Ann Dypiangco, LCSW • 2023-05-24
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In mental health, a comprehensive mental status exam (MSE) is a vital assessment tool to evaluate an individual's cognitive, emotional, and behavioral functioning. The mental status examination for mental health professionals is akin to a physical health examination for doctors working in the healthcare system (Voss. R., Das. J, 2022).
It is comprehensive and provides valuable insights into a person's mental state. The MSE also aids psychotherapists, social workers, and psychiatrists in finding an accurate diagnosis, monitoring treatment progress or lack thereof, and informing treatment plan recommendations and therapeutic interventions.
This blog post will explore…
Let's jump in!
Presentation of appearance and behavior commonly refers to how an individual appears at the onset of the session. Therapist observation is made of an individual's physical appearance, grooming, and overall behavior. Look for unusual or inappropriate behaviors, such as restlessness, agitation, or bizarre clothing choices. Two examples include a client who shows up to a session in mid-July wearing a winter parka or another who is odorous, has patches of hair missing, and is unkempt.
Appearance and behavior also include the individual's demeanor, any notable mannerisms, or other behavior such as restlessness, fidgeting, eye contact, body language, and overall level of engagement. An individual's speech should also be assessed, including looking at rate, volume, fluency, and content in demonstrated speech patterns,
A clinician must consider how a client's cultural background affects their appearance and behavior and not place value judgments based on their own life experience. An example is an Indigenous client may feel emotionally unsafe during an assessment with a white clinician. The white clinician may identify the client as 'guarded' or 'uncooperative,' but the reality is the client is rightfully bringing their survival skills from a historical context into the interaction.
2. Thought Processes. This includes assessing the individual's thinking patterns and how thoughts are organized. Observe for signs of coherence, logic, and reasoning, the ability to convey an organized timeline and stay with one line of thinking, and whether or not the client's speech makes sense. If a client is difficult to follow in conversation, a therapist would categorize their speech patterns as tangential or circumstantial, which may be indicative of a thought disorder. Word salad is an extreme type of disorganized thought pattern and exists when an individual says a string of words, each having nothing to do with the next. A therapist should note any signs of disorganized thinking, tangentiality, or racing thoughts.
‘Do you ever see things that other people don't see?’
‘Do you ever hear things that other people don't hear?’
Sometimes, a client may respond 'no' to these questions but then appears to be laughing out of nowhere, talking to someone who is not there, or trying to grab something in the air you cannot see. In this case, a therapist documents, 'Client denied experiencing auditory and visual hallucinations but appeared to be responding to internal stimuli.'
'Do you ever feel suspicious of other people?'
'I've noticed you looking at the corners of my ceiling. May I ask what you are looking for?'
4. Cognition. This portion of the MSE assesses the individual's cognitive functioning, including their awareness of space, time, person, and place, as well as memory, attention, and executive functioning. When a therapist assesses memory, they begin the cognitive assessment by telling the client five random words, such as car, rabbit, hotel, planet, and sand. They then let the client know they will ask the client to repeat those words in a few moments. The therapist then asks common questions used to assess cognitive functioning, including, 'What is your name?' 'What is the date?' 'If you were walking down the street and found an envelope with an address and stamp, what would you do with it?' 'and 'Who is the President of the U.S. right now?' Following these questions being answered, the therapist asks the client to repeat the five words said a few minutes prior.
5. Mood and Affect. This evaluates the individual's emotional state and the expression of feelings they are experiencing. Therapists assess a client's overall mood, how their face and body language demonstrate their feeling state, and the appropriateness of emotional responses.
Assessing affect is not always straightforward; documentation around this aspect of a client's presentation can be confusing.
Let's dive deeper to clarify.
Affect is a crucial component of the mental status exam and is also typically used at the start of every psychotherapy progress note. Assessing effect means observing the client's emotional state and expression of the feelings they are experiencing.
To assess emotional states objectively, it can be helpful to remember the ABCs of Affect.
Affect: Affect refers to the individual's current facial expression of their emotional state.
Behavior: Behavior refers to the individual's observable actions, mannerisms, and movements that express their emotional state.
Cognition: Cognition involves the individual's thoughts, beliefs, or perceptions associated with their emotions.
After assessing affect, objective clinical documentation on the presented feeling state is imperative to ensuring the client's chart can provide an accurate, thorough snapshot of the client's presentation and current level of symptoms for future reference. The mental status exam and the progress note both typically remark on client affect. This is often done using one of 5 descriptors followed by a comment on the client's behavior observed and verbalized statements.
Example 1: The client is a 42-year-old Mexican American unpartnered woman who identified as a lesbian and is seeking treatment following her mother's death. During the assessment, the client was cooperative with questioning and demonstrated euthymic mood and congruent affect. The client teared up at times when describing her mother's recent passing and exhibited a normal range of emotions associated with the grief process.
Example 2: The client is a 21-year-old biracial Caucasian/Black American male presenting to therapy following a psychiatric hospitalization. The client presented with labile affect, including tearfulness, laughing hysterically following a joke he told, and anger at the clinician within a 10-minute span. The client demonstrated a tangential thought process, pressured speech, and was hyperverbal throughout the assessment.
Another helpful framework to use when evaluating the various aspects of an individual's presentation and mental health is the 4 P's of mental health assessment. These are also used in the Biopsychosocial Assessment.
Predisposing Factors - These are factors in a client's life that contribute to the presenting problem. They can include genetic, biological, or environmental influences and past childhood experiences.
Precipitating Factors - This refers to events or experiences that have contributed to or led to the client's presenting problem. This can include trauma, environmental or relationship stressors, or a recent loss of a loved one or job.
Perpetuating Factors - These are ongoing stressors in the client's life, such as addiction, an abusive or strained marriage, or caretaking for a loved one who is medically fragile.
Protective Factors - This looks at the positive aspects of a person's life as a part of case conceptualization. Protective factors include strengths, community and social supports, hobbies, healthy coping skills, and a history of success at school or work.
Each clinician must conduct an MSE in a way that is comfortable for them and provides accurate results. Here are some general guidelines for conducting a comprehensive mental status exam.
Conducting a comprehensive mental status exam is an essential skill for all mental health professionals. By assessing the various components of an individual's presentation, including appearance, behavior, thought processes, perception, cognition, and affect, clinicians can gain valuable insights into an individual's mental health struggles and subsequently provide them with more accurate diagnoses, formulate effective recommendations, and engage the client in more personalized treatment.
Ann Dypiangco, LCSW is a mental health therapist and tech enthusiast who specializes in perinatal mental health and trauma. With a master's degree from Boston College, Ann has extensive training in psycho-sensory techniques such as EMDR and Havening. She is licensed in California and runs a small virtual practice. Ann is passionate about the intersection of technology and mental health and is excited about how AI and the metaverse will transform the industry.
All examples of mental health documentation are fictional and for informational purposes only.
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