In a therapeutic intervention it is essential that the psychologist collects all possible information from the patient: family environment, social, economic, work or educational conditions and clinical history. In order to make the most accurate diagnosis possible, it is important to take the above into account and add all the observations and what was collected in the mental examination
This is done during therapy sessions; It is made up of both observations and inferences on the part of the psychologist and what the patient says and expresses.
The health professional will have to clarify and update diagnostic aspects and therapeutic decisions according to the changes observed during the interviews.
These are the 15 elements to analyze to perform a mental exam:
1. Physical appearance
Pay attention to posture, personal hygiene, way of dressing and body constitution. If the patient has been treated for some time, it is important note changes observed since the last session since they are usually related to the evolution of the mental state.
2. Orientation
Make sure it covers all 3 dimensions: personal, temporal and spatial. Basic questions about what is your name, date of birth, date of the session place where the interview takes place.
Evaluate speech speed, voice volume, articulation of words, coherence and spontaneity.
4. Motor activity
Emphasis on standing, ambulation, posture, facial gestures, tics, abnormal movements (tremors, automatisms) and general body movement. Observe if they are exaggerated movements, it could be a sign of a manic phase, or slow, which They could be a sign of a depressive phase or schizophrenic disorder It is important that in subsequent sessions, changes are observed in response to drugs and therapy.
5. Affection
It is the emotional state expressed by the patient throughout the interview. Inconsistencies can be observed and the affect is inappropriate in relation to the facts it tells as well as absence of emotional response or instability.
6. Mood
It cannot be observed, rather it is inferred by the psychologist and a comparison has to be made between what you observe and what the patient says This describes your mood in the last few days or weeks.
7. Expression of thought
Assess the form of expression, speed of thought and quality of ideational flow. If it is logical, if it has a purpose, if it is tangential, if there are ideational leaks or failure in associations Alterations in this element may represent thought disorders, a manic phase of Bipolar Disorder, substance intoxication.
8. Content of thought
What it contains: if there is presence of delusional thinking, common in schizophrenic and thought disorders; obsessive, mainly in obsessive-compulsive disorder, but which can also appear in eating and impulse control disorders; or overrated ideas.
9. Perceptual alterations
It is necessary to ask directly if the patient sees, hears, smells or feels things that are not based on any sensory or sensory stimulus, that he knows that others do not feel or perceive. The therapist must also be attentive to the patient’s reactions to the questions, if when he answers first he turns away or talks to someone else. The alterations are related to hallucinations, schizophrenic and psychotic disorders or substance intoxication.
It is extremely important to approach patients who have a history of violent acts, problems with the law, a personal history of attempted suicide, or a family history. If in the interview it emerges that you plan to commit suicide or kill someone, the focus must be changed immediately, this element becomes urgent. It is necessary to direct him to hospital care in case of suicidal ideation or notify the police, in case of homicidal ideation.
11. Attention, concentration and memory
It can be evaluated without the need for specific questions, but only by analyzing behaviors and responses during the session. If you do not have enough information, you can ask the patient to spell words backwards and forwards, have them remember series of numbers or letters. It is important that in this section the cultural and educational level of the patient is taken into account.
If a cognitive deficit is suspected, It is recommended to apply the Cognitive Mini-Exam
12. Abstract thinking
The simplest way to evaluate this element is to ask the patient to explain the meaning of a saying or proverb. Concrete thinking can present itself as an alteration or as a symptom of some mental disorder such as schizophrenia.
13.Insight
It is the level of understanding of the current mental situation, whether you have a disorder or not. The degree of therapeutic compliance can serve as an indicator for this step.
14. Judgment capacity
It is advisable to ask questions about how they react to specific situations that have a high probability of occurring and that are related to the patient’s daily life.
These elements are evaluated with specific questions: sleep cycle, how much you sleep, sleep quality and frequency. If there have been changes in your sexual motivation and practices with your partner (if you have one) or if there has been any change in your eating habits or appetite.
Its use in psychotherapy
The mental examination is not a one-time evaluation, but rather a constant, throughout the therapeutic treatment, the psychologist must be analyzing and evaluating these aspects to have a broader overview of the individual’s evolution. It is important that all changes that are observed are noted down to find possible causes and infer consequences. And in this way, shape the therapy according to the patient’s needs.
