15 Steps to Performing a Mental Exam in Therapy

In a therapeutic intervention, it is essential that the psychologist collects all possible information from the patient: family environment, social, economic, professional or school conditions and clinical history. In order to make a diagnosis as accurate as possible, it is important to take into account the above and add the observations and the product of the mental examination.

This is done during therapy sessions; it is shaped both by the psychologist’s observations and inferences and by what the patient says and expresses.

The health professional he will have to clarify and update the diagnostic aspects and the therapeutic decisions depending on the changes you observe during the interviews.

    How to take a mental exam

    Here are the 15 things to analyze for a mental exam:

    1. Physical appearance

    Pay attention to posture, personal cleanliness, dressing style, and body build. If time has already been spent treating the patient, it is important note the changes observed since the last session, As they are generally related to changes in mental state.

    2. Orientation

    Make sure it covers all 3 dimensions: personal, temporal and spatial. Basic questions on how to say, date of birth, date of session, Place where the interview takes place.

    3. Speech and language

    Evaluate speed of speech, volume of voice, articulation of words, consistency and spontaneity.

    4. Motor activity

    Emphasis on standing, walking, posture, facial gestures, tics, abnormal movements (tremors, automatisms) and body movements in general. Observe if these are exaggerated movements, may be a sign of a manic phase, or slow, that they could be a sign of a depressive phase or a schizophrenic disorder. It is important that in subsequent sessions changes are observed in response to drugs already in treatment.

      5. Affects

      It is the emotional state expressed by the patient throughout the interview. Incongruities can be observed and that the affection is inadequate for the facts it counts, As well as the absence of emotional response or instability.

      6. Mood

      It cannot be observed, it is rather inferred by the psychologist and a comparison must be made between what he observes and what the patient says. This describes his mood over the past few days or weeks.

      7. Expression of thought

      Evaluate the form of expression, speed of thought and the quality of the flow of ideas. If it is logical, if it has a goal, if it is tangential, if there are ideal leaks or failures in associations. Alterations of this element can represent disturbances of thought, a manic phase of bipolar disorder, intoxication by a substance.

      8. Content of thought

      What it contains: if there is presence of delusional thought, Common in schizophrenic and thought disorders; obsessive, mainly in obsessive-compulsive disorder, but which can also appear in eating disorders and impulse control disorders; or overdone ideas.

      9. Alterations in perception

      It is necessary to ask directly whether the patient sees, hears, smells or hears things which are not based on any sensory or sensory stimulus, which he knows that others do not feel or perceive. The therapist should also be attentive to the patient’s reactions to questions, whether they first turn to another camp or speak to someone else. The alterations are linked to hallucinations, schizophrenic and psychotic disorders or substance intoxication.

        10. Thoughts of suicide and / or homicide

        It is extremely important to treat patients who have a history of violent acts, legal issues, a personal history of attempted autolytic or family. If during the interview it appears that you are planning to commit suicide or kill someone, the goal must be changed immediately, this item becomes urgent. He must be directed to hospital care in the event of suicidal ideation or notify the police in the event of suicidal ideation.

          11. Attention, concentration and memory

          It can be assessed without the need to ask specific questions, but only by analyzing behaviors and responses during the session. If there is insufficient information available, the patient may be prompted to spell words correctly and vice versa, allowing them to remember a series of numbers or letters. It is important that this section takes into account the cultural and educational level of the patient.

          In case of suspicion of cognitive deficit, it is recommended to apply the cognitive mini-exam.

          12. Abstract thought

          The easiest way to assess this item is to ask the patient to explain the meaning of a saying or proverb. Concrete thought can be presented as an alteration or as a symptom of a mental disorder like schizophrenia.

          13. Insight

          It is the level of understanding of the current mental situation whether or not you have a disorder. The degree of treatment adherence can be used as an indicator for this step.

          14. Ability to judge

          It is advisable to ask questions about how you react to specific situations which are very likely to occur and which are related to the daily life of the patient.

          15. neurovegetative, sexual and appetite

          These elements are assessed with specific questions: sleep cycle, how much sleep, sleep quality and frequency. If there have been changes in your motivation and sexual practices with your partner (if applicable) or if there has been a change in your eating habits or if you are winning.

          Its use in psychotherapy

          The mental exam is not a one-off assessment, but constantly, throughout the therapeutic treatment, The psychologist must analyze and evaluate these aspects to have a broader vision of the evolution of the individual. It is important that all observed changes are noted to find possible causes and deduce consequences. And in this way, model the therapy according to the needs of the patient.

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