How to Perform a Mental State Examination (MSE)

How to Perform a Mental State Examination (MSE)

Medically Reviewed by Dr Andrew Stein MD, Consultant Physician (Hospital Specialist). Last updated: June 2026

The Mental State Examination (MSE) is the psychiatric equivalent of a physical examination. It provides a structured “snapshot” of a patient’s psychological functioning at a specific point in time.

Unlike a history, which looks at the past, the MSE focuses on current presentation.

Introduction: The “WIPER” for MSE

Establishing rapport is critical in psychiatry. Ensure the environment is safe, private, and comfortable.

• W – Wash: Standard hand hygiene remains essential.

• I – Introduce: State your name and role clearly.

• P – Permission: Explain that you would like to ask some questions about how they have been feeling lately.

• E – Environment: Ensure the room is quiet and the seating is arranged at an angle (not directly face-to-face) to reduce confrontation.

• R – (Re)position: Ensure both you and the patient are comfortably seated. Note your proximity to the exit for safety.

Part 1: Appearance and Behaviour

Observe the patient from the moment they enter the room.

• Appearance: Note their clothing (appropriate for the weather?), hygiene, any visible scars (self-harm), or stigmata of drug/alcohol use.

• Behaviour: Is the patient restless, agitated, or retarded (slowed down)? Note eye contact—is it avoided, intense, or appropriate?

• Rapport: Is the patient guarded, hostile, or overly familiar?

Part 2: Speech

Focus on the mechanics of speech rather than the content.

• Rate: Is it fast (pressured speech in mania) or slow (depression)?

• Volume: Is it loud or a barely audible whisper?

• Tone: Is there a lack of normal variation (monotone)?

• Fluency: Are there stutters, word-finding difficulties, or “clanging” (rhyming speech)?

Part 3: Mood and Affect

These terms are often confused but represent two different things:

• Mood: The patient’s “climate”—their internal emotional state. Ask them: “How would you describe your mood lately?”

• Affect: The “weather”—the emotional state you observe externally.

  • Range: Is it restricted (flat) or expansive?

  • Congruence: Does their affect match their mood? (e.g., laughing while describing a tragedy is “incongruent”).

Part 4: Thought (Form and Content)

Thought Form

The logical flow of ideas.

• Flight of Ideas: Rapidly shifting from one topic to another with a logical link.

• Loosening of Associations: Shifting between topics with no logical link (“Knight’s Move” thinking).

Thought Content

What the patient is actually thinking about.

• Delusions: Fixed, false beliefs held despite evidence to the contrary.

• Obsessions: Repetitive, intrusive thoughts.

• Suicidal/Homicidal Ideation: Always ask directly: “Have you felt that life is no longer worth living?”

Part 5: Perception

Assess for sensory experiences in the absence of a stimulus.

• Hallucinations: Most commonly auditory (hearing voices) in schizophrenia, or visual in organic brain syndromes.

  • Ask: “Do you ever hear or see things that other people can’t?”

• Illusions: Misinterpretations of real stimuli (e.g., a coat on a hook appearing as a person).

Part 6: Cognition

In a brief MSE, perform a “mini” cognitive screen:

• Orientation: Does the patient know the time, place, and person?

• Attention/Memory: Ask the patient to repeat a name and address, or perform “serial 7s” (subtracting 7 from 100).

Part 7: Insight and Judgement

• Insight: Does the patient recognize they are unwell? Do they believe they need treatment?

• Judgement: Can they make appropriate decisions? (e.g., “What would you do if you smelled smoke in a cinema?”)

Part 8: Completing the Examination

To finish your OSCE Mental State Exam, state you would:

1. Risk Assessment: Perform a formal risk assessment for self-harm and harm to others.

2. Physical Exam: Perform a full neurological exam to rule out organic causes.

3. Collateral History: Speak with family or friends to verify the patient’s account.

4. Urine Drug Screen: To check for substance-induced psychosis.

Summary Checklist: The ASEPTIC Acronym

Video Demonstrations

For a visual guide to conducting a psychiatric interview:

• Mental State Examination Technique – Dr. James Gill

• Psychiatry OSCE: Assessing Psychosis