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The Mental Status Assessment

The Mental Status Assessment. The Mental Status Exam in Context. Part of a comprehensive intake and assessment Although not a formal psychometric instrument, it is essential Informs any/all assessment procedures Can result in a provisional diagnosis (working hypothesis).

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The Mental Status Assessment

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  1. The Mental Status Assessment

  2. The Mental Status Exam in Context • Part of a comprehensive intake and assessment • Although not a formal psychometric instrument, it is essential • Informs any/all assessment procedures • Can result in a provisional diagnosis (working hypothesis)

  3. Therapist Approach to the MSE • Orient to the task • Establish rapport • Position of the therapist • Safety considerations • Combination of therapist skills • Observation • Inquiry • Observation/inquired • MSE in the context of intake/work-up • Record review • Intake paperwork

  4. Therapist Approach to the MSE (cont.) • Important!! • When conducting a MSE, investigate, observe, notate, inquire! • Counseling skills and approach are essential • Counseling/therapy does not happen during the MSE • **see Polanski reading pg. 361

  5. MSE: Typical Domains • Appearance • Behavior/Activity • Mood/Affect • Speech & Language • Thought Processes, Content, Perception • Cognition • Insight & Judgement

  6. Appearance • Observation • Grooming • Poise • Clothing (appropriate for weather) • Body-type/nutrition • Age • Presentation of self • Cultural sensitivity essential

  7. Behavior/Activity • Observed • Quantitative & Qualitative • Looking for: • Psychomotor agitation • Psychomotor retardation • Akathesia

  8. Mood & Affect • Inquired/Observed • Mood –subjective report of “the way they feel” • Emotion perceived by client • Affect –How the client presents • Examiner looking for: • Congruence/incongruence • Appropriateness

  9. Speech & Language • Observed • Describe it. . . • Physical characteristics • Relevance to topic • Paralinguistic • loudness • Rhythm • Intonation, phonation • Articulation • coherence

  10. Thought Processes, Content, Perception • Observed/Inquired • Perception • Hallucination or illusions? • Hallucination –false perception without sensory stimuli • Auditory, Visual, Tactile, olfactory • Illusion –misperception of sensory stimuli • Auditory, Visual

  11. Thought Processes, Content, Perception (cont.) • Thought & Thought Content • Form of thought –the way in which a person thinks and gets it across • Flight of ideas • Loose associations • Tangentiality

  12. Thought Processes, Content, Perception (cont.) • Content of Thought • Description of what the client is actually thinking about, what is inside their head. . . • Delusions, paranoia, suicidal/homicidal • Delusions: fixed false beliefs that are usually not bizarre and therefore believable

  13. Cognition/ Sensorium • Observed/Inquired • Alertness, Level of Consciousness • Orientation to time • Orientation to place • Orientation to person • Note: distinguish between dementia and disassociation

  14. Cognition/ Sensorium (cont.) • Memory • Recent • Remote • Recent past • Immediate retention • Recall (Don’t forget to check it out)

  15. Cognition/ Sensorium (cont.) • Concentration & Attention • Serial 7’s or 3’s • Can you spell _______ backwards • Errors in mood disorders

  16. Cognition/ Sensorium (cont.) • Check capacity to read/write • Visual spatial ability (complex figure) • Abstract thinking • Fund of information • Impulse control

  17. Insight & Judgment • Insight –refers to the awareness of how one’s own personality traits and behaviors contribute to what is troubling the client • Judgment –process, and formulation that leads to a decision about an appropriate course of action to achieve realistic goals. • Judgments require adequate insight and cognitive functions

  18. Understanding the MSE --Barry • http://youtu.be/6ss827LbbtA

  19. Practice • In your groups: • Perform a MSE on your client –record it • Role play the client/therapist • Complete provisional axis diagnosis • Begin to choose your assessments

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