NCMHCE Exam Review Mental Health Assessment Part 2

Welcome to the NCMHCE Exam Review Podcast. I'm your host, Dr. Donnelly Snipes. This podcast is brought to you by Counselor toolbox podcast and allce.com counselor continuing education, where you can get unlimited on demand CEUs for $59 or or unlimited live webinars for $40. Go to allce.com. Hey there everybody, and welcome to part four of the NCMHCE review. I am Dr. Donnelly Snipes. Today we're going to be talking more about assessment. And this is only the first part of actually really going into the assessment because you remember on the NCMHCE a big portion of a big, big portion of what they're looking at is can you accurately diagnose? And remember with the ncmhce, they want you to read the scenario and then from that scenario say, okay, I think this person probably has X diagnosis, whether it's depression or anxiety or whatever. And then try to ask questions that support your theory, which is not what we do, at least the majority of us do in clinical practice. Generally we try to rule out other things. But for the ncmhce, remember, you're gonna rule in your hunch, basically, so you're gonna ask questions that support your hypothesis. So in this review, we're going to also look at some acronyms that'll help you remember what to look for when assessing for particular problems. Now, I'm not covering everything in the DSM 5 in this review. That's gonna be. I do strongly suggest that you go online and Google mnemonics for, and you can do mnemonics for schizophrenia, Mnemonics for personality disorders. I'm going to give you some mnemonics for your most common mood disorders and PTSD as we go through today. So let's get on with this assessment is the process of gathering, analyzing and integrating information into a comprehensive picture. So you're going to ask a bunch of questions, and each question gives you a building block. And you're going to take those building blocks and you're going to form a creation that describes the nature, frequency, intensity and duration of the client's problem. So what is it like for that client if they say they're depressed? What is the nature of that depression? What are the symptoms that go along with that? Because not every person presents the same with when they have depression. There are, I think I did the math one time and it was like 114 different permutations of the way that depression can present. So what does depression look like for that person? How frequently do they feel depressed. Is it coming and going a little bit or is it most of the time, most days, for six months? We want to take a look at that to figure out what we're dealing with. What is the intensity of the problem? Are we dealing. We'll just stick with depression for this example. Are we dealing with something like persistent depressive disorder, which used to be called dysthymia, or are we dealing with a single major depressive episode or recurrent major depressive episodes or bipolar? So we're going to ask about the intensity of the experience and we're going to be looking at the duration of the client's problem. Obviously, that's one of the criteria when you're looking at the DSM 5. They're going to say it has to have been being experienced for X period of time. We want to look at the role of the client, significant others, and the environment or community in the client's current issues. So what role does the client play? What role do their cognitions play? What role does their history play? What role do their significant others play? Are they supportive or are they contributing to the problem? If you have a person, for example, who's experiencing major depressive disorder and they don't have anybody to rely on and their one stable social support just died, you know, that's going to be what we call a clue that there's some grieving going on. And we want to look at the environment in the community. Is the person in a safe place or are they living in a house that is riddled with stress because of domestic violence or something? We're going to look at the functioning of the client and the significant others. How is your household doing? You know, I want to get an idea of how well things are going because generally you don't have a client who is doing super duper awesome well and everybody else in the family is falling to pieces. But like, likewise, you don't have a client generally who is completely decompensating and the entire rest of the family unit is just hunky dory. When we're dealing with people, they don't live in isolation. So generally their situation is impacted by their environment and the significant others in their environment and their environment and their significant others in their environment impact them. It's a reciprocal relationship. We want to look at client motivation to address presenting issues. Now, if they show up voluntarily, great. But we also want to know from a cultural standpoint, you know, what is it that they see as their presenting issue and what do they think is going to Help if they don't think, you know, maybe they are really ready to quit being depressed, or they're really ready to quit being sick and tired all the time. Okay, that's wonderful. But if they don't feel like they have the ability to change anything, they may not be motivated or if they're afraid of the potential outcomes, they may not be motivated to try anything. And we need to know what resources they have and what resources they might need in order to resolve problems and effectively participate in treatment. We need to look at, you know, what can we build off of and what resources do we need to link you to. The presenting issue represents the problems that are foremost in the client's mind. The client may come in and his significant other said, you need to go in and talk to somebody about your depression. Because I'm at my end, I don't know what to do about it. And the client comes in and they're like, yeah, I'm depressed, but my main presenting issue is, you need to get my significant other off my back. And that person is driving. Driving me crazy. So that would be more of a relationship issue. We want to look at what the client's presenting issue is. Denial of any problems may also provide you information into their insight, judgment, and motivation. So with that example that I just used with the person denying that there was a problem that needed assistance, they may not have insight into the depth of the problem, or they may not have insight into how their emotional issues are impacting their relationship with their significant other and why that person is so adamant that they get treatment. We do want to pay attention to these things when we start talking about the presenting issue. Now, we're just going to assume for the sake of this presentation that the person is voluntary. They're coming in, they're like, doc, I'm depressed. Help me out. So we're going to start asking them, you know, about the nature of their depression. What are the symptoms you have? When did it begin? Give me an idea. Is this something that began a week ago after your mother died, or is this something that began two years ago and you just haven't felt right since? Give me an idea so I can start looking at whether we're talking about persistent depressive disorder, major depressive disorder, recurrent major depressive disorder, or one of the bipolars? What makes it worse? People generally have an idea about things that make it worse. They may not know everything, but we can ask them because most people have an idea about some things that make their depression worse or their condition. What makes it better. Most of the time, people don't come in to counseling during their first episode of an issue, a mental health issue of any sort generally. Or maybe it started and they've been struggling with it for a while and they finally decided that, you know what, I can't fix this on my own. I need help in that intervening time, either in prior episodes or leading up to when they came into treatment for this episode, they've probably tried things to help themselves feel better. And some of those things likely worked at least a little bit. It may not have been the be all end all may not have worked permanently, but it helped for an hour, for a day, for, you know, three days. Those are the things we want to know about. We want to build on those and get curious. How often does this problem occur and to what intensity? If we're talking about depression, are you depressed most days? Most of the time? Every day? Most of the time, most days. And that's really important for them to realize that, yes, you can have major depressive disorder and still have little blurps in there where you actually feel happy for a moment. And that's okay. It doesn't mean that you don't have depression. It means that, you know, you do have little blurps in there. And I want to learn more about those blurps so we can increase them. You like my clinical word Blerp, but whatever. If the client is reporting multiple symptoms, you want to assess the when it began, what makes it worse and what makes it better, how often it occurs and to what intensity for each symptom. Have an idea. That way you can look at fatigue, you can look at sleep changes, you can look at appetite changes. You know, obviously sleep changes and fatigue often go hand in hand, as do eating changes. And all three of those can throw the system out of whack and increase apathy and symptoms of depression. We do want to look at the biopsychosocial interaction. What are the antecedents of the problem or of the symptom? What is going on before it happens? That way, we might have an idea about what triggers these sleep problems or appetite changes and how do you feel when this is occurring. When you can't get to sleep, for example, people who are depressed may sleep at weird hours. Then when they're trying to get to sleep at the normal bedtime, they can't get to sleep and it gets really frustrating. People with anxiety may have difficulty shutting off their brain so they can get to sleep and they get really frustrated. Well, when they get frustrated, that triggers that HPA axis and they start getting revved up, which is completely counter to what they need to do to go to sleep. So we're looking at what may trigger that. How do you feel when this is occurring? Because that'll give us an idea about what might be maintaining this cognitively, physically, emotionally. And what happens right after the problem, Right after you figure out that oh crap, I'm never going to get to sleep tonight, or when you were depressed and you know, it started to lift, what happened right after that to give you give us an idea about how the person copes and what might be maintaining it. So if the person was depressed and they were just could barely function and then they started to come out of their depression and all of a sudden, you know, they got hit with all this stuff that they got behind on when they were depressed, then they might feel overwhelmed, which could trigger another depressive episode. Think about if you take, when you go on vacation, a lot of us say, you know, we need a vacation after we come back from our vacation because it's just we're so overwhelmed with catching up on work. Well, when people are depressed it's not a vacation, trust me, it is not a vacation. But they're not able to keep up often with their normal level of productivity. So when they start feeling better, a lot of people try to hit the ground running and play catch up, get overwhelmed, burnt out, exhausted and trigger a relapse. We also want to find out, regardless of what we think the diagnosis is, what stressors are occurring and what is their frequency, intensity and duration. So let's talk about work. You know, do you like work? Think about how much time you spend at work. If you hate your job or you hate your co workers, then that's probably going to significantly, significantly contribute to mood issues. What's the intensity of these stressors? Maybe you're having conflicts, maybe the person's having conflicts with their significant other and you know, a little conflict here and there, you know, may not be a big deal. But if they are getting into these blow up arguments every single night, that's probably going to be something that's contributing to their mood issue. And what is the duration of these stressors? We'll stick with the arguing with your significant other. Has this been something that's been recent? Like maybe it started when your symptoms started or shortly after there, or has this been something that's been ongoing and maybe your symptoms might be resulting from exhaustion or frustration with dealing with this situation. How does the client deal with stressors when you're under stress, what are your coping skills? How do you deal with adversity? And are the stressors. We don't want to assume. Are the stressors in the client's mind impacting the course of the presenting problem? If we can look at the stressors, and I like to chart things out on a whiteboard partly because I'm a visual learner, but chart things out about when the symptoms began and what stressors are going on and when those began, because it gives people a visual way of conceptualizing, oh, yeah, I can see where that might be a problem. I can see where that might be contributing to my depression or my anxiety or whatever. The next thing we want to look at is people's emotional range. And discontrol or flattening can be equally problematic. You know, emotional dysregulation is when you go from 0 to 250 in 1.2 seconds flat. There is no in between. You are either calm or you're enraged. You are either calm or you are scared to death. Flattening is, you know, just what it sounds like. People just don't feel much. Think about, think like Eeyore. You know, they're just not able to experience that range of emotions that healthy people are able to experience. And this can impact the client's health, relationships, and functioning at school and work. People who avoid dealing with emotions and have more emotional flattening may develop depression, anger, or anxiety. Well, think about it. If you are avoiding dealing with emotions and you're avoiding dealing with the stuff that's causing emotions, guess what? That can start making you feel hopeless and helpless because you're just stuffing stuff into this closet. You're stuffing your skeletons into that closet. And it's going to be harder and harder to keep that closet closed, which can contribute to a sense of helplessness. It can contribute to a sense of resentment, negativity, irritability, and even anxiety. People who experience dysregulation also have problems with depression, anger, and anxiety because their emotions are so powerful and seem so overwhelming. It's important to remember that trauma induced changes in emotional range may also impact the client's ability to function or remember. For example, with ptsd, you may have people who withdraw and become emotionally numb. You may also have higher levels of irritability and aggression in some people with ptsd. So we do want to be aware. And PTSD can lead to brain changes that contribute to emotional dysregulation. Always take into account trauma if it's presented in the, the vignette. And remember that affect Is the current transient state? How is the person right now? And we need to always assess affect as well as the congruence of affect to the nonverbals. If they're sitting there and they're acting like everything's fine and they're telling you this really horrible stuff that's going on in their life, then their affect is incongruent. So we do want to look for that. When the client presents with mood symptoms, inquire about previous episodes of the same symptoms, how the person's dealt with those before, and if there was a previous episode, was there full remission? Did the person have a major depressive episode before and then they had a period where they felt really good, you know, they were having a good range of emotional experiences, they didn't feel depressed most days, yada yada, or did they go more to a low grade or a persistent depressive situation? Want to get an idea about what's going on with depression? Things that you're going to look for. Anhedonia, which means loss of pleasure in things. Dysphoria, which means unpleasant emotions. And this generally is feeling sad, feeling trying not to use this word of the diagnosis. We don't want to say depressed, feeling sad, feeling blue. But also in children especially maybe some irritability, sleep changes, appetite changes, changes in psychomotor behavior. And this is one that they don't really explain to you too well unless you've had depression or had a really good instructor. Changes in psychomotor behavior in depression often look like slowing. And for the person, it feels like they are carrying an 80 pound rucksack on their back. Their arms feel heavy, their legs feel heavy. It's like they're trying to move through water when they're walking. So everything feels a lot slower. And it actually may be going a lot slower for that person. They start walking more slowly, they start talking more slowly. We want to pay attention to that. A reduction in libido, reduction in energy. Now, energy is different than psychomotor behavior. Psychomotor behavior is how quickly or slowly you do things. Energy is whether you feel like you got the pep to actually get up and get it done, or if you feel fatigued. We want to look for non verbals indicating any of the above. You know, if the person is hunched over and moving slowly or kind of nodding off in your office, anything like that, or if they're tearful. That gives us some ideas about what's going on. The person may be highly self critical, may report things in using a lot of cognitive distortions A lot of all or none. Polarized thinking, personalization, magnification, exaggeration. Please review your cognitive distortions. They may have a sense of hopelessness and pessimism, irritability, guilt and shame. Difficulty concentrating. And remember, difficulty concentrating. Some of us, when we get sleep deprived, have difficulty concentrating. So we want to look at what's causing it and withdrawal from relationships. These are all the things. And you're like, oh my gosh, how am I going to remember to check for all of those? Well, let's break it down for you. Let's hit the highlights. The mnemonic is a sad faces. And I know that is not grammatically correct, but you're just going to have to deal with it. You want to look for appetite changes, sleep changes. A is for anhedonia. D is for dysphoria. F is for fatigue. A is for agitation or retardation, that psychomotor movement stuff. C is for concentration, diminished. E is for esteem, low self esteem, a sense of guilt. And S is for suicidal thoughts or thoughts about death. So asad faces can help you remember the different things that you want to specifically assess for. So let's move on to mania, because sometimes you end up with a client who has bipolar disorder. We do want to assess for mania, know the difference between bipolar one and bipolar two and know the difference between depression and persistent depressive disorder and mania and hypomania. Those are going to be important. We're just going to talk about mania right now. With mania, and this is not a hard one to pick out. You want to look for elevated mood, grandiosity, possibly irritability and aggression. When someone is manic, they're often pursuing thrill seeking activities. They're often pursuing, pursuing stimulation. And if you stand in their way, they can get really ticked off. And generally in mania, people have very low impulse control. So combine high frustration with low impulse control and you have the perfect mixture for irritability and aggression, pressured speech, flight of ideas. Now remember, flight of ideas is just all over the place. You know, they're talking about one thing, then they switch topics on you and they start talking about something else and you're just trying to keep track. One of the things that I found helpful with working with clients with mania, and this is kind of off topic again, have a whiteboard if you have a client who is in an active manic episode and, or you can do it on a piece of paper, but I like the whiteboard. And as they bring up different topics, write it on the whiteboard and point out that okay, you know, I hear you want to talk about that, but we need to. I want to stay on this other topic right now, and we'll come back to this then. They feel like you're hearing them. They feel like you understand that they have 17 things that are important to talk about today and they just can't figure out how to organize it. Restlessness, you know, difficulty sitting still. I don't want to say agitation because that implies irritability, but they are. They're jumpy in their seat, they're fidgety. They're not able to sit still still. Hypersexuality. This is really important to look for. One of the. A key feature for a lot of people who are in a manic episode is hypersexuality. If you are working in a treatment center, if somebody is getting ready to have a manic episode, this may be one of the first signs that shows up that they are headed toward the kickoff of a manic episode. Impulsivity, limited insight, poor concentration, impatience, gregariousness. You know, people who are manic are typically pretty happy as long as they're not being prevented from doing what they want to do. And sometimes provocativeness. And that will go along with the hypersexuality. Your mnemonic for mania is dig fast. Distractibility. A person with mania, again has their thoughts going six different ways. So you're going to look for flight of ideas and difficulty concentrating, indiscretion, low impulse control, high seeking of rewarding, pleasurable activities. Grandiosity. They feel 10 foot tall and bulletproof. They think they can do anything. And they are thrill seeking, flight of ideas. Activity increase, sleep deficit. A lot of times people who have mania or hypomania aren't sleeping at all or not sleeping much. But they don't feel like they need to sleep if they're experiencing a mixed episode. That's a whole different ball game that you want to research. But let's just stick with pure mania for right now. And they're talkative. People with mania are often extraordinarily talkative and they do have the pressured speech. So dig fast. Distractibility, indiscretion, grandiosity, flight of ideas, activity, increase sleep deficit and talkativeness. Anxiety is another common thing that you're going to see in practice and on the test. What to look for. Irritability and edginess. I want you to think about times when you get anxious. You know, are you patient? Are you as tolerant of things? Probably not. So put yourself in this person's shoes. Irritability and edginess, uneasiness or worry. And if we're talking about generalized anxiety disorder this is going to be worry about a variety of things most of the time. Panic, hyper vigilance, being on guard, being over alert, psychomotor agitation, these nervous habits. A lot of times people who are anxious will be shaking their foot or moving their hands. I mean they even have the little fidget spinners and stuff. Now for people who need to be moving a lot that can be anxiety. We do want to look at what is causing this person to feel like they have to move constantly. Look at non verbals indicative of worry. If they're constantly scanning, if they startle easily, if they seem like they're edgy, if they're having gastric problems. Ruminating, constantly thinking about something. What if this happens? Persistent worrying about a variety of things. Difficulty concentrating, withdrawal from relationships, highly self critical sleep problems and clinginess and dependency. Now remember, just like with depression and mania and everything else in the DSM there is a whole laundry list of symptoms that we're going to look for. But people only need to have a certain percentage of those symptoms to meet the diagnostic criteria. You need to know how many symptoms do they need to have in order to qualify for a diagnosis of X. The mnemonic for anxiety is worrywartz. I love this one. The first one is worry. The person has to have worry and depending on the type of anxiety disorder you're talking about, the worry is going to be about different things. Social anxiety, the worry is going to be about social situations. Generalized anxiety, the worry is going to be about a variety of things. Now warts stands for worn out, they're exhausted from worrying a lot. Absent minded, difficulty concentrating, they're restless. Psychomotor agitation that we talked about. They're touchy, they may be irritable. When we are worried we tend to be less patient, more irritable and sleepless. People who worry a lot tend to have sleep disturbances. So again worrywarts is your mnemonic and it stands for worry, worn out, absentminded, restless, touchy and sleepless. And finally the last one we're going to look at today is ptsd. What to look for Exposure to a traumatic event. You know we know this re experiencing what's going on in terms of dreams, memories, flashbacks, avoidance of reminders of the event. And it can be holidays, it can be places, it can be people, it can be smells, negative thoughts or feelings that began or worsened after the trauma or difficulty experiencing positive emotions. So the person is in this negative Mood, cognitive state and trauma related arousal and reactivity. The mnemonic for this is dreams. And remember, when you go to the DSM you're going to want to look and see how many symptoms in each category re experiencing avoidance, negative feeling states and arousal. You need to know how many symptoms in each category necessary for a diagnosis of ptsd. You will also want to know the duration the symptoms have to have lasted for PTSD versus acute stress disorder. So for PTSD we're looking at dreams, disinterest in usual activities. That's the withdrawal re experiencing through nightmares, flashbacks, etc. Event preceding symptoms. So there was some traumatic event, avoidance of reminders, a month or more of symptoms. So if it's been less than a month, you're looking more at acute stress disorder and sympathetic arousal. This is your hyper vigilance. Again, dreams disinterest, re experiencing event preceding symptoms, avoidance, a month or more of symptoms and sympathetic arousal. I guess I lied. We're going to look at one more. Substance abuse. You want to look for signs of intoxication or withdrawal in your clients. Now remember, intoxication and withdrawal are going to be different for different drugs. For stimulant intoxication, you're going to have somebody that's really revved up and when they are in withdrawal they're going to be really flat and depressed. The coin flips if you're dealing with a depressant. When somebody has a depressant in their symptom, they're going to be more mellow. And when the depressant starts to wear off, they're going to have more symptoms of agitation and anxiety. So the withdrawal symptoms are generally the opposite of the effect of the drug. Either way, if you've got somebody in your office and you're just doing an assessment, you're just doing a screening, you're looking for intoxication or withdrawal. Is this person experiencing symptoms as a result of substance use? So you're going to look for sad clips, slowed reflexes. If they're slowing down, you're going to look for the aroma of drugs. Do you smell marijuana? Do you smell alcohol? Most of us haven't smelled crack, but once you've smelled it, you know what it smells like. Have you smelled it? Are you having. Is the person having difficulty concentrating? Now remember, we've talked about difficulty concentrating for every single diagnosis so far. So that's just one of those that's probably going to be there. Is there confusion, lowered inhibitions, impaired coordination? Are their pupils either blown way wider than they should Be and. Or are they constricted and they're pinpointing and do they have slurred speech? Any of these could be a sign of substance abuse, intoxication or withdrawal. They could also be a sign of a variety of other physical health problems or a head injury. So don't jump to conclusions, but think about when you're doing your assessment. Just make it simple. Think about drugs. You know, if you're taking a stimulant, what are you going to be like? If you've had way too much coffee one day, you know, multiply that times like 15 and figure, okay, that may be what somebody who is under a stimulant might act like. There are a lot of other symptoms to be aware of with intoxication and withdrawal. My gut feeling, unless things have changed significantly, you're not being asked to be drug abuse counselors. So you're not going to be quizzed on or they're not going to have you differentiate. Is this person experiencing stimulant withdrawal versus depressant withdrawal versus opioid withdrawal, etc. I don't expect that to happen now. Talk to some of your colleagues to find out if that has changed. What you generally need to know is the signs of a substance use disorder, which is what it's called now in the dsm. Physical symptoms. We want to look for physical symptoms that a client may be experiencing because physical symptoms can cause mental health symptoms and vice versa. When we look at physical symptoms, we're obviously not treating them because we are not prescribers. But we can make a referral to a medical professional if any of these symptoms pop up. So we want to ask, are you under a doctor's care? If so, why, if not, should you be? And that's one of those that in practice I regularly ask because a lot of people these days cannot afford to go to treatment because their deductibles are so high or their co pays are so high. So they should be under a doctor's care, but they're not for the ncmhce. Don't worry about that. Just ask is the client under a doctor's care? If there are obvious long standing physical developmental issues, how have they impacted the client? So if the client has a stutter or a lisp, or has visual impairment or has hearing impairment, or has really bad scoliosis or a limp or whatever it is, ask how it is impacted the client over the course of their life. We want to ask them about whether they've had convulsions or seizures. In the past recent time. You know, three to six months is usually good. Ask them about their libido. Has their sex drive changed? What about their appetite and their sleep? See how this keeps coming up. Their sex hormones. And I just put sex hormones generally because I was trying to make my mnemonic here. But with sex hormones, we're looking at premenstrual dysphoric disorder and we're also looking at low testosterone. You will see symptoms of depression with both low T&PMDD. So you may consider, especially if there's changes in libido or if the mood symptoms correspond with a woman's menstrual cycle. You may consider referring to a medical professional for a blood workup for that. How is their energy? Is it good or is it low? Low energy could mean a variety of things. Hypothyroid, diabetes, high energy, you know, feeling like they have excessive energy could also mean hyperthyroid. We don't want to rule out necessarily the medical symptoms. If they've had a, what we're looking for is a change, a dramatic change in their energy or physical symptoms in, in the recent time. And have they had any experiences of dizziness or fainting? So the mnemonic for this is clast. Clast stands for convulsions or seizures, libido, appetite, sleep problems or changes. Sex hormones. Remember estrogen, low testosterone, energy and dizziness or fainting. Let me also put in with sex hormones. If a woman has recently given birth or stopped breastfeeding, then there's going to be significant changes in estrogen levels which can contribute to depression. And then you want to ask the person to describe their childhood health just so we have an idea about how their developmental course went. And we might be able to pick out and see if there were periods of maybe undiagnosed ADHD or anxiety. Again, you're really not going to see a lot of this on the ncmhce. In general, if there's something in their childhood health, it's going to be pretty glaring for a medical referral. You really seriously want to consider an immediate medical referral. If the person has an eating disorder, you suspect that they may have AIDS or HIV that's been undiagnosed or untreated. If you suspect that they have tuberculosis. Most states require us as clinicians to go through annual tuberculosis training because it still exists. Long standing depression, ongoing physical complaints such as chest pains, dizziness, abdominal pains, chronic cough or fatigue may indicate that there's some underlying major physical issue going on that needs to be addressed. Cardiac problems, and there's a variety of them. Cardiac problems can contribute to both anxiety and depressive symptoms. Anxiety symptoms if the person's having heart palpitations and panic attacks. Panic attacks look a lot like a cardiac problem. And cardiac problems can also cause depressive symptoms. If the heart isn't getting oxygen throughout the body sufficiently to keep them oxygenated, if they are having chest pains and dizziness, if they're having what you think is a panic attack, don't diagnose. You know, if in doubt, always call the paramedics. But that's a whole different story. If there are abrupt personality or behavioral changes that may indicate the onset of a psychotic break, that may indicate the onset of a manic or depressive episode. So just be aware of this. But we also want to be aware that abrupt personality or behavioral changes can also be due to brain tumors, stroke and a variety of other physical health conditions that only a doctor is going to see if the person is experiencing delirium or dementia. And be aware. I don't think, again, I don't think it's going to be on your NCMHCE exam. But do be aware that people with a history of alcoholism as well as people who have had gastric bypass surgery or who are anorexic, are all at risk for something called Korsakoff syndrome, which results from a thiamine deficiency. And it presents as a. It presents as dementia. The lay term for it is alcohol related dementia, Korsakoff syndrome. But we know now that other things cause it besides just alcohol. So if you've got somebody who is presenting with signs of something other than age appropriate cognitive decline, they need to be assessed by a medical physician. That's redundant by a physician in order to figure out where it's coming from. Is it early onset Alzheimer's? Do they have a thiamine deficiency? Do they have a brain tumor? What's going on? And substance abuse. If you suspect substance abuse, you need to refer to someone who can assess for substance abuse issues. Okay, so your medical referral mnemonic is. The best I could come up with is eat loads, eating disorder, AIDS and tuberculosis. L is for long standing depression. O is for ongoing physical complaints, A is for abrupt personality or behavioral changes. D is for delirium or dementia, and S is for substance abuse. Those are the reasons that you would want to make an almost immediate medical referral. Alrighty. As promised, at the end of every presentation, we're going to go over some test taking tips. Remember that everything in the NCMHCE has one clear diagnosis and assumes a mutual respect between client and counselors. The test is measuring for ideal questions and treatments, even if those might not be appropriate or applicable in some real world situations. So you want to think of a utopia, you want to think of a textbook situation, not necessarily a real world situation. When you read the initial scenario, focus on the symptoms and all components of the question and this keeps coming up in test taking tips. You don't want to just focus on what is that diagnosis. If there are multiple parts of the question. If the question indicates or the scenario indicates that the client is grieving and withdrawn, then we would want to look for remedies that target each area, such as support groups. Support group for grief could target both the grief and the withdrawal. Social withdrawal symptoms Consider whether the information that's being requested is actually beneficial and and whether it will narrow down the diagnosis. Asking too many questions is going to lower your score in general practice. You know, if you've been doing this for a while, you're probably used to asking a whole lot more questions than you need to to do a complete biopsychosocial trans diagnostic assessment. That's not what you do on the ncmhce. What you want to do is get an idea, formulate in your mind, I think this is what we're looking for. And then look for information to support that diagnosis. Gather support for your diagnosis, not to rule out other diagnoses. So you're ruling in. And I know I said that on the last one, but this is so important because it is so different than what we do in actual day to day practice. Alrighty everybody. Thanks for being with me and I'll see you in episode five. Thank you for joining me today. Subscribe to the NCMHCE Exam Review Podcast to be notified when new episodes are released. And while you're at it, subscribe to Counselor Toolbox podcast to stay up to date on current trends in counseling and earn your continuing education on the go.