MENTAL STATUS EXAM SENSITIVE SUBJECTS CLASS 3 PSY600: Diagnosis and Treatment of Mental Health...

MENTAL STATUS EXAM

SENSITIVE SUBJECTS

C L A SS 3

PSY600: Diagnosis and Treatment of Mental Health Disorders

Mental Status Exam

The Mental Status Exam (MSE) is a summary of your observations of the client’s “here and now” functioning in certain key areas.

This is an important tool for assessing current functioning and also for tracking a client’s functioning over time

Mental Status Exam-Behavioral

General Appearance and Behavior Physical Characteristics Alertness Clothing and Hygiene Motor Activity Facial Expression Voice/Speech Attitude Toward Examiner


Mood Mood: How the client reports feeling most of the time

(climate) Affect: How client shows emotion in session (weather) Assess for:

Type: Dysphoric, euthymic, elevated, expansive, irritable, anxious

Intensity: mild, moderate, severe Lability: How rapidly does mood/affect change?

Range of affect: normal, restricted, blunted, flat Appropriateness: Does mood/affect match situation and

content?


Flow (Process) of Thought: How does the client think? Discerned through speech Defects of association - Do client’s thoughts appear

to flow logically and coherently from one to the other? Loose associations (derailment) Tangentiality Flight of ideas Poverty of speech


Flow (Process) of Thought: How does the client think? Rate and Rhythm of Speech

Pressured (push of speech) Increased latency of response Circumstantial Distractible

Speech abnormalities Thought blocking Clanging Echolalia Word salad Perseveration

Mental Status Exam-Cognitive

Content of Thought: What the client thinks about

Particularly assess for delusions Identify true delusions Assess for mood congruence Determine the type of delusion


Perception Hallucinations (type and severity) Anxiety (incl. panic attacks) Phobias Obsessions/Compulsions Suicidal/Homicidal Ideation


Consciousness and Cognition Orientation times three (X3): time, place, person Level of intelligence Ability to concentrate/focus Memory (immediate, recent, remote) Language (comprehension, fluency, naming,

repetition, reading, writing)

Mental Status Exam

Insight and Judgment

Insight – what are client’s ideas about what is wrong/why they are seeking Tx

Judgment – client’s ability to decide on appropriate course of action to achieve realistic goals

When reporting your assessment of these areas, be specific.

Mental Status Exam

You will probably be able to assess most of the areas covered in the MSE during the natural course of your interview without specifically asking If you have doubts, ask the client Always ask specifically about suicidal/homicidal ideation

Problems in the areas covered in MSE will usually be fairly obvious: you are looking for the unusual, the remarkable. If you observe something notable, investigate further

Be as objective as possible. Don’t make judgments as to why the client is presenting a certain way

Suicide

ASK EVERY CLIENT IN EVERY INITIAL INTERVIEW ABOUT SUICIDAL THOUGHTS, FEELINGS OR ACTIONS

Acutely suicidal feelings are usually temporary, and it is our job to help get clients through crisis periods.

Suicide

Suicide is the 11th leading cause of death in the U.S., with 11 deaths per 100,000 caused by suicide

8-25 attempts take place for each completed suicide4 times as many men complete suicide as women;

women attempt more Men use more certainly lethal methods, particularly firearms

Non-Hispanic whites and Native Americans have the highest suicide rates

Blacks, Asian/Pacific Islanders, and Hispanics have the lowest rates

(NIMH, 2009)

Suicide

Talking about suicide WILL NOT incite itNOT talking about suicide could cause you

to miss the chance to prevent itPeople who are having suicidal thoughts

WILL usually tell someone, especially if asked directly Directly ask client, “Have you ever had thoughts

about hurting yourself?”

Assessing for Suicide Risk

If you’re concerned a client is suicidal, assess for the

following risk factors:Diagnosis

Dx that includes depressive or intensely anxious mood (MDD, Bipolar in a depressive episode, PTSD)

Dx that includes impulsivity, poor judgment, antisocial or suicidal tendencies (Borderline, substance abuse, Antisocial Personality, binging anorexia, gambling)

Mental Status Exam Do a current, direct assessment: ask directly, but also

assess indirect signs

Assessing for Suicide Risk

Predominant Mood Depressed Overly calm, especially if it’s a significant change

History Personal history of attempts Family history of suicide or attempts History of psychotic or dissociative Sx (delusions,

hallucinations, depersonalization)Substance Use

Can be disinhibiting Can be a sign of severe distress

Assessing for Risk of Suicide Attempt

Determine level of risk of near-term attempt When did they last have suicidal thoughts? How often do they have suicidal thoughts? Is client comfortable with having these thoughts? Has client attempted before?

If yes, How physically and psychologically serious was client?

Why didn’t it succeed? Were substances involved?

Does client have a plan? What is level of premeditation?

Does client have means to carry out plan? Why is client suicidal now?

Managing Suicidality

Take clinical steps to prevent attempt Alert your supervisor to your concerns Contract: written or verbal Increase frequency of contact with you Alert someone in client’s life to the potential danger Consider emergency psychiatric evaluation Consider hospitalization if you feel client won’t be safe

under any other circumstances

Document everything you do scrupulously

Assessing for Dangerousness

Dangerousness is rare in most outpatient populations.

Ask a general question of everyone: “Have you ever had thoughts of harming others?”

If the answer is no, move on, unless other information you have indicates otherwise

If the answer is yes, follow up with Hx and risk assessment

Absence of Hx of violence doesn’t mean there is no future potential

Assessing for Dangerousness

Risk factors Potentially violent or impulsive Dx (e.g., Borderline,

Antisocial Personality, PTSD, Schizophrenia) History of hallucinations or delusions

Command hallucinations/paranoid delusions History of Violence

If yes, get details History of Substance Abuse History of Being Abused by Others

Cycle of violence Did abuse cause CNS or head injury?

Observed signs – MSE Agitation, thought content, appearance/Bx

Responding to Dangerousness

If you think client is a danger to someone other than you, alert your supervisor and: Take Steps

Increase frequency of sessions or phone contact Contract Consider hospitalization Consider medication Consider exercising duty to warn

Responding to Dangerousness

If you believe your client is a danger to YOU, do whatever you have to do to be safe. Don’t be alone in agency Don’t put client between you and the door Respond to client calmly and firmly In extreme cases, consider keeping door open or seeing

client in public area of agency Alert others who will be in agency when you see clientTrust your gut, but if you feel many of your clients are a

danger to you, or only certain types of clients, seek supervision

Assessing for Substance Abuse

Substance abuse plays a significant role in destructive and self-destructive behaviors

Purpose of assessment is to learn if substances play a part in the person’s life and/or interfere with functioning

If someone is otherwise predisposed to dangerous or suicidal behaviors, substance use will highly increase risk they will act on these impulses


Ask the client about his/her use of specific substances, not just substances in general

How recently have they used?How often do they use?How long have they been using?Ask about past periods of useHow much do they use, and has this

amount changed over time?Why do they use?


Under what circumstances do they use?What happens when they use?How does use affect client’s life?Has client ever tried to stop? Was it

successful?Does client think he/she has a problem with

substance use?


Substance use can:

INCREASE IMPULSIVITY DECREASE INHIBITIONS

When assessing for substance abuse, adopt a non-judgmental tone; just get the facts

Ask client about substance use, but be aware that you can get literally true answers that are nonetheless misleading

Detecting substance abuse can be a key measure in preventing harm

MENTAL STATUS EXAM SENSITIVE SUBJECTS CLASS 3 PSY600: Diagnosis and Treatment of Mental Health...

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