Chapter 3: Biopsychosocial Assessment Flashcards
What is the definition of an assessment?
is a time-limited, formal process that collects information from many sources in order to reach a diagnosis, to make a prognosis, to render a biopsychosocial formulation, and to determine treatment.”
What is a biopsychosocial psychological assessment?
“a structured interview that gathers information from and/or tests a person to evaluate their mental health concerns.”
What are the characteristics important to a biopsychosocial assessment?
time-limited, formal, and must come up with a diagnosis
Who are the information sources for the assessment?
Client, family, friends, staff, medical examinations, and tests, any other sources
What are the 8 main steps of a comprehensive assessment?
Obtaining a history Evaluating the mental status Collecting auxiliary data Summarizing principal findings Rendering a diagnosis Making a prognosis Providing a biopsychosocial formulation Determining a treatment plan
What are the critical elements of an assessment of substance abuse?
Type of substance used
Frequency and amount of use
Duration of use
Whether the use is leading to impairment in the client’s life and functioning
Whether anyone in their life has alerted them to the impact of their abuse
What are the critical elements of an assessment of risk for suicidal ideation?
Current plan for suicide (detailed plan) Previous attempts at suicide History of depression and/or suicide Social isolation Recent diagnosis of a serious/terminal illness
What are 3 additional questions in a comprehensive assessment?
Why is family history relevant to client assessment?
Why is a medical assessment significant and necessary when (available)?
How would you assess spirituality and/or religious affiliation? Why would it be important to do so?
What is a mental status exam (MSE)?
Describes the patient’s appearance, behavior, speech, emotions, and cognitive and perceptual processes; it is an objective report of the client’s current mental state as observed by the clinician
T or f? The psychiatric history provided by a client is a subjective account yet the MSE is objective.
T
What are the 12 most important elements to note in a mental status exam?
Appearance Motivation Judgment Intelligence (intellectual development) Insight (what they're experiencing currently and what could help their issue/situation) Thought process Perception Attention span Emotions (mood - affect) Speech Behavior (including impulse control) Orientation
What is the first step in conducting a mental status exam?
Appearance (looking at if a client is dressed appropriately for the weather or current surroundings - looking at context)
When looking at a client’s appearance what are we looking for?
How does their appearance tell me something about their current mental or emotional condition
What do we do when we are looking at speech?
The first element of speech is that we note the volume of the client or the speaker. How are they speaking? Is their volume appropriate/suitable for the context or the environment? The second element is the rate or the speed of their speech. Is it slow it takes them long to finish a sentence, and are they talking so fast that it is hard to keep up. What is the manner of speech? Is the client slurring?
What is poverty of speech known as?
Alogia (Starting and stopping to speak)
What is latency of speech?
Taking a long time for a client to speak
What is apraxia of speech?
Difficulty with skilled movements even when a person has the ability and desire to do them.
Apraxia is caused by brain disease or damage. The brain is unable to make and deliver correct movement instructions to the body.
One type of apraxia affects speech. The brain struggles with lip, jaw, and tongue movements. Other types affect the accuracy of limb movements, response to verbal commands, and facial movements, such as winking.
Treatment may include physical, speech, and occupational therapy.
When it comes to affect, a normal range is broad. T or f?
T
What is the subjective experience a client is talking about what they’re feeling on the inside?
Mood
T or f? The mood is what you feel on the inside, and affect is what you see on the outside. T or f?
T
When we are talking about assessing a motion, what two things are we looking for?
Mood and affect
T or f? Affect is what they’re showing on the outside, in their body language, in their speech, in their behaviors
T
What refers to the fact that what they’re telling you that they’re experiencing subjectively is matched by their body language and by their speech.
mood congruency
What does mood congruency mean?
It just means that whatever the client is experiencing and the mood that they’re telling you about is reflected in their affect.
What is also referred to as depression?
Dysthymia
What means normal mood in depression; everything is fine?
Euthymia
What means elevated mood in depression where somebody is extremely happy, full of life, really feels they’re on top of the world?
Euphoria
What, in depression, means that a person is on the other end of feeling happy, down and out, and don’t feel good about anything?
Dysphoric
T or f? Most individuals who have schizophrenia start off with overvalued ideas? This then proceeds to illogical thinking, magical thinking (superstitions), and finally leads to delusions.
T
A person needs medication to recover from their delusional thinking or get back to a former state where delusions were not present. T or f?
T
For some people, overvalued ideas start to control their life and end up as delusions. A reality check is important in this case. T or f?
T
No amount of talk therapy can help a delusional person, only medication can help. T or f?
T
What is the term used to describe what a person is experiencing or sensing around them; we are talking about our five senses, smell, taste, touch, hear, and sight?
Perception
What are some of the most common hallucinations?
Auditory
T or f? Depersonalization and derealization are intermingled, and they are either the same thing or different things.
T
What is the term used to describe the idea that a part of a person’s body does not work or exist; for ex, a person thinks they cannot lift or use their left arm?
Depersonalization
What is an out-of-body experience where a person feels they’re floating above themselves and observing that’s going on in their lives? It could also feel like a person is in a dream-like haze. So everything is kind of hazy and cloudy around them, and they’re in that sort of morning dream state when you’re not fully awake or not fully asleep. But you’re not sure if it’s a dream or real.
Derealization
What is the experience called where you feel like you’ve been there already or done that already? Many people experience this, but chronic episodes of these may point to something being perceptually, mentally, or emotionally.
Deja-vu
What is important in diagnosing for cognitive disorders like ADHD, or learning disorders, or other related attention/concentration conditions?
Does the person pay attention to detail
Can the person pay attention to detail
Can he/she follow through w/instructions
Why or what is it we are looking for one we assess if a person is aware of the time, place, activity or name/date of birth of something they are partaking in?
When assessing for cognitive conditions such as Alzheim’ers disease, someone under the influence of substances, alcohol, or on the autism spectrum disorder.
What are we testing when we test for someone’s ability to recall events, experiences in their lives, both recently or in the past?
Memory
What type of memory is when you recall what was said three minutes ago, numbers, or words?
Immediate
What is known as distant memory, recalling events from adolescence or after a long time?
Distant
What is confabuation?
False memory
When is confabulation seen?
In dementia, and Alzeimer’s disorder/disease
T or f?
So sometimes in the initial stages of Alzheimer’s disorder where a person is experiencing memory loss, they’re embarrassed by it. So you might ask a question like, hey, isn’t it hot out there?
And instead of answering the question, because they don’t remember what hot means or what the temperature is, they change the topic. And say, you’re talking about hot, let me tell you about how I struggled through my life. And so they distract you or change the topic.
And they’re doing it because they’re embarrassed about what was being discussed and they don’t have a recollection. Like if you’re talking about your favorite sports team and their score in the game last night, and they don’t remember. And they’re like, Jets! I hate the Jets! They don’t. But they don’t want to answer the question because they’re embarrassed. It’s like a change of topic?
Confabulation
What are the last three elements of the mental status exam?
Judgment, intelligence, and insight
