Clinical Assessment - concepts Flashcards
Important concepts to the clinical assessment
Why does the presenting problem matter?
It identifies the client’s primary concern and sets the focus for treatment. Understanding the duration, severity and impact helps in forming a diagnosis and treatment goals.
Why is the history of the problem important?
It helps differentiate between acute v. chronic issues, identifies triggers, and provides insight into past coping mechanisms and previous treatment.
Why is a biopsychosocial assessment necessary?
It ensures a holistic understanding of the client by examining biological, psychological and social influences on mental health.
What is the importance of a MSE?
It provides a snapshot of the client’s current cognitive, emotional and behavioral functioning, helping to rule out severe psychopathology
Why must risk assessments be conducted?
Identifying risks like suicidality or harm to others ensures appropriate intervention, crisis planning and legal/ethical compliance
How does differential diagnosis impact treatment?
It helps differentiate between conditions with overlapping symptoms, leading to the most effective treatment approach.
Why is case conceptualization critical?
It organizes client information into a coherent framework, guiding interventions and tracking progress.
How does treatment planning contribute to therapy?
It provides clear, measurable goals that align with the client’s needs and theoretical orientation.
Why must ethical and legal factors be considered?
Ensuring confidentiality, informed consent, and compliance with CA laws (mandated reporting, Tarasoff) protects both the client and the therapist
Why is it important to adjust assessments for special populations?
Different groups (kids, neurodivergent individuals, trauma survivors) require tailored approaches to effectively assess and treat them.
Why use standardized assessment tools?
They provide objective data that enhance diagnostic accuracy and treatment planning.
Why is cultural competence important in assessment?
It ensures that the assessment is accurate and respectful, avoiding biases that could lead to misdiagnosis or ineffective treatment.
10 Components of a MSE
Appearance
Behavior
Speech
Mood and Affect
Thought Process
Thought Content
Perception
Insight
Cognition
Judgment
Judgment (MSE)
Decision-making ability (e.g., hypothetical scenarios, real-life situations)
Impulsivity and risk assessment
Cognition
Orientation (person, place, time, situation)
Attention and concentration (serial 7s, spell “world” backward)
Memory (immediate, recent, remote)
Abstract thinking (proverb interpretation)
Insight (MSE)
Awareness of one’s mental health condition
Understanding of symptoms and need for treatment
Thought Content
Delusions (paranoid, grandiose, persecutory, somatic)
Obsessions or compulsions
Phobias
Suicidal or homicidal ideation
Perception (MSE)
Hallucinations (auditory, visual, tactile, olfactory, gustatory)
Illusions or misinterpretations of stimuli
Thought Process (MSE)
Coherence (logical vs. illogical)
Rate of thoughts (normal, racing, slowed)
Organization (linear, tangential, circumstantial, disorganized)
Mood and Affect (MSE)
Mood (self-reported emotional state, e.g., anxious, sad, euphoric)
Affect (observable emotional expression, e.g., flat, blunted, labile)
Appropriateness of affect to context
Speech (MSE)
Rate (e.g., slow, rapid)
Volume (e.g., loud, soft)
Tone (e.g., monotone, pressured)
Clarity (e.g., slurred, mumbled)
Coherence and fluency
Behavior (MSE)
Level of cooperation (e.g., friendly, guarded, hostile)
Psychomotor activity (e.g., agitation, retardation, tics)
Eye contact
Appearance (MSE)
General description (e.g., well-groomed, disheveled)
Clothing and hygiene
Apparent age vs. actual age
Facial expressions
Posture and body movements
