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)
Axis I
Clinical disorders
Other conditions that may be focus of clinical attn
• Includes all current disorders except
– Personality disorders
– Mental retardation
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List principal diagnosis first
List all Axis I
Include major stressors if focus
Ok to defer or assign no diagnosis
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
Axis III
General Medical Conditions
• Relevant to understanding or management
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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
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”
Axis IV
Psychosocial and environmental problems
• Primary support
group
• Housing
• Social environment
• Health care
• Educational
• Legal system
• Occupational
• Others
• Economic
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
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
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
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
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Appearance
Motor
Speech
Affect
Thought content
Thought process
Perception
Intellect
Insight
Assess all
items based
on current
observations
The very basic…
• Orientation x4
– Person
– Place
– Time
– Situation
AKA
“Oriented x4”
Appearance
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Age
Sex, race
Build
Position
Posture
Dress
Grooming
• Manner
• Distinguishing features
• Prominent physical
abnormalities
• Emotional facial
expression
• Alertness
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
• Phobias
• Death wishes
• Ideas of reference
• Homicidal ideation
• Paranoid ideation
• Depressive cognitions
(guilt, worthlessness)
• Magical ideation
• Obsessions
• Ruminations
• 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
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Identifying information
Presenting problem(s)
Other current problems and previous difficulties
Present life situation
Family of origin
Current family
Developmental history
Medical & counseling history
See Seligman (2004)
Additional information
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