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Mental State Examination

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James Cook University
James Cook University

This document provides an overview of the role of an occupational therapist in an acute 34-bed mental health unit. The OT assists clients to maximize their independence in daily activities and life roles by assessing how their mental illness impacts functioning. The OT's duties include participating in clinical reviews, conducting assessments, providing individual interventions such as skill-building groups, and coordinating discharge planning. The recovery program run by the OT incorporates psychoeducation, health promotion, and recreational groups to support clients' recovery progress.

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Brock Cook Occupational Therapist Townsville Integrated Mental Health Service
Overview of my Acute Mental Health Unit  34 Bed inpatient unit ○ 8 HDU Beds ○ 26 Open Beds  Located adjacent to main hospital  Multidisciplinary Team ○ OT, OT Assistant, Social Worker, ATSI Worker, Nurses, Psychiatrists, Doctors
OT Role  To assist individuals to maximise independence in their daily occupations and life roles  To assess how an individual‟s mental illness impacts on their ability to function in their everyday occupations and roles
So what do I do??????  Clinical reviews ○ Discuss as a multidisciplinary team each clients progress ○ Clients requiring OT assessment identified ○ Treatment plans, assessments, therapy programme input and discharge planning  Occupational Therapy Assessment ○ ADL‟s ○ Meal Preparation ○ Reports completed & discussed at clinical review  Individual Intervention ○ As per recommendations from assessment ○ Eg. Visual Prompting for self care, graded exposure ○ Referral to other agencies eg. SOLAS, Queensland Lifestyle Services  Weekly Recovery (Group) programme
Recovery Programme  Provides a structure to the clients day  Supports the client in recovery by the utilisation of group work  Staff involved in the program include ○ OT, OT Assistant, NGO‟s ○ Consumer consultant
Recovery Program  Groups provide an opportunity to observe within a more informal setting client skill level and abilities, motivation, memory, concentrati on, ability to plan, to organise, to judge, decision-making skills, self control, social skills, motor skills, insight into current admission, social interactions, etc
Therapy/Recovery Groups Psycho educational  Self esteem  Goal setting,  Social skill groups  Anger management  Relaxation techniques  Stress Management Health Promotion  Alcohol and drugs in your life  Healthy life style choices  Healthy eating  Community Support Information Group Recreational  Community Meetings  Exercise- Gym, morning walks  Pool Competitions  Pamper Time  Activity based groups utilising volunteers  Art & Craft  Practical Skills Based groups that support existing and/or focus on developing new skills  Cooking group  BBQ
Non standardised Assessments  Observation skills  Practical activities eg BBQ, cooking  Social activities eg, Sussex on Quinn  Liaison with treating team  Case notes  Feedback from client & family  Feedback from community case managers
Standardised Assessments  OTENT-Occupational Therapy Evaluation of Needs and Treatment which focuses on ADL‟s, Task Organisation skills, Interpersonal abilities and motor tasks  Modified Barthel Index  Brookvale Living Skills Assessment  CAM  ACLS  LOTCA
Example Role for Occupational Therapy  Build rapport  Consumer Screening Tool ○ Explore interests, strengths, goals  Involvement in recovery programme ○ Healthy Promotion Groups ○ Goal Setting ○ Self Esteem ○ Relaxation ○ Community Support Information Group ○ Recreational Groups  Assessment ○ ADL‟s ○ Meal Preparation ○ Seek family support/collateral  Referral to other agencies ○ ATODS, GROW, ROADS, Sussex On Quinn ○ Family Support- Mental Illness Fellowship
OT and Mental Health  Any Questions
Mental State Examination
Mental State Assessment  Part of „everyday‟ practice in mental health  Useful in any direct client care role  Important for client sensitive practice
Mental State Assessment  Comprehensive initial assessment includes case history plus mental state examination  Many different formats - key elements remain the same
Considerations  Cultural issues  Culture specific phenomena  Legal issues  Confidentiality  Mental Health Act  Capacity  Documentation
Rapport  Think about the individual person, not the mental illness.  Treat a person with a mental illness like anyone else, with the same respect and individuality.  Even when acutely psychotic, a person can communicate and interact rationally if interviewed skillfully.  Interact directly and openly with the person, using simple, clear language.  Do not talk about the person behind their back.
Interview and communication  Adoption of an attentive and unhurried appearance and attitude.  Observation of the client for non-verbal cues.  Effective questioning techniques including:  Open Ended Questioning e.g. “ tell me what has been happening”, “tell me more about that”, “how have you been feeling recently”
Interview and communication  Effective questioning techniques including:  Listening For Verbal Cues e.g. “I don‟t care what happens”, “I‟ve given up”, “I can‟t cope”  Clarifying Questions e.g. “ what do you mean when you say you feel strange/weird/out of it?”  Specific Directed Questioning to identify key symptoms of psychiatric illness  Screening questions for risk of self-harm in high risk groups
Case History  Demographic information  Presenting complaint/problem Question: “ What has been happening for you that brings you here today..How can I help?”  History of the presenting complaint Question: “How long has this been happening for you?”  Medical history Include: Past and present medications.  Psychiatric history Question: “Have you ever seen any one in mental health before?”  Family history Include: Medical and Psychiatric histories
Case History  Substance Usage Include: Illicit substances, Prescription medications, alcohol and tobacco. Quantities and frequencies of use.  Personal history Development- Milestone achievement Education- Grades, enjoyment Relationships- Past relationships/bonding,? Abuse. Forensic- Past and current charges, offences  Premorbid personality Question: Do you think, or has anyone else commented that you have changed since this all started?”  Current situation Can include: Current residence, current relationships/supports, level of functioning at work, school, home.
Risk Assessment  On initial assessment importance in 2 key areas. - Self harm/Suicidal ideation Include: history of self harm/suicidal ideation, current acts/ideation, plans for the future. - Violence/Homicidal ideation Include: history of aggressive/violent behaviour, current aggressive behaviour/ideation.
Mental State Examination
Mental State Examination: MSE  Systematic approach to evaluating a consumer‟s mental state at a particular point in time.  Important part of a comprehensive mental health assessment.  Commences an MSE immediately by observing the consumer and continuing to do so throughout the contact.  Broken into 9 components.
Written MSE  Professional and objective manner using terminology that is non-prejudicial of the consumer in a moral or ethical sense.  Structured format helps clinicians avoid oversights and ensures the MSE is readable and coherent.  Utilising specific and conventional terminology helps in communicating to others, but be aware of misinterpretation.
MSE- Appearance and Behaviour  Detailed description of what you see  Clothing  Hygiene  Physical features  Behaviour  Rapport Whoever reads your notes should be able to have mental picture of how the client presented.
MSE- Speech  Volume  Rate  Tone  Coherence  Succinct? Over inclusive?  Content
MSE - Mood and Affect  Mood = subjective: what the client states  Affect = objective: what do you see? Mood: “I feel sad” Affect: client appeared teary, low range of emotional reactivity Congruent? Does what is stated match watch you see?
Thought Form / Process  Assessed through observations  It reflects the persons pattern of thought  Loosening of association  Flight of ideas  Racing thoughts  Tangentiality  Circumstantiality  Word salad/incoherence  Neologisms  Clang/associations  Thought blocking
Thought Content  Assessed through interviewing  Describes themes a person is thinking  Delusions  Paranoia  Preoccupation  Obsessions  Compulsions  Phobias  Suicidal Ideation
MSE - Perception  Hallucinations  Gustatory= taste  Auditory  Visual  Somatic  Tactile  Olfactory= smell  Vestibular= sensation of movement  Heightened or Dulled Perception  Illusions  Depersonalisation  Derealisation
MSE –Insight, Judgement Insight  Knowledge of medications, experiences, effects of substance use Judgement  Ability to sift through information  Impulsive ???Capacity to organise and understand???
MSE – Cognition  Alertness / consciousness  Memory  Orientation  Abstract thought  Concentration
MSE – Neurovegatative Sleep  quantity, quality, circadian rhythms Eat  quantities – lack of or too much, patterns, dietary balance Motivation Energy Libido
Performing an MSE http://www.youtube.com/watch?v=ZB28gfSmz1Y
Discussion & Write Up  Break into groups  If this is going to be your assessment piece to hand in, fill in the MSE blank form.  Ask questions if your unsure of how to describe what you observed
Questions…

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Mental State Examination

  • 1. Brock Cook Occupational Therapist Townsville Integrated Mental Health Service
  • 2. Overview of my Acute Mental Health Unit  34 Bed inpatient unit ○ 8 HDU Beds ○ 26 Open Beds  Located adjacent to main hospital  Multidisciplinary Team ○ OT, OT Assistant, Social Worker, ATSI Worker, Nurses, Psychiatrists, Doctors
  • 3. OT Role  To assist individuals to maximise independence in their daily occupations and life roles  To assess how an individual‟s mental illness impacts on their ability to function in their everyday occupations and roles
  • 4. So what do I do??????  Clinical reviews ○ Discuss as a multidisciplinary team each clients progress ○ Clients requiring OT assessment identified ○ Treatment plans, assessments, therapy programme input and discharge planning  Occupational Therapy Assessment ○ ADL‟s ○ Meal Preparation ○ Reports completed & discussed at clinical review  Individual Intervention ○ As per recommendations from assessment ○ Eg. Visual Prompting for self care, graded exposure ○ Referral to other agencies eg. SOLAS, Queensland Lifestyle Services  Weekly Recovery (Group) programme
  • 5. Recovery Programme  Provides a structure to the clients day  Supports the client in recovery by the utilisation of group work  Staff involved in the program include ○ OT, OT Assistant, NGO‟s ○ Consumer consultant
  • 6. Recovery Program  Groups provide an opportunity to observe within a more informal setting client skill level and abilities, motivation, memory, concentrati on, ability to plan, to organise, to judge, decision-making skills, self control, social skills, motor skills, insight into current admission, social interactions, etc
  • 7. Therapy/Recovery Groups Psycho educational  Self esteem  Goal setting,  Social skill groups  Anger management  Relaxation techniques  Stress Management Health Promotion  Alcohol and drugs in your life  Healthy life style choices  Healthy eating  Community Support Information Group Recreational  Community Meetings  Exercise- Gym, morning walks  Pool Competitions  Pamper Time  Activity based groups utilising volunteers  Art & Craft  Practical Skills Based groups that support existing and/or focus on developing new skills  Cooking group  BBQ
  • 8. Non standardised Assessments  Observation skills  Practical activities eg BBQ, cooking  Social activities eg, Sussex on Quinn  Liaison with treating team  Case notes  Feedback from client & family  Feedback from community case managers
  • 9. Standardised Assessments  OTENT-Occupational Therapy Evaluation of Needs and Treatment which focuses on ADL‟s, Task Organisation skills, Interpersonal abilities and motor tasks  Modified Barthel Index  Brookvale Living Skills Assessment  CAM  ACLS  LOTCA
  • 10. Example Role for Occupational Therapy  Build rapport  Consumer Screening Tool ○ Explore interests, strengths, goals  Involvement in recovery programme ○ Healthy Promotion Groups ○ Goal Setting ○ Self Esteem ○ Relaxation ○ Community Support Information Group ○ Recreational Groups  Assessment ○ ADL‟s ○ Meal Preparation ○ Seek family support/collateral  Referral to other agencies ○ ATODS, GROW, ROADS, Sussex On Quinn ○ Family Support- Mental Illness Fellowship
  • 11. OT and Mental Health  Any Questions
  • 13. Mental State Assessment  Part of „everyday‟ practice in mental health  Useful in any direct client care role  Important for client sensitive practice
  • 14. Mental State Assessment  Comprehensive initial assessment includes case history plus mental state examination  Many different formats - key elements remain the same
  • 15. Considerations  Cultural issues  Culture specific phenomena  Legal issues  Confidentiality  Mental Health Act  Capacity  Documentation
  • 16. Rapport  Think about the individual person, not the mental illness.  Treat a person with a mental illness like anyone else, with the same respect and individuality.  Even when acutely psychotic, a person can communicate and interact rationally if interviewed skillfully.  Interact directly and openly with the person, using simple, clear language.  Do not talk about the person behind their back.
  • 17. Interview and communication  Adoption of an attentive and unhurried appearance and attitude.  Observation of the client for non-verbal cues.  Effective questioning techniques including:  Open Ended Questioning e.g. “ tell me what has been happening”, “tell me more about that”, “how have you been feeling recently”
  • 18. Interview and communication  Effective questioning techniques including:  Listening For Verbal Cues e.g. “I don‟t care what happens”, “I‟ve given up”, “I can‟t cope”  Clarifying Questions e.g. “ what do you mean when you say you feel strange/weird/out of it?”  Specific Directed Questioning to identify key symptoms of psychiatric illness  Screening questions for risk of self-harm in high risk groups
  • 19. Case History  Demographic information  Presenting complaint/problem Question: “ What has been happening for you that brings you here today..How can I help?”  History of the presenting complaint Question: “How long has this been happening for you?”  Medical history Include: Past and present medications.  Psychiatric history Question: “Have you ever seen any one in mental health before?”  Family history Include: Medical and Psychiatric histories
  • 20. Case History  Substance Usage Include: Illicit substances, Prescription medications, alcohol and tobacco. Quantities and frequencies of use.  Personal history Development- Milestone achievement Education- Grades, enjoyment Relationships- Past relationships/bonding,? Abuse. Forensic- Past and current charges, offences  Premorbid personality Question: Do you think, or has anyone else commented that you have changed since this all started?”  Current situation Can include: Current residence, current relationships/supports, level of functioning at work, school, home.
  • 21. Risk Assessment  On initial assessment importance in 2 key areas. - Self harm/Suicidal ideation Include: history of self harm/suicidal ideation, current acts/ideation, plans for the future. - Violence/Homicidal ideation Include: history of aggressive/violent behaviour, current aggressive behaviour/ideation.
  • 23. Mental State Examination: MSE  Systematic approach to evaluating a consumer‟s mental state at a particular point in time.  Important part of a comprehensive mental health assessment.  Commences an MSE immediately by observing the consumer and continuing to do so throughout the contact.  Broken into 9 components.
  • 24. Written MSE  Professional and objective manner using terminology that is non-prejudicial of the consumer in a moral or ethical sense.  Structured format helps clinicians avoid oversights and ensures the MSE is readable and coherent.  Utilising specific and conventional terminology helps in communicating to others, but be aware of misinterpretation.
  • 25. MSE- Appearance and Behaviour  Detailed description of what you see  Clothing  Hygiene  Physical features  Behaviour  Rapport Whoever reads your notes should be able to have mental picture of how the client presented.
  • 26. MSE- Speech  Volume  Rate  Tone  Coherence  Succinct? Over inclusive?  Content
  • 27. MSE - Mood and Affect  Mood = subjective: what the client states  Affect = objective: what do you see? Mood: “I feel sad” Affect: client appeared teary, low range of emotional reactivity Congruent? Does what is stated match watch you see?
  • 28. Thought Form / Process  Assessed through observations  It reflects the persons pattern of thought  Loosening of association  Flight of ideas  Racing thoughts  Tangentiality  Circumstantiality  Word salad/incoherence  Neologisms  Clang/associations  Thought blocking
  • 29. Thought Content  Assessed through interviewing  Describes themes a person is thinking  Delusions  Paranoia  Preoccupation  Obsessions  Compulsions  Phobias  Suicidal Ideation
  • 30. MSE - Perception  Hallucinations  Gustatory= taste  Auditory  Visual  Somatic  Tactile  Olfactory= smell  Vestibular= sensation of movement  Heightened or Dulled Perception  Illusions  Depersonalisation  Derealisation
  • 31. MSE –Insight, Judgement Insight  Knowledge of medications, experiences, effects of substance use Judgement  Ability to sift through information  Impulsive ???Capacity to organise and understand???
  • 32. MSE – Cognition  Alertness / consciousness  Memory  Orientation  Abstract thought  Concentration
  • 33. MSE – Neurovegatative Sleep  quantity, quality, circadian rhythms Eat  quantities – lack of or too much, patterns, dietary balance Motivation Energy Libido
  • 35. Discussion & Write Up  Break into groups  If this is going to be your assessment piece to hand in, fill in the MSE blank form.  Ask questions if your unsure of how to describe what you observed