Conducting A Diagnostic Interview With A Mental Statu 698474

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.

Paper For Above instruction

Conducting a comprehensive mental health evaluation is essential for accurate diagnosis and effective treatment planning. The process involves a detailed diagnostic interview supplemented by the Mental Status Exam (MSE), which provides structured observations of cognitive and emotional functioning. This paper presents a diagnostic summary and MSE of Carl, based on his interview with Dr. Sommers-Flanagan, followed by an analytical discussion to inform clinical decision-making.

Part I: Diagnostic Summary and MSE

Client Demographics

Carl is a 35-year-old male presenting for mental health assessment. He lives alone and is employed as a software engineer. He reports a long-standing history of emotional distress but no recent hospitalizations or psychiatric treatments prior to this assessment.

Chief Complaint and Presenting Problem

Carl reports experiencing persistent feelings of sadness, low energy, and difficulty concentrating over the past three months. He also indicates episodes of irritability and occasional thoughts of worthlessness, which have been impairing his daily functioning.

Present Illness

The symptoms of low mood and anhedonia have fluctuated but remain predominantly present. He notes that stress at work and personal relationships seem to exacerbate his symptoms. No recent episodes of mania or psychosis have been reported.

Past Psychiatric Illness

Carl reports a history of anxiety during adolescence, which was managed with therapy but without medication. There are no reports of prior depressive episodes or other psychiatric diagnoses.

Substance Use History

Carl denies current substance use but admits to occasional alcohol consumption, particularly on weekends. He reports no history of substance abuse or dependence.

Past Medical History

Medical history is unremarkable, with no chronic illnesses or hospitalizations. He reports being generally healthy.

Family History

Family history reveals depression in his mother and anxiety in a sibling. No history of schizophrenia or bipolar disorder is reported in the family.

Mental Status Exam (MSE)

Appearance: Carl appears neatly dressed, aged approximately 35, with appropriate hygiene.

Behavior or Psychomotor Activity: His movements are normal; no psychomotor agitation or retardation observed.

Attitudes toward the Interviewer: Engagement appears cooperative, exhibiting mild reluctance when discussing personal feelings.

Affect and Mood: Mood reported as "down," with restricted affect during the interview.

Speech and Thought: Speech is normal in rate and volume; thought process is logical and coherent; no evidence of circumstantiality or tangentiality.

Perceptual Disturbances: No hallucinations or perceptual distortions noted.

Orientation and Consciousness: Fully oriented to person, place, time, and situation.

Memory and Intelligence: Short-term and long-term memory are intact; intelligence seems average based on conversational responsiveness.

Reliability, Judgment, and Insight: Carl demonstrates good reliability; judgment appears adequate; insight into his emotional state is moderate.

Part II: Analysis of MSE

Analysis reveals areas requiring follow-up, particularly regarding the depth of Carl’s insight and the severity of his depressive symptoms. Specific questions about suicidal ideation and psychomotor changes should be explored further, given the reported feelings of worthlessness, which may elevate suicide risk (American Psychiatric Association, 2013). Incorporating the cross-cutting symptom measures, as recommended by the DSM-5 (2013), would enhance assessment validity by capturing the breadth of mental health domains, such as anxiety, mood, and psychosis symptoms, in a standardized manner (Chu et al., 2013).

Carl’s responses, indicating persistent low mood without psychotic features, support a preliminary diagnosis of Major Depressive Disorder (MDD). However, the absence of pervasiveness and interference levels would determine if this diagnosis remains provisional or warrants further clarification. The structured observations of the MSE are consistent with a depressive mood disorder, but additional data regarding suicidality, sleep patterns, and functioning are essential before confirming a final diagnosis.

Given the current assessment, it would be appropriate to begin discussing potential diagnoses with Carl, emphasizing collaborative evaluation and considering DSM-5 criteria. A tentative diagnosis of MDD can be communicated, including the need for further evaluation and possibly integrating standardized scales such as the Patient Health Questionnaire-9 (PHQ-9) to objectively measure symptom severity (Morrison, 2014). This approach facilitates shared understanding and encourages client engagement in treatment planning.

In conclusion, the combination of the interview data and structured mental status observations provides a sound foundation for diagnostic formulation. Continued assessment, employing comprehensive standardized measures, would further refine the diagnosis and guide effective interventions (Spadunata, 2010; Osteen et al., 2014).

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
• 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. https://doi.org/10.1037/a0030868
• Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians (2nd ed.). Guilford Press.
• Spadunata, L. (2010). Is “Observe and Report” Good Policy? ASIS. Retrieved from https://www.asisonline.org
• 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), 291–305.