Welcome to our licensure exam podcast . I'm Dr Linton Hutchinson , here with my co-host , stacey Frost .
Stacy FrostHi there everyone . Today we're going to be talking about the mental status examination , which is a structured assessment tool used to evaluate a client's current state of mind , cognitive abilities and overall psychological functioning . We're focusing this episode on two specific domains that are assessed on the MSE appearance and behavior .
Dr. HutchinsonAre those the only sections that are on the MSE Stacey ?
Stacy FrostOh no , there's several more domains , but we would be here for like a week if we took them all in this one episode so we just thought we'd pick a couple for this one and do some more later .
Dr. HutchinsonYeah , that's a good idea . We'll pick a couple others for another episode with a few case studies . That demonstrates how assessing a client's appearance and behavior can help you determine the current mental state and aid in the diagnostic process and guiding the kind of treatment decisions that you make .
Stacy FrostAll right , so we'll start with appearance , which is pretty straightforward . You'll be making notes on the client's physical presentation , including their clothing , grooming , physical build and nutritional status , level of eye contact , gait and posture , and any physical abnormalities or signs of injury or maybe scarring . The client's appearance gives you valuable information about the client's overall self-care , physical health and potential mental health concerns .
Dr. HutchinsonAnd this is what those signs might be telling you about the client . Okay , if you see poor grooming or hygiene , this may indicate some kind of depression or neglect . It's sort of giving you as you being a detective . It's giving you some clues to examine areas that you might want to explore . If the client avoids eye contact , what would that be ? It might be a sign of anxiety , so that might be another area that you would attack . Alternatively , staring off into space or appearing distracted could suggest attention problems , disassociation or even a psychotic disorder . If you look at them and you see visible injuries , this could be related to self-harm , abuse or risk-taking behaviors that warrant further investigation .
Stacy FrostYep , and you can gain a lot of insight into a client from observing their appearance . Sometimes the clues are a little bit more subtle , though , so , in addition to clothing , grooming and obvious injuries or scars , you also want to pay attention to their dental health , their nails and their skin .
Dr. HutchinsonRight Missing or badly decayed teeth could be a sign of depression , where the individual even lacks any motivation or energy to attend the basic grooming and health needs . It could also indicate a more chronic pattern of self-neglect , possibly related to mental illness , substance abuse or cognitive impairment . What kind of substance abuse might that be , stacey ?
Stacy FrostI'm thinking methamphetamines , that one pops to mind most readily .
Dr. HutchinsonYeah , yeah , me too .
Stacy FrostThen there's also nail biting , skin picking and hair pulling , which can be a sign of anxiety , stress or even obsessive compulsive behaviors . Riddle or discolored nails could be a sign of nutritional deficiencies , poor diet or even eating disorders . For example , excessive hair growth on a client's knuckles might be the first sign of a serious mental problem . Linton , I can see , let me see your hands . You're looking for it , aren't you ? That's the second sign .
Dr. HutchinsonAnd you're such a trickster , Stacey .
Stacy FrostI finally got you . Payback is such a witch . Oh yeah , Rich , I'm sure . Hey , this has been slightly modified for the younger audience .
Dr. HutchinsonOh , okay . Well , you just wait . You just wait . The podcast isn't over yet , buddy . Anyway , the MSC is all about gathering data points and using them to generate hypotheses , not making definitive diagnoses . If you notice something unusual about a client's nails , for example , it's an opportunity to inquire further . With sensitivity and respect , you might say something like hmm , I noticed your nails look a little bit bitten down there . I'm wondering if that's related to stress anxiety . Have you been experiencing anything like that lately ?
Stacy FrostOh , you know what , Linton , now that you mention it , all this talk about nails has me looking at my nails . I know they're bitten down to the nubs , but it's from all that scraping of the 1980s wallpaper . Cj and I are trying to get off while we're remodeling our office .
Dr. HutchinsonUh-huh , sure , sure . And I suppose the scratches and cuts on your body are from feeding your chickens and stealing their eggs on your body or from feeding your chickens and stealing their eggs .
Stacy FrostNo , that happens when I don't give them enough treats . I get pecked . Do you really so ? I do actually . Yeah , they're spoiled . They're really spoiled on mealworms and all kinds of treats . So , yeah , okay , um , all right , so moving on . Uh , here's a question I've got for you , linton . All of us talk about asking clients further information about appearance . Some clients might be a little bit more sensitive to making observations about how they look . Even if your questions are phrased what you think is in a gentle way , they might feel self-conscious . Exposed , even get a little bit defensive . Exposed , even get a little bit defensive . So how would you navigate a situation where the client seems uncomfortable with ?
Dr. Hutchinsonyou saying anything or asking about their appearance at all . Well , you know , it's always always important to consider the timing and the context of your questions Instead of leading with questions about the client's appearance right off the bat . You need to wait until you've established some kind of rapport and trust with the client before you go that route . Another strategy is to use more general , open-ended questions that give the client space to bring up appearance issues on their own . You might ask them like what have you been doing to take care of yourself lately , instead of I see you chewed your nails down to the nubs .
Stacy FrostI'm trying to think of there . There must be some therapists out there who actually would say it that way . Who would lead with that as a comment ?
Dr. HutchinsonNo kidding , can you say , albert Ellis , as an aside , he bluntly pointed out clients' irrational thoughts and beliefs , sometimes , sometimes mostly all the time , in a confrontational manner . He used colorful , forceful language and didn't mince words . For example , he would tell a client that they were full of , let's say , rubbish . I remember going to a really I remember going to a conference here in Orlando when he was the main speaker and let me tell you , more than one therapist walked out on that lecture .
Stacy FrostOh boy , I bet that was quite an experience . Do you remember where he was from , wynton ?
Dr. HutchinsonYeah , I do . Well , he spent a lot of his time teaching in New York City at New York University .
Stacy FrostI love your New York accent . It sounds a little bit more Bostonian to me . I know you spent some time up there .
Dr. HutchinsonYeah , I did .
Stacy FrostRather than focusing on quickly getting to the core of the client's issues using this sort of in-your-face type of therapy . I'd rather go on the Alfred Adler side of the spectrum here and use a more encouragement-based approach to therapy .
Dr. HutchinsonGot it .
Stacy FrostYou know where you work on instilling courage and confidence to make positive changes . But that is a whole other podcast , so we'll get back to some more ideas about what you can do if your client seems uncomfortable with being put on the spot with your observations about their appearance .
Dr. HutchinsonOkay , okay .
Stacy FrostYou could , for example , explain your rationale behind asking about their appearance . So , using the nail biting example like we've been talking about , after validating their reaction , you might say something to the effect of you know , I'm sorry if my observations felt a little intrusive . I bring up these details because sometimes they can give clues about what you might be going through , like if you're struggling with anxiety or depression that maybe you're not aware of . But I respect your privacy and your right to share what feels comfortable to you . Can you help me to understand what came up for you when I mentioned your nails .
Dr. HutchinsonThat's a much softer kind of an approach , obviously . Yeah , Okay , Now that you've got a pretty good understanding of what to look for when assessing a client's physical appearance good understanding of what to look for when assessing a client's physical appearance , let's
move on to behavior . When assessing behavior , you observe the client's actions , their mannerisms and reactions during a session or the interview On the exam . You'll be given clues to their presenting problems , either directly through reporting the results of an MSE or your observation of their behaviors in the session .
Stacy FrostRight and you'll be documenting their level of cooperation . So are they cooperative working with you ? Are they hostile ? Are they maybe more guarded ? And their psychomotor activity , which means their level of physical activity ? Are they pacing around your office ? Are they fidgeting with their hands and they're having a hard time staying seated , or are they so tired that they're nodding off in the middle of the interview ? Are their movements noticeably slow ? That type of thing ?
Dr. HutchinsonSo , just like with appearance , your observations of behavior can provide valuable diagnostic clues . For example , if a client frequently figures and taps their foot or wrings their hands , they may be experiencing anxiety . A client with depression might exhibit slower movements and appear real lethargic , slouching in their chairs and speaking real , real , slow . And a client with a history of trauma or PTSD might appear hypervigilant or easily startled during the session . They could have difficulty relaxing and instead maintain a rigid posture or appear always on guard .
Stacy FrostThose are great examples . Of course , it's important not to jump to conclusions based on appearance and behavior alone . You need to integrate those observations with the full clinical picture and it's important to interpret behaviors within the context of the situation . So let's say Clinton , not related to anyone in this podcast . Clinton comes into your office for his Wednesday appointment . It's pretty close to lunchtime . He usually chooses a time slot later in the day , but this is the only opening that you had Now . You notice that Clinton seems a bit distracted and he's eager to wrap up this session before it even begins . Well before diagnosing him with ADHD or bipolar disorder , you'd want to consider that he may simply be hungry , distracted and thinking about his meal . It is , after all , wednesday , his favorite BOGO public sushi day .
Dr. HutchinsonAnd you know Kai will always give me a second helping of wasabi Right . But make sure to consider the duration of the client's behavior over time . For example , if Tracy not related to anyone here , stacy , your next client comes in after lunch where she has just finished stuffing her face with sauerkraut washed down with a few pints of Beck's beer , that very well could be the reasons why it's hard for her to respond or think of anything else . But if Tracy consistently shows difficulty focusing , appears lethargic or was easily distracted from the topic at hand , that behavior would be more clinically relevant if it persists from session to session . In that case you might explore if she's experiencing underlining anxiety , adhd symptoms or some other issue interfering with her attention and engagement .
Stacy FrostYou know , linton , all this talk about sauerkraut really has my stomach rumbling . So how about we do a quick summary of what we've talked about and then we get off to eat our lunch ? When assessing appearance on the MSC , we observe the client's clothing , grooming , hygiene , physical build , level of eye contact , facial expressions and posture , and any visible injuries or abnormalities , and these observations can give us clues about the client's self-care , their physical health and potential mental health concerns . Now it's important to pay attention to real , subtle details too , like dental health , nails and skin , as these can also provide insights into the client's overall well-being and functioning . When asking about sensitive appearance issues , it's crucial to establish rapport , choose the right timing and frame your questions gently and with empathy . Open-ended questions about self-care can invite reflection without putting the client on the spot and in terms of behaviors .
Dr. HutchinsonWe observe the client's actions , mannerisms and reactions throughout the interview . This includes their level of cooperation , psychomotor activity , impulse control and ability to regulate emotions .
Your observations can provide valuable diagnostic clues , but should always be interpreted in context of the client's full presentation and circumstances .
Stacy FrostExactly . And one more thing before we go you want to make sure that you're taking your client's cultural background into consideration too . I know we mentioned eye contact , and sometimes a kind of decreased eye contact can be a sign of anxiety . It could also be a cultural . There could be a cultural explanation for those kinds of behaviors .
Dr. HutchinsonAnd as you study for your exams , remember it's in there , it's in there .