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Clinical Practice Guidelines

Mental state examination


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See Also

    Acute behavioural disturbance: Acute management  
    Acute behavioural disturbance: code response 

    Key points

    1. A Mental State Examination (MSE) is a part of every mental health assessment
    2. Interpretation of the MSE must keep in mind the patient’s age and developmental level
    3. If there is any indication of current suicidal or homicidal ideation in the child or adolescent they must be referred for further assessment by a mental health clinician 

    Background

    • The MSE is used to gain an understanding of the patient’s psychological functioning at a particular point in time in order to direct care appropriately 
    • You will find you perform many parts of the MSE intuitively every time you interact with or observe others  

    The Mental State Examination

    Component What to assess
    Appearance & Behaviour Physical appearance Gender; ethnicity; body habitus; apparent age; cleanliness and grooming, hair/clothing style, cosmetics and jewellery; syndromic features.
    Manner of relating to clinician and parents Ease of separation from each parent; reactions to meeting the clinician (eg eagerness to please, defiance, overfamiliar); eye contact; facial expression. Note presence of hallucinatory behaviours (eg talking to self; laughing incongruently).
    Activity level Psychomotor slowing or agitation, sustained or episodic, goal-oriented or erratic; coordination, unusual postures or motor patterns (eg tics, stereotypies, odd mannerisms, tremors).
    Speech Spontaneous and talkative to mute. Fluency, rate, volume, tone.
    Mood Predominant emotion over days/weeks (eg euthymic, apathetic, angry, dysphoric, apprehensive, euphoric). Use 0-10 scale (0: extremely sad & wishing to end life immediately, 10: extremely happy).
    Affect Current observed emotional state. Describe type, range (constricted to labile), reactivity (blunted or flat to reactive), & appropriateness.
    Thought Stream (i.e. speed) Poverty of thought (thought blocking), poverty of content (perseveration), racing thoughts, flight of ideas.
    Form Logical & goal-directed or disordered (eg circumstantial, tangential, derailment, looseness of associations, word salad).
    Content Obsessions, delusions (eg persecutory, referential, grandiose, somatic, bizarre), phobias, magical thinking, thoughts of harm to self or others.
    Perception Altered bodily experiences (eg depersonalization, derealization), passivity phenomenon, illusion, hallucination (eg auditory, visual, olfactory, tactile).
    Cognition Level of consciousness Alert, drowsy, delirium, stupor.
    Orientation Awareness to confusion of self, current setting, date & familiar people.
    Attention Need for redirection/repeating, sustained activity, distractibility.
    Memory Immediate (eg repeat numbers, names back), short-term (eg recall three objects at 2 and 5 minutes), long-term (e.g. recall events of past week).
    Ability Impression of current abilities; concrete to abstract thinking.
    Insight & Judgment Insight Intact, partial or poor insight. Ability to identify potentially pathological events (eg hallucinations, suicidal impulses); acknowledgement of a possible mental health problem; locus of control (internal v external).
    Judgment Intact to impaired judgment. Problem solving ability in context of current psychological state (can be explored by recent decision making).

     

    Consider consultation with a mental health clinician when

    Unusual or incongruous features noted in a Mental State Examination

    Consultation with a mental health clinician should occur when

    • A situation of immediate risk of harm to self or others by a patient.
    • Risk of imminent departure from the emergency department by a patient known to be at risk of harm to self or others.
    • An acutely psychotic/agitated patient, whose immediate management requires significant sedation which will subsequently impede psychiatric assessment.

    Note: consultation with a mental health clinician is mandatory for a patient being held under a legislative Act.

    Last updated November 2018

  • Reference List

    1. Akiskal HS. The mental status examination. The medical basis of psychiatry. 2008, pg 3-16
    2. American Academy of Child and Adolescent Psychiatry. Practice parameters for the psychiatric assessment of children and adolescents. Journal of American Academy of Child and Adolescent Psychiatry, 1997 pg 4–20
    3. Arciniegas DB. Mental status examination. Behavioural neurology and neuropsychiatry. Cambridge University Press 2013 pg 344-393
    4. Chang MY, Davis AS. Neuropsychological assessment. Encyclopedia of child behaviour and development, Boston 2011
    5. Daniel M, Gurczynski. Mental Status Examination. Diagnostic interviewing, Boston 2009 pg 61-88
    6. Harvey PD. Clinical applications of neuropsychological assessment, Dialogues Clin Neurosci 2012
    7. Mendez MF. The mental status examination handbook. 2022
    8. Soltan M, Girguis J. How to approach the mental state examination BMJ 2017
    9. Trzepacz PT, Barker RW. The psychiatric mental status examination. Oxford University Press 1993 pg 3-177