Mental State Examination – what’s that?

In January 2012, I touched on Mental State Examination (MSE) rather briefly. I pointed out an example of what is a substandard MSE.

In this post I go into the depths of what a MSE is. A few general statements first.

In General

1. MSE is important. However, it is value is not to be overestimated for reasons that will be explained later.
2. Not all patients will give full access to their mental state.
3. A very important part of the MSE is based on observations of the patient. (Even with ‘physical examinations’, observation was always a big part of the activity).
4. Non-cooperation does not mean that a MSE cannot be performed.
5. Observation requires no consent – because it is what everybody can see without seeking permission. Normally though, a psychiatrist or other health professional, will inform the patient of an examination and seek consent.
6. Anything that limited the extent or reliability of the MSE must be stated. This is not just about court reports. It is sound clinical practice.
7. Careful documentation of the MSE is absolutely essential.
8. Assessors should record all relevant verbal and non-verbal findings.

The following is a real ‘supposed’ Mental State Examination (totally anonymised). It is totally substandard and inexcusable.

MSE
Relaxed, engaged well, fleeting eye contact (known ASD)
Speech: N
Euthymic, appropriate laughter
Persecutory delusions, somatic passivity.
Multiple Voices – some are better, no command hallucinations
Insight – partial – he is able to be re-assured – to practice other helpful coping strategies
Has Capacity

Some specifics

1. The MSE is partly opinions formed by the assessor i.e. observations are rarely made without forming opinions. For example, “I observed a bad odour coming from the direction of the patient as he entered the room“,  is an opinion and also an observation. The word ‘bad’ is partly opinion. Note that an opinion-observation about body-odour, is determined at a later stage e.g “The patient was malodorous. There was no other explanation for the bad odour in the room.”  OR – “The patient appeared to be drowsy and unsteady on his feet.” – are opinions as well as observations. Expert assessors for courts are allowed to give such opinion evidence. Who is an expert, is a separate matter.
2. Whilst opinion-observations are allowed, assessors need to stick very close to facts. A fact is what any reasonable person would observe; not simply what ‘an expert’ would observe. An expert-opinion-observation is more qualified in nature. If assessors state (for example), “He appeared to be thought disordered“, it is important to record what was said to confirm that opinion-observation. ‘What was said’, is not an interpretation of what was said. It is the actual words of the interviewee.  This means that interviewers ought to make significant snippets verbatim records as far as practicable.
3. The comprehensive scope of the MSE is so wide and deep, it is important for assessors to report things that were not found or observed. These become important for others to understand how diagnoses were made or ruled out.

Scope

1. From the mindmap (click to enlarge), it will be seen that MSE carried out by a suitably trained expert can uncover a lot of information from a cooperative subject. All nodes on the mindmap graphic and footnotes, are not visible. The finer bones are for experts.
2. The mindmap outlines the scope only. It doesn’t mean that all assessors have to do all of what’s in there.
3. The full examination carried out diligently is not something that can be done in 15 minutes.
4. I suggest that a proper exploration of mental state would take about 45 minutes.
5. Where a MSE cannot be full or is limited in some way, this should be declared at the outset with full reasons.

Terms used in the mindmap are not defined. This mindmap ought not to be used by untrained persons or to diagnose anyone.

For those seeking expert opinions

1. ‘Quick psychiatric reports’ in letters or expert witness reports, are a nonsense.
2. Pay with peanuts and you’ll attract ‘monkeys’ or ‘cowboys’. Does this serve the courts, clients or the interests of justice? I think not.
3. Instruction such as ‘Comment on Mr X’s mental state‘ is useless.
4. Instruction such as “Carry out a psychiatric examination of Mr X, decide on whether he suffers with a psychiatric disorder and if so explain it is relevance (to X, Y, or Z matter).” – is far more sound.
5. The Courts and legal persons must know what a Mental State Examination is, the applicable relevant standards and ensure that expert witnesses deliver what they are instructed on.

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