15 steps to taking a mental exam in therapy

In a therapeutic intervention, it is essential that the psychologist collects as much information as possible from the patient: family environment, social, economic, work or educational conditions and history clinical In order to make a diagnosis as accurate as possible, it is important to take into account the above 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 by 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.

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How to do a mental exam

These are the 15 elements to analyze to perform a mental exam:

1. Physical appearance

Pay attention to posture, grooming, dress, and body build. If the patient has been treating for a long 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 of his name, date of birth, date of the session, place where the interview is carried out.

3. Speech and language

Evaluate speed of speech, volume of voice, 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 can be a sign of a manic phase, or slow, that 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.

• Related article: "The 6 types of schizophrenia and associated characteristics"

5. Affected

It is the emotional state expressed by the patient throughout the interview. Inconsistencies can be observed and that the affect is inappropriate in relation to the facts that it tells, as well as absence of affective response or instability.

6. Mood

It cannot be observed, rather it is inferred by the psychologist and you have to make a comparison between what you observe and what the patient says. It describes her state of mind in the last 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 of associations. Alterations in this element may represent thought disorders, a manic phase of Bipolar disorder, substance intoxication.

8. Thought content

What it contains: if there is presence of delusional thinking, common in schizophrenic and thinking disorders; obsessive, mainly in obsessive compulsive disorder, but that can also appear in eating behavior and impulse control disorders; or overrated ideas.

9. Perceptual disturbances

It is necessary to ask directly if the patient sees, hears, smells or feels things that are not based on any sensory or sensitive 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 answering she first turns to the other side or talks to someone else. The alterations are related to hallucinations, schizophrenic and psychotic disorders or substance intoxication.

• You may be interested: "The differences between hallucination, pseudo-hallucination, and hallucinosis"

10. Suicidal and / or homicidal ideation

It is extremely important to address in patients who have a history of violent acts, problems with the law, personal history of attempted suicide or family. If in the interview it appears that he plans to commit suicide or kill someone, the focus should be changed immediately, this element becomes an urgency. You need to be directed to hospital care in case of suicidal ideation or notify the police, in case of homicidal ideation.

• Related article: "Suicidal thoughts: causes, symptoms and therapy"

11. Attention, concentration and memory

It can be assessed without the need for specific questions, but only by analyzing behaviors and responses during the session. If there is not enough information, the patient can be asked to spell words backwards and forwards, make him 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.

In case a cognitive deficit is suspected, It is recommended to apply the Mini-Cognitive Exam.

12. Abstract thinking

The easiest way to evaluate this element is by asking the patient to explain the meaning of a saying or proverb. Concrete thought can present itself as an alteration or as a symptom of a 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

Ask questions about how you react to specific situations that have a high probability of occurring and that are related to the daily life of the patient.

15. Neurovegetative, sexual and appetite

These elements are evaluated with specific questions: sleep cycle, how much you sleep, quality of sleep and frequency. If there have been changes in your sexual motivation and practices with your partner (if any) or if there has been any change in your eating habits or your appetite.

Its use in psychotherapy

The mental exam is not a one-time evaluation, but a constant, throughout the therapeutic treatment, the psychologist must be analyzing and evaluating these aspects to have a broader panorama of the evolution of the individual. It is important that all the changes that are observed are noted to find possible causes and infer consequences. And in this way, to mold the therapy according to the needs of the patient.