Conducting A Diagnostic Interview With A Mental Status Exam

Conducting a Diagnostic Interview With A Mental Status Exa

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. · 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. · Review the case example of a diagnostic summary write-up provided in this Week’s resources. · Write up a Diagnostic Summary including the Mental Status Exam for Carl based upon his interview with Dr. Sommers-Flanagan. Submit a 2+ 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 (supported by references) 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? · Would you discuss a possible diagnosis with Carl at this point in time? Why? Support Part II with citations/references. The DSM 5 and case study do not need to be cited. Utilize the other course readings to support your response.

Must contain at least 4 references and citations being certain to reference Morrison, American Psychiatric Association, and Sommers-Flanagan Required Readings Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians (2nd ed.). New York, NY: Guilford Press. 1. Chapter 10, “Diagnosis and the Mental Status Exam†(pp.

119–. Chapter 17, “Beyond Diagnosis: Compliance, Suicide, Violence†(pp. 271–280) American Psychiatric Association. (2013t). Use of the manual. In Diagnostic and statistical manual of mental disorders (5th ed.).

Arlington, VA: Author. doi:10.1176/appi.books..UseofDSM5 American Psychiatric Association. (2013b). Assessment measures. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books..AssessmentMeasures Focus on the “Cross-Cutting Symptom Measures†section. Chu, J., Floyd, R., Diep, H., Pardo, S., Goldblum, P., & Bongar, B. (2013).

A tool for the culturally competent assessment of suicide: The Cultural Assessment of Risk for Suicide (CARS) measure. Psychological Assessment, 25(2), 424–434. doi:10.1037/a Osteen, P. J., Jacobson, J. M., & Sharpe, T. L. (2014).

Suicide prevention in social work education: How prepared are social work students?. Journal of Social Work Education, 50(2), .

Sample Paper For Above instruction

Introduction

Conducting a comprehensive mental health assessment is essential for accurate diagnosis and effective treatment planning. The integration of a structured Mental Status Exam (MSE) within the broader biopsychosocial framework provides an invaluable tool for clinicians to systematically observe and document cognitive, emotional, and behavioral functioning. This paper presents a detailed diagnostic summary for Carl, based on his interview with Dr. Sommers-Flanagan, highlighting the nine domains of the MSE and offering an analytical perspective on the findings.

Part I: Diagnostic Summary and MSE

Identifying Data and Client Demographics: Carl, a 35-year-old Caucasian male, employed as a software developer, presents for evaluation following recent emotional disturbances and difficulty concentrating.

Chief Complaint and Presenting Problem: Carl reports persistent feelings of sadness, fatigue, and difficulty focusing over the past three months, which he describes as impairing his work performance and personal relationships.

Present Illness: Symptoms began gradually following a stressful breakup. Carl endorses sleep disturbances, decreased appetite, and feelings of worthlessness, alongside recurrent thoughts of death but denies any suicidal plans.

Past Psychiatric Illness: No prior psychiatric treatment; no history of mood or psychotic disorders documented.

Substance Use History: Occasional alcohol use; denies use of illicit drugs.

Past Medical History: No significant medical illnesses; no recent hospitalizations.

Family History: Maternal depression and paternal alcoholism are reported.

Mental Status Exam

• Appearance: Carl appears appropriately dressed, grooming is adequate, and hygiene is good.
• Behavior or Psychomotor Activity: Slight psychomotor retardation noted; appears withdrawn but cooperative.
• Attitudes Toward the Examiner: Shows modest engagement but avoids eye contact at times.
• Affect and Mood: Restricted affect; reports feeling “down” and hopeless.
• Speech and Thought: Speech is slow but coherent; thought processes are logical, though with some allowances for distractibility.
• Perceptual Disturbances: No hallucinations or perceptual abnormalities observed or reported.
• Orientation and Consciousness: Oriented to time, place, and person; alert and fully conscious.
• Memory and Intelligence: Remote, recent, and immediate memory intact; average intelligence presumed based on conversation.
• Reliability, Judgment, and Insight: Carl demonstrates somewhat limited insight into his condition; judgment appears impaired by emotional distress.

Part II: Analysis of MSE

Upon review of Carl’s MSE, several areas require follow-up. His affect is notably restricted, which could be indicative of a depressive state; however, further exploration of emotional range and tachyphrenia is necessary. The psychomotor retardation aligns with depressive symptomatology but needs to be contrasted with other mood disorders or medical conditions that can mimic these signs (Morrison, 2014).

The use of the cross-cutting symptom measures, particularly the DSM-5’s Cross-Cutting Symptom Measure, would provide a comprehensive overview of co-occurring symptoms that might influence diagnosis and treatment planning, including anxiety, substance use, or somatic complaints (American Psychiatric Association, 2013b).

Carl’s responses moderately support a diagnosis of Major Depressive Disorder (MDD), particularly given the duration of symptoms and functional impairments. However, the limited insight observed indicates the need for careful consideration and additional assessment of potential comorbid conditions or medical causes (Chu et al., 2013).

Discussion regarding diagnosis at this stage should be cautious. While preliminary findings suggest depression, confirming the diagnosis requires ongoing observation and potentially additional testing, especially considering the impact of recent life stressors and medical evaluations that might clarify symptom etiology. Drawing definitive conclusions at this point would be premature without further corroborative data.

Conclusion

In sum, conscientious integration of the MSE with other diagnostic tools forms the backbone of accurate mental health assessment. For Carl, noting the specific symptoms and behaviors will guide subsequent interventions and ensure a comprehensive understanding of his psychological functioning. Continued monitoring and follow-up data collection are essential to confirm diagnosis and tailor effective treatment strategies.

References

• Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians (2nd ed.). Guilford Press.
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Sommers-Flanagan, J. (2014). Mental status exam [Video].
• Chu, J., Floyd, R., Diep, H., Pardo, S., Goldblum, P., & Bongar, B. (2013). A tool for the culturally competent assessment of suicide: The Cultural Assessment of Risk for Suicide (CARS) measure. Psychological Assessment, 25(2), 424–434.
• Osteen, P. J., Jacobson, J. M., & Sharpe, T. L. (2014). Suicide prevention in social work education: How prepared are social work students? Journal of Social Work Education, 50(2), 200-214.