Five Questions on The Way to Diagnosis: One Big Messy Package

FIVE QUESTIONS ON THE WAY TO DIAGNOSIS: One Big Messy Package

Major Parts of a Personal and Social History

Mental health professionals recommend the need to understand the whole patient to diagnose a condition correctly. Therefore, they should understand environmental and historical factors that place an individual at the risk of developing a mental health problem, such as depression. The diagnosis should go beyond the presenting symptoms, behavioral and emotional characteristics to include social and health histories that provide information regarding the patient’s condition. Mental health care providers who ignore the factors are most likely to provide incomplete care and place patients at the risk of relapse. In Dennis’ case, the case manager should establish the personal and social history factors that are likely causes of his emotional and behavioral symptoms. Childhood factors that affect the individual include being raised in a single-parent home. Dennis is a mixed racial child (black/white) raised in a predominantly black, urban community. The patient has never lived in the same household with his white father, who is now married and living with his new family. Dennis has grown up in the same community but reports that he has few friends or close relatives. He recently found out that he has a sister in the same community college but seem uninterested to know her since he fears that his mother will not like the idea. In family history, Dennis has a close relationship and takes care of his mother due to the deep sense of responsibility, having lived with her his whole life. He is currently in a community college and works full time at a local nursing home during his adulthood. He loves taking care of older people and seems to be happier in the nursing home than in community college.

How Physical and Mental Disorders may be Related

Mental health care providers should understand the relationship between physical and mental health to correct diagnosis and provide comprehensive treatment. Information regarding the connection between the two spheres of health informs the need for comprehensive assessment, diagnosis, and treatment. One of the clear connection is between the physical experiences of combat, such as in the Vietnam War, and presenting mental illnesses, such as post-traumatic stress disorder and anxiety disorders. Individuals living with serious and chronic health illnesses are at a higher risk of developing various mental health conditions, such as anxiety and depression. Co-existing mental and physical health problems have a detrimental impact on the patient’s wellbeing and quality of life. Besides, they can cause a cycle of physical and mental health issues if untreated for a long time. Hence, mental health professionals should realize that physical illness can be a risk factor for mental illnesses. Physical illnesses have diverse connections to mental health, such as being a causal factor, worsening mental health symptoms, or mental health resulting from physical health treatment. Working with the patient to understand symptoms and health history can help understand the physical illness whose existence can cause or worsen mental health symptoms, such as depression. For example, post-partum hormonal problems can cause mental health problems, such as post-partum repression in women, revealing a close connection between physical and mental health. The information is critical since treatment for mental health conditions without understanding and treating physical illnesses might be counterproductive. While not all mental health conditions have a physical illness connection, mental health professionals should understand the potential connection since ignoring reality can be detrimental for the patient.

The Major parts of the Mental Status Examination (MSE)

Mental health illness diagnosis is a critical step in providing effective treatment to relieve the symptoms. Mental health examination (MSE) is one tool that helps mental health care providers diagnose and treat mental health illnesses. The person conducting the assessment focuses on how the patient looks, feels, and behaves during the assessment. However, the person conducting the assessment should focus on the characteristics that the patient does not show at the moment. SME has various parts that the clinician should understand to conduct a comprehensive examination of the patient. Appearance is the first part, which relates to the patient’s observation during the examination instead of questioning or another approach to obtain further details. Although the general appearance does not provide adequate details, it helps the clinician to have an initial picture of the mental health condition. However, the appearance could change from one instant to another. Another part of the assessment is the level of attention, checking whether the patient is alert or drowsy. Various attention levels suggest different types of mental disorders, such as hypervigilance among individuals with post-traumatic stress disorder. The amount of activity is another important part of SME, which indicates the possibility of mental health illnesses. For example, a patient who appears uncomfortable and keeps juggling the legs could be suffering from anxiety. The flow of speech, such as loose associations, could suggest mental health disorder, such as anxiety. Content of thought can also play a role in mental health diagnoses, such as through hallucinations or delusion. Cognition and intellectual resources’ flaws can be indicative of conditions, such as dementia, while insight and judgment are common among patients with alcoholism or substance abuse disorder.

How to use the results of the MSE in the diagnostic process

The mental status examination (MSE) can support the diagnosis of a wide range of mental health problems by considering the different components, such as appearance, mood and affect, cognition, and judgment. A focus on one or a few of the components cannot provide comprehensive diagnoses of a mental health condition. Thus, the clinician should collect quantitative and qualitative data during the assessment by observing and interviewing the patient to determine appearance and behavior. Information from the assessment is considered against common symptoms for mental health conditions. For example, mental health professionals recognize that cognitive decline and poor judgment are common symptoms among individuals with dementia. Hyperactivity and attention deficit can suggest that an individual has attention deficit hyperactivity disorder (ADHD). The assessment results summarize the examination outcome on a comprehensive, cross-sectional level for the clinician to make an objective diagnosis. However, the clinician should include the patient’s biographical information and psychiatric history to use the assessment results to support diagnosis and effective treatment. Furthermore, the assessment results provide fundamental data to establish the criteria for mental health diagnosis according to DSM-5 criteria. The mental health diagnostic tool includes conditions that an individual should meet to be diagnosed with a specific type of mental health condition. For instance, the assessment can prove inattention in children, failure to pay attention to detail, being easily distracted, hyperactivity and impulsivity to support the DSM-5 criteria for attention deficit hyperactivity disorder. The assessment’s results help the clinician determine the type of treatment depending on the diagnosis or order further tests or examinations to get a more accurate diagnosis.

A Mental Status Examination Rating for Dennis

The health care provider helping Dennis should conduct a mental health assessment to determine his condition and provide relevant intervention to recover and live a productive life. For example, one of the items that the assessment will focus on is mood and effect. The clinician will ask the patient to rate the mood from 1 to 10. His mood during the assessment is 3, which shows that he is more sad than happy. The table below summarizes Dennis’ assessment results:

The assessment results indicate that the patient has some cognitive flaws, evident in his poor schoolwork, misspellings in written language, and transposed letters or numbers that place him at the risk of being kicked out of the community college. From the assessment, most of the scores, such as memory, language, reasoning, and constructional abilities, are closer to 1 than 10, indicating the limitations in Dennis’ cognitive capabilities.  Besides, the patient’s mood is low at a score of 3, which reveals that the patient is sad or depressed, especially when he is away from the nursing home where he enjoys taking care of older residents. His appearance and general appearance also indicates that the patient might be suffering from depressive symptoms, possibly due to his family history and personal conditions, such as the conflict within him regarding whether to meet his sister. Therefore, the therapist should provide effective intervention to support the client to overcome the depressive mood and become happy in other environments outside the nursing home.

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