PSY600: Diagnosis and Treatment of Mental Health Disorders

1. PSY600: Diagnosis and Treatment of Mental Health Disorders Mental Status EXAM SENSITIVE SUBJECTS Class 3

2. 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

3. Mental Status Exam-Behavioral • General Appearance and Behavior • Physical Characteristics • Alertness • Clothing and Hygiene • Motor Activity • Facial Expression • Voice/Speech • Attitude Toward Examiner

4. Mental Status Exam-Behavioral • 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?

5. Mental Status Exam-Behavioral • 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

6. Mental Status Exam-Behavioral • 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

7. 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

8. Mental Status Exam-Cognitive • Perception • Hallucinations (type and severity) • Anxiety (incl. panic attacks) • Phobias • Obsessions/Compulsions • Suicidal/Homicidal Ideation

9. Mental Status Exam-Cognitive • 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)

10. 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.

11. 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

12. 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.

13. 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 suicide • 4 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)

14. Suicide • Talking about suicide WILL NOT incite it • NOT talking about suicide could cause you to miss the chance to prevent it • People who are having suicidal thoughts WILL usually tell someone, especially if asked directly • Directly ask client, “Have you ever had thoughts about hurting yourself?”

15. 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

16. 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

17. 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?

18. 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

19. 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

20. 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

21. 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

22. 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 client Trust your gut, but if you feel many of your clients are a danger to you, or only certain types of clients, seek supervision

23. 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

24. Assessing for Substance Abuse 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 use How much do they use, and has this amount changed over time? Why do they use?

25. Assessing for Substance Abuse 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?

26. Assessing for Substance Abuse • 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