Categories of Mental Status Exam from the Handout (see MSE Part 2 Template for how to organize information below) Appearance: Presenting Appearance (including sex, chronological and apparent age, ethnicity, build, and physical deformities; Basic Grooming and Hygiene (plus appropriateness of attire, accessories like glasses or a cane); Gait and Motor Coordination (plus posture, work speed, any noteworthy mannerisms or gestures). Manner and Approach: Interpersonal Characteristics and Approach to Evaluation (resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness); Behavioral Approach (distant, indifferent, anxious, alert, etc.) Speech (normal rate and volume, pressured, slow, etc.); Eye Contact (makes, avoids, etc.); Expressive Language (circumstantial and tangential responses, mumbling, vocabulary usage) Receptive Language (normal, difficulty understanding questions); Recall and Memory (can explain recent and past events in their personal history, recalls three words, etc.). Orientation, Alertness, and Thought Processes: Orientation (person, place, time, and situation); Alertness (sleepy, alert); Coherence (coherent and easy to understand, overly detailed and difficult to follow); Concentration and Attention (naming the days of the week in reverse order, ABC’s backward); Thought Processes (loose associations, flight of ideas, delusions); Hallucinations and Delusions; Judgment and Insight; Intellectual Ability; Abstraction Skills (able to explain a parable or saying). COUC 521 Page 3 of 4 Mood and Affect: Mood (feels most days: euthymic, sad, anxious, angry); Affect (felt at any given moment); Rapport (easy to establish, easily upset); Facial and Emotional Expressions (relaxed, tense, smiled, laughed); Suicidal and Homicidal Ideation (past and recent in both areas); Risk for Violence (previous criminal history, dislike for a specific demographic); Impulsivity. Categories of Mental Status Exam from the Textbook (extra information) Appearance: How was the client dressed and groomed (e.g., neat, disheveled, unkempt)? Behavior/Psychomotor Activity: Did the client exhibit slow movement, restlessness, or agitation? Did the client have any unusual behaviors such as tics, mannerisms, gestures? Attitude toward Examiner: Was the client’s attitude toward the examiner cooperative, friendly, attentive, defensive, hostile, evasive, guarded, and so forth? Affect and Mood: Did the client have sad, angry, depressed, or anxious mood? Was the client emotionally responsive (affect)? Was affect congruent with mood? Speech: How was the quantity, rate of production, and quality of the client’s speech (e.g., minimal – mostly yes and no answers; talkative; rapid/pressured speech)? Perceptual Disturbances: Did the client experience hallucinations or illusions? If so, what sensory system did they involve (e.g., auditory, visual, olfactory, tactile)? Thought: Did the client have any disturbances in thought process, which involves the rate of thoughts and how they flow and are connected (e.g., racing thoughts, flight of ideas, tangential). Were there any disturbances in thought content, such as delusions, obsessions, preoccupations, or suicidal or homicidal thoughts? Orientation (Ox4): Was the client able to state (a) their name and recognize people around him or her, (b) the current location/place, (c) the date and time, and (d) the situation (can describe the purpose of the meeting). Memory: How was the client’s recent memory (e.g., what did he or she have for breakfast?) and remote memory (e.g., memories from childhood)? Concentration and Attention: Was the client’s concentration or attention impaired? Was the client distractible? Information and Intelligence: Can the client accomplish mental tasks that would be expected of a person of his or her educational level and background? Judgment and Insight: Does the client have the capacity for social judgment? Does the client have insight into the nature of his or her illness? COUC 521 Page 4 of 4 Reliability: How accurately was the client able to report his or her situation?
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