Dress: You may find it casual, business, fashionable, unconventional, immaculate, cmsa/portals/0/pdf/MemberOnly/CCMCertificationGuide.pdf.

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1 Case Management: The Mental Status Examination Part 1: Introduction The mental status examination (MSE) is based on your observations of the client. It is not related to the facts of the client’s situation, but to the way the person acts, how the person talks, and how the person looks while in your presence. A mental status examination can be an abbreviated assessment done because someone appears to be in obvious need of hospitalization, or it can be an elongated process that takes place over several int erviews. The MSE always has the same content, and you write your observations in roughly the same order each time. Although a formal MSE would be done by a physician or psychologist, you can do an informal MSE in which you systematically look at the perso n’s thinking process, feeling state, and behavior. You will want to understand the way the person functions emotionally and cognitively. Much of the examination is done by observing how people present themselves at the interview and the manner in which th ey spontaneously give information about themselves and their situations. The examination is not done separately but is an integral part of the assessment interview. Questions that relate to mental status are framed as part of the overall assessment and not as a separate pursuit. There will be times when you or a clinician might ask for psychological testing to confirm your evaluation of the person, but during your own MSE of the person, this is not done. Some of the terms you learn in this chapter are not necessarily words you will use in describing your clients and their appearance or behavior. This chapter is meant to familiarize you with the way some professional practitioners describe their clients and patients. If you know these terms, you will be able to follow the notes and discussions better. Part 2: Observing the Client What to Observe Your mental status examination of the individual involves observations of the following: General appearance Behavior Thought process and content Affect Impulse control Insight Cognitive functioning Intelligence Reality testing Suicidal or homicidal ideation Judgment A good case manager is a good observer. You pick up many details about the person, all of which are relevant to understanding the client’s me ntal status. In a sense, you watch for the most obvious and the most subtle visual and verbal clues as to who your client is. Use what you see and hear to give you direction in regard to what questions to ask.

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2 How to Observe Throughout the interview note how the person communicates verbally and nonverbally and how the person behaves. In addition, you look at the content of the communication. You are looking at both what the person tells you and how the person tells it. As people talk about why they came t o your agency for services and about the main problems they are confronting, you will make some judgments about how they functioned in the past and how well they are functioning currently. You will note how they tell their stories. Is the person cooperativ e and friendly? Does he appear to be relieved and eager to talk to you, or is he mute, guarded, and uncooperative? Is she weepy and hesitant as she speaks, or is she forthright and stern? Does the person twist a tissue in her hands or rock back and forth i n her chair, or does she use appropriate gestures? Does he relax during the interview or remain guarded and uncooperative? At times you may need to assess the client’s mental status through the observations of others who are close to them. Your clients may not always be able to tell you much about past events or functioning, and you will need to turn to others for that information. If there is no reliable source, you may not be able to perform a complete MSE that has a clear degree of certainty. Documentin g Your Observations To back up your observations, use both descriptions of the individual’s behavior during the interview and direct quotes made by the person in the interview. In this way, you carefully document your observations and your resulting conclu sions. When you describe the person, be sure that your values and prejudices do not appear in your notes. Use adjectives that describe the individual, but are objective. All editorial comments and value judgments should be omitted. Figure 18.1 defines some general terms that are commonly used when documenting observations of clients. FIGURE 18.1 General terms used in documentation Primary language: When you see this on a form, give the person’s native language, and if it is not English, tell how well the pe rson functions with English. Presenting problem: In one or two sentences, tell why the person is coming to see you now. Use the person’s own way of telling about it. Past psychiatric history: Use incomplete sentences. Give dates, approximately how long, an d summarize if there is much detail. Functional ability: Note particularly if the person is able to display and carry out age – and stage -appropriate skills and tasks. Also note any recent change. Moods/emotions: What does the person or the person’s family say? How do they seem to you? Physiologic: What does the person or the family say about the person’s appetite, sleep, and sexual activity? Thinking: What is the person saying about how she is thinking? Are you able to follow her thinking? Does the story ma ke sense? Are there delusions?

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3 Perception: Are there any hallucinations? Orientation/cognition/memory: Does the person think he can find his way? Does he know where he is? Does he remember well? Does he know what day this is? Mental status examination: This is a word picture that tells what the person looks like now, not all the time. Part 3: Mental Status Examination Outline Anthony LaBruzza (1994), in his book Using DSM -IV , provides a good outline for the mental status report that you will complete afte r the interview. He stated that his outline is not meant to be followed precisely, but it does give the major points and a framework to determine what is important. The outline in Figure 18.2 [not shown here] provides the major categories you must cover in a mental status report. This section discusses the outline for the mental status examination and report in detail, defining terms to use and identifying items on which to focus for each category you will cover in mental status examinations and reports. Pa y particular attention to the terms that have Always in boldface in the descriptor, as these are important items to which you must always give attention. I. General Description A. Appearance 1. Dress and Grooming. You may find the person’s appearance to be a verage, meticulous, slightly unkempt, or disheveled. The person may have body odor, no makeup, makeup that is skillfully applied, or garish makeup. Meticulous: The appearance is perfect, unusually so. Skillfully applied: The person is made up [skillfully ]. Garish: The person looks outlandish. Self -neglect: Always indicate when you think this is present. It involves such things as having body odor or looking disheveled and unkempt. Dress would be dirty, stained, or rumpled. This can be a sign of a mental illness such as depression or schizophrenia. Dress: You may find it casual, business, fashionable, unconventional, immaculate, neat, stained, dirty, rumpled. Immaculate: This means the person is [very] neat. Unconventional: Use this term to refer to cl othes that are inappropriate to the setting. Fashionable: This is fine unless the person looks like something out of Vogue in an office in a small town or average city. 2. Physical Characteristics. Note those features that are outstanding. Look at body buil d, important physical features, and disabilities. Note voice quality. Is it strong, weak, hoarse, halting? 3. Posture and Gait. Note gait and any need for devices such as a cane or crutches. Look at coordination and gestures. For instance, does a right -handed person make most of her gestures with her left hand? Something like this could be a clue to neurological difficulties. Does the person limp or appear to slump? Does the person seem unsteady or shuffle?

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4 B. Attitude and Interpersonal Style Look at the attitude the person has with you. You may find it cooperative, attentive, frank, playful, ingratiating, evasive, guarded, hostile, belligerent, contemptuous, seductive, demanding, sullen, passive, manipulative, complaining, suspicious, guarded, withdrawn, or obsequious. Hostility: Always note when the person is hostile. Uncooperative: Always note when the person does not or cannot cooperate. Inappropriate boundaries: Always note if the client is too friendly, touches you, or attempts to draw you out per sonally. Seductive: Too close a relationship too soon; might call you by your first name or touch you Playful: Jokes, uses puns, self -deprecating humor Ingratiating: Goes along with whatever you think; wants to please Evasive: Talks, but gives nothing Guarded: Is more reserved than evasive; contributes the bare minimum, often with suspicion Sullen: Angry and somewhat uncommunicative Passive: Barely cooperates, needs to be led; generally without overt hostility Manipulative: Asks for special favors, uses guilt, solicits pity, threatens Contemptuous: Superior, sneering, cynical Demanding: Sense of entitlement Withdrawn: Volunteers little, appears sad Watch your own emotional reactions to the people. Your reactions will give you important clues. Als o pay attention to the person’s facial expression . You may find it pleasant, happy, sad, perplexed, angry, tense, mobile, bland, or flat. Bland: Intense material, but looks casual Flat: No facial expression Mobile: Rapid changes in facial expression and mood C. Behavior and Psychomotor Activity Look at the quality and quantity of the person’s motor activity. You may find the individual is seated quietly, hyperactive, agitated, combative, clumsy, limp, rigid, or has retarded motor function. You may find the person has mannerisms, tics, twitches, or stereotypes. Seated quietly: Uses normal gestures, but does not move around much Hyperactive: Is busy with hands and possibly feet Agitated: Cannot sit still (could be secondary to antipsychotic medication) Combative: Looks ready to hit, threatening Awkward: Unable to manage activity like sitting in the chair or writing; drops things (may be part of the illness or reaction to medication) Rigid: Sits like a tin soldier Mannerisms: These are unconscious repe titive actions Posturing: The person assumes certain postures and holds them inappropriately Tics and twitches: Less voluntary body movements Stereotypes: Four mannerisms strung together Motor hyperactivity: Always report this when you see a lot of hyp eractivity, restlessness, and agitation. It may indicate a manic state, reaction to medication, or anxiety. Motor retardation: Always report this when you see the patient moves slowly, in a constricted manner and with minimal motor responses. Speech and t hought are slowed, often depressed. Depression can give the appearance of cognitive impairment. Mannerisms and posturing: Always indicate mannerisms you see and any posturing.

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5 Tension: Always note tension, particularly if the person seems tense and the i nterview does nothing to relax the person. Severe akathisia: Always note severe restlessness. Sometimes it may be part of an illness, and sometimes it may be due to medication. If the physician believes it is due to an illness and increases the medication , the person may grow much worse. Therefore, try to establish when it started, how long it has gone on, and whether it has grown worse recently. Always note the following when present: pacing, fidgeting, nail biting, trembling or tremulousness (a common s ide effect of lithium carbonate and tricyclic antidepresssants), and abnormal movements such as rocking, bouncing, or grimacing (particularly strange facial movements). Tardive dyskinesia: Always note this condition if you see it or suspect this is what yo u are seeing. It occurs among psychiatric patients who have been on antipsychotic medications over a long period of time. The term literally means “late appearing abnormal movements” and seems to involve the muscles of the face, mouth, and tongue. Sometime s the trunk and limbs are also affected. These movements can be slow and irregular ( athetosis ) or quick and jerky ( choreic ). All the movements are brief, involuntary, and purposeless. A person may twist the tongue and lips, make odd faces, bounce or tap t he feet, or actually writhe and squirm in the seat. Catatonic behavior: Always note this behavior. It is generally a sign of severe depression or schizophrenia, catatonic type. It generally appears as a rigidity of posture wherein attempts to reposition th e person are rigidly resisted. The person may voluntarily pose in bizarre and inappropriate ways. In waxy flexibility, the limbs of the person will remain in the position in which they are placed. There is also a catatonic excitement wherein the patient e ngages in almost continual, purposeless activity that is nearly impossible to interrupt. Sometimes the patient engages in echolalia (repetition of everything that is heard) or mimics and imitates others during this episode. D. Speech and Language Speech i s important because it is the primary means of communicating. Important to note are such things as rate, clarity, pitch, volume, quality, quantity, impediments, use of words, the ability to get to the point, and articulation. You may find speech to be a no rmal rate, slow, hesitant, rapid, pressured, monotonous, emotional, loud, whispered, mumbled, precise, slurred, accented, stuttering, stilted, rambling. Pressured: Often rapid but constantly talking; cannot be interrupted (often a sign of a manic episode). Person appears to have racing thoughts. Monotonous: No variation in tone Emotional: Very expressive Accented: Note a native accent and also if the patient seems to accent certain words or syllables inappropriately Impoverished: May say very little eit her because of depression or because he is being interviewed in a language other than his native one; may also indicate a lack of facility with language Neologisms: Always note when the person makes up entirely new words with idiosyncratic meanings. (This can occur due to aphasia or brain injury due to accident or stroke.)

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6 You should be able to identify any neurological language disturbances . Strokes, head trauma, and brain tumors can cause patients to lose their facility with language. Try to determine i f the client has always had a language difficulty. Patients with schizophrenia may use loose associations as they talk. Those in a manic state may be prone to flight of ideas. Aphasia: Loss of ability to understand and produce language; damage usually to left hemisphere of the brain (left -handed people often have this in the right hemisphere) The type and extent of aphasia depends on location and extent of brain injury. Global aphasia: Can neither speak nor understand, read, write, repeat words, or name o bjects Broca’s aphasia: Can understand written and spoken language, but has trouble e xpressing own thoughts verbally Wernicke’s aphasia: Inability to understand language and uses fluent, bizarre, nonsensical speech (The person may also act strangely and appear euphoric, paranoid, or agitated. It is easy to think this is a psychotic thought disorder, but in schizophrenia the person is generally able to write and speak in her language, repeat words, and name objects.) Dysarthria: Difficulty articulating du e to problems with the mechanisms that prooduce speech. This sometimes produces distorted or unintelligible speech. The person usually can read and write normally. Ask the patient to repeat “No ifs, ands, or buts” to hear dysarthria better. Perseveration: Defined as the persistence “in repeating a verbal or motor response to a prior stimulus even when confronted with a new stimulus” (LaBruzza, 1994, p. 113). The client may give the same answer to different questions, stay on the same subject, or repeatedly return to the same subject. Stereotypy: “Constant repetition of speech or actions” (LaBruzza, 1994, p. 113). The patient may pull a shoe on and off, twist and untwist the hair, or repeat the same phrase or word over and over. These behaviors appear to be ritualistic and are common in childhood autism. Give verbatim examples of what the individual has said to support your assessment of speech. II. Emotions A. Mood This is the way a person is feeling at any given time. You may find it euthymic, depressed , sad, hopeless, empty, guilty, irritable, angry, enraged, terrified, expansive, euphoric, elated, sullen, dejected, or anxious. Ask yourself, what seems to be the dominant mood of the person? Euthymic: Normal mood Expansive: Feels very good and is getti ng better Euphoric: Out -of-sight happy Anxious: Worried and distressed B. Affect Affect refers to the underlying flow of moods. This would be the outward expression of the emotional state. You can see it in the way patients use and position their bodies and in their tone and manner of speaking. You may find it broad, appropriate, constricted, blunted, flat, labile, or anhedonic.

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8 Stupor: The person is semicomatose, and it takes vigorous stimulation to arouse her; she c annot arouse herself. There is no normal interaction du ring the interview as a result. Coma: This is the most severe consciousness problem wherein the person cannot be aroused and does not respond to any stimulation. Oriented x3: Means the person is orie nted as to who he is, where he is, and when it is. Even when a person is having difficulty with consciousness, he may be oriented. If orientation problems occur as a result of lack of consciousness, it typically happens that the sense of time is affected first, followed by the sense of place, and finally by the sense of person. To be fully oriented requires an intact memory; thus, disorientation means there are memory deficits. Ask for current date: Reasonably accurate dates are acceptable. Ask where the person is: You can also ask for a home address, the present city or state, or for directions from here to the person’s home or another familiar place. Sometimes people confused about place will behave as if they are at home or in another very familiar sett ing while in your office. Ask who the person is: Ask for personal identifying information (age, birth date, name). Ask if the person recognizes or knows other people who might be present. Does she know her relationships to these other people? B. Attentio n and Concentration Always note inability to pay attention and if the person appears easily distracted. Attention: Can the person remain focused on the interview? If you feel a need to test this in the person, you can use digit repetition. Say five numbe rs, and then ask the person to recite them back to you. Concentration is needed to learn new tasks and for academic success. Concentration: The person can concentrate on one thing for an extended period of time. You can test the person’s concentration by asking the person to perform a complex mental task. (Serial 7s is one way of testing; in this method, you ask the person to add in increments of 7 or subtract from 100 by 7s. Be sure your instructions are on the client’s level of education, and do not use this exercise if severe academic problems are present. Be careful not to humiliate people!) C. Memory Memory involves the ability to learn new material, to retain and store information, to acknowledge and register any sensory input, and to retrieve or re call stored material. When there are problems, they usually have to do with three areas: 1. Registration 2. Retention 3. Retrieval

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9 Destruction of significant parts of the brain causes problems with memory. All memory deficits should be noted. The physici an or clinician will want to do further tests. If you suspect something, ask others who know the individual about their perceptions of the patient’s memory functioning. Short -term memory: Refers to immediate recall limited to about seven items and generall y lasts for about one minute. Some problems may be due to inattention, so evaluate attention before memory. Long-term memory: Rehearsal allows material in short -term memory to convert to long -term memory. Anxiety about the interview or the person’s situat ion or even depression can interfere with this. Amnesia: Inability to remember Anterograde amnesia: Cannot learn new material Retrograde amnesia: Cannot recall recent past events Head injuries: Most common deficits are inability to recall names, recent events, and spoken messages, and forgetfulness or forgetting to do something important. The person may have trouble telling you what she is experiencing with her memory. Memory loss may be permanent if there was severe or repeated head injury. Transient global amnesia: Lasts minutes to several hours and is usually seen in older people. The person experiences sudden confusion, loss of memory, and disorientation and cannot recall what happened during the time period in question. Retrograde amnesia will be p resent. Person will be distraught, asking for reassurance as to where he is and what he is doing. This is caused by an insufficient amount of blood to the brain. Memory Testing. First, ask the person if she has been having any problems with memory. A fami ly member may be able to shed some light on memory issues if any exist. During the interview, note memory lapses and difficulty recalling what the interviewer has just said. If you notice memory loss, note it so that further testing can be done. All the me mory tests described in the following would be done only if you had considerable questions about a person’s memory: To test immediate recall: Use a random list of digits, saying them in a normal tone of voice, about one digit per second. Ask the person to repeat them. Start with two digits and keep adding until the person fails. Give the person two times to try this. If the person fails at five digits or less, there is reason for concern about sustained effort, attention span, and immediate memory. Anxiety and depression are the most common reasons people fail this test (LaBruzza, 1994, p. 125). Strokes and other brain i njuries can also affect recall. To test recent memory: Ask the person to recall events that have happened in the last few hours or days bef ore she came to see you. You might ask what she had for lunch or where she parked the car. It is helpful if you can validate the answers with someone close to the client who knows. Another way to test is to ask about something that may have happened or bee n discussed earlier in the interview. You may get several different versions. In cases of assault or trauma and where the victim feels comfortable with you, the different versions may indicate the she is able to recall more of the details each time she go es over what happened. With some people, you might give three or four unrelated words and ask them to recall these words after a short interval. Begin by saying the words in a normal tone of voice and ask them to repeat the words back to you. Note how many times a client must do this before learning the words. About 3 to 5 minutes later, ask clients to

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10 recall the words. With a normal memory, a person should be able to recall them (LaBruzza, 1994, p. 126). To test remote memory: You can ask people about per sonal events in their lives and commonly known public events that happened in years past, such as major news stories. Use material that should be known by a person who is reasonably well informed. If the person does not appear to be able to do this test be cause of a lack of education, a difference in culture, or mental retardation, decide carefully what you will ask the person (LaBruzza, 1994, p. 128). Additional information on memory and aging and how to assess memory can be found in Chapter 8 of Fundamen tals/or Practice with High Risk Populations (Summers, 2002). D. Ability to Abstract and Generalize Proverbs. Cultural background and intelligence can influence how well a person thinks abstractly or how well the person can deal with similarities. Proverbs are generally used to see how well a person thinks abstractly. You need a general fund of information to be able to use proverbs in this way. Tell the person you are going to say a proverb and you would like the person to tell you in his own words what he thinks the proverb means. Then judge how concrete or abstract the reply is. Repeat the person’s response verbatim in your report. Individuals who are psychotic or on the verge of psychosis will often indicate this in their response to a proverb. Use prov erbs that are free of gender and racial bias. The following are some proverbs you can use (LaBruzza, 1994, p. 129): A stitch in time saves nine. A rolling stone gathers no moss. Don’t judge a book by its cover. Two wrongs don’t make a right. “A rolling stone gathers no moss” could be explained by a person who thinks concretely as, “If you roll a stone down the hill, it can’t collect moss.” A more abstract response might be, “If you keep moving, life remains interesting and challenging.” Similarities an d Differences. Ask the person to tell you how two objects or two events are different or alike. This will require the individual to think somewhat abstractly about categories and relationships. Name two items and ask the person how these differ and how the y are similar. The following are some combinations you might use (LaBruzza, 1994, p. 129): Apples and oranges Trees and flowers Houses and cars Dogs and cats E. Information and Intelligence To get an idea of the person’s overall intelligence, ask ques tions that tap the person’s fund of general information. It should be information known by the general public. Again, you must be sensitive to the person’s cultural background, level of education, and intelligence. The following are examples of some questi ons you might ask (LaBruzza, 1994, p. 130): Who were the last four presidents? Who is the governor of the state?

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11 How many weeks are there in a year? What is the capital of the state (or the country, or France)? Who was Mark Twain? IV. Thought and Perc eption When a person’s perceptions are disordered, it offers important clues to what the diagnosis might be. Here you want to know how people actually perceive themselves, the world around them, and others in their world. What does the person think, and w hat thoughts and concepts are most on his mind? Perception is the way in which we form an awareness of our environment. People who have difficulties with perceptions often perceive their world inaccurately (LaBruzza, 1994, p. 131). A. Disordered Perception s Following are some terms that describe various disordered perceptions: Illusions: The person either misperceives or misinterprets a sensory stimulus. A tree branch brushing the side of the house in the wind sounds like people entering the house, or a di shwasher running sounds like people talking in another room. Hallucinations: In the absence of external stimuli, the person perceives something. The most common hallucination is hearing voices. Voices generally increase when the person is around white noi se. White noise is even background noise, such as the dishwasher running, a roomful of people chattering, or rain drumming on the roof. If you can, find out who is talking, what they are saying, and how the person feels about it. Is there a command for the person to do something? If so, include the command in your report. Some commands are dangerous to the person or to others. Alwa ys note hallucinatory behavior. Depersonalization: The person feels est ranged or detached from herself. Derealization: The per son feels detached from what is going on around her. Be sure to note this. A person who dissociates cannot always be sure that what is happening is real (LaBruzza, 1994, p. 132). B. Thought Content The following terms are used to describe thought content : Distortions: A person distorts a part of reality. A woman with anorexia believes she is fat when she is thin. A person who is well believes his cough indicates tuberculosis. A person whose neighbor does not think to wave assumes the neighbor is angry. Delusions: An inappropriate idea from which a person cannot be dissuaded using the normal means of argument or evidence. Sometimes it is culturally inappropriate as well. Evidence to the contrary has no effect. For example, a client might insist that she ha s a case in court that will eventually yield her a great sum of money. No amount of persuasion or documentation can dissuade her from that belief and convince her that this isn’t so. Always report the content of a delusion. Note if the delusion is incongru ent with the client’s mood. Delusions indicate psychosis. Always note if delusions are present. People with paranoid delusions believe they are being singled out for harassment or are being controlled by forces outside of themselves. They may have an enti re system of interconnected ideas developed that support their delusions. Common to schizophrenia are:

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