Mental state examination

Appearance & behaviour

The big three to look out for are self neglect, eye contact and rapport. For more details:

Physical

• Posture
• Motor abnormalities

Appearance

• Clothes
• Accessories
• Self Care

Behaviour

• Rapport
• Eye contact
• Emotion
• Expressions

Speech

Rate

• Slow in depression
• Fast in mania
• Sponteneity – do they talk with being asked

Quality

• Makes sense
• Volume (loudness) - quiet in depression, loud in mania
• Articulation - dysarthria
• Unusual speech rhythm, melody, pitch - dysprosody

Mood & Affect

Mood

Subjective mood - what the patient says, ie. "I feel like death!" Objective mood - how the patient comes across, ie. fidgeting and hesitant speech.

Affect

How fast mood changes:

• Labile affect: changes too much - Someone can't have a yoghurt and they scream with rage, and then start crying - think hormonal teenage girl.
• Blunt affect: changes too little - Their dog dies, and they say "Oh. That's a shame". They win the lottery, and they say "Oh. That's great".
• Incongruous: doesn't fit - Their mum dies, and they're incredible happy.

Thoughts

Form

• disorganised thought
  • tangential thinking - never reaches point, keeps going off on tangents: "pub, tub [because of rhyming], I like ice cream!" [comes in tubs]
  • loosening of association - less severe than tangential thinking: "pub, alcohol, smoking, smoking ban"
  • circumstantiality - eventually get to the point but take ages
• flight of ideas
• thought blocking - common schizophrenic symptom

Content

• thought alienation - thought broadcast, insertion and withdrawal "People hear/insert/remove thoughts from my head"
• delusions of control - "I'm not in control of my body"
• persecutory delusions - "The FBI are stealing my biscuits"
• grandiose delusions - "I'm the King of the world"
• religious delusions - "I'm a ninja Jesus"

Perception

• Hallucinations - I see a monkey over there (there's nothing over there)
• Illusions - I see a monkey over there (there's a dog over there)

Cognition

Check they know Time, Place, Person.

• What time is it? What is the date?
• Where are you?
• What is your name?

If they fail that, do a 'mini mental' cognitive exam, and further testing if needed

Insight

Do they know they are ill? Be tactful, to avoid scaring them - don't ask "How long have you been mental?"; try "Why are you in hospital?"