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MENTAL STATUS EXAMINATION TACTICS and TECHNIQUES

9 May, 2015

1.00    WHEN DOES ONE DO AN MSE (MENTAL STATUS EXAMINATION)?

1.10    In a sense, all of the time.  You should always be watching and listening for clues that a symptom exists, whether taking a history or just listening

1.20    Begin “where the client is”, using naturally occurring processes as much as possible

1.21    If the client is nervous or shy, go for history first.  This helps them to get acquainted with you, begin investing in you, and calm down

1.22    If the client is focused on his or her subjective suffering, do the MSE at the start of the session

1.23    If the client is not in need of immediate ventilation, pursue symptoms when they are detected

1.24    If the client needs to ventilate at some point, note symptoms/clues and come back to them later in the interview to get details

1.25    If the client is not in need of ventilation but is being circumstantial,  tangential, or otherwise overly verbose, don’t be afraid to provide some structure for the MSE:

“I am sorry to have to interrupt you, but there are a number of questions I will need to ask you in the limited time we have left in this interview.  The answers I need are very important for ensuring that your treatment will be on track right from the start.  Please try to confine your answers to the questions asked.”

(Don’t push it if the client cannot respond to structuring efforts.  The MSE is very important, but it is not the only important element of an initial session.)

1.30    At all times, be sensitive to your client’s needs.  You can do, or finish, an MSE in a following session

1.40    Bear in mind that some clients are minimally tolerant of MSE procedures — such as persons with true Borderline Personalities, Paranoid Personalities, and the like

2.00    DON’T BE SHY ABOUT ASKING MSE QUESTIONS!

2.10    Most clients will not spontaneously reveal all of their important symptoms.  You have to ask

2.20    Most clients expect, and very much appreciate, interest in all the details of their suffering

2.30    You begin to model part of the process of therapy for the client

2.31    The MSE procedure suggests that meaning, and therefor hope, may be gleaned from subjective chaos

2.32    The client is trained from the start in introspection and reflection

2.33    Calm interest in the client’s pathology is a structuring experience, promoting an observing ego modeled around an introject of yourself

3.00    GETTING THE DETAILS (DOING THE `DANCE OF THE MSE’)

3.10    Ask a specific question to see if a particular symptom might be present

3.11    If the response is negative, double check with a rephrased question

3.12    If the response is still negative, go on to the next symptom starting as at 3.10 above

3.20    If the response is positive, ask the client to give you a recent example

3.21    This helps to make sure that the client has indeed had the symptom you are asking about.  Some clients may be anxious to please, or may have misunderstood your question

3.22    Whether your question was correctly understood or not, asking for examples will deepen your knowledge of the client, and expand your knowledge of psychopathology

3.30    If the response is positive and valid, four questions should always follow:

3.31    When did the symptom start (onset)?

3.32    How often does the symptom occur (frequency)?

3.33    Has the client had this symptom before (history)?

3.34    Are there any identifiable situations, events, affects, or the like, which seem to elicit the symptom (precipitants)?

3.40    Go on to the next symptom beginning once again as at 3.10 above

4.00    AN ALTERNATE, RESEARCH-ORIENTED APPROACH TO MSE QUESTIONING

(PROGRESSIVE BALL-PARK QUESTIONS)

4.10    With a particular symptom in mind, ask a general, “ball-park” question

4.20    While the response remains completely negative, continue with a series of two or three more questions of increasing specificity relative to the symptom you had in mind, culminating in a specific question as in 3.10 above.  Be sure to ask about the specific symptom one last time with a rephrased question as in 3.11 above

4.21    Go on to the next “ball-park” question

4.30    If any response is positive, or if it is negative relative to the symptom you had in mind but another symptom or clue is detected in the response, pursue it as from 3.20 above.  Don’t forget section 3.30!

NOTE: It should be obvious that, as a clinician, you should be well versed in psychopathology – in the wide variety of symptoms a client may have. You can only find out by accident what you don’t already know about. Be well versed as well in the terminology of signs and symptoms. It may sound a bit OCD, but at least skimming through a psychiatric dictionary such as Hinsey and Campbell is a good start.

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