NCMHCE Exam Review | Mental Status Exam

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 hi everybody and welcome to the NCMHCE Review. This is part one, brought to you by allce.com counselor continuing education and counselortoolbox podcast. The first thing that we're going to talk about in this review is how to conduct a mental status exam and kind of why we do it. Obviously, a mental status exam is giving us information about, guess what, the client's mental status. It's an evaluation of the client's current mental functioning when they're in your office. You can combine this information with other information that you glean during the screening or the assessment in order to arrive at a formal diagnosis. So what is it that we're looking at in a mental status examination? The first thing we're looking at is your behavioral aspects. When the client walks into your office, are they dressed appropriately for the weather and for the situation? Have they bathed? You know, people with major depressive disorder often don't have the energy to bathe, so that might be an issue that we've got going on. What is their weight? If they are extremely overweight or extremely underweight, they may have some issues with eating disorder or they may have some other underlying physiological issues. But we do want to pay attention to this. Also, people who are in fluoride psychotic episodes often are not paying attention to their nutrition. So we want to kind of factor that in. If their weight seems to be grossly one end or the other too high or too low, we do want to pay attention to what's causing that. We also want to look for age appropriateness of their dress and obviously there's wide variety here. But if you have a 20 year old come in and he starts sucking on a pacifier, that's obviously going to be something of concern. If you have a young child who is six or seven and comes in in a three piece suit, that gives you a little bit of information to go wonder what's up with that. But we also want to be cognizant of, you know, just general weather appropriateness. If it's 30 degrees outside and they're showing up in a tank top and shorts may make you wonder about their judgment. On the other hand, if it is 80 degrees or 90 degrees outside and they're showing up in long sleeves and long pants. Maybe they get chilly, that's something to consider. But maybe they're hiding scars from where they have been either injecting or cutting. Or maybe they just are unaware of their body sensations. Again, people who are in fluoropsychotic episodes often tend to dress inappropriately for the weather. You'll see them walking around in 80 degree weather with a heavy coat on. We want to look at communication barriers. How able are they to listen as well as to communicate their needs? And for example, when you're working with somebody who has fetal alcohol spectrum issues, they can often talk at the level developmentally higher than what they are. They may be 16 and talking at the developmental level of a 20 year old, but what they're understanding, what they're hearing in return is at the level of more like an 8 or a 9 year old. We do want to be aware of communication barriers. We also want to be aware of any communication barriers, such as hearing impairment or visual impairment that will impact our ability to effectively carry out our assessment potentially unless we make modifications as well as any dementia. And this could be dementia related to age or dementia related to alcoholism or something else like that. But we do need to be aware of those communication barriers. And if you go to Counselor Toolbox podcast, there is an episode on communicating with the cognitively impaired that can be really helpful, especially if you're working with a population who happens to have certain physical disabilities which may impair their ability to effectively communicate. We want to look at alertness. Is the person alert? That's a pretty simple thing. And a lot of these behavioral aspects you're just going to glean from the minute you meet this person, you're going to have an idea about, you know, what their mental status is. And you're not going to have to sit here and go through this specific check sheet unless you happen to have that on your intake form. But are they alert or do they seem to be really spaced out? Somebody who is under the influence of alcohol or drugs or detoxing from alcohol or drugs is not going to have the same level of alertness as somebody who is present and ready to participate in an assessment. What is their movement and activity level? What is their tension level? If they seem to be really tense, if they seem to be really hyper vigilant, we want to pay attention to that. Do they have any non goal directed behaviors such as picking or tapping or something else that might be associated with anxiety or adhd? What are their facial expressions? And do they have continuity with the person's words. If they say that, they are just deliriously happy, but they look like somebody just stole their puppy, obviously there's going to be some disjoint here that we need to pay attention to. What about eye contact? Now, we know with people with autism spectrum disorders, as well as schizoid personality disorder, that they have difficulty with making direct eye contact. So we do want to be aware of that. Lack of eye contact can also be a cultural thing, and it can also be an issue related to shame. You don't want to make any assumptions. You just want to take this information factually and ask the question, why? Why is this happening? Why is the person not making eye contact? Speech patterns are also something that you want to pay attention to. Is the person articulating their words clearly or are they slurring their words? Remember, slurring does not necessarily mean intoxication. It can relate to a hearing impairment that has gone undiagnosed or maybe their hearing aid isn't working like it's supposed to. It can relate to malformation in certain parts of the mouth. It can relate to variety of different issues. It can also relate to something like serotonin syndrome. Stuttering, mumbling, baby talk, and use of cultural dialects are also things that we want to pay attention to and, you know, figure out. You know, why is this happening with this person? What makes it worse, what makes it better? Stuttering may be something that is the person needs a referral to an occupational therapist for. It may be triggered or worsened by anxiety. Same thing with mumbling. And we want to pay attention to the attitude towards the therapist. Does the person want to be here? Do they look at you and have a transference reaction? Do they have ill feelings about being there? If they are involuntary clients, they may have a bad attitude towards the therapist or they may be trying to persuade you that they don't need to be there, so they're just turning on all the charm. We do want to be aware, again of all of these things and take them at face value. For right now. We're not. We're just gathering information. We're not making any diagnostic impressions just from a mental status exam, mood and affect. We want to ask the client, how do you feel on most days? I mean, some days we all have really crappy days occasionally, but most of the time, how do you feel? Depressed, anxious, happy, angry. You know, give them a variety of things. If you're working with children and adolescents, it may be helpful to have one of the Face posters because they may not have the verbal skills that to identify their emotions that adults may affect is more variable. So their mood is how they feel on most days. Their affect is how they feel right now or at a specific time. How do you feel right now gives you an idea of their affect. How do you feel when you go to school is an idea of their affect. Because it is a specific time when you're going to school, how do you feel? For example, my son, when he was going to one of his schools, it was a very bad fit for a variety of reasons. But his affect before school was always highly anxious and he would get really nervous and sick to his stomach. That was something that I needed to pay attention to because when he wasn't getting ready to go to school, his mood was just fine. It was just during that particular time of day. We want to look at the type, quality and appropriateness of people's affect. If their affect is bland, you know, they're just kind of flat. They're just kind of there. It may indicate dementia. It may indicate flattening from psychotic issues. It may indicate flattening from medications. We do want to be aware flow of thought. When we're working with people in this assessment, you're doing a mental status exam. It's not just something you do in two minutes, it's something that you're paying attention to throughout the assessment. Is their flow of thought spontaneous or only in response to questions? If somebody is involuntary, then they may be much more only in response to questions. But most of the time when we're asking assessment questions, especially when we ask open ended questions, the person will answer the question and elaborate on it. If they're not doing that, then they have a restricted flow of thought. If they have incoherent rambling, they may be intoxicated. They may also be experiencing some level of psychotic issues. Common issues that you may see in the flow of thought. If you're dealing with somebody who has in the middle of a manic, hypomanic or schizophrenic episode, they may have a flight of ideas, you know, just kind of all over the place. They may have tangential speech, which is that they provide answers that are unrelated to the questions. You may ask, how are you doing today? And they say, I decided to wear blue jeans because it was going to be cold. Okay, not really an answer to my question. Or they may have loose associations. For example, they may say, I got up and it was sunny today. I had oatmeal for breakfast. My dog Died on Thursday. Okay, where did that come from? Not everybody who has loose associations or fast moving thoughts has mania or schizophrenia. They could be, especially with a flight of ideas. You may see that some in children who are gifted as well as those who have add, we do want to be aware. If their flow of thought seems different than the, quote, average person, then we want to pay attention to it and identify whether this is an issue or whether this is just, you know, symptomatic of the situation. Sometimes when people come into our offices, they become very nervous and their flow of thought changes from what it normally is to what they think we want them to say. Their flow of speech, you want to pay attention to their rate of speech if it's pressured. And they're talking a lot and they're talking really fast and they're talking about a variety of things and they keep going on like this and you just don't feel like you can get a word in edgewise and you're wondering if they're ever going to stop to take a breath. Exactly. That could be a sign of hypomania or mania. If they are speaking too slowly and they're having difficulty answering questions, it may be a sign of depression, intoxication or other cognitive impairment. Those things we want to pay attention to. We also want to do a suicide. An assessment of their suicidal and homicidal ideation. Are they currently experiencing suicidal or homicidal thoughts or. And have they in the past experienced suicidal or homicidal thoughts? And if they have, we want to inquire a little bit more about what triggered those things and where they're at with those feelings right now. Cognitive aspects of the mental status exam, we want to look at thought content. Is it logical or is it completely delusional? If somebody is telling you they're sitting in your office and telling you about how the CIA is pursuing them and they are in witness protection because they put some big mob boss in jail or something, Is it possible? Yeah, anything's possible. Is it likely? Probably not. So we do want to pay attention to that. What is their perception? Is it accurate? Are they perceiving the situation correctly? Are they seeing the same things you're seeing? Are they hearing the same things you're hearing? Or are they experiencing hallucinations? One of the common mistakes that a lot of clinicians make is when they're asking about hallucinations or delusions. They may ask, do you see or hear things that really aren't there? Well, if somebody is in a psychotic episode, those things are really There to that person, they can't understand why other people can't see or hear them. They're really there to that person. A better way of asking that question is, do you sometimes see or hear things that other people can't see or hear that they understand? They're like, oh, yeah, you know, I am constantly seeing this or arguing with somebody that the sky is green when, you know, they keep telling me it's blue. Consciousness and cognition. Is the person aware of and able to process and communication information? And communicate information? Can they hear questions and take in that information and process it and give you back something that is integrated? Are they able to pay attention? If they are fidgeting in their seat and getting up and pacing around after five minutes, we want to make a note of that. If you know it doesn't happen until after 90 minutes, well, then most normal people's attention span is gone after that. I know some assessments can go 60, 90, 120 minutes, and that's a really long freaking time. What is their attention span compared with the average person that you see? What is their orientation to person? Do they know who they are? Do they know who you are? To place, do they know where they are and why they are there and to time? Did they arrive on time? Do they have a concept of time or does time seem to go really slowly for them? We want to pay attention to language comprehension and fluency. Do they understand? Do they use a variety of words or are they very limited in their vocabulary? If this is a person with English as a second language, then obviously their fluency is going to be different. Ideally, you're doing the assessment in their native language. We want to look at their memory, their immediate memory, in five to ten seconds. If I. If you ask them something, can they remember what you asked them? Now they may be off in la la land somewhere daydreaming, because you've been typing notes for five minutes and then you ask them a question and they're like, huh, what? What did you say? But if you have eye contact, you know you have their attention and you ask them something, then you ask them to repeat back what you just said. Can they remember that within 5 to 10 seconds? Can they remember things for 5 to 10 minutes? If you show them a card and it has a queen of hearts on it, and then ten minutes later you ask, do you remember what was on that card that I showed you? Can they remember that? And long term, can they provide autobiographical history? And this can be, do you remember what you had for breakfast this morning? That's a difficult one because they can confabulate. They can make up what they think they had for breakfast. It's difficult to know if they're telling the accurate response to what they're saying. They're not trying to lie. They may just be remembering what they usually have for breakfast. So we want to make sure that when we're looking at long term memory, we know what the answer is to the question that we're asking. You may ask, you know, did it rain where you were at yesterday? If, if you know they were in the same city you were and you know that it was sunny everywhere and you asked that question, then you will know that if they say, yeah, it poured like cats and dogs, you'll know that they are not remembering long term. You can also ask autobiographical questions and people may say, you know what? I don't remember, I don't remember that person, or I don't remember that period of time. If somebody has a deficit in their memory, immediate, short term or long term, it could indicate early onset dementia or something causing dementia, which again can be caused by alcohol intoxication, a deficiency of thiamine called Korsakoff Syndrome. It can be caused by early onset Alzheimer's, brain damage, tumors. There are a variety of things that can cause problems in memory. Amnesia, a mental disorder due to a medical condition such as stroke or chronic fatigue. Both of those, as well as many others, can cause problems with memory. As I mentioned earlier, Korsakoff syndrome, which is substance abuse mental disorder, can cause problems in memory, especially your immediate and your short term depression. People with depression often have difficulty recalling facts and anxiety. When you're anxious and you're stressed and you're worried, you're focused in the future. So it's a lot of times people with anxiety have only sparse attention to the present and very little attention to the past. So they're not remembering a lot of things. Another aspect that we want to look at is general intelligence. Poor intelligence despite a good educational background can indicate a neurological problem. Fetal alcohol spectrum issues, which is in the category on the dsm. I can't remember exactly what they call it right now in the dsm, but it's in the areas for further exploration. We can also look at other neurological problems that may be causing difficulty with acquiring and remembering information. You need to consider age, education level, culture and degree of depression, and anxiety when assessing performance on certain general intelligence tasks. For example, 29% of Americans and can't name the vice president. Okay, that's. So we want to make sure that we're asking a question that most people actually know, like what month is Christmas in? Or you know, I don't know. Make sure when you're asking the questions that the person has a chance of having the answer. Abstract thinking is another thing that we ask. You may have them interpret a proverb like don't count your chickens before they hatch or a bird in the hand is better than than two in the bush. What does that mean? Obviously you're not going to ask that of an 8 or a 10 year old and expect the same results as you're going to get from a 28 year old or a 30 year old asking them a proverb or something that is meaningful and developmentally appropriate. Insight and judgment we want to figure out if they have insight about their problem severity and what needs to happen. A lot of times when you're working with people who are involuntary and or who may have substance abuse issues, their insight about the problem is very limited. And people with psychotic disorders and personality disorders also often have very limited insight because their problems, their presenting issues are ego syntonic. It's part of them. They don't see it as weird. They see everybody else as having the problem. Poor insight is associated with cognitive disorders, depression, psychosis and mania, as well as personality disorders. Poor judgment is often associated with mania, hypomania, FASD or substance abuse issues. Poor judgment means you know the difference between right and wrong. You know what you should or shouldn't do, but you just do it anyway. You, you have poor judgment and poor anticipation of the outcomes. So a mental status exam should be done at admission to aid in assessment and treatment plan development. In order to write an effective treatment plan with the client, we need to understand cognitively where they are at physically, how much can they do, what are they capable of doing, what are they motivated to work on, and in what ways do we need to approach it for this person? Someone with limited language fluency is going to need a different type of treatment plan than someone who has perfectly fluent language abilities. Someone with cognitive dysfunction is going to need a much different treatment plan than someone who is gifted or who has Asperger's syndrome or something. A mini mental status exam should be done at each contact. Notice I don't say at each session, it should be done at each contact. So if your client calls you on the phone and cancels their appointment or calls you on the phone in a crisis, it's ideal to do a mini mental status exam and document that are they oriented to person, purpose and time? This can easily be done during sessions if the person has to sign in. If they show up where they're supposed to be when they're supposed to be there, that's pretty good orientation. Thought, Content and Perception when they come to sessions or when you're talking to them, ask them what were two things that you got out of our discussion today? Or this group session? Gives you an idea about how well they're able to take in information. Remember what you talked about, formulate it into something useful. Fund of information and memory how did you apply the tools or homework from last week? If somebody calls you in a crisis, you can say okay, what did we talk about last week in terms of tools that you could use to address this issue? See if they can remember that information. Future Plans what do you plan to do over the next week to improve your recovery? Or what can you do between now and the next session to get you through this crisis? Their Mood what is your mood right now? What is your affect? If you want to use the proper term, are you happy? Anxious? Angry? Irritable? Depressed? Give me a word here. And judgment. If you start having a bad day, what are you going to do? What is your plan? These questions you can have on a sign in sign out sheet for clients to fill out at the beginning and or end of an individual or group session. But these are also questions you can ask them on the phone. Obviously modify them a little bit. If they call in and they're having a crisis, but it's not actually an appointment time in order to identify their mental status at that point in time. Judgment and future plans are also good to assess to get an idea. It's not a perfect assessment and it's not an in depth assessment by any means, but to get an idea about any suicidal ideation that may be there. If they refuse to make future plans or they're indicating poor judgment, you may need to probe a little bit further to make sure they're actually safe. So each one of these episodes is going to end with a little bit of a test taking tip for your NCMHCE in this session we're going to talk about eliminating response options. If you're taking the test and there is an ethics related question, it's an ethical issue dilemma that's being asked. Your best guess is the answer that is best for the client. You really want to focus on client advocacy. What is in the best interest of the client that you are working with? Some of these scenarios I won't say a lot can involve other people like caring parents or referral sources. So you do need to pay attention to, you know, what is in the best interest of the client. When eliminating response options, you can generally eliminate answers which don't answer the whole question. Make sure you read the whole question and then when you read the answer, go back and basically correlate each part of the answer with each part of the question to make sure that you're getting a complete answer to the complete question. You can generally eliminate answers that are true but not relevant to the presenting problems and situation. For example, if the person is a survivor of domestic violence that may not have anything to do with the current presenting issue of postpartum depression. If the answers use extreme words like always or must, that's a good indication that that's what probably not going to be the correct answer. Because in counseling things rarely always happen, and things rarely must happen all the time. If the answer represents a common misconception or a layperson's view of things, not what our clinical knowledge informs us of, then you can generally eliminate that. You want to make sure to check each answer against every part of the clinical simulation, especially the diagnoses. And if two options are similar, choose the one that's more case specific and make sure that that answer is relevant in general to both the case and the question being asked so that the case can be one thing and the question being asked can be completely different. But we want to make sure that the answer you're providing answers the question completely as it pertains to the case at hand, not as it pertains to the case. You just read about the 53 year old male, or the case before that about the 17 year old female, but this one pertains to the 35 year old female that you are working with who happens to have four children or whatever. Make sure it applies to the case and fully answers the question. I know that sounds simple, but when you read these questions on the test, it is really easy to assume or to look too broadly at what they're asking. Thanks for being with us today and we will look at more things on doing the assessment in the next episode in NCMHCE Review Part two. 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.