Mental State Examination (MSE) Case Study

• Lachlan Donnet-Jones

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

A Mental State Examination (MSE) is defined as “[a] medical examination comprising the systematic evaluation of the mental status of the patient” (Dorland, 2011). A MSE evaluates many characteristics of a patient including appearance, psychomotor behaviour, speech, thinking and perception, emotional state including affect and mood, insight and judgment, intelligence, sensorium, attention and concentration, and memory (Dorland, 2011). The initial segments evaluated during a MSE are appearance and behaviour. It is important to note the patient’s appearance as this can provide useful information into the level of self-care, daily living skills and lifestyle of the patient. Behaviour is important to record as it can provide much insight into the patient’s emotional state and attitude. A MSE is an important process in determining a patient’s capacity to make [or not] independent health care decisions and provide the necessary support to better the patients welfare (Volicer, 2011).

Appearance: The initial insight into Amanda’s appearance occurs as the paramedic crew arrive, finding her ‘sitting upright, looking dazed and anxious with shortness of breath’. It is apparent that Amanda appears distressed, confused and anxious enough to cause her to become dyspnoeic (shortness of breath) (Shiber and Santana, 2006). Amanda is a young woman with dyed, untidy and matted hair who presents with a poor level of personal hygiene and self-care. Amanda has many facial piercings, her pupils are extremely dilated and her arms are covered in sores. Subsequent to Amanda’s arrival at the emergency department (ED) she appears very tense and her facial expressions change rapidly from smiling to terrified. Amanda’s mother re-counted that Amanda ‘comes home dishevelled and dirty’, and that she has ‘lost a lot of weight’.

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Behaviour: Following the handover to the clinician at the hospital, it is observed that Amanda appears to be suffering a level of psychomotor agitation as she is ‘very tense… pacing up and down the corridor wringing her hands’. Amanda appears unable to focus, demonstrated by abnormal and erratic eye movements, ‘her eyes stare intensely either into the ceiling above or at staff members’. Amanda appears to be suspicious of and distrust staff members as she distances herself as much as possible from any physical contact and enters the room ‘like she’s about to enter a trap’.

During the interview Amanda screams ‘They’re everywhere. Everywhere…under my skin!’. Amanda appears to be experiencing tactile hallucinations, she believes there is something beneath her skin, when there is not. Amanda also appears to be experiencing auditory sensation (voices) without an authentic (real) stimulus i.e. auditory hallucinations. This is seen as she looks up at the ceiling yelling ‘Shut up shut up shut up!!!!!! then distressed, proceeds to scream and hold her ears as if to block a loud noise’ and furthermore, ‘Why am I here???!!! You won’t tell her anything will you?’. Amanda talks about ‘her’, which may be referring to her mother, but it may also be referring to someone else.

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

Cognition is defined as ‘the mental processes by which a person acquires knowledge.’ Among these are reasoning, creative actions and solving problems (Marcovitch, 2009). Cognition is an essential in determining what we think and how we think. In an MSE, thought form and thought content are used to gain an understanding of the patients thinking, specifically how they think (form) and what they are thinking of (content) (Trzepacz and Baker, 1993). Thought form is the quantity, rate, tempo and logical coherence of a person’s thoughts. The thought form may include highly irrelevant comments, frequent changes in topic and pressured or halted speech (Kaufman and Zun, 1995). In contrast, thought content refers to selective attention (focus on a selective topic), preoccupation or exaggerated concern (obsessions, compulsions and hypochondria) and distorting or ignoring reality (illusions, hallucinations and delusions) (Trzepacz and Baker, 1993).

During Amanda’s interview a number of sentences allude to disturbed thought content such as ‘You know don’t you? You know it’s in my veins!’ and ‘Every one of us is falling – the whole planet is falling!’. Amanda’s exclamations are examples of unsubstantiated thinking and are possibly part of an illusion. The thought form of such exclamations is disorganised, hastily changing from one topic to another, “they’re in my veins”, “the whole planet is falling!”, ‘Shut up shut up shut up!!” and ‘Forgive me! Forgive me!’. While the specific idea changes there is a recurrent theme to Amanda’s thought content, disastrous, guilty and fearful situations that are beyond her control. It is evident based on the irrelevant topics and unsubstantiated thinking observed in Amanda’s speech that her thought content is disturbed. Amanda’s thought form also appears disturbed demonstrated by the ‘flight of idea’s’ she experiences and her inability to focus on a relevant topic within the context of the situation (Trzepacz and Baker, 1993).

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?

Listening is defined as ‘a complex process that encompasses the skills of reception, perception and interpretation of input.’ (Stein-Parbury, 2013). As opposed to hearing, listening is consciously chosen, one must be paying ‘active attention to what is being said’ (Stein-Parbury, 2013). Additionally there are two terms for listening, active and passive. Active listening is effective listening. It requires concentration to process words into meaning which in turn leads to learning. Hearing, or passive listening, is one of the five senses a human possesses, it is simply perceiving sound (vibrations) via the ear. Hearing alone is a subconscious process and happens automatically. A nursing research paper provides a succinct definition of the difference between hearing and listening. Hearing is ‘being there’ for patients whereas listening is ‘being with’ patients (Fredriksson, 1999).

In order to conduct effective active listening and exchange information with patients a clinician needs to possess the required listening skills. There are five categories of listening skills; perceiving; interpreting; recalling; and attending and observing, which will be discussed in relation to Amanda’s case (Stein-Parbury, 2013). Observation from the clinician is important in Amanda’s case as much information can be learnt simply from observing Amanda’s behaviour. Observing involves paying careful attention to what is expressed and how it is expressed (Stein-Parbury, 2013). Non-verbal cues such as facial expression, eye contact, body posture and movements ‘[convey] emotional and relational information [Henry et al. 2012] that can inform the clinician of Amanda’s feelings and emotional state.

The clinician notices that Amanda is ‘wringing her hands from time to time’, which may suggest she is feeling nervous and anxious. This is an example of observation, by paying careful attention to Amanda’s non-verbal cues (hand wringing) the clinician has an increased awareness of Amanda’s feelings. Amanda’s eyes ‘stare intensely either into the ceiling above or at staff members’, the clinician may interpret this as a sign of distrust and suspicion. Using this knowledge the clinician recognises the absence of trust and can address this in his response to build rapport.

Although observing and interpreting the patient’s non-verbal cues is important, it is equally important for the clinician to provide their own non-verbal cues for the patient to interpret. This is referred to as attending. A common mnemonic used for this is SOLER (Sit squarely, Open posture, Lean forward, Eye-contact, Relaxed) (Egan, 2002). Encouragement such as quiet murmuring (e.g. “Mmm”) and head nodding is also used to show attentiveness and openness, allowing the patient to feel understood. Despite many methods of encouragement and understanding the clinician may still find barriers with particular patients. In Amanda’s case some barriers may include Amanda’s apparent lack of awareness to her environment, she may be unable to listen or acknowledge the clinician, such as when she is staring at the ceiling. Amanda’s hallucinations can potentially disrupt or prevent any congruent conversation and distort her responses.

Observation and attending are important skills in listening as they are ‘fundamental in establishing effective relationships’ (Stein-Parbury, 2013). Using listening skills to develop a comprehensive understanding of Amanda’s situation the clinician can respond accordingly in a manner that matches Amanda’s needs.

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.

Hungerford (2011) defines therapeutic communication as ‘a communication technique utilised by a health professional to engage with a person and enable them to achieve personal change’. It is essentially the face to face communication between clinician and patient that aims to enable positive change in the patient. An anxious patient such as Amanda can be difficult to manage, especially in the presence of bystanders or relatives who are distressed, in Amanda’s case it is her mother. While Amanda’s mother may mean well, she is most likely contributing to Amanda’s anxiety. Rather than aiding health professionals she is hindering their ability to reduce Amanda’s anxiety as she ‘[is] constantly obstructing and getting in their way causing interruptions’. In addition to increasing Amanda’s anxiety, health professional’s attention may be taken away from Amanda and focused on calming the mother down. This has a negative impact of the patient’s well-being, increasing the time it takes to de-escalate the situation and decrease the patient’s anxiety.

Amanda’s mother’s constant interruptions have a negative impact of the patient’s well-being. For example, ‘She is not right; she is really unwell’ as heard from Amanda’s perspective is escalating the situation, making Amanda feel worse than she has too and increasing her anxiety. A potential method to avoid relatives increasing patient anxiety is to separate them. The paramedics separate them during transport, taking Amanda in the ambulance where she can receive further care that is needed, and Amanda’s mother via police. At the ED Amanda’s mother continues to interrupt clinicians. To remove the potential of increasing Amanda’s distress, the clinician interviews Amanda alone. Although Amanda’s mum provided important information it was beneficial to interview Amanda alone. In a situation where a relative is distressed and interferes with treatment it is most appropriate to kindly separate them from the patient, take them to another area where they can calm down and perhaps have a drink or some food.

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 confidentiality (8).

A clinical handover is ‘the transfer of professional responsibility and accountability for some or all

aspects of care for a patient, or group of patients, to another person or professional group on

a temporary or permanent basis’ (National Patient Safety Agency, 2014). The aim of the handover is to establish effective communication of clinical information during patient transfer from the care of one health professional to another. There are numerous steps or processes involved in an effective handover. First, the clinician sending information needs to show strong leadership. Second, any members of the medical team involved in the care of the patient prior to or subsequent to the handover should have an active role in the handover. Third, a multifaceted quantity of information involving the patients past, current and future care should be provided. Finally, the fourth step is to ensure patients that are not stable are quickly reviewed, further care is planned and the tasks are prioritised appropriately (AMA, 2006).

Patients expect that confidentiality is respected and personal information is treated with utmost care. Confidentiality is an important legal obligation of health professionals. Delicate and sensitive information regarding patient care should not be discussed in potentially compromised areas, ideally in private quarters away from the public. A final factor to consider during patient handover is the level of objective information. Objective information is fact-based, measurable and observable, as opposed to subjective information which is based on personal opinions, interpretations and judgement (Hjørland, 2007). Health professionals are required to avoid relaying information that is judgemental, opinion and subjective as this form of information can lead to misinformed health professionals which consequently creates poor or inappropriate patient care (Hemmings and Brown, 2009).

References

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

Dorland, (2011). Mental Status Examination. In: Dorland’s illustrated medical dictionary, 20th ed. Philadelphia, USA: Elsevier Health Sciences.

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

Fredriksson, L., 1999. Modes of relating in caring conversation: a research synthesis on presence, touch and listening. Journal of Advanced Nursing 30, 1167-1176.

Hemmings, C Owen & L, Brown, T 2009. ‘Lost in translation: Maximizing handover effectiveness between paramedics and receiving staff in the emergency department’,Emergency Medicine Australasia, 21, 2, pp. 102-107, Academic Search Complete, EBSCOhost, viewed 4 May 2014.

Henry, S.G., Fuhrel-Forbis, A., Rogers, M.A.M., et al., 2012. Association between nonverbal communication during clinical interactions and outcomes and outcomes: a systematic review and meta-analysis. Patient Education and Counselling 86, 297-315.

Hjørland, B. (2007). Information: Objective or subjective/situational?. J. Am. Soc. Inf. Sci., 58:1448–1456. doi:10.1002/asi.20620

Kaufman, D. and Zun, L. (1995). A quantifiable, Brief Mental Status Examination for emergency patients.The Journal of emergency medicine, 13(4), pp.449–456.

Marcovitch, H. (2009). Cognition. In:Black’s Medical Dictionary, 42nd ed. A & C Black.

National Patient safety Agency, (2014). As cited inSafe handover: safe patients. London: British Medical Association, p.7.

Shiber, J. and Santana, J. (2006). Dyspnea.Medical Clinics of North America, 90(3), pp.453-479.

Stein-Parbury, J. (2013).Patient and person. 5th ed. Sydney: Elsevier Churchill Livingstone.

Trzepacz, P. and Baker, R. (1993).The Psychiatric Mental Status Examination. 1st ed. New York: Oxford University Press.

Volicer, L. Mahoney, E. Hurley, A. 2011 ‘Mental status measurement: Mini-mental state examination‘ inEncyclopedia of nursing research, Springer Publishing Company, New York,