Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
“The First Interview” – Morrison
Chapters 10-12
Chapter 10: Control of the Later Interview
 Take Charge
o Sometimes you won’t be able to draw on one event and have to briefly
sympathize and keep it pushing to ask about other childhood traumas;
o Try:
 “That sort of experience can really make [FEELING/EMOTION]. Did you
have other sorts of distressing problems as a child? For example, did
anyone ever approach you about sex?;”
 Stop taking notes and put the pen down;
 If you need to interrupt, raise your pointer finger and take a breath to
signal you need to speak;
 Try to quickly get a word in between sentences;
 If client brings up something previously discussed, you will have to
clearly state the need for pursuing other topics;
 Close-ended questions can help here;
 “I need to interrupt here to ask about something else that’s
important;”
 Nod or smile when you get the brief answer you want;
o Try direct approaches:
 “For me to help you best, it’s important that we cover a lot of ground.
That means we’ll have to move on to another area;”
 “Our time is getting a little short so… .”
 Close-Ended Questions
o Substitute a multiple-choice response when your client can’t answer a question
that is well less defined;
 “Well, has it been 1 week or 2, or more like 6 months, or perhaps a year
or more?;”
o Avoiding suggesting how you would like your client to answer (leading).
 Sensitivity Training
o “I realize that [SITUATION] makes it hard for you to talk about
[PERSON/EVENT RELATED TO SITUATION],” = acknowledges importance
enough to pursue;
o “How do you think other people would deal with [ISSUE/EVENT],” = reduce
client’s sense of personal involvement and responsibility and also shows client is
not alone;
o “What if [ - CONSEQUENCE] happened – how would you feel?;” = give client
some distance from an emotionally charged situation;
o “Have you ever had the opportunity to tell [PERSON] you were sorry for
[ACTION/EVENT]?;” = chance might have prevented some praise that your
client should have done but did not.
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide

Transitions
o Use client’s own words;
o Sometimes two topics come up (duh) but try to get closure on topic A first
before you open up topic B discussion:
 You can always bring up topic B later by saying something like “A few
minutes ago you mentioned [topic B]. Could you tell me more about
that;”
o Make the interview feel like a conversation;
o If you have to make an abrupt transition, CALL IT OUT so your client knows
what’s up:
 “I think I’ve got a good picture of [BEHAVIOR/ISSUE]. Now I’d like to
move onto something different;”
o Also, using a single word and emphasizing it at the right time can signify a
transition  “NOW…;”
o Even if a client is angry or anxious, acknowledge the transition and that the
patient has a right to his/her feelings in the moment:
 “I can see that it’s pretty upsetting to talk about [ISSUE]. I don’t blame
you. It’s an area we can easily skip for now. Instead, let me ask you some
more about [NEW TOPIC].”
Chapter 11: Mental Status Exam (MSE) I: Behavioral Aspects
 MSE = assessment of client’s current mental functioning.
 Choose a format, memorize it, and perform it the same way every time.
 Two main areas: behavioral and cognitive.
 Behavioral Aspects
o Observing speech and behavior;
 General appearance and behavior;
 Mood;
 Flow of thought.
 Cognitive Aspects
o Thinking/talking about;
 Content of thought;
 Perception;
 Cognition;
 Insight and judgment.
 General Appearance and Behavior
o Physical characteristics:
 Apparent age align with actual age? (Age can suggest certain diagnoses);
 Body build, posture, graceful movements vs. jerking movements, any
physical characteristics (scars, tattoos, missing limbs), general nutrition
and body weight, handshake grip firm vs. limp.
o Alertness:
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide

Seriously
ill/hospitalized
patients;
Signify psychosis
– schizophrenia
Full or normal = awareness of environment and responds quickly to a
variety of sensory stimuli;
 Drowsiness (can be stimulated to wake up) and clouding of
consciousness (think of someone who has OD on drugs or has
pathological impairment of most cognitive functions);
 Coma;
 Stupor = awake but chooses not to move or speak (*IS THIS
CATATONIA?);
 Hypervigilance/Hyperalertness (found in paranoid disorders, some use of
substances, and PTSD).
o Clothing and Hygiene:
 Clean and well cared for vs. dirty and tattered?;
 Casual vs. formal;
 Modern vs. outdated;
 Appropriate for the climate of meeting?;
 Jewelry?;
 Keep an eye out for bright colors (mania), misbuttoned shirt (dementia),
weird dress (psychosis), disheveled (serious illness such as schizophrenia
or SUD).
o Motor Activity:
 Body attitude (relaxed vs. stressed);
 Amount of motor activity (reduced = brain dysfunction, complete
immobility = profound depression or catatonia);
 Excessive motion (akathisia/antipsychotic drugs = restlessness, uneasy
shifting of position = anxiety or restless leg syndrome);
 Hands and fingernails (tremors = anxiety or pseudoparkinsonism
[antipsychotic gen. 1 or Parkinson’s);
 Inappropriate behaviors/skin or clothing picking (delirium tremens =
SUD);
 Involuntary face and limb movements (tardive dyskinesia);
 Mannerisms  unnecessary behaviors that are part of a goal-directed
activity (common and normal) vs. Stereotypies  not goal-directed (ex:
peace sign);
 Posturing  strikes and holds pose;
 Negativism  persistent silence and ignoring/turning away from;
 Waxy Flexibility  move client’s limbs slow and steady;
 Catalepsy  client stays in an odd/unusual posture you put them in even
though you told them to relax already.
o Facial Expression:
 Tics?;
 Fixed, motionless expression  senile or Parkinson’s or
psuedoparkinsonism [antipsychotic gen. 1];
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
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Eye contact? – Psychotic client fixated on you vs. depression fixated on
floor;
Client glances around or attends to voices not present = psychoses;
WATCH for behaviors that contradict the statements such as:
 Restlessness of akathisia but client denies taking antipsychotics;
 Sad face and wants to cry but says happy otherwise.
o Voice:
 Prosody = normal lilt vs. monotonous and dull;
 Education or family background?;
 Accent?;
 Stutter, lisp, mumble = speech impediments;
 Word phrases used habitually;
 Tone of voice: friendly, angry, bored, sad?
o Attitude toward Examiner:
 Cooperative vs. Obstructionistic;
 Friendly vs. Hostile;
 Open vs. Secretive;
 Involved vs. Apathetic.
Mood
= the way a person claims to be feeling.
Affect = how the person APPEARS to be feeling.
Described via: type, lability, appropriateness, intensity.
o Type:
 Basic quality mood/emotions
 1 mood usually is dominant; if not, normal or about medium is sufficient;
 Ask:
 “How are you feeling now?,” “What is your mood at this time?;”
 Also infer from body language to get a sense of feelings.
o Lability:
 2+ within moods within a brief time span;
 (!) Wide swings of mood = increased lability (abnormal);
 Microdepression  manic euphoria: suddenly burst into tears, then
returns to high spirits vs. cognitive disorders  affective incontinence;
 Flattening of mood  reduced variation of mood;
 Blunting  lack of emotional sensitivity.
o Appropriateness:
 Estimate of how well the client’s mood matches the situation and
content of thought (schizophrenia = person laughs when discussing
something sad);
 La Belle Indifferénce  talk about physical complaints nonchalantly/like
NBD.
o Intensity:
 Mild vs. moderate vs. severe;
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
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 Reactivity: fleeting vs. prolonged vs. in between.
Flow of Thought
Either 1.) defects of association (the way in which words are joined together to make
phrases/sentences) and 2.) abnormal rate and rhythm;
Record in exact “ “;
o Association:
 Spontaneous speech vs. response to questions;
 Derailment/loose associations  breakdown of thought association in
which 1 idea runs into another; makes sense to the client but not to you
(psychosis/schizophrenia and mania too);
 Flight of Ideas  word/phrase from one thought makes the client take
off in another directions (mania);
 Tangentiality  describes an answer irrelevant to the question asked
(psychosis/schizophrenia and mania too);
 Poverty of Speech  brief answers when elaboration should be done
and may say nothing for long periods (depression);
o Extreme muteness = little or no speech at all (schizophrenia or
somatic symptom disorders);
o Pg. 133-134 = list of speech abnormalities commonly seen with
schizophrenia or psychoses of neurocognitive origin.
o Rate and Rhythm of Speech:
o Push of Speech/Pressured Speech  rapid, considerable length
(mania = push of speech and decreased latency of response – words
cannot keep up with thoughts);
o Increased Latency of Response  longer than normal to answer or
uses long pauses between sentences and when the statement is
finally delivered, it is oftentimes brief and delivered excruciating
slowly (severe depression or neurological disorders);
o Circumstantial Speech  extraneous material included with
principal message;
o Distractible Speech  speaker’s attention is diverted by stimuli that
are extraneous to the conversation (usually normal but can be found
in mania);
o Verbal Tics  conventional expressions that people overuse without
realizing;
 “You know;”
 “I go/said;”
 “Basically;”
 “Really;”
 “Awesome.”
Chapter 12: Mental Status Exam (MSE) II: Cognitive Aspects
 Should You Do a Formal MSE?
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide

o Start by explaining what you are going to do and that this is totally normal for
EVERY client;
o Remember, use positive feedback time to time;
o Respond attentively to any distress that may arise and take a break if needed;
o Best to do during 1st interview.
Content of Thoughts
o = whatever the speaker is focused on at the moment.
 Delusions  fixed, false belief that the culture nor education can
account for;
 Screen by asking:
o “Have you ever had any thoughts or feelings that people
were spying on you, talking to you, or trying to harm you
in some way?;”
o Have you ever had any other thoughts or ideas that others
might consider unusual?;”
o Try to have client further clarify by saying “How do you
know that [DELUSION] is the case?;”
 “Is it possible that this feeling is due to some sort
of nervous or emotional problem?,” “NO,” or when
there is an obviously false explanation despite the
clear evidence to contrast it = a delusion;
 You can respond gently with – “I think that
other explanations might be able to
account for your discomfort. You could be
mistaken, or it might be some form of
nervousness;”
 Also follow up and find out how long it’s
been present, actions client has taken,
future actions client plans to take, how
client feels about it, and why s/he thinks it’s
happening;
 If client can agree that there may be another
explanation possible = not a delusion;
 Sometimes you may need a 3rd party to verify where the truth
lies;
 Mood-Congruent  content of delusion is aligned with client’s
mood (mood disorder) vs. Mood-Incongruent (schizophrenia);
 Types:
o Death/nihilistic;
o Grandeur (mania or schizophrenia);
o Guilt (depression and delusional disorder);
o Ill health/bodily change (severe depression or
schizophrenia);
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
o Jealousy (alcoholic paranoia or schizophrenia and
delusional disorder);
o Misidentification/Capgras syndrome  like a doppler
ganger (brain pathology or schizophrenia);
o Passivity/Influence  controlled through outside
influences OR s/he controls the environment
(schizophrenia);
o Persecution  s/he claims to be threatened, ridiculed,
discriminated against, or interfered with (schizophrenia);
o Poverty (severe depression);
o Reference  paranoia, whispers about client or media
contains messages intended for client (schizophrenia or
other psychoses);
o Thought Broadcasting (schizophrenia);
o Thought Control (schizophrenia).

Perception
o Hallucinations  false sensory perceptions that occur in the absence of a
related sensory stimulus;
 Sometimes can occur if a client relives a trauma (PTSD);
 Characterize the severity for AUDITORY HALLUCINATIONS: vague
noises | mumbling | understandable words | phrases | complete
sentences;
 Screen by asking:
 (Auditory) “Do you ever hear voices or other sounds when there is
no one around to produce them?;”
 (Visual) “Do you ever see things other people cannot see?;”
 If yes for AUDITORY HALLUCINATIONS…ask “Could this be
coming from you, like your conscience or your own thoughts?,”
and if this is no, ask for more details:
o How often, is it as clear as [THERAPISTS] voice right now,
where is it coming from, whose voice, just 1 or multiple
voices, does it talk about the client, what does it/they say,
do they have conversations with one another, what do
you think the cause is, can other people hear the voices,
how does the client react, does the voice order client to do
things and does the client obey if so?
 Audible thoughts (client hears his/her own thoughts so loudly that others
hear it) and multiple voices suggest schizophrenia;
 Characterize the severity for VISUAL HALLUCINATIONS: points of light |
blurred images | formed people (size) | scenes or tableaus;
 Especially want to know when they occur (under substances or
other times), content, and the response to them;
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
Psychosi
s due to
brain
tumor,
toxicity,
or
seizure
disorder;
schizoph
renia
o Visual hallucinations can be a characteristic of psychoses
related to substance use;
o Images appear to linger can be psychedelic drug use;
o Schizophrenia experience illusions or transformations of
stimuli (visual) but can also experience auditory too;
 Other hallucinations:
 Tactile;
 Olfactory;
 Gustatory (taste).
o Anxiety Symptoms  fear that is neither directed nor caused by anything
specific that a client can identify;
 Screen by asking:
 “Do you think you worry about things excessively or out of
proportion to their real danger to you?;”
 “Does your family tell you that you are a worry-wart?;”
 “Do you feel anxious or tense much of the time?;”
 Panic Attack  episode where a client suddenly experiences intense
anxiety with bodily sensations;
 Episode peaks within a few minutes and wanes within a half hour;
 Screen by asking:
o “Have you ever had a panic attack – a time you suddenly
felt overwhelmingly frightened or anxious?”
o Phobias  an unreasonable and intense fear associated with some object or
situation;
 Specific phobias or social phobia;
 Different from a delusion because the client KNOWS how unreasonable
the feelings are;
 Screen by asking:
 “Have you ever ad fears that seemed unreasonable or out of
proportion to you, but that you just couldn’t shake?;”
 “Have you ever been afraid of leaving home alone, or being in
crowds, or in public places such as stores or on bridges?;”
 Best measured in terms of the effects in activities such as school,
work, and family life; also ask about onset, duration, treatment,
and severity level.
 Dysmorphia/Body Dysmorphic Disorder
o Obsessions and Compulsions
 Obsession  belief, idea, or thought that dominates the client’s thought
content and persists, despite the fact that the client recognizes its
unreality and may try to resist;
 Compulsions  acts performed repeatedly that the client knows is
neither useful nor appropriate;
 Screen by asking:
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide

Profound distress or lack of
sleep; if repeated and
severe enough =
depersonalization/derealiz
ation disorder;
Also with PTSD and brain
pathology.
“Have you ever had obsessional thoughts or ideas? I mean,
thoughts that may seem senseless to you, but keep coming back
anyway?;”
 “Have you ever had compulsions, such as rituals or routines that
you feel you must perform over and over, even though you try to
resist?;”
 Best measured in terms of the effects in activities such as school, work,
and family life; also ask about onset, duration, treatment, and severity
level.
o Thoughts of Violence
 Screen suicidal ideas by asking “Have you any ideas or thoughts of
harming yourself in any way or of killing yourself?;”
 Further, ask “What would it take to make suicide seem less
attractive?;”
 Screen homicidal ideas or violence towards others by asking “Have you
ever felt so angry or upset that you thought about harming someone
else,” “Have you ever had trouble resisting the urge?;”
 Any positive answer needs to be followed up on ASAP and compared
with historical information you have obtained.
o Experiences that can be Worrisome… But are Usually Normal
 Illusions  misinterpretations of actual sensory stimuli;
 Example: A coat hanging up looking like a person;
 Distinguish from a hallucination from the environmental
circumstances and timing;
 Déjà vu;
 Overvalued Ideas  beliefs we hold despite lack of proof as to their
worth;
 Depersonalization  alteration in one’s own perception of self/being
detached from body or mind;
 Derealization  environment feels ureal;
 Screen by asking:
o “Have you ever felt unreal? As if you were a robot?;”
o “Have you ever felt things around you are unreal?”
Consciousness and Cognition
Ability to absorb, process, and communicate information.
o Attention and Concentration
 Attention  ability to focus on a current task or topic;
 Concentration  Ability over a period of time to sustain that focus while
rejecting other, competing demands;
 Can infer from the interview more or less but if you wanted to formally
assess:
 1.) Ask client to compute 100-7 and continue -7 until s/he reaches
0 OR instruct to count backwards by 1s starting from 87 and
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Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
stopping at 63 OR ask to spell a word forwards and OR ask to
recall a series of #s forwards and backwards
 2.) If client mentions date in the past, ask how old they were and
fact check the date + age
 Reduced attention = epilepsy and cognitive disorders as well as
schizophrenia and bipolar.
o Orientation
 Assess by asking: “Where are we now [city, state, and facility]?;”
 No answer or incorrect answer = serious pathology;
 If confusion is present, ask “Would you tell me your full name
again?”
o Language
 = comprehension, fluency, naming, repetition reading, and writing;
 Comprehension  should already be evident from course of
interview;
 Fluency  should already be evident from course of interview;
 Naming  problems may be evident if client cannot use proper
term/name for an object/item = naming aphasia;
o Screen by asking client to name parts of a ballpoint pen
(point/tip, clip, barrel);
 Repetition  ask client to repeat a standard/simple phrase;
 Reading  ask client to read a sentence or two;
 Writing  ask client to write a sentence;
 Expressive Dysphasia  difficulty expressing what you want to
say so ask client to name parts of a pencil;
 Apraxia  inability to perform a voluntary act, despite intact
motor pathways;
o Screen by asking client to copy a simple geometric figure
(triangle and circle);
 If not, able to = ideomotor apraxia;
o Lesion on right side of brain;
o Ask for a neurological eval.
o Memory
 Screen by asking:
 “Have you had any problems with your memory? I’d like to test
it;”
 Immediate Memory  tests attention which may have already been
accomplished with serial 7s, counting backwards, or just general
attention during interview;
 If you want to formally assess, name 3 unrelated items and ask for
it back;
o Then, ask for it again 5 minutes later to test short-term
memory;
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
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
Failure = serious cognitive disorder or severe stress
from depression, psychosis, or anxiety;
 Long-term/Remote Memory  ability to organize information necessary
to relate the history of the present illness;
 Amnesia  temporary loss of memory often due to physical or
psychological trauma (includes all traumas: alcohol-related blackouts,
PTSD, dissociative disorders);
 Screen by asking:
o “Have there been periods of time that you cannot
remember at all?;”
o “Have others ever commented that you have trouble with
your memory?;
 If so, determine if fragmentary  remembers isolated bits from
affected periods of time OR en bloc  complete loss of memory
for that time;
 Confabulation  unconscious memory creation where client truly
believes the stories s/he is telling, especially when about self;
 = ability to remember is seriously impaired by chronic alcoholism
with thiamine deficiency.
o Cultural Information
 “Name the 5 most recent presidents beginning with the current one;”
 If this is difficult ask:
o “Who is the governor of this state?;”
o “Name 5 large cities;”
o “Name 5 rivers.”
o Abstract Thinking
 “How are an apple and orange alike?;”
 “What is the difference between a child and a dwarf?”
o Test of Cognitive Ability
 Mini MMSE/Folstein test (Mini-Mental State Exam);
 Result <24 out of 30 = dementia;
 Montreal Cognitive Assessment (MoCA) = more sensitive to mild
impairment;
 Result <26 out of 30 = cognitive impairment.
o Special Note Concerning Intelligence
 Intelligence (superior | average | low) from historical information
(education, occupation) x interview itself;
 Remember cultural background, degree of alertness, cooperation,
depression, and psychosis;
 Ask client to multiply 2x3, then 2x6, 2x12, etc.;
 Correct answer at 2x48 = normal range or better on the Wechsler
Adult intelligence Scale (WAIS).
Insight and Judgment
Jennette Schray
EDU 6270: Case Conceptualization – Weekly Readings’ Study Guide
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Insight  validity of client’s ideas about whatever problem you’re evaluating;
o Will recognize 1.) something is not right, 2.) can have implications for future
well-being, 3.) cause could be biological, psychological, or social, and 4.) some
form of treatment is needed;
o Screen by asking:
 “Do you think there is something wrong with you?;”
 “Could the voices you hear be due to an illness?;”
 “What do you think has caused it?;”
 “What sorts of problems do people have who come here?;”
 “Do you think you’re impaired in any way?;”
 “Do you think treatment might be in order?;”
o Can be: full | partial | nil;
o = typical of neurocognitive disorders, severe depression, any psychoses
(schizophrenia and bipolar 1 disorder with psychotic features).
Ask client’s self-image by asking:
o “What strengths do you think you have?;”
o “What do you like about yourself?;”
o “How do you think other people see you?’
Judgment  ability to decide upon an appropriate course of action in the pursuit of
realistic goals;
o Screen by asking:
 “What do you expect from treatment?;”
 “What are your plans for the future?;”
o State aspects of insight that appear deficient and give examples as to why.
When Can You Omit the Formal MSE?
Omit formal tests of orientation, knowledge, attention, and memory IF:
o Your patient has given a detailed, well-organized history;
o Test results are available;
o Client is already distressed due to being quizzed from other examiners and is
embarrassed or angry = abbreviate exam.