Professional Documents
Culture Documents
Mental State
Examination (MSE):
a basic training guide
Wendy Shannon Palmerston Association Inc project staff and talent Brendan Mounter and the staff at Professional Public Relations Pty Ltd who produced the
DVD and booklet.
Leith Maddock Palmerston Association Inc project staff and talent
Palmerston Association Inc staff who assisted with various tasks throughout the development
Sandra Harris Palmerston Association Inc project staff and talent of this resource.
Jodee Harley Palmerston Association Inc project staff All of the consortium members for their support and advice.
6 References 39
1 Introduction
Purpose conditions and assessments can be accessed
from the Guidelines on the management of What is meant by a Why do AOD clinicians
The intention of this Mental State Examination
co-occurring alcohol and other drug and baseline Mental State need to know how to
(MSE) DVD and accompanying booklet
mental health conditions in alcohol and other
drug treatment settings 1
Examination? do a baseline Mental
is to assist alcohol and other drug (AOD)
clinicians to be more confident in completing
http://www.med.unsw.edu.au/ This DVD and booklet present a pared down
State Examination?
NDARCWeb.nsf/page/Comorbidity+ version of the MSE, which we have called a
a baseline MSE on their clients. The DVD A high prevalence of comorbidity among
Guidelines baseline MSE. AOD clinicians need to be able
has been designed to be an introductory clients of AOD services means that agency
instructional training tool on the baseline MSE. to assess a clients mental state sufficiently clinicians are frequently faced with the need
It is recommended that AOD clinicians seek
additional comprehensive training on the
What is a Mental State to be able to identify a mental health issue,
especially in terms of any immediate risk issues
to manage very complex mental health
MSE to be clinically competent in the Examination? for the client or others. Further training would
symptoms and/or problems, which can
interfere with the clinicians ability to treat a
assessment tool. be needed to carry out a comprehensive MSE. clients AOD use effectively. In view of this, it
A Mental State Examination (MSE) is the Diagnosis and treatment of co-occurring (or becomes very important that AOD clinicians
The DVD contains three visual case study process of assessing an individuals mental comorbid) mental health issues remain the have the knowledge and skills to identify
scenarios which clinicians can use to test state and behaviour at the time of an interview. realm of qualified mental health professionals. mental health symptoms, and in turn are
their knowledge and skills in conducting It uses a common format and language to
skilled in how to manage the symptoms. The
an MSE. Firstly however, it is strongly record information, which can be readily The AOD clinician also needs to be able to
MSE is one tool used in mental health settings
recommended that clinicians read understood across different services. The goal discern if the client is suitable for ongoing
to screen for mental health symptoms. Training
sections 1, 2 and 3 of this instructional is to identify signs and symptoms of mental treatment at the AOD service without specialist
AOD clinicians in the baseline MSE will enable
booklet before watching the DVD. illness to ensure appropriate assistance can mental health intervention, or if there is a
them to feel more confident in identifying
Where guided to do so on page 22, please be given to the client and that any risks are need to refer the client for a more thorough
mental health disorders/issues. Once
download the relevant forms from the internet. addressed. The MSE can be brief or more MSE and possible medical, psychiatric or
identified, mental health disorders/issues can
You will need these to assist you in carrying thorough depending on the circumstances psychological intervention.
be more appropriately addressed through
out an MSE on the visual case study scenarios. (i.e. in an emergency it would be brief) and
other assessments and/or referrals to qualified
can be repeated during the period of a clients
mental health professionals.
The following pages briefly define the MSE and treatment to observe changes over time.
the domains of this mental health assessment
tool. Further information on mental health
of rapport building baseline Mental questioning about the clients experience 1. Appearance
in undertaking a State Examination may be required. An MSE can occur during
an initial assessment or as part of an ongoing
2. Behaviour
baseline Mental State Whilst there is a comprehensive list of series of appointments. 3. Speech and language
Examination criteria and psychiatric terminology used in a 4. Mood and affect (feelings)
comprehensive MSE, it is not necessary for
Taking the time to establish rapport with a AOD clinicians to have a detailed knowledge Format of the 5. Thought content (thinking)
client, before embarking on an MSE, is very
important. Consumer feedback tells us that
of all of these for a baseline MSE. What
is essential is for the clinician to have an
baseline Mental State 6. Perception
continuing to acknowledge the clients feelings understanding of the basic concepts used in Examination 7. Cognition
and experiences during the information an MSE. An AOD clinician will need to be able
gathering process is important for the success to recognise the basic concepts in a clients There are varying formats for carrying out an 8. Insight and judgement
of the interview and ongoing engagement. presentation and then describe them in the MSE. For the purpose of this training DVD,
Clinicians need to listen closely to what the clinicians own words. These descriptions will the format outlined in the Guidelines on the Pages 14 to 18 provide a brief description of
client has to say and ask for clarification or need to be put in a clients clinical notes. management of co-occurring alcohol and each of the domains listed above.
examples if needed. Showing empathy to other drug and mental health conditions in
a clients distressing thoughts and beliefs A baseline MSE is done in the normal course alcohol and other drug treatment settings 1
(without indicating an uncritical acceptance of a session with a client. The clinician uses will be used.
of the persons ideas and impulses) is their observational and listening skills to obtain
appropriate. the information that they require to undertake The following format can be used for
the MSE. Open ended questions are also recording the observations made during an
useful for gathering relevant information. MSE. Primarily there are eight domains that
The MSE is not a series of questions but an need to be considered and assessed.
evaluation process based on the clinicians
observations and interactions with the client.
Appearance Speech and language Mood and affect inappropriate expressing an
inconsistent emotion to what they are
Accurately and non-judgementally describe Describe:-
(feelings) talking about (i.e. laughing when talking
about a loved ones death).
your observations of the persons physical
(a) How is the client talking (speech)? How does the client describe his/her
appearance. How does the client look? emotional state (mood)? Exploring mood
high or elevated excessively
Consider: age, gender, race/ethnicity, build, rate rapid, pressured, slow, retarded happy or overly animated in their
is very important because it can give an expressions and gestures.
hair style & colour, grooming, posture, level
of hygiene, mode of dress, apparent level of
volume loud, whispered, quiet indication of potential risk to self or others. Use
tone monotone, varied the clients own words if possible. Is the client
health, signs of AOD use. down, depressed, sad, anxious, angry, irritable,
quantity of information poverty or
happy, ok, fearful, or up? Thought content
pressure of speech, mute/silent
(thinking)
Behaviour quality stutter, slurring or any What do you observe about the persons
atypical qualities emotional state (affect)? A persons mood and What is the person thinking about?
Accurately and non-judgementally describe affect should be congruent with each other. Consider the following:
your observations of the persons behaviour. (b) How does the client express himself/ So when describing a persons affect, what
Avoiding assumptions is important so signs herself (language [form of thought])? do you observe about the clients emotional the amount of thought and its rate
of illness can be separated from culturally state? of production Does the clients
appropriate behaviours. How does the client incoherent/illogical disorganised speech flow easily? Does the
behave? Consider: general behaviour, facial or senseless speech For example consider the following: conversation stay on track? Is there
evidence of any limitation in the clients
expression, eye contact, body movements derailment unrelated or loosely depressed is the person flat, ability to think (i.e. look for slow/hesitant
and gestures. How is the client reacting connected ideas restricted, tearful, deflated, has blunted
to being in the session? i.e. co-operative, speech)?
tangentiality or loosening of facial expressions?
angry, hostile, withdrawn, inappropriate, afraid,
association unrelated or incomplete continuity of ideas Do the thoughts
suspicious, evasive. anxious is the person agitated, fiddly, being expressed flow logically and
replies distressed, fearful, irritable, distracted? stay on track? Are certain words
absence or slowing of thought angry is the person hostile, defensive, or ideas repeated? Are there gaps
thought blocking thought flow is easily provoked? in the flow of thinking?
briefly interrupted or absent labile rapidly changing their mood.
These include paranoid, depressive, associated risk. attention can the client stay
The purpose of this domain is to ascertain focussed during the appointment?
anxious and obsessional thoughts and dissociative symptoms such as:
overvalued ideas. whether the person displays behavioural
derealisation (the external world memory can the client tell you what
evidence of hallucinations or other perceptual he/she did yesterday/last week?
thoughts of harm to self or others disturbances.
seems strange or unreal)
Has the client expressed thoughts of depersonalisation (the person feels orientation can the client tell you
harming themselves or others? Consider the following: detached from their own thought what day of the week it is?
processes or body).
This criterion also includes non-suicidal concentration can the client focus
self harm such as cutting, excessive hallucinations are false perceptions in illusions, where the person misinterprets on a simple mental task, such as
picking, burning of self. Evidence of the absence of any stimulus. They are sensory stimuli (e.g. hearing rustling adding?
any suicidal, self harming or homicidal the most common form of perceptual leaves as voices).
thoughts need to be followed by a disturbance, particularly auditory abstract thinking can the client
identify similarities between two related
thorough risk assessment. This training
items?
DVD does not train clinicians on how to
Insight and judgement The counsellor can then decide whether
the client:
to be contacted for support and assistance.
If it is assessed that a clients judgement is
medication being used to assist with
withdrawal.
significantly impaired (and they refuse any any acquired brain injury from AOD use.
Insight refers to the clients capacity to is appropriate for ongoing AOD
support person to be contacted) it may be
recognise his/her own problems and counselling; or
appropriate to contact the clients registered If the client is very intoxicated, or in active
symptoms. Judgement refers to the clients
is appropriate for ongoing AOD next of kin. However, this should only be withdrawal, it is not appropriate to do an MSE.
capacity to make sound, reasoned and counselling in conjunction with GP carried out after consulting with a clinical However, due to developed tolerance to their
responsible decisions. follow-up; or supervisor. drug of choice, it is common for AOD clients
Once the MSE is completed, requires psychiatric assessment and to attend appointments whilst intoxicated and
intervention before counselling can without obvious impairment to their normal
a formulation can be made and
an action decided upon.
proceed. Incorporating level of functioning. A baseline MSE may be
If unsure, the AOD clinician should consult AOD factors in the appropriate under these circumstances but
should be discussed with a supervisor and
with their supervisor or team before making baseline Mental State reviewed at the earliest opportunity.
Formulation the formulation and any subsequent referral.
Examination
and action: The MSE, formulation and action should be
reviewed regularly to monitor any changes in
the clients mental state.
When completing an MSE with AOD clients, Referral process
Once a baseline MSE has been completed their current AOD use must be considered as it
the AOD clinician can make a formulation. may affect the way the client presents. Urgent matters (i.e. risk of harm to self
The formulation summarises the information or others): If a client is already known to a
gathered so the clinician can systematically Carers, family These factors include: mental health service, the case manager
develop a hypothesis about the clients mental
state, which is then used to inform any action
members and other how recent was their last AOD use?
or duty officer can be contacted and asked
to follow up on the concerns raised. Please
taken. supports: is he/she still intoxicated? discuss this with your supervisor if you are not
the presence of AOD withdrawal sure how to proceed.
The formulation should include the nature If during an MSE a client is found to be symptoms (depression, hallucinations,
and severity of symptoms and any risk issues. significantly unwell, it is recommended that delirium tremens).
It can also include information about the the client be asked if they would like a carer,
clients recent and past drug use. family member or another significant other
If the client is not known to a mental health If the AOD clinician is unsure how to access
service, and the matter is urgent, then the appropriate mental health support they can
AOD clinician can suggest to the client the call the duty officer at the local mental health
following: service and discuss the referral process
with them.
go to the nearest emergency
department (ED)
Less urgent matters (i.e. no immediate
go to their general practitioner (GP) risk): If the client is already a client of a
contact the Mental Health Emergency mental health service the case manager or
Response Line (MHERL) duty officer can be contacted and asked to
follow up on the concerns raised.
It may be appropriate, depending on the
service, for the AOD clinician to contact ED If the client has not previously sought help for
or the GP and discuss their concerns prior to mental health issues they should be referred to
the client being seen, or even accompany the a GP for further assessment and treatment or
client when they attend for assessment. referral. It may be appropriate, depending on
the service, for the AOD clinician to contact the
If the client is not willing to seek help and the clients GP and discuss their concerns prior to
AOD clinician is concerned about the risk of the client being seen, or even accompany the
harm to self/others then this matter should client when they are assessed. It is common
be referred to a senior manager for further for AOD clients not to have a GP so assistance
assessment. The police or other emergency with making an appointment may also be
services may become involved if this is required.
determined to be the appropriate action from
the management of a service. As there is a Some emergency and after hours contact
duty of care in this situation confidentiality numbers have been provided in section 5 of
can be breached. All actions taken should be this booklet.
documented.
Before continuing you should: Instructions for use the without commentary case study, as
this will replay the same case study but will
1. Read the previous sections of this Each case study has been developed to allow also contain some additional comments on
booklet. a clinician to practise their knowledge and how to carry out an MSE on that client.
skills on conducting an MSE
2. Download the Assessment of Mental
If necessary, you can take notes while
State table from Press Start to watch the introduction to watching the case study scenarios. Remember,
http://www.palmerston.org.au/ the DVD. This will briefly explain the purpose there is no right or wrong way of writing
publications.htm of the DVD and will then return to the main your assessment and observations of a client.
3. Download the Mental State Assessment menu for you to select your case study Try to use simple language that is non-
form for each case scenario you are scenarios. It is suggested that you complete judgemental and follow the MSE guidelines in
completing (three in total if you intend at least two case study scenarios to practise the Assessment of Mental State table to the
to complete an assessment on all your MSE knowledge and skills. The first best of your ability.
three visual case studies) from case study scenario entitled Lisa without
http://www.palmerston.org.au/ commentary and Lisa with commentary To view an example of an MSE on each
publications.htm is suggested for all clinicians. client (on Lisa, Glen and Barry) please go to
section 4 of this booklet. It may be useful to
4. Please note: Some versions of In all cases, the case study scenario without read these examples after you have finished
Windows Media Player do not commentary should be played first. Once completing your MSE on each case study
support the playing of DVDs. If you are you have finished watching the without scenario, and while you are watching the
having trouble playing this DVD via your commentary case study scenario, return with commentary version of the case
PC, its recommended you download to the main menu of the DVD. Then using study scenario.
VLC Player (www.vlc.org). If you the table and MSE form (that you have
are unable to access this website, downloaded from the internet) attempt to
please consult your IT administrator. complete an MSE on the client presented.
Once you have finished, watch the with
commentary case study scenario in its
entirety. The scenario with commentary
should only be played after you have watched
4 Example
of an MSE
assessment
on each visual
case study
scenario
24 Understanding the Mental State Examination (MSE): a basic training guide 25
4 Lisa: MSE Assessment Example
4 Lisa: continued...
Thoughts of harm to self or others her the medication. Lisa also found it difficult commanding, telling her she needs to protect the appointment. Lisa can continue to attend
(risk assessment): Lisa holds the belief that to concentrate during the session. Otherwise herself from her boyfriend. Lisa is sleeping AOD counselling as well as addressing her
her boyfriend wants to harm her, so she is she was alert and oriented to time and place. with a kitchen knife under her pillow in case mental health issues with a mental health
protecting herself by sleeping in the garden he comes into the garden shed during the specialist.
shed with a knife under her pillow. There is no night. Her boyfriend may be at risk of harm
history of domestic violence in the relationship
nor does Lisas boyfriend have a history of
Insight and judgement: in this situation. Although Lisa was convinced
as to the reality of what she was experiencing,
harming others. While Lisa holds the belief that Lisa showed insight and judgement. She was she showed some insight into her own mental
her boyfriend wants to harm her, there may be willing to consider that the experiences she health and was agreeable to being assessed
a risk of harm to him. Lisa has no previous was having could be due to a recurrence of at the local Mental Health Service.
history of self harm or harm to others. her mental illness and was agreeable to the
Mental Health Service being contacted for Lisa has a diagnosed mental illness and has
further assessment. not been taking her medication for some
Perception: weeks. She is a regular cannabis smoker and
has used speed twice in the last week.
Lisa was experiencing auditory hallucinations.
She reported she was hearing different voices
Formulation:
saying horrible things such as you are no Lisas mood and affect are congruent. Action:
good, you are ugly and that she needs to She said she felt worried and she presented
protect herself from her boyfriend. She was as fearful. Her speech was normal in rate and The duty officer at the Mental Health Service
observed replying to what appeared to be tone. She showed signs of delusional and was notified of the AOD counsellors concerns
voices during the appointment. paranoid thinking, believing she was being about Lisas mental health and possible risk
spied upon by cameras in the house and to her boyfriend. An afternoon appointment
that her boyfriend had planted a transmitter was arranged for Lisa with her mental health
Cognition: in her stomach so everyone would know worker. Although Lisa stated she was capable
of attending the appointment by herself, it may
what she was thinking. She said she was
hearing derogatory voices and was seen also be appropriate for the AOD counsellor
Lisa had misplaced her medications and could
to be actively listening and replying to them to ask Lisa if she would like a carer or family
not remember when she had last taken her
during the appointment. The voices are also member to be contacted to help her attend
tablets. She usually relies on her parents giving
4 Glen: continued...
Cognition: not coping well and had taken leave from his
employment to get some help.
Glen is alert and orientated to time and place. Glen says his alcohol intake has increased
to six cans on a week night and increases
significantly when he goes out drinking with
Insight and judgement: his mates.
Formulation:
Glen was initially angry and upset in the
interview and he described himself as
stressed. His father had recently died in
tragic circumstances and he was experiencing
relationship problems. He communicated
easily and coherently and showed no evidence
of delusional thinking. Glen expressed his
emotions and indicated no intent to harm
himself or anyone else. He showed insight
and judgement in that he recognised he was
Behaviour:
Barry seems hostile, frustrated and Thought content
uncomfortable and uses a lot of hand gestures (thinking):
that include rubbing his forehead and eyes.
Barry is stressed and anxious and thinks his
wife and boss are colluding against him.
Speech and language: Thoughts of harm to self or others
(risk assessment): Although Barry has
Barry spoke with a clear tone occasionally
thought about suicide he feels he would never
raising his voice. Although stressed he
do that to his children as he saw what his
expressed himself clearly.
brothers children went through. Barry admits
he would benefit from further counselling.
35
4 Barry: MSE Assessment Example
4 Barry: continued...
Action:
Formulation:
Barry is suitable for ongoing counselling at
Barry is not sleeping well. He is waking during the AOD service but a GP appointment to
the night in a panic and he is still grieving discuss his low mood, poor sleep, feelings
the suicide of his brother two years ago. Barry of panic and use of Nurofen Plus should be
is upset and angry that his wife has recently encouraged. He was also given a leaflet with
left him. His irritability and alcohol use have emergency counselling contacts in case his
increased to the point where it has become mood worsened between appointments. The
a problem at work and he has been sent for counsellor should discuss this session with a
counselling. Barry does not show any signs of supervisor and monitor Barrys mood and risk
confused, disordered or delusional thinking. of suicide at subsequent appointments.
He shows judgement in that he sees the need
5 Emergency and
6 References
The DVD has been designed to be an instructional training tool and is best used in conjunction with first
reading the accompanying booklet. The DVD has three visual case scenarios which clinicians can use to test
their knowledge and skills in conducting an MSE.
Please note: Some versions of Windows Media Player do not support the playing of DVDs. If you are having
trouble playing this DVD via your PC, its recommended you download VLC Player (www.vlc.org).
If you are unable to access this website, please consult your IT administrator.
ADDRESS Fax
3/73 Hay St, Subiaco, WA 6008 (08) 6380 1376
PO Box 8241, Subiaco East, WA 6008
Phone EMAIL
(08) 9287 5400 mail@palmerston.org.au
2011
Funded by the Australian Government, Department of Health and Ageing through the
Improved Services Initiative