Assignment: Conducting a Diagnostic Interview With a Mental Status Exam
Before moving through diagnostic decision making, a social worker needs to conduct an interview that builds on a biopsychosocial assessment. New parts are added that clarify the timing, nature, and sequence of symptoms in the diagnostic interview. The Mental Status Exam (MSE) is a part of that process.
The MSE is designed to systematically help diagnosticians recognize patterns or syndromes of a person’s cognitive functioning. It includes very particular, direct observations about affect and other signs of which the client might not be directly aware.
When the diagnostic interview is complete, the diagnostician has far more detail about the fluctuations and history of symptoms the patient self-reports, along with the direct observations of the MSE. This combination greatly improves the chances of accurate diagnosis. Conducting the MSE and other special diagnostic elements in a structured but client-sensitive manner supports that goal. In this Assignment, you take on the role of a social worker conducting an MSE.
To prepare:
Watch the video describing an MSE. Then watch the Sommers-Flanagan (2014) “Mental Status Exam” video clip. Make sure to take notes on the nine domains of the interview. http://www.psychotherapy.net.ezp.waldenulibrary.org/stream/waldenu/video?vid=276
Review the Morrison (2014) reading on the elements of a diagnostic interview.
Review the 9 Areas to evaluate for a Mental Status Exam and example diagnostic summary write-up provided in this Week’s resources.
Write up a Mental Status Exam for Carl based upon his interview with Dr. Sommers-Flanagan.
BY DAY 7
Submit a 2- to 3-page case presentation paper in which you complete both parts outlined below:
PART I: DIAGNOSTIC SUMMARY AND MSE
Provide a diagnostic summary of the client, Carl. Within this summary include:
Identifying Data/Client demographics
Chief complaint/Presenting Problem
Present illness
Past psychiatric illness
Substance use history
Past medical history
Family history
Mental Status Exam (Be professional and concise for all nine areas)
Appearance
Behavior or psychomotor activity
Attitudes toward the interviewer or examiner
Affect and mood
Speech and thought
Perceptual disturbances
Orientation and consciousness
Memory and intelligence
Reliability, judgment, and insight
PART II: ANALYSIS OF MSE
After completing Part I of the Assignment, provide an analysis and demonstrate critical thought in your response to the following:
Identify any areas in your MSE that require follow-up data collection.
Explain how using the cross-cutting measure would add to the information gathered.
Do Carl’s answers add to your ability to diagnose him in any specific way? Why or why not?
What concerns would you have about Carl’s mannerisms in the interview or his spontaneous content and unusual beliefs?
How would you address these mannerisms and beliefs?
Would you discuss them with Carl now or in the future? Why?
The Diagnostic Interview:
The Mental Status Exam, Risk and Safety Assessments Program Transcript [INTRO MUSIC PLAYING] DIANE RANES: As you will quickly realize, professional diagnosis is far more than just linking a person with a diagnostic label. In fact, linking an individual to a diagnostic label without a complete professional process is directly in violation of many social work ethical codes. Professional diagnosis is a broad and a continuous process that is actually closer to developing a working hypothesis than to labeling. Professionals form their initial diagnostic hypothesis, and they continue to refine it using evidence-based tools or validating it over time in the treatment process. The professional diagnostic process starts with very good data gathering, including a number of different kinds of elements that you might not be familiar with. Diagnosis starts with a particular type of interview called a diagnostic or psychiatric interview. And that interview uses many elements from a biopsychosocial assessment. But it also includes some unique parts like the mental status exam, which is a structured way of assessing mental functions such as memory, speech, thought processes, affect, and orientation. The psychiatric interview also includes details of symptom occurrence and any other psychiatric or family histories of psychiatric issues. Gathering complete information is followed by a careful analysis, which is called a differential diagnosis. That aspect of diagnostic thinking is about carefully considering each of the many possible conditions that a client might have in weighing the most likely possibilities. Especially in diagnosis, you are searching for patterns of symptoms and other distinguishing features which best explain an illness. So the logical process of decision making that you use to narrow down choices is this decision tree, which is simply a way of step-by-step considering alternative diagnoses that might have similar symptoms. Sometimes the decision trees are based on preexisting models done by psychiatric experts. These are especially helpful when you’re new to the process. So within a decision tree process, you’re simply comparing and contrasting the symptoms and the observations from your mental status exam to the DSM V’s knowledge base, criteria by criteria. And often you’re looking at several possibilities. A decision tree simply helps you not miss any important steps by going through the options one at a time. The logical process of analysis with or without a decision tree helps the diagnostician avoid error, especially familiarity bias and to generally keep an open mind. That is especially important when you have an early idea about a diagnosis that you think might be accurate. Not jumping to conclusions too © 2018 Laureate Education, Inc. 1 The Diagnostic Interview: The Mental Status Exam, Risk and Safety Assessments quickly guards against making mistaken diagnoses, which can be very harmful. And these are called false positives. Remember too, that diagnosis is continuous. While a professional diagnosis starts at a particular moment in time, when the client comes to you for help, it’s not a static process. That initial moment is like taking a photograph. It represents only a small sample of an individual’s total functioning. In diagnosis, we look in depth at the last 12 months of a person’s functioning. But the story does not end there. Past information can help to confirm a diagnosis, as in a bipolar disorder where a person sometimes has 10 years of mistaken diagnosis before a correct one is made. Current and ongoing functioning is even more reliable than past history in validating a diagnosis. If a person responds well to the treatment plan, more confirmatory information should emerge. If not, the entire process should be reviewed. If we believe that individuals change and that they are impacted by everything around them, then it’s easy to recognize that many initial diagnoses might need regular reevaluation. That matters even when an illness has more enduring features as in schizophrenia, which is a lifelong disorder. Even here, the person may be reaching a phase of partial remission. And we’ll need that milestone added to the diagnosis to understand the cycles. Even in the short-term conditions such as an adjustment disorder, the DSM will have guideline information as to what might occur in treatment response. In adjustment disorder, a person should be substantially recovered within six months’ time. Viewing diagnosis in this continuous, ongoing and integrated way will avoid error. You’ll find that quality treatment requires tracking progress. And treatment plans often need adjusting for all kinds of unforeseen events. Diagnosis can be changed when new information comes into the picture. A diagnostic interview also uses evidence-based tools to ask about risk situations, whether those are caused by violence, general safety, or the risk of death by suicide. You probably already know that the World Health Organization has identified depression as the leading mental health problem worldwide. Nearly one in 10 people worldwide has a mental disorder. And within those who are ill, the World Health Organization considers clinical depression and suicide risk as the top priorities worldwide. Here in the United States, the National Institute of Mental Health tell us that the classic form of depression, which is major depressive disorder, impacts about 16 million adults aged 18 or older in one year alone– only one year, and that is only one of the unipolar depressive illnesses, and only one cause of suicide. Suicide risk is on the rise in the United States overall and within many special © 2018 Laureate Education, Inc. 2 The Diagnostic Interview: The Mental Status Exam, Risk and Safety Assessments populations. While most nonprofessionals think of suicide as an inherent part of a mood disorder, suicidality is very common in many other types of mental disorders. Suicide attempts are common in borderline disorders, in bipolar disorders, in PTSD, in schizophrenia, and in many other conditions and situations. And risk escalates even further in all situations if substance use is involved. Some individuals will also develop the desire to kill themselves as part of receiving an intractable physical illness diagnosis. Suicide risk is obviously on a wide continuum, ranging from recurrent vague wishes to be dead to direct plans and very overt suicidal behaviors. Even chronic self-harm without suicide intention can easily escalate to a direct attempt to die. We also know that the risk of suicide is very high in the six months after a person has seen a medical provider, and even after they have been admitted to suicidal ideation treatments. Suicide risk remains very high after discharge from hospital stays and from other forms of active treatment. Sadly, few states and few mental health professionals have been adequately trained in suicide prevention in response.
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