I’ve been rotating through psychiatry, and it’s both more challenging and more fun than last year. One thing I’m happy about is that I already know how to perform a Mental State Evaluation (MSE). I remember it was really daunting to learn, and I’m also hearing from my friends in the year below me that they are having the same problem.
The problem is that it’s hard to teach the MSE. Here are some of my tips, for med students doing MSEs the first time. I’m by no means an expert, but these pointers have helped me.
Before you start with the meat of the MSE, some things have to happen:
1. Know definitions
Knowing definitions in Psychiatry is kind of circular. Without knowing them, you’ll never recognise the signs in a patient. But without seeing the signs, the definitions will always be just some words strung together. I highly suggest knowing the definitions as well as possible before you do your first MSE. It’s pretty uncomfortable when you’re listening to a patient and you’re thinking, “I know something is very wrong here, but I don’t know what.” (It happens all the time. You’ll get better. Also, if you can’t name the sign: describe it.)
2. MSE is different to any examination you’ve learned
Realise that you’re learning this anew, and accept that it won’t come as easily as the inspection-palpation-auscultation trope you know so well. The thing about the MSE is that you perform it at the same time as you perform the history. The history is like your instrument for eliciting signs and symptoms.
3. Be safe and comfortable
Many students are worried about doing MSEs. They can be daunting. But as one of our professors put it, it’s the people on the street that are unpredictable. When someone has psychiatric pathology, you can predict them and protect yourself and them against possible risks. However, if you feel incredibly uncomfortable, don’t do an evaluation alone. Always position yourself nearest the door. If a patient is acutely manic, it may be best that he/she be sedated first, and your supervisor or the ward matron should be called in this regard.
4. To that end: establish rapport
Obviously, the first step to ANY consultation should be to establish rapport. But in the MSE, this is a wholly vital step, so much so that it is justifiable to spend even more time on it. I find it useful not to start right on in with, “What’s the matter?” but to ask some basic questions to make your patient feel more comfortable around you. Remember: nobody wants to go to a psychiatrist! (Or to a med student rotating through psychiatry.)
5. Context is important
I like to start by accumulating details about the patient. Where are they from? What is their race? Are they employed? In Psychiatry, these are very important as they directly affect not only the symptoms your patient presents with or the extent to which they effectively mask them, but they also directly affect how your patient will respond to different kinds of therapy. Don’t underestimate the PTSD a fifty-year-old man may have because he grew up in the Apartheid Era and was repeatedly detained without trial. Don’t underestimate the influence just growing up in a gang riddled neighbourhood may have on a toddler.
6. Ask about the main complaint
This is not part of the MSE yet, but it will help you examine the mental state. Note that a patient’s perception of their reason for presenting may be vastly different to the real reason.
7. Further questions on history
If you like talking or stories, you’ll love this. Psychiatry is interested in how the patient grew up, what happened to them during their childhood, even if they are now eighty years old! Don’t forget to ask about substances, forensic history, psychosexual experiences and familial relationships. Also the normal things like previous medical/surgical/psychiatric history.
8. Detail, detail, detail
An MSE is not a point-form examination. Your patient had TB? Great. They completed their 6 month regimen? Great. But were they ostracised by their community? Did they have trouble remembering to take their medication? Did they have any fearful experiences like coughing up litres of blood? Did they feel like a burden when they went to hospital? Did their estranged spouse attempt to have their children removed from their care?
Another example is that it’s not enough simply to write which drugs a patient has abused and for how long. Psychiatrists want to know why the patient started, why they like it, how they obtain it, and whether they have ever considered stopping.
9. Sometimes it’s hard to cut short
When you know you need loads of information, it can be hard to know when to interrupt your patient. And in psychiatry, when a patient is being tangential or circumstantial, it is REALLY hard to bring them back to the point. Like anything, this takes practice (I’m still bad at it). Sometimes you need to be firm and bring the patient back into focus. But take heed of how you phrase your questions. I slightly different manner of speaking may give much better results.
10. The embarrassed patient
Sometimes a patient is acutely aware that something is wrong. Some psychotic patients know that they shouldn’t be hearing voices, and some depressed patients are too proud to admit it. Empathy is the name of the game, but how do you put it into action? Again, it comes down to a lot of rephrasing.
Example: instead of asking a patient whether they have ever considered suicide, it may be useful to say, “Sometimes, when people have been through the things you have, they feel like they can’t go on with life. Have you ever felt that way?” It immediately conveys that you understand why they might feel that way.
Now, for the MSE. Most hospitals have pre-printed forms that can serve as guides, with more detailed headings. So I’m just going to discuss some broad headings. Better detail is available in all psychiatry textbooks. Note that order is NOT that important. You use the order that flows best in each situation.
1. Appearance and Behaviour
This is more than whether the patient is jaundiced or pale or obese. Is your patient well-kempt or shoddy? Have they combed their hair and shaved? Are they wearing pyjamas and slippers or day-clothes? What about their eye-contact – do they avoid it, or is it inappropriately obtrusive? Do they smile when you greet them? Are they restless or agitated? What about their attitude – are they co-operative or quite negative?
You may have picked up on this during your interview. Is your patient oriented to date, place and person? Do they know their situation? What is your impression of their intellect? If you find you have to explain things the way you might to a child, there is a good chance for cognitive or intellectual deficits. Depending on how busy your hospital is you will either do a mini-mental on every patient, or only on those with potential cognitive deficits. Remember, it’s pretty hard to do an accurate MMSE on a patient who is acutely psychotic!
How fast is your patient speaking? How loudly? Is their speech pressured, or do you have to drag things out of them? Do they speak clearly? Is their speech logical? Do they make up new words? Do they take forever and a day to get to the point? Do they never reach the point?
Here we look at form and content. Note that speech and though overlap a little. Is your patient having flights of ideas or pressured thoughts, or does it appear as though they are thinking nothing? For content, are they delusional? Do they obsess over certain ideas? Do they think about harming themselves or others?
Here you are particularly interested in hallucinations or illusions experienced by the patient.
6. Mood and Affect
Be very clear about how the patient feels subjectively and what you witness objectively. Is the mood elevated or depressed? Remember to ask about functional symptoms like appetite, sleep and libido. Here I also usually enquire about anxiety symptoms.
7. Insight and judgment
Does your patient understand what is happening to them? Do they understand the necessity for treatment/therapy? Or do they think what has happened to them is nothing out of the ordinary? Do they understand the consequences of certain actions, and do they understand what is appropriate in interacting with others and their environment?
8. Risk assessment
Taking everything into context, you have to assess the patient’s risk to self and others. If their risk is moderate to high, you have to do a 72-hour assessment (under South African law – your country’s might differ slightly).
I have some more to say, but this post is getting pretty long. Feel free to add your tips (as I said, I’m NOT an expert) or ask questions (which I may or may not be able to answer). More later!
On a related-but-unrelated note: June is Mental Health Awareness Month with Ula and Leah. It’s a bookish event, so this post is not part of that, but here’s a heads-up that there will be some bookish posts about Mental Health! And some none-bookish ones too!