For illustration see this cartoon by Merinda Epstein.
We all meet people in our daily lives and as human beings we are acutely tuned to noticing difference between ourselves and others. The step between subconscious awareness and conscious noticing and recording as an examination is one of the situations where psychiatrists demonstrate their ability, and arguably it is an area at which psychiatrists are most practiced and skilled.
A psychiatrist’s mental state examination is a systematic way asking patients about their thoughts and feelings so as to reveal and document them. How one asks such questions, follows up on the answers, records the responses and draws conclusions from them are skills to be learnt and practiced like any other means of examination. Technical terms to document certain phenomena which would not be known to someone who is not a student of psychopathology.
The success of a mental state examination depends in part on the cooperation and capacity of the patient to follow the psychiatrist’s questions, but cooperation is not essential. It is more difficult to perform and children and is complicated by any barriers that may exist between psychiatrist and patient such as language and cultural differences.
By convention a mental state examination is recorded under the following headings: Appearance, behaviour, speech, mood, thought, perceptions, cognition and insight. The mental state examination concerns the patient at a particular moment in time; historical details should not be recorded.
In this section try to describe how the patient looks. It can be useful to consider what would help someone else pick out a person should they need to select them from a room full of people. Give details of patient’s apparent age, sex, ethnicity, clothing, tattoos, personal hygiene, state of self care, scars and piercings.
Describe what the patient was doing at the time of interview. Were they engaged in the interview process or did they appear distracted/preoccupied/perplexed? Did they make eye contact? Where there obvious mannerisms/tics/stereotypes? You can document things that happen during the interview here, for example if the patient walked out of the interview before it was complete
nb: The difference between ‘speech’ and ‘thoughts’ in the mental state examination is tricky. Psychiatrists assume that the content of what is being said by a patient is an expression of the inner process of thinking. Therefore in ‘speech’ the form of speech is discussed, whereas in ‘thoughts’ the content of someone’s speech is recorded.
What was the rate (fast, slow, pressured), volume (quiet, shouting) and rhythm of someone’s speech? Were they interruptible? What was the tone (monotonal, angry, agitated)? Include errors of pronunciation, slurring, punning, rhyming, clang associations. Was the speech circumstantial/tangential? Was it goal directed or rambling.
Consider also whether thought disorder is present. Terms that describe this include loosening of association, knight’s move thinking, word salad, thought block, perseveration and neologisms.
This can be described under two headings:
Objectively – how the patient appears to you – do they appear elated, flat/blunted, incongruous depressed or anxious? Is their mood reactive, for example do they smile when talking of something that they enjoy?
Subjectively – how does the patient describe their own mood? Are they expressing depressive attitudes? You can ask about the symptoms of depression here if you wish, but as these are often asked about as experienced over the past two weeks, it is best dealt with in the patient’s history I feel.
See note on ‘speech’ above. What do the preoccupations of the patient appear to be during the interview? Are there any abnormal beliefs? Are these delusional or overvalued ideas? Do they have any paranoid ideation? Do they think that someone is following them? Do they have any obsessional ruminations, compulsions or rituals?
Ask here about any abnormal experiences. Try to get as much information as possible about their content, personal explanations and response to the experience. A knowledge of hallucinatory experiences is useful here.
This is rarely done in practice unless cognition is suspected to be impaired. It requires a cooperative patient, and a mini mental state examination is a good place to start.
It is a feature of a lot of mental illness that someone suffering from it is unaware of their predicament. Insight is a measure of the patient’s ability to accept that they are ill and is not an ‘all or nothing’ phenomena. Broadly, insight runs at one extreme from those who are unwilling to accept that they have a mental illness, to those that are willing to consider that their experiences are consistent with mental disorder, to those that are accepting of a psychiatrist’s viewpoint and are compliant with medication. There are entire books written on this.
The mental state should be tailored to the patient you meet. With some patients their history may be such that it is sufficient to write ‘no evidence of psychotic symptoms’ under thoughts. With others you may wish to document that you have asked after specific psychopathology consistent with psychotic illness.
The cartoon is a reminder to keep an open mind about the power relationships between doctors and patient and the risk of drawing erroneous conclusions. See Margaret Mitchell effect
(September 2018 edit – for copyright reasons I removed the illustration)