NCMHCE Exam Review Screening

Hi, everybody, and welcome back to NCMHCE Review Part 2. Today we're going to be talking about screening, and this is brought to you by allce.com counselor continuing education and Counselor Toolbox Podcast. In the first episode, we talked about mental status exam, which is something, again, that you should do during the assessment, as well as doing an abbreviated version at every single client contact, and that should be documented. That way you can identify if, heaven forbid, you should ever show up in court that you were paying attention to the client's mental status and their capacity to make informed decisions and use good judgment based on accurate insight. We're going to move on to screening. When we start meeting clients, one of the first things we need to do is kind of screen for what's going on to gather a little bit more information in order to figure out what we need to drill down on a little bit more. So in order to do effective screening, you really need to know your diagnoses backwards and forwards, your diagnostic criteria for the most common things. You're going to be looking at things like anxiety, depression, ptsd, bipolar disorder, eating disorders, substance abuse, and we're going to look at a lot of those today. When you're asking these screening questions, you're going to ask the big questions that give you the aha moment that, oh, maybe this is something I need to pursue further. You're not going to be asking every single nitpicky question to validate a diagnosis. Screening is just identifying whether something needs further exploration. So for anxiety, do you worry about a lot of things most of the time? Do you worry about specific things like germs or getting into a car accident? A lot. Do you sometimes get so worked up or anxious that you just can't eat or sleep? This is giving us an idea about whether the person has a specific phobia, generalized anxiety, and maybe the intensity of that anxiety. Obviously, there are a lot more criteria that need to be met in order to actually give the person a diagnosis of an anxiety disorder. But this gives us an idea that this is an area we need to look at a little bit more closely. If they answer affirmatively to these questions for ptsd, ask somebody, have you been in a really bad situation in which you had no control, or have you been in terrifying situations? And I'm using these questions kind of broadly because most people have been exposed to trauma in their life. We know this from the Adverse Childhood Experiences survey. We know this from other research on rape and domestic violence and a variety of other things. We want to find out has this person been exposed to an extreme situation doesn't mean they necessarily have ptsd. Do you ever have memories of those situations that disrupt your day? So we're asking about flashbacks here. Do you startle really easily? And do you find yourself being irritable and pessimistic about things in general or about the world? This gives you a little bit of insight regarding whether they might have PTSD or if it happened within the past two weeks. Acute stress disorder, anger. Now, when we're looking at anger, we're really looking at things like intermittent explosive disorder. But sometimes anger is just a focus of clinical attention. It may fall under adjustment disorder or something else. They don't have anger as a diagnosis in the dsm, but it does give us an avenue that we may want to pursue about what is causing the anger and how to help people deal with their anger. So you ask them, do you often get angry? When you get angry, do you feel like you're ready to explode? And this goes with that intermittent explosive disorder. Do you think that you're more irritable than other people? There are a lot of things like generalized anxiety and PTSD that also may lead to irritability. But we do want to get a sense of what's going on with their anger. Depression. Do you feel pleasure or happiness on a regular basis? And obviously you're going to use your own words to ask this question. What we want to figure out is, is the person experiencing a major depressive episode or persistent depression? Have your sleep patterns changed? Now, remember, with persistent depressive disorder, it can go on for years. So you don't want to say, have your sleep patterns changed in the last two weeks? If you're looking at major depressive disorder, then you're going to put that time frame on there. But right now we're just screening for depressive symptoms. And when we get into the assessment, then we will start asking about time frames a little bit more. How's your appetite? If they report they have no appetite or all they do is eat pizza or whatever, we want to note that if their appetite has changed or if their appetite's not good. Remember, if we're looking at persistent depressive disorder, their appetite may have been not good for quite a while. Now, do you often feel guilty? And how is your energy throughout the day? All of these will give us indications about whether we need to pursue this depression avenue. Looking at persistent depressive disorder, major depressive disorder, postpartum depression, bipolar disorder, there are a variety of things that we will need to differentially diagnose when we get into the assessment, adhd. And this is true for adults as well as children. A lot of adults that I worked with had adult adhd, relatively speaking, a lot of adults that I worked with, but it had gone undiagnosed or diagnosed as something different. It had been diagnosed as bipolar disorder or oppositional defiant disorder. So again, in the screening, we just want to ask these general questions. Do you have difficulty finishing tasks, getting organized, or sitting still for a long time? Do you have difficulty staying focused and filtering out distractions? I had an awesome experience one time when I was in graduate school. One of our cohort was doing a presentation on ADHD to help us understand what it was like to live with adhd. And she started doing her presentation, and then somebody turned on a radio while she was talking. So we're all trying to filter out the radio and listen to her, and it's annoying, but we're doing it. Then she started having somebody else flick the lights on and off, on and off, on and off. So we had the radio and the lights going, and we're still trying to pay attention to her. And then she had somebody else start tapping their desk while we were trying to pay attention to her. Her point was, people with adhd, every stimulus has equal weight, so they have difficulty filtering out those extra stimuli, and it's difficult to stay focused on what's going on. Which is why if you have somebody, a child with adhd, and you've got the windows open and there are kids outside playing soccer or something, it's going to be easy for that child's attention to get drawn to what's going on out there, and harder for him or her to pay attention to what's going on in the room, even if it's something they're interested in. And do you have difficulty waiting your turn or not interrupting? This is a big one. It causes a lot of interpersonal problems and can cause problems at work, but it is a big sign of potential ADHD that we want to ask about obsessions and compulsions. Do you sometimes have thoughts you can't get out of your head? And we will all, at points in time, ruminate about certain things. However, most of us, even when we are ruminating about something, we can put it aside if we need to. You know, you can be worried about the test results that you're waiting to get back from your doctor, but you can put it aside to focus on making dinner or doing something else. People with obsessions can't put those obsessions aside. And so we want to ask them, do you have these thoughts that you just can't get out of your head? How much time do these thoughts take up on an average day? If they say five minutes, okay, not a big deal. If they say the majority of the day, it's just constant. That's something else. Do you ever feel like you have to do something over and over or. And if you don't, something bad's gonna happen, like check the windows or check the stove. If so, how much time do you spend each day doing those things? And these obsessions are. If you think of them as protective or compulsions are protective rituals. If the person does this thing over and over again and they do it right, then everything will be fine. We also want to screen for delusions and hallucinations. Remember, you don't want to say, have you ever experienced something that really wasn't real? Because in their mind, it's real. So you want to ask questions like, have you ever thought that people could read your mind or control your thoughts? Make sure when you present that and present these questions, you don't present it as, of course, you don't ever have this happen or present it like, oh my gosh, something's wrong with you. Just very matter of factly. Have you ever thought that people could read your mind or control your thoughts? Have you ever felt like your mind was playing tricks on you? And there could be a lot of things going on here. Do you ever see or hear things that other people cannot see or hear? And do you ever have difficulty knowing if you're awake, dreaming? These are indications of difficulty differentiating reality from fantasy? Differentiating, or maybe they're living and experiencing things that other people aren't experiencing. People with Parkinson's disease often have. More than 50% of people with Parkinson's disease will experience some hallucinations at some point in time during their disease. People in psychotic episodes may experience hallucinations. We do want to, when we get down to the assessment, drill down a little bit more to figure out what's causing these. Some people who used hallucinogenics will many, many years later have hallucinations. That could be another cause for it. We're not getting into those things right now. We're just identifying. Do you occasionally have delusions or hallucinations? And if so, let me note it and we will look at that more in depth when we get to the assessment. Eating disorders. Now, this is a really tricky area to get in. Eating disorders in themselves generally have to deal more with control issues. And a Fear of fat more than other things. So we want to ask people, how would you describe your eating habits? A lot of people with eating disorders are not going to want to tell you their weight. That's very triggering for you. For them, if you ask them, you know, what is your weight or you know, what is your body fat percentage or something, it can be very triggering. So you want to be careful how you ask these questions. How would you describe your eating habits? That's pretty nonjudgmental. People with anorexia don't eat a lot of if you know, and they may tell you exactly what they eat because it's very structured. People with bulimia may or may not talk about binging and their compensatory habits, but most people with eating disorders are not generally going to say that their eating is terribly abnormal unless they are wanting treatment for their eating disorder. You have to look at the reason the person was referred to treatment. Do you have any concerns about your weight? Both people with anorexia and people with bulimia are often going to have concerns about being too fat. Not always, but often. And how do you maintain your weight? You know, this can be a very non judgmental question to put out there. And they may say talk about restriction, they may talk about purging, they may talk about excessive exercise. We just want to hear how do you maintain your weight? To get an idea of whether it sounds like it's healthy. And you always want to stay away from the word normal impulsivity. Asking people, do you ever find yourself doing things without really thinking about the consequences first? I don't know about you, but I can be impulsive at times. They have all those things right next to the cash register that are, quote, impulse buys. And you may buy those things and then get to the car and be like, why did I buy that? Or you may be bored one day and get on online. I won't say at a particular store, get online and buy a bunch of things that you really don't need just because you didn't have anything else to do. We want to separate that. When we get to the assessment, we're going to look more in depth about how often this impulsive behavior occurs because pretty much everybody impulsively does things occasionally. Do you ever do things you know you shouldn't, but you just can't seem to stop yourself? You know, you know you shouldn't have another drink alcohol, but you do it anyway? You know you shouldn't have that extra piece of chocolate cake, but you do anyway. And do you buy things that you really don't need just because they're there? And we already talked about that. But some people with compulsive shopping issues may do that a whole lot. So we're just getting an idea about whether the person does tend to have some impulsive behaviors. When we get to the assessment, we will look at the extent of that and how the intensity of their impulsivity. Mania or hypomania. Have you ever had so much energy that you just couldn't sit still or found yourself not needing to sleep or needing much less sleep than usual? People in a hypomanic episode often are not going to have the psychotic features and not engage in the degree of risky behaviors that someone in a full out manic episode will experience. But they may feel like they don't need sleep, they may feel like they're being driven by a motor and they just, they can go and go and go like the Energizer bunny. We want to pay attention to that remembering. With bipolar disorder you don't necessarily have to have a depressive episode and in order to major depressive episode in order to qualify for bipolar. So you want to, you want to know the difference between bipolar one and bipolar two when you get to assessment. But if somebody indicates that they have had some signs of mania or hypomania, we're going to want to investigate that further. Another question you can ask them. Do you have times when you talk a lot more than usual and your brain just seems to be going really, really quickly? If there are times when this happens and it's not the norm, then we can be pretty sure that we're not dealing with ADHD or giftedness. But again, we can't make any differential diagnoses in the screening. We're just identifying areas for further investigation. Substance misuse. Have you been bothered by using medicines or drugs without a doctor's prescription or in greater amounts or for longer than prescribed or for longer than you intended? So this includes over the counter medications. This includes prescription medications and illicit drugs. Have you ever used them in a way that bothered you? Have you used more than intended or spent more time engaging in an activity than you intended? Did you use more alcohol, you intended to have a drink and you drank a whole bottle, or you intended to make one bet or play poker for one hour and you ended up playing all night long? Have you spent more time planning, engaging in or recovering from the use of a substance or engaging in activity? It's not just the time you're doing it, it's the time you're obsessing about it and planning it, leading up to it, and the time that you're recovering from it afterwards. You're either working off the hangover or you're trying to figure out how to recoup the money that you lost. In gambling, for example, have you ever given up or had difficulty in significant areas of your life as a result of the use of a substance or engaging in an activity? Have you, for example, skipped your kids ball games because you decided to stay home and play online poker, or you were using substances too much that you forgot to pick your kid up from school? Another screening tool that we often use in substance abuse is called the cage, and it's very simple. Have you ever tried to cut down or stop using but been unable to? A stands for annoyed. Are you ever annoyed when people talk to you about your substance use? G stands for guilt. Do you ever have guilt about your substance use? And E stands for eye opener. Do you ever need to take a hit, have some of the substance, do some of the activity in order to get your day started? So when we're talking about process addictions, for example, people with compulsive sexual behavior may feel like they have to log on to a pornography website and and masturbate before they can even get on with their day. They need it to get up and get going. And this is an indication that the dopamine system is out of whack, if you will. So it's important to screen for a variety of issues. DSM is your best friend. Know those diagnoses in and out, backwards and forward, forwards. So you can effectively diagnose especially the most common disorders that you're going to be working with. And don't forget about developmental disorders and disorders of early childhood, because even if you don't plan on seeing children in your practice, they are fair game for the ncmhce. Many disorders have overlapping symptoms. Anxiety, ptsd, adhd, bipolar and depression all have overlapping symptoms. So it's going to be important when you get into the assessment to start differentially diagnosing. And I'll give you a hint, we may get to it in a minute. When you're doing the assessment portion of your exam, when they're asking you questions, you don't want to be, you know, shooting fish in a barrel. And it's more of a rule in than a rule out. So if you think by your initial gut feeling is that this person has anxiety disorder, then you're going to want to assess to see if they have anxiety symptoms you're not going to want to rule out and then whatever's left is what they have you want to rule in. So if you think they have anxiety, look for anxiety. Psychiatry.org has multiple free cross cutting symptom measures that you can be aware of. They're super helpful in clinical practice and not as helpful for the ncmhce, but you can download them, you can use them for free and it helps you screen for a lot of these disorders and know what to screen for. So if you're not sure what questions to ask to screen for depression, go to psychiatry.org and look at their level two screening for depression. Screening just gives you a launch pad to help guide an in depth biopsychosocial assessment process. Screening sometimes will be done before the client actually gets to your office, but again, when you're taking the ncmhce, they are likely going to assume that you are screening. The initial vignette that they give you is very sparse, so you have to screen ahead of time to figure out what where you're going to dive in deep for the assessment. Test taking tip. Your first priority on the NCMHCE is identifying the correct diagnosis for everybody. In this scenario you do want to know what's going on with the other people, but specifically for your client. Generally you're only going to have one person who is clearly your identifiable client, which is awesome. However, if for example, you're dealing with a mother who is the presenting patient, but she also has Johnny who may be experiencing ADHD issues and problems at school that are causing her stress, then we may need to explore both of those. Just really depends on the scenario. Don't try to be too broad. And this is what I was just talking about on the last slide. If the scenario is about someone who recently underwent a trauma and the question asks for what to evaluate to support a provisional diagnosis, think about what you would assess for a provisional diagnosis of PTSD or asd, not what else could it be? What you want to go is my gut tells me the primary diagnosis is likely PTSD or acute stress disorder. So let me start asking questions about that. Thank you for being with me today. And in the next installment we will be looking at the assessment. So we've talked about in part one we talked about mental status. In this episode we talked about screening. And in part three we're going to move on to the full out assessment process. Thank you for being with me today.