Mental State Examination (MSE) | Case Study

• Ellie Fitz-Gerald

1. Giving examples from the case study, how would you describe Amanda’s behaviour and appearance as set out in a MSE?

A mental state examination (MSE) is used to assess an individuals mental capacity and reasoning at the time of an interview. It couples a number of cognitive domains in an attempt to characterise a person’s mental state (PCDCBP, 2011). The first domain of a MSE is a visual assessment of the patient, non-judgementally describing an accurate appearance of the patient including as many details as possible. These aspects include but are not limited to age, gender, build, posture, grooming, hygiene, heath levels, signs of drug use, hair style and colour and ethnicity. Behaviour is another non-judgemental assessment of the patient’s behaviour in general, but also a description of eye movement and eye contact, body movement and any gestures that are made. This is often coupled with an interpretation of the patient’s reaction to their current situation; examples may include descriptions such as being cooperative, hostile, withdrawn or suspicious (PCDCBP, 2011).

Appearance: Amanda is a young woman with dyed blue and pink hair, which is mattered and unkempt. She has a number of piercings in her nose, eyebrow and lip. Her arms are covered in sores and her pupils are dilated. On paramedic arrival, they described that Amanda was “sitting upright appearing dazed and anxious”. In the cubicle on arrival to ED, she appeared very tense. Later in the cubicle, Amanda is smiling and then quickly appears terrified. Amanda’s mother has reported that “she [Amanda] comes home dishevelled and dirty. She has lost a lot of weight…”

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Behaviour: Amanda’s behaviour over the course of the case study could be described as erratic, often shifting between states of anxiety, happiness and terror. On arrival of the paramedics, Amanda was described as “anxious and short of breath”. In the cubicle at the ED, Amanda was pacing up and down the corridor and wringing her hands occasionally, responding quickly to any stimulus by staring intensely at the ceiling or at staff members. A description of her eye sight involved her manner and gaze alternating “between being intrigued to afraid to hostile”, coupled with difficulty remaining still. Amanda was hesitant to be touched, and noted to be constantly picking at sores. Later, Amanda was later happy and quickly turned to terror and despair. Amanda is described by her mother in these examples; “Amanda hasn’t been herself since dropping out of university…”, “She has lost contact gradually with nearly all of her friend and become increasingly isolated”, “Over the last three months her behaviour has become increasingly odd and erratic”, “goes out, sometimes for days at a time”, “talking loudly to herself in her room…over the past week she has been shouting…but there was no one in her room with her.”, “Last night she burst out of her bedroom and screaming incomprehensibly at her father then stopped suddenly and went back into her room.”

2. Define cognition and then briefly discuss how we might interpret how both Amanda’s thought content and thought form are disturbed?

According to Miller and Wallis (2009), cognitive or executive control, or cognition, refers to the ability to coordinate thought and action and direct it toward obtaining goals. Cognition is important in planning and sequencing complex events of behaviour, as well as prioritizing goals (Miller and Wallis, 2009). Thought content and processing is a somewhat subjective insight into cognitive capacity. For example, thought process can be a description of a patients thinking and a characterisation of how a patient’s ideas are communicated. The speed of thought is how quickly a patient changes ideas, known as ‘flight of ideas’ (Snyderman and Rovner, 2009). An example exhibited by Amanda is in the ED cubicle where she had asked the clinician “You wont tell her anything will you?”, quickly progressing through a series of thoughts from “you know don’t you?” to “They’re everywhere” to “The whole planet is falling” and then “Shut up shut up”.

Additionally, thought form is another domain which could be described as goal-directed or conversely, disorganised. These terms carry descriptors, describing whether a patients thoughts are logical, tangential (quickly diverging, as shown through Amanda’s haphazard thought progression), circumstantial (unsupported thinking) or loosely associated (Snyderman and Rovner, 2009). Amanda displays a number of disorganized thought categories, stating “Everyone of us is falling – the whole planet is falling” is a description of both unsupported thinking, and potentially an illusion Amanda is experiencing. Another interpretation of disordered thought is that of intrusive thoughts or obsessive ideas. As severity of mental health illness increases, patients may exhibit delusional thinking (a false belief not held by peers that persists despite evidence to the contrary), hallucinations (false perception of sensory stimuli) or illusions (a misperception of real life) (Martin, 1990). Amanda illustrates both hallucinations and illusions. Amanda seems to demonstrate hallucinations through multiple spoken phrases: “They’re everywhere. Everywhere…under my skin”, “Shut up, shut up…”, “Can’t you hear what they’re saying?! All the children have been hurt”. Taken together, Amanda’s thought content and process appears compromised.

3. Briefly explain the differences between hearing and listening. Choose two skills of listening and discuss how you would use these skills to effectively communicate with Amanda. What are some of the barriers you might face in the process?

Hearing is the process of physiological receiving and processing sounds, without being fully attentive or actively concentrating on what is being said. This is passive listening. In contrast, listening is an active process, paying attention to what is being said, constructing meaning from, and in addition, often responding appropriately to what has been said using astute observation (Purdy and Borisoff, 1997). Listening is necessary for the health professional as it involves more than simply sending and receiving words, and can validate the patient’s emotions and promote an understanding between patient and health professional. Hearing on the other hand does not continue or encourage interaction. Listening can be enhanced by actively applying numerous measures. Two of these are providing non-verbal cues and picking up on the non-verbal cues of the patient. Providing non-verbal cues to Amanda would encourage a non-judgemental and mutual understanding environment, often involving the implementation of an acronym SOLER (Sit squarely, Open posture, Lean forward, Eye-contact, Relaxed) (Egan 2002). In addition to this, nodding the head and quiet murmurs as encouragement also aids active listening, this may assist in making Amanda feel better understood, and potentially play a role in reducing her defensiveness to a medical situation. Secondly, picking up on non-verbal cues from the patient is critical in making them feel understood. A health professional should endeavour to pay careful attention to what the patient is expressing and how they are displaying these emotions. This may manifest through facial expression, body posture, movements or excessive/poor eye contact and illustrate a patient’s emotion or frame of mind (Egan, 2002). In Amanda’s situation, recognizing that she is in distress by verbally acknowledging it may led to some kind of mutual understanding and rapport building between Amanda and the health professional. Some barriers to this include Amanda’s current inability to adequately perceive her environment correctly. Amanda does not seem as aware of her surroundings and stares often at the ceiling. She may be inattentive to the non-verbal postural cues by the health professional aimed to place her at ease. Her responses may be skewed and irrational, and the potential hallucinations that she may be experiencing are external to any verbal communication that can resolve her distress.

4. Define therapeutic communication. Using case study examples, explain the difficulties involved in communication when managing a complex scene that includes an anxious patient who presents in the emergency department with a distressed and demanding relative.

Therapeutic communication occurs between a health professional and a patient, which considers a patients experienced emotion and explores the meaning and potentially faulty cognition in an attempt to resolve them. It is often formal, purposeful and structured, with a long term goal to produce a desired change (Plutchik, 2000). Managing patient anxiety in a scenario with a demanding relative has its challenges. When paramedics have arrived to the scene of Amanda, her mother is quite distressed, yet Amanda is highly anxious, “The mother is constantly obstructing and getting in their way causing interruptions”. The assertiveness of Amanda’s mum may obfuscate the ability of the paramedics to create a therapeutic relationship with Amanda in order to de-escalate the situation. Furthermore, this may worsen the anxiety experienced by Amanda. Moreover, attention may be given to the mother in order to place her at ease. One manner to reduce this difficulty is to try to separate the parties. In the ED, this dynamic may result in similar difficulties, and the presence of a demanding relative in this context could potentially result in Amanda having difficulty communicating additional information due to her anxiety. Although in the case study Amanda’s mum is not particularly difficult, in the scenario where a distressed and demanding relative was present in the ED and hindering patient treatment the best course of action would be to kindly ask them to take a seat in the waiting area. If the distressed relative is being quite difficult to handle other tactics include asking relative to go and get an item such as a drink for the patient, which would require that they leave the area. If the relative continues to cause disruption to the patient care they must be informed that if they cannot allow the healthcare team to complete their care for the patient they will be removed from the area/hospital.

5. What are the key components of an effective handover between health professionals from different disciplines? Discuss the important considerations of patient handover in regards to objective information and confidentially.

A clinical handover is the transfer of professional responsibility, accountability, clinical information and patient to another set of health professionals on a permanent or temporary basis. In order for an effective handover to occur, numerous considerations must take place. First, the handover should have clear leadership. Second, there should be support for the handover process to come from all levels of the medical team. Third, adequate information regarding the patient and the current situation and future direction should be provided if applicable. Fourth, tasks must be prioritised, further care plans put in place and unstable patients are reviewed in a rapid manner (AMA, 2006). A qualitative study on paramedic and emergency department handovers showed that paramedics wish for a consistency in the terminology used, a shared understanding of the team members in each of the roles of health professionals, and a standardized approach to handovers, such as a predetermined format which is flexible and recognises professional judgement and experience (Owen et al. 2009). A problem arises when considering the objectiveness of information that is acquired from various sources. In order to address this, health professionals should speak non-judgementally, and take note of what was observed, as opposed to spoken by the patient, or reported by a significant other in terms of incidents. These processes maintain some level of objectiveness. Confidentiality is a necessary and critically important obligation and law-binding role of all health professionals. One manner to protect confidentiality would be to initiate handover in an area whereby members of the public cannot overhear.

Reference List

AMA (2006) Safe handover: Safe patients: Guidance on clinical handover for clinicians and managers. Australian Medical Association. Kingston, ACT, Australia.

Egan, G. (2002) The skilled helper: a problem-management and opportunity-development approach to helping. 7th edition. Pacific Grove, California: Brooks/Cole.

Miller, EK, and Wallis, JD (2009) Executive Function and Higher-Order Cognition: Definition and Neural Substrates. In: Squire LR (ed.) Encyclopedia of Neuroscience, volume 4, pp. 99-104. Oxford: Academic Press.

Martin, DC (1990) Clinical Methods: The History, Physical, and Laboratory Examinations. 3^rd edition., Butterworth Publishers

Owen, C, Hemmings, L, Brown, T (2009) Lost in translation: Maximizing handover effectiveness between paramedics and receiving staff in the emergency department, Emergency Medicine Australasia, 21: pp. 102-107.

PCDCBP (2011) Understanding the Mental State Examination (MSE): a basic training guide. Palmerston Association Inc. Subiaco, WA.

Plutchik, R (2000) Emotions in the practice of psychotherapy: Clinical implications of affect theories. American Psychological Association. Washington, DC, US. pp. 149-168.

Purdy, M and Borisoff, D (1997) Listening in everyday life: A personal and professional approach. Second Edition. University Press of America Inc. LLanham, Maryland.

Snyderman, D and Rovner, BW (2009) Mental Status Examination In Primary Care: A Review. Am Dam Physician, 15(80): pp. 809-814.

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