DSM and the Family

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Reading 4

Lukas, S. (1993). Where to Start and What to Ask: an assessment handbook. New York: W.W. Norton – chapter 2. pp 13-30

Chapter 2: looking, listening and feeling: the mental status exam

MSE = mental status exam – clinical observation – as opposed to a biopsychosocial assessment which is what the client had told you. 

MSE’s are snapshots. So, various MSE can be made over time to see whether the presenting issue or mental state is permanent or a result of a temporary stressor. Some organizations have a set form for it 
 

A MSE has a set content and order of things. It has set axis:
Appearance – i.e. dress appropriately/how does he walk/does he look healthy or sick/cleanliness
Speech –i.e. not what he said, but how he said it:
  • Speed
  • Impediment
  • Volume
  • Baby-talk vs. rushed
Emotion [what is predominant mood/affect]. Mood is how mow client feels most of the time while affect is how client appears to be feeling while he is with you [look/sound regardless of underlying mood]. You may also want to look at variability of affect. You may also want to look at:
  • Intensity of affect -i.e. excessive in any direction or blunt/flat
  • Lability: i.e. shifts fast
  • Appropriateness: to the content/situation
Thought process and content [process =how does he think, content = what does he think]. The thought process of thought includes how the person puts together thoughts and ideas. i.e.:
    1. Circumstantial: lack of goal
    2. Preservation: i.e. repetitive
    3. Association: how one idea links to the next one:
      • Tangential – slight connection between ideas
      • Loose association - no apparent connection between ideas
      • Flight of ideas –i.e. fast movement between random ideas. Client is “flying” and cannot stop it.

        àif your observations of the thought-processes do not fall under the above categories, just describe what you have observed.

      -Thought content: what does client think is going on around him? How does he fit into his narrative? How roles do other people play into the narrative? Thought distortions include:

        • Delusions: unshakable ideas
          • Delusions of grandeur: someone who is sure he is God
          • Delusions of persecution: i.e. convinced that the IRA is following him
          • Thought broadcasting: the idea that one’s thoughts are being broadcast.
          • Ideas of reference: the thought that insignificant or unrelated events are secret ideas aimed specifically at him
          • Delusions of control: the thought that someone external is controlling one’s thoughts or actions (i.e. chip-in-my brain delusion).
          • Somatic delusions
 

Other thought disturbances include:

            • delusions are different from obsessions (recurrent thoughts) and compulsions (recurrent actions). The most common compulsions are checking things/counting/cleaning. Compulsions usually have an obsession behind it.
            • phobias are fear-related obsessions
            • homicidal or suicidal ideation
Sensory perceptions: are there any indications of illusions/hallucinations.
  • Illunsions are normal sensory events that are misperceived
  • Hallucinations is an experience of one of the five senses which is clearly not true, and unrelated to an external event
      • Visual
      • Auditory
      • Olfactory – smell
      • Tactile – touch
      • Gustatory – taste
Mental capacities [i.e. orientation/your estimate of his intelligence/can he remember/concentrate/how are his judgment/insight].
    1. orientation
      • The phrase “person oriented x3” means an orientation to:
        • Time – time of day, date, year, etc.
        • Place – is the person able to know where he is?
        • Person – does the person know who he is (i.e. name!)
    1. Observed level of intelligence
    2. Concentration: i.e. can the person attend reasonably to the discussed topic? Is he easily distracted? If in doubt, ask the person to count backwards from 20, or to subtract from 100 in 3s.
    3. Memory – i.e. what happened 10 minutes ago (immediate memory) yesterday (recent memory) or in his childhood (remote memory)
    4. Judgment and capacity for insight:
      • Judgment: i.e. is judgment impaired? [driving at 140km/h]. Is his judgment impulsive? [bar fights]. Give examples on the MSE! If nothing comes up in the interview, ask “what happened if you saw someone get hurt?” or “smelled smoke in a movie theatre that was filled with people?”
      • Insight: definition of insight= does he understand that he has a problem? 
        • Insight questions include: Is it externalized [“it’s all because my mommy did not feed me Toblerone 49 years ago?”] Does he want help? Why now [is it because of a realization that things need to change or because youth-protection is threatening to take his kids away?]. use the insight measure with caution, since apparent lack of insight does not necessarily indicate real insight, since the person may not be fully comfortable [yet!] in talking about yucky things [i.e. emotions, eeew.]
 
Attitude towards interviewer: i.e. how is he behaving to you?
      • Suspicious or uncooperative?
      • Afraid or arrogant?
      • Reserved or flamboyant?
      • Does the person have a capacity to have a working alliance with the therapist? i.e. around building a shared understanding of the issue.
 
 

2 (related) diagnostic fallacies of ‘not knowing’

 

-the author of the book offers two pieces of advice to the beginner interviewer:

  1. Trust your gut feelings about what you are observing
  2. The more practice you get doing MSEs, the faster they will take you to produce/finish them
 
Outline for a Mental Status Exam
Appearance
  1. does the client look healthy?
  2. Does he look his age? If not, does he look older or younger?
  3. Does he have any obvious deformities? Describe
  4. Is he appropriately dressed
  5. Is his clothing clean?
  6. Does he walk/move in an unusual way?
  7. Does he sit in a comfortable posture
  8. Does he have any visible scars?
  9. Does his height and weight appear to be appropriate?
  10. Does he have any visible tics or unusual movements of the body, face or eyes?
  11. Does he make eye contact? If so, consistently or intermittently?
  12. What is the client’s facial expression? Does it change over the course of the interview?
Speech
  1. does the client speak?
  2. Does he speak rapidly or slowly
  3. Does he have a speech impediment?
  4. Does he speak unusually loudly or softly
Emotions
  1. what is the client’s predominant mood? Describe the comments and behaviours on which you base your observation
  2. what is the client’s predominant affect? Describe the comments and behaviours on which you base your observation
  3. does his affect vary over the course of the interview
  4. does his affect seem excessive at any time? Describe?
  5. Does he exhibit labile affect
  6. Is his affect appropriate to the content of the interview?
Thought process and content
  1. is the client’s thought process circumstantial?
  2. Is it preservative?
  3. Is his thinking tangential
  4. Dies he demonstrate loose associations or flights of ideas
  5. Does he exhibit somatic delusions or delusions of grandeur, persecution, or control? If so, on what comments do you base this observation?
  6. Does he appear to exhibit thought broadcasting or ideas of reference? on what comments do you base this observation?
  7. Dues he suffer obsessive thoughts or experience compulsive behaviours? If so, describe
  8. Is he phobic? If so, what is the nature of his phobia
  9. Is there any indication of homicidal or suicidal ideation? If so, on what comments do you base this observation?
  10. Is there a particular object that seems to preoccupy the client’s thought? If so, describe.
Sensory perception
  1. does the client appear to have any hearing problems?
  2. does the client appear to have any sight problems?
  3. Does this client suffer from illusions or hallucinations? If so, are the latter auditory, visual, olfactory, tactile or gustatory? If so, on what comments/behaviours do you base this observation?
Mental capacities
  1. is the client oriented to time/place/person?
  2. Does the client appear to be average intelligence or above?
  3. Does he exhibit a capacity for concentration within normal range
  4. Does he exhibit appropriate recent/remote/immediate memory. If not, on what do you base this observation?
  5. Does judgment seemed impaired in any way? If so, on what comments/behaviours do you base this observation?
  6. Does he have an appropriate sense of self-worth? If not, on what comments/behaviours do you base this observation?
  7. Does he appear to understand the consequences of his behaviour
  8. Is he capable of insight
Attitude towards interviewer
  1. what is the client’s attitude towards you
  2. does it change over the course of the interview
  3. does he respond to empathy
  4. does he appear to be capable of empathy

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