Slide 1 HSNS310/510 Comprehensive mental status assessment: Mental State Examination, History taking & Risk Assessment Coordinator: Dr Irene Ikafa XXXXXXXXXX XXXXXXXXXX Room 226, School of Health...

Slide 1 HSNS310/510 Comprehensive mental status assessment: Mental State Examination, History taking & Risk Assessment Coordinator: Dr Irene Ikafa XXXXXXXXXX XXXXXXXXXX Room 226, School of Health Copyright COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. * Objectives At the end of this session you should be able to: Understand the components of mental state examination(MSE) Take a mental health history Discuss risk assessment Conduct a comprehensive mental health status assessment on a mock client with some confidence or on a case study What is Mental State Examination (MSE)? The MSE is a process of obtaining information about specific aspects of individual’s mental experiences & behaviour at the time of the interview It is one way of gathering data required to assess an individual experiencing mental illness All clinicians working in mental health settings should be able to conduct a mental state examination using a standardised format Mental State Examination cont’d Can be made in the course of taking the history Determine medical or psychiatric emergency In emergency situations – MSE may be brief Active listening & observation Routine part of any interaction with clients Requires establishing good rapport Clinician must allow clients to express their concerns Must be documented in a professional, sensitive & objective manner Why do a MSE? Determine risk & severity - risk to self or others Identify signs & symptoms Monitor change or improvement Recognise common language Generate hypothesis Implication for interventions Documentation – if it’s not documented, it was not done When is MSE conducted During admission In the course of taking history On one to one interaction If there is any change in clinical presentation What is included in history taking? Psychiatric history which includes: Individual details Identify presenting problem History of presenting problem Previous medical/surgical history Personal history Family history Premorbid personality Illicit drug use/ alcohol abuse history Forensic history Mental State Examination Dos & Don’ts during MSE DO build a good rapport & trust Active listening & observation Use closed-ended questions e.g. When did it happen? Use open-ended question e.g. Could you tell me about your relationship with your family? Allow clients to express concerns DON’T argue or interrupt clients Avoid asking why questions Overview of mental state examination Appearance Behaviour Speech Mood & Affect Form of thought Content of thought Perceptual disturbances Sensorium & cognition Insight Formulation Appearance Age Gender Race/ethnic background Build Hair style & colour Apparent health Level of hygiene Mode of dress Physical abnormalities/ striking features Behaviour Eye contact Individuals reaction to present situation Individuals motor activity Abnormality in movement Expressive gestures Speech Articulation disturbances (slurred speech or stammering) Rate (rapid, pressured, slow) Volume (loud, whisper, quiet) Quantity (monotonous, mutism) Mood and Affect Mood subjective/ internal feeling state use clients own words Affect objective/ external feelings & observable manifestations moment to moment expression Affect Affect is described by using: 1. Range & intensity Normal affect – normal emotional expressions Restricted affect - decrease in emotional expressions Blunted affect - severe decrease in emotional expressions Flat affect - total or near absence emotional expressions 2. Stability Stable - no fluctuation in affect Labile - excessively rapid changes in affect Diurnal variation – if feel rotten in the morning & bright in the afternoon 3. Appropriateness & congruity Appropriate & congruent to the conversation or situation XXXXXXXXXXe.g. sadness at funeral & laughter at joke Thought form Thought form refers to organisation, flow & production of thoughts & include: Amount of thoughts & its rate of production Continuity of ideas Disturbance of language Thought form: organisation, flow & production Loosening of Associations - ideas are unrelated & not connected Tangentiality - replies to conversation are irrelevant & oblique Circumstantiality - a pattern of speech that is indirect & delayed in reaching its goal Flight of ideas - abrupt changes in conversation, where there is no common connection in the ideas expressed Perseveration - persistent repetition of the same words or themes Thought blocking - sudden interruption in flow of thinking, thoughts are absent for a period of time Neologisms - creation of new words that have no meaning Thought content Suicidal thoughts Thoughts to harm others Delusions Assessment of delusions What is going on? Why is it going on? What are you going to do about it? Thought content cont’d Delusions - false belief which cannot corrected by others from same group or cultural background & includes: Delusions of persecution Delusions of reference Delusions of control/influence/passivity thought broadcasting thought withdrawal thought insertion Grandiose delusions Delusions of guilt & unworthiness Religious delusions Thought content cont’d Delusions: Nihilistic delusions Delusions of jealousy Somatic delusions Hypochondriacal delusions Dysmorphic delusions Other unusual thought content include: Overvalued ideas Obsessions Phobias Perceptual disturbances Hallucinations - false perception without any external stimuli & incudes: Auditory Visual Olfactory Gustatory Tactile Other perceptual disturbances: Derealisation Depersonalisation Illusions Sensorium & Cognition Level of consciousness or alertness – coma to stupor Memory - immediate, short & long-term Orientation – time, place & person Concentration – ask a client to subtract serial 7’s from 100 or spell WORLD backwards to test concentration Abstract thoughts - involves ability to deal with concepts. May be assessed by asking a client to interpret meaning a proverb Mini-Mental State Exam - measure cognitive impairment in people with dementia Insight Capacity to recognise own problems & symptoms Knowledge of medication Amenable to treatment Likelihood of compliance with treatment Judgement Formulation Summary of signs & symptoms Summary of risk features Strengths & weaknesses Prior life experiences Current state of health Attitude towards illness Supports Risk assessment!! What is risk assessment A process of assessing whether or not a person may harm him/herself or others It is assessing the likely occurrence of a future event & likely impact of that event This assessment involves chance, uncertainty & unpredictability Types of risks Risk to self Risk of suicide Risk of deliberate self-harm Risk of exploitation Risk of substance abuse Risk of self-neglect Absconding Risk to others Risk of violence or homicide Intentional/unintentional harm to a child Deliberate fire setting Who conducts a risk assessment? Mental health professionals working in mental health facilities There is a responsibility on all clinical staff to act on information they receive regarding risk Psychiatrists are responsible for ensuring that risk assessment is done before a decision is made to discharge or grant leave to a client Risk assessment applies to everyone in contact with mental health services When is risk assessment done? As part of an overall assessment on entry to mental health facilities If there are major changes in client's circumstances When a client is moving between services Prior to granting leave or discharge At the request of another agency, such as a day centre, hostel or housing facility Information gathering Information sources include: Consumer/client Carers or significant others General Practitioner (GP) Progress notes Agencies involved in client's care e.g. day centre staff, housing officers If a client has committed a serious offence then access to witness statements is important Contributing factors History - previous attempts, frequency & family history Trigger factors Diagnosis - nature & severity of symptoms Treatment - effectiveness & side-effects Current thoughts & emotions -How often? How intrusive? Hopeless, impulsivity Current social circumstances Drug or alcohol abuse Risk factors & protective factors Risk factors - increase likelihood of mental illness & includes: Family violence Poverty/ low family income Inconsistent behaviour management of children Abusing alcohol & illicit drugs Protective factors - enhance individual to maintain mental health & includes: Family support Social support network Positive sense of self Peer group & supportive neighbourhood Determining suicide risk When determining risk of suicide it may be important to: Explore suicidal thoughts (how often, how long, intensity) Explore suicidal plan (specific, lethal, available, proximity of help) Assess consumer's perception of self-control History of previous attempts Other attempts (close friends, family members) Extent of suicidal intent Also assess risk to others (hurting others, who & how) Levels risk of suicide No risk: No evidence of past or current risk and client has protective factors. Client is commenced on hourly visual observation Low risk: No current risk identified. However, there is some presence of risk factors. Client is commenced on 30 mins visual obs Moderate risk: Definite indications of current risk but no definite plan. Start 15 mins close visual obs High risk: Clear plan of suicide in the immediate or near future Start one to one special/ continuous observations Risk Assessment Tools MH-OAT Assessment form (Mental Health Assessment form) Brief Risk Screen Other Risk Assessment Tools CAGE screening tool for alcohol Questions to ask during an interview in order to determine problematic alcohol abuse include: "Have you ever felt that you should Cut down on your drinking?" "Have people Annoyed you by criticizing your drinking?" "Have you ever felt bad or Guilty about your drinking?" "Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?" The words 'drug abuse’ can substitute alcohol abuse if the intention is to assess illicit drug abuse Kessler Psychological Distress Scale (K10) Klessler Psychological Distress Scale (K10) is a measure of psychological distress for anxiety & depression K10 uses a five point Likert scale – all of the time, most of the time, some of the time, a little of the time & none of the time Scoring from 5 (all of the time) through to 1 (none of the time) The maximum score is 50 indicating severe distress & minimum score is 10 indicating no distress Legalities Limits of confidentiality - make it clear from start A client says, “I am feeling unsafe”, client is looking for help Duty of care – the nurse has a duty of care to maintain a safe environment for the client Consult senior staff if you are working with high risk clients Coroners Act Where the death is of a person held in care, a coroner must comment on the quality of the supervision, treatment and care of the person while in that care What next? The current case formulation should address how serious, imminent, volatile & specific risks Risk management care plan Interventions Involve interprofessional team through communication Consult other senior staff or have supervision if you are working with high risk clients Exercise Conduct a comprehensive mental health status on Mrs Jones’s case study which includes history taking, MSE & risk assessment using MH-OAT Assessment form (Mental Health Assessment form) or; On a mock client with some confidence References Evans, J. & Brow, P XXXXXXXXXXNursing Practice for Mental Health Disorders (1st ed). Philadelphia. Lippincott Williams & Wilkins. Elder, R., Evans, K., & Nizette, D XXXXXXXXXXPsychiatric and Mental Health Nursing (2nd Ed)