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

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.

Multiaxial Evaluation (review)

Other conditions that may be focus of clinical attn 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

Personality disorders 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

General Medical Conditions 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

Psychosocial and environmental problems 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”

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

Global Assessment of Functioning (GAF) 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

Global Assessment of Functioning (GAF) 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

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

Determining a GAF Score (p. 34) 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

Communicating severity and impairment 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)

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

Mental Status Exam

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

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)

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

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

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

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

Motor Retardation (slowed) Agitation Abnormal movements Gait Catatonia

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

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

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

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

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

Biopsychosocial History

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

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

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

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

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

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