Mental Status Assessment

1. Mental Status Assessment Adapted from Casey Barrio, Ph.D. University of North Texas Amy McCortney, Ph.D., LPC-S, NCC

2. DSM IV-TR and the DSM 5 • Note: • DSM III, DSM IV, and DSM IV-TR all included the use of multiaxial diagnosis, a practice that was widely adopted in assessment and managed care • The DSM 5 is intended to be a “non-axial” or more holistic view of biopsychosocial functioning • However, it is likely many assessment methods, as well as insurance forms, will continue to include the multiaxial format through a transition time.

3. Multiaxial Evaluation (review)

4. Axis I Clinical disorders Other conditions that may be focus of clinical attn • Includes all current disorders except • Personality disorders • Mental retardation • List principal diagnosis first • List all Axis I • Include major stressors if focus • Ok to defer or assign no diagnosis

5. Axis II Personality disorders Mental Retardation • Includes • Personality disorders • Mental retardation • Personality traits • Defense mechanisms • Note if principal reason • List all Axis II • OK to defer to assign no diagnosis

6. Axis III General Medical Conditions • Relevant to understanding or management • Directly causes disorder (xx due to yy) • Causes d/o to worsen • D/o is a reaction to medical dx • Choice of meds is influenced • Management or safety is issue • Incidental • Specify • “None” if none • “Deferred” if in progress • “By patient history” if not formal

7. Axis IV Psychosocial and environmental problems • May include problems that… • affect dx, tx, prognosis • Put one at risk for mental d/o • are a result of mental d/o • Include • Relevant in past year • Very salient context/history • If focus, also gets coded on Axis I • Often include “mild” “moderate” “severe”

8. Primary support group Social environment Educational Occupational Housing Economic Health care Legal system Others Axis IV Psychosocial and environmental problems

9. Axis V Global Assessment of Functioning (GAF) • Level of psych, soc, and occ functioning • 100-point scale includes attention to • Severity • Functioning • Rate • current period (lowest past week) • past year • discharge/termination

10. Axis V Global Assessment of Functioning (GAF) • Often used to determine level of care • Generally… • 50-70 Outpatient • 30-50 Intensive outpatient/partial hosp • 1-30 Inpatient

11. Severity & Course Specifiers • Mild Few symptoms in excess of min; minor impair • Moderate • Severe Many symptoms in excess, several particularly severe symptoms, marked impairment • Partial remission • Full remission • Prior history

12. Axis V Determining a GAF Score (p. 34) • Start at top and use “EITHER OR” logic Is either severity OR level of functioning worse? • Move down until range matches severity OR functioning (WHICHEVER WORSE) • Go one lower to make sure both are TOO SEVERE • Determine SPECIFIC number within 10-point range

13. In a nutshell… Communicating severity and impairment • DSM-IV severity specifiers (Axis I) • Co-morbid personality disorders (Axis II) • Co-morbid medical conditions (Axis III) • Listing all stressors (Axis IV) • GAF (Axis V)

14. Checking in… Why do counselors assess? When do counselors assess? How do counselors assess?

15. Mental Status Exam

16. Purpose & Overview • Standard practice at most agencies • Crisis situations • Necessity of treatment / level of care • Managed care requirements • Provides baseline • Assists in documentation

17. Purpose & Overview con’t • Generally adjunct to intake • Ongoing observation & integrated assessment • What’s not present is as important as what is • Objective measure (SOAP) although some assessment (SOAP)

18. Overview of MSE areas • Appearance • Motor • Speech • Affect • Thought content • Thought process • Perception • Intellect • Insight Assess all items based on current observations

19. The very basic… • Orientation x4 • Person • Place • Time • Situation AKA “Oriented x4”

20. Age Sex, race Build Position Posture Dress Grooming Manner Distinguishing features Prominent physical abnormalities Emotional facial expression Alertness Appearance

21. Behavior • Eye contact • Habits • Movements • Willingness to respond • Attitude toward counselor • Evidence of internal stimuli

22. Motor • Retardation (slowed) • Agitation • Abnormal movements • Gait • Catatonia

23. Speech • Rate • Volume • Amount • Articulation (clarity) • Spontaneity • Changes in patterns

24. Affect • Stability • Range (long-term, immediate) • Appropriateness • Intensity • Affect (outward appearance) • Mood (internal - self-report)

25. Suicidal ideation Death wishes Homicidal ideation Depressive cognitions (guilt, worthlessness) Obsessions Ruminations Phobias Ideas of reference Paranoid ideation Magical ideation Delusions Overvalued ideas Other major themes Thought Content

26. Thought Process • Stream • Associations (flight of ideas, loose) • Coherence • Logic • Clang associations (rhyming/pattern) • Perseverative (repetition) • Neologism (new words) • Blocking (interruption in flow) • Attention

27. Perception • Hallucinations (all 5 senses) • Illusions • Depersonalization (of self) • Derealization (of outside world) • Déjà vu • Jamais vu (French, “never seen”)- disfamiliarity

28. Other MSE observations • Approximate IQ • Insight • Awareness of problem & self • Judgment • Ability, given info, to make sound decisions • Impulse control • Ability for person to control/resist urges

29. Biopsychosocial History

30. Purpose of Intake Interviews(Seligman, 2004) • Determine suitability for services • Assess urgency of situation • Familiarize person with process • Elicit positive attitudes toward counseling • Gather information for dx and tx plan

31. Variables to consider • Information gathering methods • Depth & duration • Client needs • Referral source • Presenting problem • Urgency • Motivation & functioning

32. Skills for intake interviewing • Establish rapport • Educate regarding process • Goals and expectations • This session different from others • Balance • Open-ended ? for perspective • Closed-ended ? for efficiency • Reflections & encouragers • Descriptive Empathy • Directness / assumptions may help

33. Major areas of assessment • Identifying information • Presenting problem(s) • Other current problems and previous difficulties • Present life situation • Family of origin • Current family • Developmental history • Medical & counseling history • Additional information See Seligman (2004) AND Zimmerman psychosocial outline

34. Intake Reports • Identifying information • Overview of presenting problem, symptoms, impact on person • Mental Status Exam • Other problems and difficulties • Present life situation • Information on family of origin and present family

35. Intake Reports (con’t) • Developmental history, important incidents • Medical and treatment history • Case conceptualization including strengths and areas of difficulty • Multiaxial diagnosis • Treatment plan and other recommendations • Conclusion and summary