The mnemonic
ASEPTIC can be used to remember the domains of the MSE: • A - Appearance/Behavior • S - Speech • E - Emotion (Mood and Affect) • P - Perception • T - Thought Content and Process • I - Insight and Judgement • C - Cognition
Appearance Clinicians assess the physical aspects such as the appearance of a patient, including apparent age, height, weight, and manner of dress and grooming. Colorful or bizarre clothing might suggest
mania, while unkempt, dirty clothes might suggest
schizophrenia or
depression. If the patient appears much older than his or her chronological age this can suggest chronic poor self-care or ill-health. Clothing and accessories of a particular subculture,
body modifications, or clothing not typical of the patient's gender, might give clues to
personality. Observations of physical appearance might include the physical features of
alcoholism or
drug abuse, such as signs of
malnutrition, nicotine stains, dental erosion, a rash around the mouth from
inhalant abuse, or needle track marks from intravenous drug abuse. Observations can also include any odor which might suggest poor personal
hygiene due to extreme self-neglect, or
alcohol intoxication. Weight loss could also signify a depressive disorder, physical illness, anorexia nervosa
Attitude Attitude, also known as
rapport or cooperation, refers to the patient's approach to the interview process and the quality of information obtained during the assessment. Observations of attitude include whether the patient is cooperative, hostile, open or secretive. include observations of specific
abnormal movements, as well as more general observations of the patient's level of activity and arousal, and observations of the patient's
eye contact and
gait.).
Stereotypies (repetitive purposeless movements such as rocking or head banging) or mannerisms (repetitive quasi-purposeful abnormal movements such as a gesture or abnormal gait) may be a feature of chronic schizophrenia or
autism. More global behavioural abnormalities may be noted, such as an increase in arousal and movement (described as
psychomotor agitation or
hyperactivity) which might reflect
mania or
delirium. An inability to sit still might represent
akathisia, a side effect of antipsychotic medication. Similarly, a global decrease in arousal and movement (described as
psychomotor retardation,
akinesia or
stupor) might indicate depression or a medical condition such as
Parkinson's disease,
dementia or delirium. The examiner would also comment on eye movements (repeatedly glancing to one side can suggest that the patient is experiencing hallucinations), and the quality of eye contact (which can provide clues to the patient's emotional state). Lack of eye contact may suggest depression or autism.
Mood and affect The distinction between
mood and
affect in the MSE is subject to some disagreement. For example, Trzepacz and Baker (1993) describe affect as "the external and dynamic manifestations of a person's internal emotional state" and mood as "a person's predominant internal state at any one time", whereas Sims (1995) refers to affect as "differentiated specific feelings" and mood as "a more prolonged state or disposition". This article will use the Trzepacz and Baker (1993) definitions, with mood regarded as a current subjective state as described by the patient, and affect as the examiner's inferences of the quality of the patient's emotional state based on objective observation. a feature of
conversion disorder, which is historically termed "
hysteria" in older texts.
Speech Speech is assessed by observing the patient's spontaneous speech, and also by using structured tests of specific language functions. This heading is concerned with the production of speech rather than the
content of speech, which is addressed under thought process and thought content (see below). When observing the patient's spontaneous speech, the interviewer will note and comment on
paralinguistic features such as the loudness, rhythm,
prosody,
intonation, pitch,
phonation,
articulation, quantity, rate, spontaneity and latency of speech. A structured assessment of speech includes an assessment of expressive language by asking the patient to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests also form part of the
mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under Cognition (see
below). Language assessment will allow the recognition of medical conditions presenting with
aphonia or
dysarthria, neurological conditions such as
stroke or
dementia presenting with
aphasia, and specific language disorders such as
stuttering,
cluttering or
mutism. People with
autism spectrum disorders may have abnormalities in paralinguistic and
pragmatic aspects of their speech.
Echolalia (repetition of another person's words) and
palilalia (repetition of the subject's own words) can be heard with patients with
autism, schizophrenia or
Alzheimer's disease. A person with schizophrenia might use
neologisms, which are made-up words which have a specific meaning to the person using them. Speech assessment also contributes to assessment of mood, for example people with mania or
anxiety may have rapid, loud and
pressured speech; on the other hand
depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.
Thought process ist
Adolf Wölfli could be seen as a visual representation of formal thought disorder.
Thought process in the MSE refers to the quantity, tempo (rate of flow) and form (or logical coherence) of thought. Thought process cannot be directly observed but can only be described by the patient, or inferred from a patient's speech. Form of the thought is captured in this category. One should describe the thought form as thought directed A→B (normal), versus formal thought disorders. A pattern of interruption or disorganization of thought processes is broadly referred to as
formal thought disorder, and might be described more specifically as thought blocking, fusion, loosening of associations, tangential thinking, derailment of thought, knight's move thinking. Thought may be described as 'circumstantial' when a patient includes a great deal of irrelevant detail and makes frequent diversions, but remains focused on the broad topic. Circumstantial thinking might be observed in
anxiety disorders or certain kinds of
personality disorders. Regarding the tempo of thought, some people may experience 'flight of ideas' (a manic symptom), when their thoughts are so rapid that their speech seems incoherent, although in
flight of ideas a careful observer can discern a chain of poetic, syllabic, rhyming associations in the patient's speech (i.e., "I love to eat peaches, beach beaches, sand castles fall in the waves, braves are going to the finals, fee fi fo fum. Golden egg."). Alternatively an individual may be described as having retarded or inhibited thinking, in which thoughts seem to progress slowly with few associations. Poverty of thought is a global reduction in the quantity of thought and one of the
negative symptoms of schizophrenia. It can also be a feature of severe depression or
dementia. A patient with dementia might also experience thought perseveration. Thought
perseveration refers to a pattern where a person keeps returning to the same limited set of ideas.
Thought content A description of thought content would be the largest section of the MSE report. It would describe a patient's suicidal thoughts, depressed cognition,
delusions, overvalued ideas, obsessions,
phobias and preoccupations. One should separate the thought content into pathological thought, versus non-pathological thought. Importantly one should specify suicidal thoughts as either intrusive, unwanted, and not able to translate in the capacity to act on these thoughts (
mens rea), versus suicidal thoughts that may lead to the act of suicide (
actus reus). Abnormalities of thought content are established by exploring individuals' thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one's own and under one's control, and the degree of belief or conviction associated with the thoughts.
Delusions A delusion has three essential qualities: it can be defined as "a false, unshakeable idea or belief (1) which is out of keeping with the patient's educational, cultural and social background (2) ... held with extraordinary conviction and subjective certainty (3)", and is a core feature of
psychotic disorders. For instance an alliance to a particular political party, or sports team would not be considered a delusion in some societies. The patient's delusions may be described within the
SEGUE PM mnemonic as: somatic,
erotomanic delusions,
grandiose delusions, unspecified delusions, envious delusions (cf.
delusional jealousy), persecutory or
paranoid delusions, or multifactorial delusions. There are several other forms of delusions, these include descriptions such as:
delusions of reference, or
delusional misidentification, or delusional memories (e.g., "I was a lamb last year") among others. Delusional symptoms can be reported as on a continuum from: full symptoms (with no insight), partial symptoms (where they may start questioning these delusions), nil symptoms (where symptoms are resolved), or after complete treatment there are still delusional symptoms or ideas that could develop into delusions you can characterize this as residual symptoms. Delusions can suggest several diseases such as
schizophrenia,
schizophreniform disorder,
brief psychotic disorder,
mania,
depression with psychotic features, or
delusional disorders. One can differentiate delusional disorders from schizophrenia for example by the age of onset for delusional disorders being older with a more complete and unaffected personality, where the delusion may only partially impact their life and be fairly encapsulated off from the rest of their formed personalityfor example, believing that a spider lives in their hair, but this belief not affecting their work, relationships, or education. Whereas schizophrenia typically arises earlier in life with a disintegration of personality and a failure to cope with work, relationships, or education. Other features differentiate diseases with delusions as well. Delusions may be described as mood-
congruent (the delusional content in keeping with the mood), typical of manic or
depressive psychosis, or mood-incongruent (delusional content not in keeping with the mood) which are more typical of schizophrenia. Delusions of control, or passivity experiences (in which the individual has the experience of the mind or body being under the influence or control of some kind of external force or agency), are typical of schizophrenia. Examples of this include experiences of
thought withdrawal,
thought insertion,
thought broadcasting, and somatic passivity.
Schneiderian first rank symptoms are a set of delusions and hallucinations which have been said to be highly suggestive of a diagnosis of schizophrenia. Delusions of guilt, delusions of poverty, and nihilistic delusions (belief that one has no mind or is already dead) are typical of
depressive psychosis.
Overvalued Ideas An overvalued idea is an emotionally charged belief that may be held with sufficient conviction to make believer emotionally charged or aggressive but that fails to possess all three characteristics of delusion—most importantly, incongruity with cultural norms. Therefore, any strong, fixed, false, but culturally normative belief can be considered an "overvalued idea".
Hypochondriasis is an overvalued idea that one has an illness,
dysmorphophobia that a part of one's body is abnormal, and
anorexia nervosa that one is overweight or fat.
Obsessions An
obsession is an "undesired, unpleasant, intrusive thought that cannot be suppressed through the patient's volition", but unlike passivity experiences described above, they are not experienced as imposed from outside the patient's mind. Obsessions are typically
intrusive thoughts of violence, injury, dirt or sex, or obsessive
ruminations on intellectual themes. A person can also describe obsessional doubt, with intrusive worries about whether they have made the wrong decision, or forgotten to do something, for example turn off the gas or lock the house. In
obsessive-compulsive disorder, the individual experiences obsessions with or without compulsions (a sense of having to carry out certain ritualized and senseless actions against their wishes).
Phobias A phobia is "a dread of an object or situation that does not in reality pose any threat", and is distinct from a delusion in that the patient is aware that the fear is irrational. A phobia is usually highly specific to certain situations and will usually be reported by the patient rather than being observed by the clinician in the assessment interview.
Preoccupations Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person's mind. Clinically significant preoccupations would include
thoughts of suicide,
homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or the
cognitive distortions of anxiety and depression.
Suicidal thoughts The MSE contributes to clinical risk assessment by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person's suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life. The most important questions to ask are: Do you have suicidal feeling now; have you ever attempted suicide (highly correlated with future suicide attempts); do you have plans to commit suicide in the future; and, do you have any deadlines where you may commit suicide (e.g., numerology calculation, doomsday belief, Mother's Day, anniversary, Christmas).
Perceptions A
perception in this context is any sensory experience, and the three broad types of perceptual disturbance are
hallucinations,
pseudohallucinations and
illusions. A hallucination is defined as a sensory perception in the absence of any external stimulus, and is experienced in external or objective space (i.e. experienced by the subject as real). An illusion is defined as a false sensory perception in the presence of an external stimulus, in other words a distortion of a sensory experience, and may be recognized as such by the subject. A pseudohallucination is experienced in internal or subjective space (for example as "voices in my head") and is regarded as akin to fantasy. Other sensory abnormalities include a distortion of the patient's sense of time, for example
déjà vu, or a distortion of the sense of self (
depersonalization) or sense of reality (
derealization).
Cognition This section of the MSE covers the patient's level of
alertness,
orientation,
attention,
memory, visuospatial functioning,
language functions and
executive functions. Unlike other sections of the MSE, use is made of structured tests in addition to unstructured observation. Alertness is a global observation of
level of consciousness, i.e. awareness of and responsiveness to the environment, and this might be described as alert, clouded, drowsy, or stuporous. Orientation is assessed by asking the patient where he or she is (for example what building, town and state) and what time it is (time, day, date). Attention and concentration are assessed by several tests, commonly
serial sevens test subtracting 7 from 100 and subtracting 7 from the difference 5 times. Alternatively: spelling a five-letter word backwards, saying the months or days of the week in reverse order, serial threes (subtract three from twenty five times), and by testing
digit span. Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). Visuospatial functioning can be assessed by the ability to copy a diagram, draw a clock face, or draw a map of the consulting room. Language is assessed through the ability to name objects, repeat phrases, and by observing the individual's spontaneous speech and response to instructions. Executive functioning can be screened for by asking the "similarities" questions ("what do x and y have in common?") and by means of a verbal fluency task (e.g. "list as many words as you can starting with the letter F, in one minute"). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE. Mild impairment of attention and concentration may occur in any
mental illness where people are anxious and distractible (including psychotic states), but more extensive cognitive abnormalities are likely to indicate a gross disturbance of
brain functioning such as delirium, dementia or
intoxication. Specific language abnormalities may be associated with pathology in
Wernicke's area or
Broca's area of the brain. In
Korsakoff's syndrome there is dramatic memory impairment with relative preservation of other cognitive functions. Visuospatial or constructional abnormalities here may be associated with
parietal lobe pathology, and abnormalities in executive functioning tests may indicate
frontal lobe pathology. This kind of brief cognitive testing is regarded as a screening process only, and any abnormalities are more carefully assessed using formal
neuropsychological testing. The MSE may include a brief neuropsychiatric examination in some situations. Frontal lobe pathology is suggested if the person cannot repetitively execute a motor sequence (e.g. "paper-scissors-rock"). The
posterior columns are assessed by the person's ability to feel the vibrations of a tuning fork on the wrists and ankles. The parietal lobe can be assessed by the person's ability to identify objects by touch alone and with eyes closed. A
cerebellar disorder may be present if the person cannot stand with arms extended, feet touching and eyes closed without swaying (Romberg's sign); if there is a tremor when the person reaches for an object; or if he or she is unable to touch a fixed point, close the eyes and touch the same point again. Pathology in the
basal ganglia may be indicated by rigidity and resistance to movement of the limbs, and by the presence of characteristic involuntary movements. A lesion in the
posterior fossa can be detected by asking the patient to roll his or her eyes upwards (
Parinaud's syndrome). Focal neurological signs such as these might reflect the effects of some prescribed psychiatric medications, chronic drug or alcohol use,
head injuries,
tumors or other brain disorders.
Insight The person's understanding of his or her mental illness is evaluated by exploring his or her explanatory account of the problem, and understanding of the treatment options. In this context,
insight can be said to have three components: recognition that one has a mental illness,
compliance with treatment, and the ability to re-label unusual mental events (such as delusions and hallucinations) as pathological. As insight is on a continuum, the clinician should not describe it as simply present or absent, but should report the patient's explanatory account descriptively. Impaired insight is characteristic of
psychosis and dementia, and is an important consideration in treatment planning and in assessing the capacity to
consent to treatment.
Anosognosia is the clinical term for the condition in which the patient is unaware of their neurological deficit or psychiatric condition.
Judgment Judgment refers to the patient's capacity to make sound, reasoned and responsible decisions. One should frame judgement to the functions or domains that are normal versus impaired (e.g., poor judgement is isolated to petty theft, able to function in relationships, work, academics). Traditionally, the MSE included the use of standard hypothetical questions such as "what would you do if you found a stamped, addressed envelope lying in the street?"; however contemporary practice is to inquire about how the patient has responded or would respond to real-life challenges and contingencies. Assessment would take into account the individual's
executive system capacity in terms of impulsiveness,
social cognition, self-awareness and planning ability. Impaired judgment is not specific to any diagnosis but may be a prominent feature of disorders affecting the
frontal lobe of the brain. If a person's judgment is impaired due to mental illness, there might be implications for the person's safety or the safety of others. ==Cultural considerations==