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VII. Mental Status Evaluation

General Behavior

  • Cooperative, passive, withdrawn, dramatic, hostile, restless

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VII. Mental Status Evaluation

 Attire

  • appropriate, seductive, untidy, loud, meticulous
  • Be especially aware of attire change from session 1 to session 2 b/c if you are found attractive by your client, they could “swim their way through Old Spice” on the way to your second session

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VII. Mental Status Evaluation

Facial expression

  • unremarkable, sad, angry, perplexed, fearful, elated, immobile, grimacing

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VII. Mental Status Evaluation

 Posture

  • rigid, erect, lump, slouchy

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VII. Mental Status Evaluation

Gait

  • normal erect, stooped, ataxic, rigid, shuffling, manneristic

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VII. Mental Status Evaluation

Motor activity

  • normal, agitated, tremor, tic, mannerisms

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VII. Mental Status Evaluation

Stream of Thought 

  • how do they go from one thought to the next

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VII. Mental Status Evaluation: Stream of Thought

 Productivity

  • spontaneous, verbose, pressured speech, mute

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VII. Mental Status Evaluation: Stream of Thought

Progression

  • normal, loose, circumstantial (going in circles),
  • perseveration (everything goes back to the reason they came in, always going back to that),
  • halting, blocking, incoherent, fragmented

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VII. Mental Status Evaluation

Language

  • normal, baby talk, peculiar expression, stilted

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VII. Mental Status Evaluation: Emotional Tone and reaction

Affect

  • indifferent, fearful, angry, euphoric,
  • shallow (they act like they get it, but they don’t),
  • blunt, flat, normal, composed, anxious, sad, tearful,
  • labile (up and down)

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VII. Mental Status Evaluation: Mental trend/Content of thoughts

Perception

  • normal,
  • auditory hallucination,
  • visual hallucination,
  • depersonalization (experience of being outside of yourself, observing yourself in the situation),
  • illusions,
  • derealization (the attribution of non-human factors to people, so others are things rather than people),
  • hypochondriasis

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VII. Mental Status Evaluation: Mental trend/Content of thoughts

Cognition

  • obsessive and ruminative,
  • preoccupied,
  • self-depreciatory,
  • idiosyncratic,
  • stereotyped

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VII. Mental Status Evaluation: Mental trend/Content of thoughts

Cognition content

  • (what are you obsessed about): obsessions, phobias, compulsive rituals, religiosity, ideas of reference (belief that inanimate objects are communicating with you)
    • (i.e. a news reporter says “good night” when closing their news update and a person thinks that reporter is specifically talking to them),
  • passivity feelings (feelings of non-person),
  • nihilistic (pessimism/vague), delusions, self-derogatory delusions, suicidal ideation, bizarre ideas (thoughts of things that couldn’t happen) vs. non-bizarre ideas (thoughts of things that realistically could have happened),
  • paranoid ideation (paranoid beliefs/thoughts)

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VII. Mental Status Evaluation: ● Orientation and Sensorium

Consciousness

  • alert, clouded, fluctuating, stuporous, apathetic
  • Patient should be “alert” when you send that bill to BCBS b/c they won’t pay for “stuporous”

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VII. Mental Status Evaluation: ● Orientation and Sensorium

 Orientation:

  • normal, disoriented to time/place/person

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VII. Mental Status Evaluation: ● Orientation and Sensorium

Memory:

  • normal, impaired (remote/recent/immediate)

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VII. Mental Status Evaluation: ● Orientation and Sensorium

Digit Span

  • forward (good-poor),
  • backward (good-poor)

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VII. Mental Status Evaluation: ● Orientation and Sensorium

Disorder of:

  • counting,
  • calculation,
  • reading,
  • writing,
  • apperception,
  • attention,
  • concentration,
  • comprehension

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VII. Mental Status Evaluation: ● Orientation and Sensorium

General knowledge:

  • consistent w/ education,
  • inconsistent,
  • able to abstract, concrete

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VII. Mental Status Evaluation: Orientation and Sensorium

Insight and judgment:

  • good,
  • poor,
  • absent,
  • superficial

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VII. Mental Status Evaluation: General Behavior/Gait

ataxic

  • an inability to coordinate voluntary muscular movements;
  • symptomatic of some nervous disorders

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VII. Mental Status Evaluation: Stream of Thought/Progression

loose

  • difficulty staying on track
  • jump from one thing to another

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VII. Mental Status Evaluation: Stream of Thought/Progression

blocking

  • as they speak they completely lose their train of thought.
  • In order to mask this they may use confabulation
  • change the conversation in a dramatic way, begin making things up
  •  can be related to amnesia, early dementia and korsocoff’s syndrome

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VII. Mental Status Evaluation: Mental Trend, Content of Thought/Perception

 depersonalization

  • outside yourself

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VII. Mental Status Evaluation: Mental Trend, Content of Thought/Perception

hypochondriasis

  • morbid condition about health, especially about death

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VII. Mental Status Evaluation: Mental Trend, Content of Thought/Perception

obsessions

  • always refer to thoughts

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Why the emphasis on treatment plan?

Clinicians benefit

  • Forced to think analytically about what we’re doing in each case
  • Objective documentation in the event ofagainslitigation
  • Needs of the client are primary (not projecting your issues on them)

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Why the emphasis on treatment plan?

Clients benefit

  • Direction for treatment is clear (agreed upon direction of treatment)
  • Outcomes are in focus and are generated FOR THE CLIENT
  • Expectation of specific result

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VII. Mental Status Evaluation: Mental Trend, Content of Thought/Cognition Content

compulsive rituals

  • always refers to behaviors [The compulsion resolves the obsession.]