality
Psychiatric Interview
Approaching the interview:
 Establish rapport – how ?

 Set the agenda – how ?

 Confidentiality – how ?
Psychiatric Interview
Essential framework

MSE
 Appearance & behaviour
 Speech
 Affect & mood
 Thought content
 Perceptions
 Insight
 Judgement
 Cognition
Mental State Exam
 Psychiatric equivalent of PE – Snapshot

 Explores all areas of mental functioning & denotes

e/o s/s of mental illnesses & risk

 Decisions about treatment, temporal- monitoring

 Data gathered throughout the i/v

 Most of the information does NOT require direct

questioning. Direct questioning- augment MSE

 Observation may be different than patient responses

Appearance
 How the patient looks / acts during i/v…..

 His / her stated age? Younger? Older?

 Ethnicity

 Gender

 Is this related to patient’s style of dress /

physical features/ style of interaction?
Appearance
 Dressing including jewellery / appropriateness to
the context….

 Grooming / hygiene- clues to fn level

 Distinguishing features- scars/ disfigurations /

tattoos
Appearance: important to report impartially
 Gender
 Apparent age
 Height and weight
 Ethnicity
 Clothing
 Hygiene
The MSE: in a nutshell
Behaviour
 Abnormalities
 Level of activity & arousal
 Eye movement and contact
 Reaction to interview (hostile, cooperative,
withdrawn)

Speech (description of the form)

 Clear, goal directed vs circumstantiality
 Rate, spontaneity
 Volume (normal?) and prosody (monotonous vs
pressured)
The MSE: in a nutshell
Affect (external facial expression)
 Congruent/ incongruent with thought content
 ‘Incongruent’ - emotional responses to their own experiences seem
inappropriate, totally out of keeping with the situation
 Normal, blunted, exaggerated, flat, heightened, euthymic (normal
mood)
 Extent of change: mobile, constricted, fixed, labile (sudden, short lived,
intense)
 Reactive (appropriate range of effect) vs unreactive

 La belle indifference
The MSE: in a nutshell
Mood (objective)
 Use appearance and behaviour features

Mood (subjective)

 Patient reported feelings

The MSE: in a nutshell
Thought content
 Main themes: delusions, ideas, preoccupations

 Suicidal ideation?

Perceptions
 Sensory abnormalities: hallucinations/ pseudohallucinations/ illusions

Insight
 Extent (impaired, fair, intact, absent)
 Are the symptoms real of part of an illness

 Are they suffering from a mental illness

 Will they benefit from treatment

The MSE: in a nutshell
Judgement
 Extent of capacity to make decisions, to respond

appropriately

 Impaired, intact

Cognition

 MMSE/ cognitive screen

 Alert? Orientated to time and place?

 After this…
Formulation
Biological Psychological Social

Predisposing factors

Precipitating factors

Perpetuating factors

Protective factors
And…
Working diagnosis
5 axes (DSM multiaxial structure)
Considerations
 Avoid a checklist of signs and symptoms to patient assessment
 Remember: MSE is relevant at that time and place- can/ will
change
 Focus on describing the phenomena you observe, providing
support, as a starting point rather than jumping to diagnosis
 Make yourself familiar with the range of abnormal phenomena
 What distinguishes a hallucination from an illusion?
 What terminology do you use to describe the phenomena observed?
 When does a patient’s experience become delusional?
 Speech, language (neologisms) or thought (delusions) abnormalities?