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
Past psychiatric illness
Substance use history
Past medical 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
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 time 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.
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)
American Psychiatric Association. (2013s). 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. (2013b). Assessment measures. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.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/a0031264 Note: You will access this e-book from the Walden Library databases.
Blackboard. (2018). Collaborate Ultra help for moderators. Retrieved from https://help.blackboard.com/Collaborate/Ultra/Moderator Note: Beginning in Week 4, you will be using a feature in your online classroom called Collaborate Ultra. Your Instructor will assign you a partner and then give you moderator access to a Collaborate Ultra meeting room. This link provides an overview and help features for use in the moderator role.
Document: Case Collaboration Meeting Guidelines (Word document)
Document: Collaborating With Your Partner (PDF)
Document: Diagnostic Summary Example (Word document) Note: This is an example of a diagnostic summary that can be used as a template for Part I of the Assignment.
Laureate Education (Producer). (2018b). Psychopathology and diagnosis for social work practice podcast: The diagnostic interview, the mental status exam, risk and safety assessments [Audio podcast]. Baltimore, MD: Author.
MedLecturesMadeEasy. (2017, May 29). Mental status exam [Video file]. Retrieved from https://youtu.be/RdmG739KFF8
Sommers-Flanagan, J., & Sommers-Flanagan, R. (Producers). (2014). Clinical interviewing: Intake, assessment and therapeutic alliance [Video file]. Retrieved from http://www.psychotherapy.net.ezp.waldenulibrary.org/stream/waldenu/video?vid=276 Note: You will access this e-book from the Walden Library databases. Watch the “Suicide Assessment Interview” segment by clicking the applicable link under the chapters tab. This is the interview with Tommi, which will be used for the Discussion.Watch the “Mental Status Examination” segment by clicking the applicable link under the chapters tab. This is the case of Carl, which will be used for the Application.