Mental Status Exam

The Mental Staus Exam is the basis for understanding the client's presentation and beginning to conceptualize their functioning into a diagnosis. (This is the data that the doctors have to read and study to know what to do during a mental health exam.)

At first all this might seem overwhelming and time consuming, but really it's not that bad to do. It can generally be done in a few minutes when you need to do specific things, and the vast majority of this you can get from interviewing and simply watching the client carefully.

Appearance

Presenting Appearance including sex, chronological and apparent age, ethnicity, apparent height and weight (average, stocky, healthy, petite), any physical deformities (hearing impaired, injured and bandaged right hand)

Basic Grooming and Hygiene, dress and whether it was appropriate attire for the weather, for a doctor's interview, accessories like glasses or a cane

Gait and Motor Coordination (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), work speed, any noteworthy mannerisms or gestures

Mood and Affect

Mood or how they feel most days (happy, sad, despondent, melancholic, euphoric, elevated, depressed, irritable, anxious, angry). Think of the climate in an area.

Affect or how they felt a a given moment (comments can include range of emotions like broad, restricted, blunted, flat, inappropriate, labile, consistent with the content of the conversation and facial expressions, pessimistic, optimistic) as well as inappropriate signs (began dancing in the office, verbally threatened examiner, cried while discussing recent happy event and unable to explain why). Think of the weather, which varies slightly from day to day.

Rapport (easy to establish, initially difficult but easier over time, difficult to establish, tenuous, easily upset)

Facial and Emotional Expressions (relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such)

Suicidal and Homicidal Ideation (ideation but no plan or intent, clear/unclear plan but no intent, ideation coupled with clear plan and intent to carry it out)

Risk for Violence (fair, low, high, uncertain, effected by substance use)

Response to Failure on Test Items (unaware, frustrated, anxious, obsessed, unaffected)

Impulsivity (low medium, high, effected by substance use)

Anxiety (note level of anxiety, any behaviors that indicated anxiety, ways they handled it)

Defense Mechanisms observed (may not have seen any, but if did, note them and the behaviors that indicated this)

I also note in this section any special considerations that were taken into account during testing, such as the testing room was noisy, I read to the client and took answers by dictation, audiotaped versions of tests were used)

Some screening questions I ask to explore other areas include:

How are you sleeping? Do you have trouble falling asleep, staying asleep, waking up? How is your energy level though the day; do you have enough energy to get things done? How is your appetite? How do you feel most days? (Depression) Note: Some antidepressants work best with clients who have trouble falling asleep, while others work best with those who can't stay asleep or wake up. This may be very helpful to others to document.

Are there things that worry you a lot? Have you ever felt an intense fear or worry that something bad would happen to you? Are there specific things that frighten you? (Anxiety)

Do you ever feel the need to do something over and over until it's perfect? Are there certain things you sometimes feel compelled to do over and over? Are there ever thoughts that you just can't get out of your head? (Compulsions and Obsessions)

Have you ever felt someone was reading you mind or making you think things? Have you eve felt your mind was playing tricks on you? Have you ever had a dream that was so intense and real, your weren't sure if you were asleep or awake? (Delusions and Hallucinations)

Do you think your eating habit are unusual? What is your weight now? What is the most and least you've weighed? Are you concerned about your weight? (Eating Disorders)

Do you ever find yourself suddenly doing something before you have really had a chance to think about it? Do you ever do things you had decided not to do, and don't know why? Does money "burn a hole in your pocket"? (Impulsivity)

Have you ever had so much energy you couldn't sit still? That you didn't need to sleep for days at a time? (Mania)

When you enter a building or get on a bus, does everyone turn to look and watch you. Do you think someone is out to get or harm you, or is plotting against you? Have you ever done something unusual, and thought someone might have drugged you to make you do it?