Mental State Examination (MSE) - Australia

Appearance

• Cisgender male
• 34 yo, appears stated age
• Anglo-Australian
• Pale complexion
• Average height, ectomorphic build
• Short brown hair, unkempt, 3-4 days of facial stubble
• Dishevelled, wearing stained tracksuit pants and an oversized hoodie
• Faded tattoo on left forearm; old superficial linear scars on bilateral volar forearms
• Dark circles under eyes, downcast gaze
• Faint odour of stale tobacco, nil alcohol fetor

Behaviour

• Poor eye contact, predominantly looking at the floor
• Furrowed brow, minimal facial animation
• Cooperative but withdrawn and passive
• Occasional hand-wringing when discussing workplace stressors
• Slow, shuffling gait upon entering the room
• Mild psychomotor retardation noted
• Minimal gesturing, hands kept mostly in lap

Speech

• Slow rate
• Low volume, occasionally requiring prompting to repeat
• Monotonous, flat tone
• Audible sighing prior to answering questions
• Nil stutter
• General Australian accent
• Poverty of speech, brief and monosyllabic responses
• Nil speech impediments
• Appropriate vocabulary, consistent with tertiary education level
• Easily understood despite low volume
• Increased latency of response with noticeable pauses

Mood

• Reports feeling "completely empty and exhausted"
• Depressed and anxious
• Severe, rated 2/10 (where 10 is happiest)
• Persistent for the past 6 weeks
• Minimal fluctuation, slightly worse in the mornings (diurnal variation)

Affect

• Appears dysphoric and fatigued
• Restricted range
• Predominantly sadness and apathy
• Appropriate to the context of recent job loss and relationship breakdown
• Blunted intensity
• Minimally reactive, failed to smile at gentle humour
• Congruent with thought content
• Consistent with reported low mood

Neurovegetative symptoms

• Initial insomnia (takes 2 hours to fall asleep) and early morning wakening (04:00)
• Decreased appetite, eating one small meal daily
• Unintentional weight loss of 4 kg over the past month
• Severely reduced motivation, struggling to complete basic ADLs
• Marked anhedonia, has ceased playing guitar and socialising
• Profoundly low energy, constant lethargy
• Nil libido reported

Perception

• Denies any hallucinations in any modality
• Denies illusions or derealisation/depersonalisation

Categories

• Nil auditory hallucinations
• Nil visual hallucinations
• Nil tactile hallucinations
• Nil olfactory hallucinations
• Nil gustatory hallucinations

Thought Form and Flow

• Bradyphrenic, reduced quantity and slow speed of thoughts
• Linear and logical connections, nil loosening of associations or flight of ideas
• Goal-directed, answers questions relevantly despite latency

Thought Content

• Principal subjects: Recent redundancy from IT role, subsequent breakdown of 4-year relationship, financial stress, and feelings of failure.
• Nil delusions (paranoid, grandiose, persecutory, or nihilistic). Nil passivity phenomena or ideas of reference.
• Preoccupied with themes of worthlessness, guilt, and being a burden to his family. Nil formal obsessions or compulsions.
• Risk: Reports passive suicidal ideation ("wish I wouldn't wake up") but denies active intent, plan, or access to lethal means. History of superficial DSH in early 20s, nil current self-harm urges. Nil risk of violence/aggression, vulnerability, AWOL, or child safety concerns.

Judgement

• Choices regarding health are currently adaptive as evidenced by voluntary attendance at today's psychology session following GP referral. However, daily functional judgement is mildly compromised by apathy, leading to neglect of financial obligations (unopened bills) and social isolation.
• Decision-making remains logical and reality-based, though heavily influenced by negative cognitive biases and pessimism regarding his future employment prospects.
• Good/intact

Insight

• Fully recognises current symptoms as a recurrence of Major Depressive Disorder.
• Understands that his low energy and social withdrawal are directly impairing his ability to seek new employment and maintain relationships.
• Attributes symptoms to acute psychosocial stressors (redundancy and breakup) compounding a biological predisposition to depression, which is reality-based and culturally appropriate.
• Good/intact

Cognition

• Alert
• Oriented to time, place, and person
• Grossly intact immediate, recent, and remote memory based on clinical interview
• Subjectively impaired concentration; objectively required one question to be repeated due to distractibility during the session