presenting problem present illness past psychiatric illness substance use history past medical history family history mental status exam W r i t i n g
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.
- 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.
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)
- 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.
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.9780890425596.UseofDSM5
American Psychiatric Association. (2013). Assessment measures. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.AssessmentMeasures
MedLecturesMadeEasy. (2017, May 29). Mental status exam [Video file]. Retrieved from https://youtu.be/RdmG739KFF8
Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians (2nd ed.). New York, NY: Guilford Press.
- Chapter 10, “Diagnosis and the Mental Status Exam” (pp. 119–126)
- Chapter 17, “Beyond Diagnosis: Compliance, Suicide, Violence” (pp. 271–280)
Sommers-Flanagan, J., & Sommers-Flanagan, R. (Producers). (2014). Clinical interviewing: Intake, assessment and therapeutic alliance [Video file]. Clinical Interviewing: Intake, Assessment & Therapeutic Alliance | Kanopy