1. Mental Status Assessment
Adapted from Casey Barrio, Ph.D.
University of North Texas
Amy McCortney, Ph.D., LPC-S, NCC

2. DSM IV-TR and the DSM 5 Note:
DSM III, DSM IV, and DSM IV-TR all included the use of multiaxial diagnosis, a practice that was widely adopted in assessment and managed care
The DSM 5 is intended to be a “non-axial” or more holistic view of biopsychosocial functioning
However, it is likely many assessment methods, as well as insurance forms, will continue to include the multiaxial format through a transition time.

3. Multiaxial Evaluation (review)

4. Other conditions that may be focus of clinical attn
Axis I
Clinical disorders
Other conditions that may be focus of clinical attn
Includes all current disorders except
Personality disorders
Mental retardation
List principal diagnosis first
List all Axis I
Include major stressors if focus
Ok to defer or assign no diagnosis

5. Personality disorders
Axis II
Personality disorders
Mental Retardation
Includes
Personality disorders
Mental retardation
Personality traits
Defense mechanisms
Note if principal reason
List all Axis II
OK to defer to assign no diagnosis

6. General Medical Conditions
Axis III
General Medical Conditions
Relevant to understanding or management
Directly causes disorder (xx due to yy)
Causes d/o to worsen
D/o is a reaction to medical dx
Choice of meds is influenced
Management or safety is issue
Incidental
Specify
“None” if none
“Deferred” if in progress
“By patient history” if not formal

7. Psychosocial and environmental problems
Axis IV
Psychosocial and environmental problems
May include problems that…
affect dx, tx, prognosis
Put one at risk for mental d/o
are a result of mental d/o
Include
Relevant in past year
Very salient context/history
If focus, also gets coded on Axis I
Often include “mild” “moderate” “severe”

8. Psychosocial and environmental problems
Axis IV
Psychosocial and environmental problems
Primary support group
Social environment
Educational
Occupational
Housing
Economic
Health care
Legal system
Others

9. Global Assessment of Functioning (GAF)
Axis V
Global Assessment of Functioning (GAF)
Level of psych, soc, and occ functioning
100-point scale includes attention to
Severity
Functioning
Rate
current period (lowest past week)
past year
discharge/termination

10. Global Assessment of Functioning (GAF)
Axis V
Global Assessment of Functioning (GAF)
Often used to determine level of care
Generally…
Outpatient
Intensive outpatient/partial hosp
1-30 Inpatient

11. Severity & Course Specifiers
Mild
Few symptoms in excess of min; minor impair
Moderate
Severe
Many symptoms in excess, several particularly severe symptoms, marked impairment
Partial remission
Full remission
Prior history

12. Determining a GAF Score (p. 34)
Axis V
Determining a GAF Score (p. 34)
Start at top and use “EITHER OR” logic
Is either severity OR level of functioning worse?
Move down until range matches severity OR functioning (WHICHEVER WORSE)
Go one lower to make sure both are TOO SEVERE
Determine SPECIFIC number within 10-point range

13. Communicating severity and impairment
In a nutshell…
Communicating severity and impairment
DSM-IV severity specifiers (Axis I)
Co-morbid personality disorders (Axis II)
Co-morbid medical conditions (Axis III)
Listing all stressors (Axis IV)
GAF (Axis V)

14. Checking in… Why do counselors assess? When do counselors assess?
How do counselors assess?

15. Mental Status Exam

16. Purpose & Overview Standard practice at most agencies
Crisis situations
Necessity of treatment / level of care
Managed care requirements
Provides baseline
Assists in documentation

17. Purpose & Overview con’t
Generally adjunct to intake
Ongoing observation & integrated assessment
What’s not present is as important as what is
Objective measure (SOAP) although some assessment (SOAP)

18. Overview of MSE areas Assess all items based on current observations
Appearance
Motor
Speech
Affect
Thought content
Thought process
Perception
Intellect
Insight
Assess all items based on current observations

19. The very basic… Orientation x4 AKA “Oriented x4” Person Place Time
Situation
AKA
“Oriented x4”

20. Appearance Manner Distinguishing features Age
Prominent physical abnormalities
Emotional facial expression
Alertness
Age
Sex, race
Build
Position
Posture
Dress
Grooming

21. Behavior Eye contact Habits Movements Willingness to respond
Attitude toward counselor
Evidence of internal stimuli

22. Motor
Retardation (slowed)
Agitation
Abnormal movements
Gait
Catatonia

23. Speech Rate Volume Amount Articulation (clarity) Spontaneity
Changes in patterns

24. Affect Stability Range (long-term, immediate) Appropriateness
Intensity
Affect (outward appearance)
Mood (internal - self-report)

25. Thought Content Suicidal ideation Death wishes Homicidal ideation
Depressive cognitions (guilt, worthlessness)
Obsessions
Ruminations
Phobias
Ideas of reference
Paranoid ideation
Magical ideation
Delusions
Overvalued ideas
Other major themes

26. Thought Process Stream Associations (flight of ideas, loose) Coherence
Logic
Clang associations (rhyming/pattern)
Perseverative (repetition)
Neologism (new words)
Blocking (interruption in flow)
Attention

27. Perception Hallucinations (all 5 senses) Illusions
Depersonalization (of self)
Derealization (of outside world)
Déjà vu
Jamais vu (French, “never seen”)- disfamiliarity

28. Other MSE observations
Approximate IQ
Insight
Awareness of problem & self
Judgment
Ability, given info, to make sound decisions
Impulse control
Ability for person to control/resist urges

29. Biopsychosocial History

30. Purpose of Intake Interviews (Seligman, 2004)
Determine suitability for services
Assess urgency of situation
Familiarize person with process
Elicit positive attitudes toward counseling
Gather information for dx and tx plan

31. Variables to consider Information gathering methods Depth & duration
Client needs
Referral source
Presenting problem
Urgency
Motivation & functioning

32. Skills for intake interviewing
Establish rapport
Educate regarding process
Goals and expectations
This session different from others
Balance
Open-ended ? for perspective
Closed-ended ? for efficiency
Reflections & encouragers
Descriptive Empathy
Directness / assumptions may help

33. Major areas of assessment
Identifying information
Presenting problem(s)
Other current problems and previous difficulties
Present life situation
Family of origin
Current family
Developmental history
Medical & counseling history
Additional information
See Seligman (2004)
AND Zimmerman
psychosocial outline

34. Intake Reports Identifying information
Overview of presenting problem, symptoms, impact on person
Mental Status Exam
Other problems and difficulties
Present life situation
Information on family of origin and present family

35. Intake Reports (con’t)
Developmental history, important incidents
Medical and treatment history
Case conceptualization including strengths and areas of difficulty
Multiaxial diagnosis
Treatment plan and other recommendations
Conclusion and summary