COUC 521 Week 4 Mental Status Exam Example

Mental Status Exam: A Second Session With the Fictional Teacher From the Initial Interview

Identification and Context

Megan Ross, a 29-year-old second-grade teacher referred by her primary care physician for fatigue, poor concentration and early waking, was seen for a second session one week after the initial interview. The session lasted 60 minutes. The examination followed the domains described by Drummond et al. (2016) and the structure outlined by Trzepacz and Baker (1993).

Appearance and Behavior

Ms. Ross appeared her stated age. She was dressed casually in clean jeans and a school sweatshirt, with her hair pulled back and no makeup. Grooming was adequate. She sat with her shoulders rounded and her hands in her lap, and she moved slowly when sitting down and standing. No tremor, tics or unusual movements were observed. She yawned several times during the session and held a travel mug of coffee throughout. She appeared thinner than her reported weight would suggest, and her clothing fit loosely. There were no visible injuries, marks or signs of self-harm on her forearms or hands.

Manner and Approach to the Examiner

She was polite, cooperative and apologetic, saying "sorry" four times when she lost track of a question. She made intermittent eye contact, looking down for long stretches when discussing work. She answered all questions but rarely elaborated without prompting. When asked open questions about her week, she gave brief answers and then waited for the next question, a change from the more talkative manner she showed when describing her students at intake. She became more engaged when the conversation turned to her sister.

Speech

Speech was soft in volume, slow in rate and reduced in amount, with pauses of several seconds before some answers. Articulation was clear and her speech was coherent.

Orientation and Alertness

She was alert and fully oriented to person, place, date and the reason for the visit. She remained attentive throughout the session, although she asked for two questions to be repeated.

Mood and Affect

Asked about her mood, she said, "Flat. Gray. Like I'm watching my life through a window." Asked to put a number on it, she chose 3, with 10 meaning her best. Her affect was constricted in range and mostly sad, with tearfulness when she described missing her friend's birthday and calling in sick. Affect was congruent with the content of her speech and with her stated mood. She smiled briefly when describing a student's drawing, showing that some reactivity remains. She did not laugh at any point in the session, and her facial expression changed little while she discussed topics that would ordinarily carry different emotional weight, such as her weekend plans and her worries about work.

Thought Process and Content

Her thought process was linear and goal directed, though slowed. Thought content centered on guilt and inadequacy, including statements that she is "failing the kids" and "should be able to handle this." She expressed worry about losing her job but no delusional beliefs, obsessions or compulsions. When asked the brief screening items from a validated suicide severity scale (Posner et al., 2011), she denied wishing to be dead, denied active suicidal thoughts and denied any preparatory behavior or past attempts. She said her faith and her sister "would never let me go there." She denied thoughts of harming others. She was given the number for the 988 Suicide and Crisis Lifeline and agreed to contact it or a trusted person if her thinking changed.

Perception

She denied hallucinations, and no perceptual disturbance was observed during the session.

Cognition

Immediate recall was intact for three words, and she recalled all three after five minutes. She completed serial sevens to 65 with one self-corrected error, describing the task as "harder than it should be." Her vocabulary and fund of knowledge were consistent with her education. No formal cognitive screening instrument was indicated given her age, history and performance.

Insight and Judgment

Insight was fair: she recognized that something has changed and wanted help, but she attributed the problem mainly to personal weakness. Judgment was good, as shown by her following through on her physician's referral, returning for this session and agreeing to further assessment. She has continued to work and to care for herself, and she has not used alcohol or other substances to cope.

Summary

The examination showed a slowed, sad and self-critical presentation with intact orientation, memory and reasoning, which fits the depression hypothesis raised at intake far better than a medical or cognitive explanation. Constricted affect, psychomotor slowing, guilt-laden thought content and reported concentration problems are consistent with a depressive episode, while preserved reactivity and the absence of suicidal ideation are reassuring. The findings do not establish a diagnosis. The Psychological Report will add standardized measures of depression and anxiety, a personality inventory and a type measure required by the course, giving the conclusions several independent methods to rest on.

References

Drummond, R. J., Sheperis, C. J., & Jones, K. D. (2016). Assessment procedures for counselors and helping professionals (8th ed.). Pearson.

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168(12), 1266-1277. https://doi.org/10.1176/appi.ajp.2011.10111704

Trzepacz, P. T., & Baker, R. W. (1993). The psychiatric mental status examination. Oxford University Press.