The Mental State Examination

Appearance and Behaviour   This section describes the appearance of the person at the time of assessment. It looks at things like  grooming; hygiene; clothing including shoes; hair; nails; build; tattoos; other significant features such as body piercing It also looks at the person’s behaviour and considers whether they were appropriate, did they concentrate? Was their manner hostile, friendly, withdrawn, guarded, co-operative, uncommunicative or even seductive?

Motor Activity   This looks at a person’s level of activity and movement. Is the person restless/  Do they have any repetitive behaviours? Are they overactive? Is there any tremors or hand-wringing? Any bizarre movements? Are they not moving much at all?

Speech   The physical aspects of speech can be described in terms of rate, volume and quantity of information (e.g. slow, rapid, monotonous, loud, quiet, slurred, whispered). Some particular characteristics of speech that you might consider are: Mute Total absence of speech, often associated with depression or post- traumatic stress Poverty of speech Restricted amount of spontaneous speech. Replies to questions are brief or monosyllabic. Pressured speech Speech is extremely rapid, difficult to interrupt, loud & hard to understand.

Mood and affect   Describe the individual’s mood . Mood  is the internal feeling or emotion which often influences behaviour and the person’s perception of the world and is the information that the person describes about their internal mood state.  (e.g. depressed, ) Describe the individual’s affect. Affect is the external emotional response and a description of what is observed (euphoric, silly, labile, suspicious, fearful, hostile, anxious, irritable) Note whether the emotional response is appropriate given the subject matter being discussed. Some terms you may need to be familiar with are: Normal affect Variation in: facial expression, voice, use of hands, body movements Restricted affect Decrease in intensity and range of emotional expression Blunted affect Severe decrease in intensity and range of emotional expression Flat affect Total or near absence of emotional expression; face immobile, voice monotonous

Form of Thought Assessed according to: Amount of thought and its rate of production (e.g. poverty of ideas, flight of ideas, slow or hesitant thinking, vague). Continuity of ideas. Refers to the logical order of the flow of ideas. Individuals may or may not be able to stick to the topic of conversation. They may digress into irrelevant conversation, completely lose their train of thought, or talk ‘around’ the topic (e.g. Refer to following box which explains some of the terms used in relation to this). Disturbances in language. Refers to the use of words that do not exist (neologisms or word approximations) or conversations that do not make sense (incoherence). Some important terms you may need to be familiar with are listed below. Circumstantiality A pattern of speech which is indirect and delayed in reaching its goal idea. The speaker is long-winded and brings in many tedious but related details before getting to the point Clanging Words are chosen for sounds not meanings (e.g. “I ate my food, mood, rude.”) Includes punning and rhyming. Distractable speech Repeated changes of topic in response to nearby stimuli. Echolalia Repetition (echoing) of other people’s words or phrases, often with mocking or staccato intonation. As distinct from perseveration which is the repetition of the client’s own words or ideas. Flight of ideas The person cannot express ideas as quickly as they come into his or her head, thus leading to fragmented thoughts, abrupt changes in topic and general incoherence. Often associated with mania. Illogicality A pattern of speech in which conclusions are reached which do not follow logically. . Incoherence (word salad) Irrelevance Replies to questions are not at all related to the main topic of discussion. Neologisms The creation of completely new words or expressions that have no meaning to anyone other than the individual (e.g. “I have a helopantic under my foot”). Perseveration Persistent repetition of the same words or ideas in response to different stimuli (not including filler like “You know what I mean”). Often associated with organic brain disease. Thought disorder A term describing a disturbance in the way thoughts are expressed, affecting structure, grammar, syntax or logic of thinking. Sometimes also refers to the content of the thoughts. Communication is disorganised and senseless and the main idea cannot be understood (e.g. “All is nothing and under nothing twists”). A disorder in the logical progression of thoughts where unrelated and unconnected (or loosely connected) ideas shift from one subject to another. There is no meaningful relationship between the ideas that are being expressed. Derailment  and Loosening of associations are terms used to describe this. Tangentially is another feature and is when replies to questions are irrelevant or oblique. The reply usually refers to the appropriate topic but fails to give a complete answer. (e.g. when asked about the type of medication taken today; “Yes, I take medication but I exercise as well Word approximations Restringing words together in new and unconventional ways to represent a specific meaning (e.g. ‘handcoat’ to mean glove). Often associated with organic brain disease.

Thought Content Delusions are false beliefs that are firmly held despite objective and contradictory evidence, and despite the fact that other members of the culture do not share the same beliefs. There are numerous types of delusions, some of which tend to be associated with different disorders. Some types of delusions that clinicians may need to be familiar with are: Delusions of persecution: These are beliefs that centre around the theme that one is being deliberately wronged, or conspired against, or harmed by another person/agency. Q: Is anyone trying to harm, kill, poison or interfere with you? Q: Do you ever feel uncomfortable as if people are watching you? Delusional mood: The person feels that his or her familiar environment has changed in some way which is puzzling, and the individual may not be able to describe this change clearly. Q: Do you ever get the feeling that something odd is going on that you can’t explain? (Do familiar surroundings seem strange?) Q: Is there something odd about the way things look, or sound, or smell or taste? Delusions of reference: The belief that events or other people’s actions or words refer specifically to the individual and have a special meaning for the individual. Q: Do people seem to say things that have a double meaning? Q: Is there an experiment going on to test you out? Delusions of control, influence or passivity: The belief that one’s feeling, impulses, thoughts or actions are not one’s own but are controlled by an external force. The individual must acknowledge that he or she no longer has a will of his or her own but is being controlled by another force (other than God or fate). Q: Do you feel that you are under the control of a person or force other than yourself? Q: Do you feel as if you’re a robot or zombie with no will of your own? Religious delusions: Here, the individual believes he or she has a special link with God. This does not include intense religious or cultural beliefs. Nihilistic delusions:  The belief that the self or part of the self does not exist (e.g. that the individual or his or her brain is dead), or that others or the world do not exist. Often associated with depressive episodes. Fantastic delusions:  This is often the belief that the individual has had an amazing adventure or experience. Often associated with manic episodes. Delusions of jealousy:  This is the belief, without good reason, that one’s partner is unfaithful. May be associated with a delusional disorder. Grandiose delusions:  Exaggerated belief of one’s importance, power, knowledge or identity. Often associated with manic episodes or schizophrenia. Q: Do you or other people think you are superior in some way? Suicidal thoughts The individual needs to be asked about suicidal thoughts, especially if there are symptoms of depression (even if mild). If suicidal thoughts or intentions are reported, an urgent referral to a psychiatrist, GP, or Area Mental Health Team must be made and recorded. Other Includes obsessions, compulsions, anti-social urges, phobias, intentions, hypochondriacal symptoms and preoccupations (perhaps with illness). If any of these characteristics are prominent they are recorded in this section.

Perception Hallucinations An hallucination is a false sensory perception in which the individual sees, hears, smells, senses or tastes something that occurs in the absence of an appropriate external stimulus. Hallucinations are not necessarily associated with a psychotic disturbance and can occur when falling asleep (hypnagogic hallucinations), when waking up (hypnopompic hallucinations) or in the course of an intense religious experience. The type of hallucination and the content should be described. An auditory hallucination is probably the most common type of hallucination, and the other modailties most commonly occur in organic mental disorders but may be a part of any psychosis.Some types of hallucinations disability workers may need to be familiar with are: Auditory hallucinations:  These may be non-verbal (e.g. tapping, humming, music, laughing, etc.) or verbal (conversational, accusatory {often associated with depression}, etc.). Q: Do you hear sounds such as muttering, whispering, music, etc.? Q: Do you hear voices talking about you or to you? Do these voices give orders? What do the voices say? (Note whether the content is depressive, grandiose, appropriate for the individual’s mood). Q: Can you carry on a conversation with the voice/s? Visual hallucinations:  Being able to see objects, people or images that others cannot see. Q: While fully awake, have you had visions or seen things that other people couldn’t see? Olfactory hallucinations:  Smelling things that do not exist, usually an unpleasant smell like rotting meat or escaping gas. Gustatory hallucinations:  Relating to sense of taste. Tactile hallucinations:  The false perception of touch or surface sensation, such as from an amputated (phantom) limb, or crawling sensations on or under the skin. Somatic hallucinations:  The false perception that things are occurring in or to the body. Other perceptual disturbances Derealisation:  The external world appears different and unfamiliar. The individual feels distanced from the world and things may seem colourless or dead. Derealisation may be associated with extreme anxiety, stress, fatigue, an affective disorder, or with hyperventilation, which is a symptom of panic disorder. Q: Have you had the feeling that everything around you is unreal? Q: Have you felt that everything is an imitation of reality, with people acting instead of being themselves? Depersonalisation:  The perception or experience of the self seems different or unfamiliar. The individual may feel unreal, or that his body is somehow distorted, or may have the sense of perceiving himself from a distance. In its severe form, the individual may feel as if he were actually dead. Associated with extreme anxiety, stress, or fatigue. Q: Have you felt as if you were outside yourself, looking at yourself from the outside? Q: Have you felt as if some part of your body did not belong to you? Heightened perception:  Perceptions are extremely vivid. For example: sounds are unnaturally loud, clear or intense; colours are more brilliant or beautiful; and details of the environment appear to stand out in an interesting way. Dulled perception:  Perceptions are experienced as dark, uninteresting and flat. For example, tastes are blunted, colours muddied or dirtied, and sounds are impure or ugly. Exclude if the individual is lacking interest in things.

Sensorium and Cognition Level of consciousness Consciousness is our state of awareness of ourselves and external world. Impairment of consciousness usually indicates organic brain disease. Some terms staff may need to be familiar with are: Clouding of consciousness Lack of clear-mindedness with disturbance in perception and attitudes. Coma Unconsciousness. Delirium Bewildered, confused, restless, disoriented. Somnolence Abnormal drowsiness common in organic brain disease. Stupor Lack of reaction to and awareness of surroundings. Memory There are three main areas of memory: immediate, recent and remote. A clinical psychologist or neuropsychologist is most able to assess formally for memory problems. If problems are detected at this level, a referral to a neurologist will be made, a GP referral is also advisable. Deficits in memory may indicate head injury, organic brain disease or dissociative states (e.g. a result of post-traumatic stress). Immediate Ask person to provide new information they have just been given, such as a person’s name. Short-term (recent) May be assessed by asking the individual about a recent topical event, where he or she lives, etc. It is important for the worker to be able to verify the accuracy of the information. Q: What did the client have for breakfast that day? Long-term (remote) Assessed via responses to childhood events, schooling, etc. The accuracy of the statements may need to be verified by a family member or close friend. Orientation Obvious disturbances in orientation are usually indicative of organic brain disease. The commonly used categories for assessment of orientation are time, place and person. Impairment usually develops in this order, and, if treatable, usually clears in the reverse order. Time; Ask the individual to tell you today’s date. Remember, however, that even non-impaired people do not always know the correct date and may be one or two days out! Place; The individual should be able to identify where he or she is and should behave accordingly. If there is any doubt, ask the individual to describe the route or means by which he or she would travel home. Person; It is rare that an individual would not know his or her own identity. (Do not confuse orientation-of-self with religious delusion, such as believing oneself to be God). Ask if the individual knows the names and relationships of any family, friends, or professionals who are in the room or in the waiting room outside. Concentration Concentration may be assessed by asking the person to complete a task - such as making a cup of tea. This task is only necessary if you suspect that there is some degree of impairment. Performance anxiety, mood disturbance, an alteration of consciousness may interfere with the task. Abstract thoughts Abstract thinking involves the ability to: deal with concepts; extract common characteristics from groups of objects; juggle more than one idea at a time; and interpret information. Abstract thinking may be assessed by asking the individual to interpret the meanings of common proverbs (e.g. a bird in the hand is worth two in the bush). Care needs to be taken when using proverbs with different cultural groups. A lack of abstract ability is often associated with organic brain disease or thought disorder. This is less applicable to people with ID as they tend to be more concrete in their thinking.

Insight Describe the individual’s mood . Mood  is the internal feeling or emotion which often influences behaviour and the person’s perception of the world and is the information that the person describes about their internal mood state.  (e.g. depressed, ) Describe the individual’s affect. Affect is the external emotional response and a description of what is observed (euphoric, silly, labile, suspicious, fearful, hostile, anxious, irritable) Note whether the emotional response is appropriate given the subject matter being discussed. Some terms you may need to be familiar with are: Normal affect Variation in: facial expression, voice, use of hands, body movements Restricted affect Decrease in intensity and range of emotional expression Blunted affect Severe decrease in intensity and range of emotional expression Flat affect Total or near absence of emotional expression; face immobile, voice monotonous