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HPS715-­‐426    
Issues  in  Psychological  Assessment  

Clinical  Assessment  –  Part  2  

 
 
Associate  Professor  Ross  King  
 

Lecture Outline
—  Assessing  specific  disorders  and  behaviours  
—  Mood  
—  Anxiety  
—  Substance  Use  
—  Mental  Status  Examina@on  

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Unit  learning  outcomes  

ULO1   Understand  the  process  of  individual  test  administra<on,  
scoring  and  interpreta<on  

ULO2   Compare  and  evaluate  the  theore@cal,  empirical  and  

prac@cal  bases  that  underpin  the  construc@on  and  
implementa@on  of  commonly  used  assessment  tools  

ULO3   Formulate  working  hypotheses  on  the  basis  of  the  

assessment  
ULO4   Communicate  assessment  results  and  case  formula<ons  
clearly  and  ethically  in  both  oral  and  wriFen  forms  

ULO5   Iden@fy,  predict  and  solve  ethical  issues  with  respect  to  
assessment  

What is the Best Way to Assess?

—  Clinician  ra@ng  scale  
—  Advantages?  Disadvantages?  

—  Client  self-­‐report  

—  Advantages?  Disadvantages?  

—  Other:  
•  Behavioural  Observa@on  –  e.g.,  MSE  

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Depends on what want to assess

—  Possible  presence  of  disorder  -­‐  screening  
—  Diagnos@c  criteria  -­‐  do  they  meet  them?  
—  Comorbid  condi@ons  -­‐  other  disorders?  
—  Person’s  individual  paOern  of  symptoms  -­‐  frequency,  
dura@on,  intensity,  triggers,  features  etc  
—  Cogni@ons,  thoughts,  beliefs  associated  with  disorder  
(e.g.,  thought-­‐ac@on  fusion  in  OCD,  maladap@ve  
schemas  in  depression)  
—  Associated  features  -­‐  e.g.,  perfec@onism  in  depression;  
avoidance  in  anxiety.  

Assessment
Screening  measures  
•  Pa<ent  Health  Ques<onnaire  -­‐9  
•  GAD-­‐7  
•  CAGE  or  TWEAK  

Clinician  ra@ng  scales  

•  Hamilton  Depression  Ra<ng  Scale  
•  Yale-­‐Brown  Obsessive-­‐Compulsive  Scale  
Self  –report  –  >  30  scales  of  depression  alone  
Broad:  
•  Beck  Depression  Inventory  
•  Depression  Anxiety  Stress  Scale  
•  Specific:  
•  Edinburgh  Postnatal  Depression  Scale  
•  Depression  in  the  Medically  Ill  Scale  

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Mood Assessment
—  Controversies  in  assessing  mood  disorders:  
—  Disease  process  (endogenous)  or  response  to  difficulty/
adversity  (reac@ve)  
—  Number  and  nature  and  types  of  depression:  
—  DSM-­‐5  describes:  
—  Melancholic  
—  Atypical  
—  Seasonal  paOern  
—  With  psycho@c  features  
—  With  anxious  distress  
—  With  mixed  features  
—  Persistent  Depressive  Disorder  (Dysthymia)  –  chronic  depression  
—  Rela@onship  between  depression  and  other  psychological  
states  such  as  anxiety  

Mnemonics  for  Depression  Symptoms  

—  SAD FACIES —  DEPRESSION

—  Sleep —  Depressed mood
—  Appetite —  Energy
—  Psychomotor changes
—  Depressed mood
—  Reduced concentration in
—  Fatigue (low energy) decision making
—  Agitation (or retardation) —  Esteem decreased,
—  Concentration Excessive guilt
—  Sleep changes
—  Interest (anhedonia)
—  Suicidal ideation
—  Esteem decreased,
—  Interest decreased
Excessive guilt
—  Other - think of manic, panic,
—  Suicidal ideation organic
—  Nutritional changes (appetite
& weight)
From: Goldstein, B & Levitt, A (2004). Assessment of patients with depression. In D.S. Goldbloom (ed.),
Psychiatric assessment skills. Mosby Elsevier

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Screening  for  Depression  -­‐  Golstein  &  LeviO’s  (2004)  

Sophis<cated  Screening  Ques<ons  for  Depression  

—  Q1:  For  the  past  2  weeks  or  more  have  you  felt  sad,  blue,  or  
hopeless  almost  all  day,  almost  every  day?  
If  no,  use  alterna@ve  descriptors  
—  Q2:  For  the  past  2  weeks  or  more  have  you  felt  low,  gloomy,  
down  in  the  dumps  almost  all  day,  almost  every  day?  
If  s@ll  no,  ask  about  anhedonia  
—  Q3:  For  the  past  2  weeks  or  more  have  you  lost  interest  (or  
pleasure)    in  things  almost  all  day,  almost  every  day?  
—  If  evidence  for  depression,  then  do  full  assessment  

From: Goldstein, B & Levitt, A (2004). Assessment of patients with depression. In D.S. Goldbloom (ed.),
Psychiatric assessment skills. Mosby Elsevier

Screening for Depression

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Diagnosis  or  symptom  severity?  

—  Mood  assessments  usually  provide  only  indica@on  of  illness  
severity  
—  Not  sufficient  for  diagnos@c  purposes  

Hamilton  Depression  Ra@ng  Scale  

—  Clinical  or  observer  rater  scale  

—  Original  17  item  version  published  1960s  based  on  

depression  symptoms  in  hospitalised  pa@ents  

—  Later  21  and  24  item  version  

—  Assesses  severity    

—  Items  -­‐  soma@c,  behavioural  and  anxiety  features  

 
—  Clinician  conducts  interview  then  rates  person  on  items  

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Hamilton  Ra@ng  Scale  of  Depression  

—  Depression  
Depressed  mood  is  not  easy  to  assess.  One  looks  for  a  gloomy  aftude,  pessimism  
about  the  future,  feelings  of  hopelessness  and  a  tendency  to  weep.  As  a  rule  
milder  depressive  mood  is  relieved,  at  least  in  part,  by  company  or  external  
s@mula@on.  When  pa@ents  are  severely  depressed  they  may  go  beyond  weeping.    
It  is  important  to  remember    that  pa@ents  may  interpret  the  word  “depression”  in  
all  sorts  of  strange  ways.  A  useful  common  phrase  is  “lowering  of  spirits.”  
 
It  is  generally  believed  that  women  weep  more  readily  than  men,  but  there  is  liOle  
evidence  that  this  is  true  in  the  case  of  depressive  illness.  There  is  no  reason  to  
believe,  at  the  moment,  that  an  assessment  of  the  frequency  of  weeping  could  be  
misleading  when  ra@ng  the  intensity  of  depression  in  women.  

13

Source: (Williams JBW: A structured interview guide for the Hamilton

Depression Rating Scale. Archives of General Psychiatry 45:742-747, 1988)

7
 Hamilton Depression Rating Scale. Arch Gen Psychiatry
(e.g., hypersomnia, hyperphagia) are not assessed (see 4 |__| Attempts at suicide (any serious attempt rate 4). urinary frequency
1988; 45(8):742–7. sweating
SIGH-SAD, page 55).
INSOMNIA: EARLY IN THE NIGHT 4 0 |__| Absent.
0 |__| No difficulty falling asleep. 1 |__| Mild.
Address for correspondence
1 |__| Complains of occasional difficulty falling asleep, i.e. 2 |__| Moderate.
Scoring more than 1⁄2 hour. 3 |__| Severe.
3 SUICIDE The
11 ANXIETYHDRS is
SOMATICin the publicdifficulty
(physiological
2 |__| Complains of nightly domain.
concomitants
falling asleep.of 4 |__| Incapacitating.
Method
0 |__for scoring varies by version. For the HDRS17, a
| Absent. anxiety) such as:
score1 of|__0–7 is generally
| Feels accepted
life is not worth living. to be within the normal gastro-intestinal – dry mouth, wind, indigestion, diarrhea,
5cramps,
INSOMNIA:
belching MIDDLE OF THE NIGHT 12 SOMATIC SYMPTOMS GASTRO-INTES
2 |__| Wishes he/she were dead or any thoughts of possible
death to self. 0 |__| No
cardio-vascular difficulty. headaches
– palpitations, 29/04/16
0 |__| None.
3 |__| Ideas or gestures of suicide. respiratory
1 |__| – hyperventilation,
Patient complainssighing of being restless and disturbed 1 |__| Loss of appetite but eating without st
4 |__| Attempts at suicide (any serious attempt rate 4). urinary frequency
sweating
during the night. encouragement. Heavy feelings in abd
3 SUICIDE 11 ANXIETY SOMATIC
Hamilton Depression Rating Scale (HDRS)
4 INSOMNIA: EARLY IN THE NIGHT 0 2|__ |__| Waking during the night – any getting out of bed rates 2 |(physiological concomitants of
__| Difficulty eating without staff urging. R
0 | |__Absent.
| Absent. anxiety) such as:
0 |__| No difficulty falling asleep. 1 |__| Mild.2 (except for purposes of voiding). requires laxatives or medication for b
1 | | Feels life is not worth living. gastro-intestinal – dry mouth, wind, indigestion, diarrhea,
1 |__| Complains of occasional difficulty falling asleep, i.e. 2 |__| __Moderate. medication for gastro-intestinal sympt
more than 1⁄2 hour. 2 | |__Severe.
| Wishes he/she were dead or any thoughts of possible cramps, belching
PLEASE COMPLETE THE SCALE BASED 63 ON |__
INSOMNIA:
A STRUCTURED EARLY
death to self. HOURS
INTERVIEW OF THE MORNING cardio-vascular – palpitations, headaches
2 |__| Complains of nightly difficulty falling asleep. 4 |__| Incapacitating.
Instructions: for each item select the one “cue” which best characterizes the 0patient. 3 |__
|__|| Be Nosure
Ideas difficulty.
or gestures
to record of suicide. the answers in the appropriate respiratory 13 GENERAL
spaces– hyperventilation, sighingSOMATIC SYMPTOMS
5 INSOMNIA:
(positions 0 through MIDDLE
4). OF THE NIGHT 1 4 |__
12 SOMATIC |__| SYMPTOMS
Wakingatinsuicide
Attempts early hours
(any seriousofattempt
GASTRO-INTESTINAL the morning
rate 4). but goes back urinary frequency 0 |__| None.
0 |__| No difficulty. 0 |__| None. to sleep. sweating 1 |__| Heaviness in limbs, back or head. Bac
1 |__| Patient complains of being restless and disturbed 1 4 |__ | Loss ofEARLY appetite but eating without staff
1 DEPRESSED MOOD (sadness, hopeless, helpless, worthless) 2 2 INSOMNIA:
|__| Unable
FEELINGS to IN
OF fallTHE
GUILTasleep NIGHT again if he/she gets out of bed. 0 |__| Absent. headaches, muscle aches. Loss of ene
during the night. 0 | encouragement.
| No difficulty Heavy
falling asleep. feelings in abdomen. 1 | | Mild.
02 ||____|| Waking
Absent.during the night – any getting out of bed rates __ __ fatigability.
2 |__0 |__| Absent.
| Difficulty eating without staff urging. Requests or
1 |__| 2These feeling states indicated only on questioning. 7 WORK 1 1 | __ |
| Complains
| Self
__ANDlaxatives of occasional
reproach,
ACTIVITIES difficulty
feels falling
he/she asleep,
has i.e.
let people 2
down. |__ | Moderate. 2 |__| Any clear-cut symptom rates 2.
(except for purposes of voiding). requires or medication for bowels or
2 |__| These feeling states spontaneously reported verbally. 2 | __more
| than
Ideas
1
⁄2 hour.
of guilt or rumination over past errors3 |
or__ | Severe.
sinful
0 |__medication
| No difficulty. for gastro-intestinal symptoms.
6 3INSOMNIA:
|__| Communicates
EARLY HOURS feelingOFstates
THEnon-verbally,
MORNINGi.e. through 2 |__| Complains deeds. of nightly difficulty falling asleep. 4 |__| Incapacitating.
1 |__| Thoughts and feelings of incapacity, fatigue or 14 GENITAL SYMPTOMS (symptoms such a
0 |__| No facial expression, posture, voice and tendency to weep. 13 GENERAL
difficulty. 3 |__SOMATIC | PresentSYMPTOMS illness is a punishment. Delusions of guilt.
1 | | Waking in early hours of the morning but goes back 0 5 | INSOMNIA:
| None. weakness
MIDDLE related
OF THE to activities,
NIGHT work or hobbies.
12 SOMATIC SYMPTOMS menstrual disturbances)
GASTRO-INTESTINAL
4 |__ __| Patient reports virtually only these feeling states in __4 |__| Hears accusatory or denunciatory voices and/or
to sleep. spontaneous verbal and non-verbal
his/her 1 2|__ 0 ||__ || No
|__HeavinessLoss ofininterest
difficulty.
experienceslimbs, back inthreatening
activity,
or head. hobbies
visual or
Backaches, work – either
hallucinations.0 |__| None. 0 |__| Absent.
2 |__| Unable to fall asleep again if he/she gets out of bed.
communication. 1 |__headaches, directly
| Patient reported
muscle
complains ofaches.
beingbyrestless
the
Losspatient
of
andenergy or indirect
disturbed and in 1 |__| Loss of appetite 1 |__ but| eating
Mild.
without staff
fatigability.
listlessness,
during the night. indecision and vacillation (feels he/she has encouragement. 2 |__ | feelings
Heavy Severe.in abdomen.
7 WORK AND ACTIVITIES 2 |__| Any clear-cut symptom rates 2.
2 |__| Waking to push during
selfthetonight work – anyorgetting out of bed rates
activities). 2 |__| Difficulty eating without staff urging. Requests or
28 0 |__| No difficulty. 2Decrease
(except for purposes of time
voiding).
1 |__| Thoughts and feelings of incapacity, fatigue or 3 |__| SYMPTOMS
14 GENITAL in actual
(symptoms spent
suchinas activities
loss of or decrease requires
libido, 15 laxatives or medication for bowels or
HYPOCHONDRIASIS
weakness related to activities, work or hobbies. menstrual disturbances) in productivity. Rate 3 if the patient does not spend at medication0for |gastro-intestinal __| Not present. symptoms.
2 |__| Loss of interest in activity, hobbies or work – either 6 INSOMNIA:
0 |__| Absent. EARLY HOURS OF THE MORNING
least three hours a day in activities (job or hobbies) 1 |__| Self-absorption (bodily).
directly reported by the patient or indirect in 1 |__ 0 | |__Mild.
| No difficulty. 13 GENERAL SOMATIC SYMPTOMS
listlessness, indecision and vacillation (feels he/she has 2 |__
excluding routine chores. 2 |__| Preoccupation with health.
1 | |__Severe.
| Waking in early hours of the morning but goes back 0 |__| None.
to push self to work or activities). 4 |__| toStopped sleep. working because of present illness. Rate 14 if|__| Heaviness 3in limbs, |__|backFrequent complaints, requests for hel
or head. Backaches,
3 |__| Decrease in actual time spent in activities or decrease 15 HYPOCHONDRIASIS
2 |__| Unable patient engages
to fall asleep againin noif he/she
activities
gets outexcept
of bed.routine chores, headaches,4muscle |__aches.
| Hypochondriacal
Loss of energy and delusions.
in productivity. Rate 3 if the patient does not spend at 0 |__| Notor present.
if patient fails to perform routine chores unassisted. fatigability.
least three hours a day in activities (job or hobbies) 1 |__| Self-absorption (bodily).
excluding routine chores. 2 7 |__ WORK AND ACTIVITIES
| Preoccupation with health. 2 |__| Any 16 LOSS
clear-cut symptomOFrates
WEIGHT
2. (RATE EITHER a OR b
4 |__| Stopped working because of present illness. Rate 4 if 83 RETARDATION
0 | |__Frequent
|__ | No difficulty. (slowness
complaints, of thought
requests for help, andetc.speech, impaired a) According to the b) According to w
patient engages in no activities except routine chores, ability
4 |__ 1 | | Thoughts
to| concentrate,
__Hypochondriacal and feelings
decreased of
delusions. incapacity, fatigue
motor activity) or 14 GENITAL SYMPTOMS (symptoms
patient: such as loss of libido,
measurement
or if patient fails to perform routine chores unassisted. weakness related
0 |__| Normal speech and thought. to activities, work or hobbies. menstrual disturbances)
0 |__| No weight loss. 0 |__| Less than 1
16 LOSS 2 OF
| __ | WEIGHT
Loss of interest (RATEin EITHER
activity, hobbies aorOR work b)– either 0 |__ | Absent.
8 RETARDATION (slowness of thought and speech, impaired
1 |__| Slight
a) According to the
retardation during the interview. week.
directly reported byb)theAccording patient or indirectto weekly
in 1 |__| Mild.
ability to concentrate, decreased motor activity) 2patient:
|__| Obvious retardation during the interview.
measurements: 1 |__| Probable weight 1 |__| Greater tha
listlessness, indecision and vacillation (feels he/she has 2 |__| Severe.
0 |__| Normal speech and thought. 0 3|__||__ No| weight Interview loss. difficult. 0 | | Less than 1 lb weight loss in loss associated with in week.
to push self to work or__ activities).
1 |__| Slight retardation during the interview. 4 3 |__ | Complete stupor. week. present illness.
2 |__| Obvious retardation during the interview. 1 |__ | |Probable
__| Decrease in actual
weight time
1 |__ spent in activities
| Greater 1 lb weight 15
or decrease
than lossHYPOCHONDRIASIS
in productivity. Rate 3 if the in patient does not spend at 0 |__| Not present. 2 |__| Definite (according 2 |__| Greater tha
3 |__| Interview difficult. loss associated with week.
4 |__| Complete stupor. 9 AGITATION present leastillness.
three hours a day in activities (job or hobbies) 1 |__| Self-absorption (bodily). to patient) weight in week.
2 0|__||__ | excluding
Definite None. routine chores.
(according 2 |__| Greater than 2 lb weight loss2 |__| Preoccupation with health. loss.
9 AGITATION 1 4 |__|to
__|patient) weight
Fidgetiness.
Stopped working because of inpresent week. illness. Rate 4 if 3 |__| Not
3 |__| Frequent complaints, assessed.
requests for help, etc. 3 |__| Not assesse
0 |__| None. loss. patient engages in no activities except routine chores, 4 |__| Hypochondriacal delusions.
2 |__ | Playing with hands, hair, etc.
1 |__| Fidgetiness. 3 |__| Not assessed. 3 | __ | Not assessed.
2 |__| Playing with hands, hair, etc. 3 |__| orMoving if patientabout,
fails to perform
can’t sitroutinestill. chores unassisted. 17 INSIGHT
3 |__| Moving about, can’t sit still. 4 |__| Hand wringing, nail biting, hair-pulling, biting of16lips.
17 INSIGHT
LOSS OF WEIGHT 0 (RATE
|__| EITHER a OR b) being depressed and il
Acknowledges
4 |__| Hand wringing, nail biting, hair-pulling, biting of lips. 8 RETARDATION (slowness
0 |__| Acknowledges being depressed and ill. of thought and speech, impaired a) According to the b) According to weekly
1 |__| Acknowledges illness but attributes ca
ability to concentrate, decreased motor
1 |__| Acknowledges illness but attributes cause to bad food, activity) patient: measurements:
10 ANXIETY
0 |__climate,
PSYCHIC
| Normaloverwork,speech and thought.
climate, overwork, virus, need for res
0 |__| No weight loss. 0 |__| Less than 1 lb weight loss in
10 ANXIETY PSYCHIC virus, need for rest, etc.
0 |__| No difficulty. 2 0|__ 1 ||__ || Slight
|__Denies No beingdifficulty.
retardationill atduring
all. the interview. 2 |__| Denies week. being ill at all.
1 |__| Subjective tension and irritability. 1 2 |__|__|| Obvious
Subjective tension
retardation during andtheirritability.
interview. 1 |__| Probable weight 1 |__| Greater than 1 lb weight loss

HDRS
2 |__| Worrying about minor matters. 2 3 |__
Total score: |__||__|Interview
Worrying
__ | about minor matters.
difficult. Total score:
loss associated with |__
in |week.
__|
3 |__| Apprehensive attitude apparent in face or speech. 3 4 |__|__| Complete
Apprehensive stupor. attitude apparent in face or speech. present illness.
4 |__| Fears expressed without questioning.
4 |__| Fears expressed without questioning. 2 |__| Definite (according 2 |__| Greater than 2 lb weight loss
This scale is in the public domain. 9 AGITATION to patient) weight in week.
—  Produces  total  score:  symptom  severity  
This scale the&
0 |__is| inNone.
 “confirma@on”  
public
1 |__| Fidgetiness.
domain. of  3 |__| loss.
Not assessed. 3 |__| Not assessed.

diagnosis   2 |__| Playing with hands, hair, etc.

3 |__| Moving about, can’t sit still. 17 INSIGHT
4 |__| Hand wringing, nail biting, hair-pulling, biting of lips. 0 |__| Acknowledges being depressed and ill.
—  <  10    not  depressed      (remission)   29
1 |__| Acknowledges illness but attributes cause to bad food,
10 ANXIETY PSYCHIC climate, overwork, virus, need for rest, etc.

—  11  -­‐  16  ‘minor’  depression   0 |__| No difficulty.

1 |__| Subjective tension and irritability.
2 |__| Denies being ill at all.

2 |__| Worrying about minor matters. Total score: |__|__|

—  17  -­‐  25  major  depression   3 |__| Apprehensive attitude apparent in face or speech.
4 |__| Fears expressed without questioning.

—  >  26  severe  depression   This scale is in the public domain.

 
—  Factor  analy@c  studies  suggest  otherwise  
—  5  factors  (global,  insomnia,  slowing,  weight  loss,  gastro-­‐ 29

intes@nal  symptoms)  (Gibbons  et  al,  1993)  

—  4  factors  (soma@za@on,  psychic  anxiety,  depression  severity,  
weight/gastro-­‐intes@nal)  (Pancheri  et  al,  2002)  

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HDRS cont.
—  Scale  fails  to  discriminate  between  different  forms  of  
depression  
—  Depression  with  predominently  cogni@ve  v.  soma@c  v.  
vegeta@ve  symptoms  

—  Clients  with  other  disorders  (e.g.,  GAD,  bulimia,  OCD)  

open  score  similarly  to  people  with  major  depression  
(DemyOenaere  &  de  Fruyt,  2003)  

Beck  Depression  Inventory  

—  Self-­‐report  scale  
—  21  items:  each  4  statements  of  increasing  severity  
—  9  cogni@ve  (self-­‐dislike,  failure,  suicide  thoughts)  
—  12  soma@c/  affec@ve  (crying,  sleep/weight/  changes  

—  Original  version  published  in  1961  

—  Based  on  Aaron  Beck’s  observa@on  of  depressed  pa@ents  in  
psychotherapy  
—  Measured:  
—  1961  original  version:  the  person’s  state  “right  now”    
—  1978  version  “last  week”;    
—  1996  BDI-­‐II  -­‐  “last  two  weeks”.  

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Proper@es  
—  Suitable  for  13  years  and  older  

—  Scale  development  based  mainly  on  white,  adult,  middle  

age  women  

—  Adequate  test-­‐retest  reliability  (r=.93)  

—  Adequate  construct  validity  

—  Hamilton  Depression  Ra@ng  Scale  r=.73  
—  Beck  Hopelessness  Scale  r=.68  

BDI-­‐  Administra<on  &  scoring  

 
Self  report    -­‐  although  clinician  explains  instruc@ons  and    
is  available  for  ques@ons.  
 
•   Illustrate  idea  of  2  week  period  with  1st  item  
•   Inspect  responses,  par@cularly  high  scores  on  
 suicidal  idea@on  &  hopelessness  
Interpreta@on  of  scores  
 Total  score  Rela<ve  Severity  
       0-­‐13                minimal  
       14-­‐19          mild  
       20-­‐28          moderate  
       29-­‐63          severe  
Note:  BDI-­‐II  is  not  a  diagnos<c  measure  -­‐  measures  severity  of  
symptoms  in  those  with  depression.  Key  issue.  

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Depression  Anxiety  &  Stress  Scale    

(Lovibond  &  Lovibond,  1995)  
—  42(or  21)  items  –  measures  Depression,  Anxiety  and  Stress  
—  Designed  to  avoid  overlap  between  constructs  
—  Each  scale  consists  of  14  primary  symptoms  in  terms  of  
severity  over  last  week  (0-­‐3  scale).  

DASS  21:    EXAMPLE  OF  SOME  ITEMS  

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how
much the statement applied to you over the past week. There are no right or wrong
answers. Do not spend too much time on any statement.
The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me to a considerable degree, or a good part of time
3 Applied to me very much, or most of the time

1. I found it hard to wind down 0 1 2 3

2. I was aware of dryness of my mouth 0 1 2 3

3. I couldn’t seem to experience any positive feeling at all 0 1 2 3

4. I experienced breathing difficulty (eg, excessively rapid breathing, 0 1 2 3

breathlessness in the absence of physical exertion)

5. I found it difficult to work up the initiative to do things 0 1 2 3

6. I tended to over-react to situations 0 1 2 3

7. I experienced trembling (eg, in the hands) 0 1 2 3

8. I felt I was using a lot of nervous energy 0 1 2 3

9. I was worried about situations in which I might panic and make a 0 1 2 3

fool of myself

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Depression  Anxiety  &  Stress  Scale    

(Lovibond  &  Lovibond,  1995)  

—  Clinical  sample  of  437  clients:    

—  high  internal  consistency  (.96  D,  .89  A,  &  .93  S)    
—  Test  re-­‐test  reliability  over  two  weeks  -­‐  .71,  .79,  &  .81  

—  Cutoffs:  provided  in  Manual  

—  DASS-­‐D  correlates  with  BDI  -­‐  .74,  DASS-­‐A  with  BDI  -­‐  .58  
—  Australian  developed  and  normed  –  and  in  use  interna@onally.  

Edinburgh  Postnatal  Depression  Scale  

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Clinician rated versus self-rated

—  Ra@ngs  consistent  in  endogenous  depression  
—  Reac@ve  and  dysthymic  pa@ents  tend  to  rate  
themselves  as  more  severely  depressed  than  clinicians  
—  Full  assessment  should  include  more  than  assessment  
of  symptoms.    
—  Need  to  assess  impairment  and  func@oning  

Source: Woo & Keatinge (2008). Diagnosis & treatment of mental disorders across the lifespan. Wiley.

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Assessment of Anxiety
—  Changes  in  DSM-­‐5  (OCD  and  PTSD  no  longer  anx  disorders)  
—  Three  groups  of  “anxiety”  disorders:  
—  Obsessive  Compulsive  Disorder  &  Related  
—  OCD,  Hoarding  Disorder,  Body  Dysmorphic  Disorder  
—  Anxiety  Disorders  
—  Panic  disorder,  Agoraphobia,  Social  anxiety,  Specific  Phobia,  
Generalised  Anxiety  
—  Trauma  &  Related  Disorders    
—  PTSD,  Acute  Stress  Disorder,  Adjustment  Disorder,  AOachment  
disorders  

Assessment of Anxiety
—  Overlap  between  different  types  of  anxiety  disorders  
—  But  also  each  has  dis@nguishing  features  

—  Assessment  Issues–  numerous  measures  exist  .    

—  Screeners-­‐  GAD-­‐7  
—  Broad  anxiety  measure  –  BAI,  DASS  
—  Disorder  Specific  –  PCL-­‐5  (Post-­‐trauma@c  checklist  for  DSM-­‐5)  
—  Need  to  carefully  scru@nise  psychometric  proper@es.  

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This outcome measure was downloaded from www.beyondblue.org.au

GAD 7
Name: _____________________________ Date: ______________

Please circle the number that best represents your response.

Over the last 2 weeks, how often have you been bothered by the following problems?

More than
Several half the Nearly
Not at all days days every day
1. Feeling nervous, anxious, or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen 0 1 2 3

Beck Anxiety Inventory

(Beck & Steer, 1990)
—  21 item self-report measure of frequency of anxiety
symptoms over past week
Sum item scores for a total GAD score.
—  Rated on 0 - 3 scale (0 - 63)
—  Cutoffs Score same as BDI-II Signature of GP
(to note that result has
been sighted)

—  Items capture both cognitive and somatic symptoms of

anxiety
—  Some  argue  more  measure  of  panic  than  general  anxiety.  i.e.  
panic  
The PHQ d isorder  
scales clients  
(including the score  
GAD-7) are adapted fromh igher  
PRIME than  
MD TODAY, other  
developed by Drsgroups  
Robert such  
L. Spitzer, Kurt as  

OCD  ,  Social  Phobia  &  GAD  (panic  bias  in  items)  

Kroenke, and Janet B.W. Williams. Copyright ©1999 Pfizer Inc

—  Factor Analysis indicates 4 factors:

—  Neurophysiological symptoms (7) - Numbness, dizzy,
shaky
—  Subjective (6) - unable to relax, terrified
—  Panic (4) - heart pounding, difficulty breathing
—  Autonomic (4) - face flushed, sweating

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Assessing Specific Anxiety Disorders:

Obsessive-Compulsive Disorder
Yale-­‐Brown  Obsessive-­‐Compulsive  Scale  (YBOCS)  
(Goodman  et  al.,  1989)  
•  Contains  3  sec@ons:  
•  Defini@ons  &  examples  of  Obsessions  &  Compulsions  -­‐  read  to  
client  
•  Symptom  checklist  -­‐  50  common  Obs  &  Comps  -­‐  asked  about  
current  &  past  
•  Clinician  ra@ng  scale:  10  core  items  
•  5  items  for  both  Obs  &  Comps:  
• Time  occupied/frequency  
• Interference  in  social  or  occupa@onal  func@oning  
•  Associated  distress  
•  Degree  of  resistance  
•  Perceived  control  over  O  &  C  
•  Each  rated  by  interviewer  of  5  point  scale  
•  Probe  ques@ons  provided  as  are  anchors    
•  Rated  with  respect  to  previous  week  

Assessing  Specific  Anxiety  Disorders:  

Obsessive-­‐Compulsive  Disorder  
Self-­‐Report  Measures    
Padua  Inventory  -­‐  Revised  (Burns  et  al.,  1996)  -­‐  obsessional  thoughts  about  harm  
to  oneself  or  others,  obsessional  impulses  to  harm  others  or  self,  contamina@on  
obsessions  &  washing  compulsions,checking  compulsions,  dressing  &  grooming  
compulsions  
Obsessive-­‐Compulsive  Inventory  -­‐  Revised  (Foa  et  al.,  2002)  -­‐18  item  
measure  -­‐  6  subscales  -­‐  washing,  ordering,  checking,  obsessing,  hoarding,  neutralising  
Obsessive  Beliefs  Ques@onnaire  &  Interpreta@on  of  Intrusions  
Inventory  (OC  Cogni@ons  Working  Group,  2001)  
OBQ  -­‐  87  items  -­‐  dysfunc@onal  assump@ons  in  6  domains  
III  -­‐  31  items  -­‐  importance  of  thoughts,  control  of  thoughts,  
responsibility  

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Social  Phobia  Self-­‐Report  

—  Social  Phobia  Scale  –  20  items  (Mafck  &  Clarke,  B  R  &  T,  1998)  
•  anxiety  related  to  social  performance    
•  “I  fear  I  may  blush  when  I  am  with  others”  
—  Social  Interac<on  Anxiety  Scale  –  20  items  (M  &  C,  1998)  
•  anxiety  related  to  social  interac@on  
•  “I  am  nervous  mixing  with  people  I  don’t  know  well”  
—  Social  Interac<on  Self-­‐Statement  Test  –  30  items  (Glass  et  al.,  Cog  
Ther  &  Res,  1982)    
•  cogni@ons  associated  with  anxiety  about  social  interac@on  
•  “I  hope  I’m  not  making  a  fool  of  myself”  

Substance  Misuse  
—  Between  30-­‐60%  of  individuals  with  depression  and  
anxiety  disorders  have  substance  use  problems  
—  Substance  use  can  ini@ated/maintained  as  a  coping  
strategy  to  manage  anxiety  or  depression  
—  Not  always  the  case  –  may  begin  early  due  to  a  
number  of  biological,  family  and  personality  factors  

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How  Common  is  Comorbidity:  Example  

Slade,  McEvoy,  Chapman,  Grove  &  Teesson  (2015).  Epidemiology  &  
Psychiatric  Sciences,  24,  45-­‐53.  
— Examined  associa@ons  between  mood,  anxiety  &  substance  use  
disorders  in  Australian  general  popula@on.  
— Data  from  2007  Australian  Na@onal  Survey  of  Mental  Health  &  
Wellbeing  –  8841  respondents  aged  16-­‐85.  
— Interviewed  in  own  homes  using  computer-­‐assisted  personal  
interview  based  on  WHO-­‐Composite  Interna@onal  Diagnos@c  
Interview.    
— Covered  life@me  experience  of  13  mental  disorders  across  
mood,  anxiety  &  substance  (cannabis,  seda@ves,  s@mulants  &  
opioids).  
 

Source: Slade, McEvoy, Chapman, Grove, & Teesson (poster presentation of 2015 article)

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Source: Slade, McEvoy, Chapman, Grove, & Teesson (poster presentation of 2015 article)

Substance  Misuse  
—  Alcohol  and  drugs  are  addic@ve,  resul@ng  in  long  term  
physical  and  psychological  nega@ve  consequences  
—  Difficul@es  with  stopping  –  withdrawal,  relapse  
—  Interac@on  with  mental  health  disorder  maintains  both  
problems  –  vicious  cycle  

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Useful  Mnemonics;  
Alcohol  Dependence:  CAGE  
—  Have  you  felt  you  should  CUT  back  your  use?  
—  Has  anyone  ANNOYED  you  with  comments  on  your  
drinking?  
—  Have  you  felt  GUILTY  about  your  drinking?  
—  Have  you  ever  had  an  EYE-­‐OPENER  in  the  morning  to  get  
rid  of  a  hangover?  

2  out  of  4  suggests  problems  

Alcohol  &  Women:  TWEAK  

—  How  many  drinks  can  you  hold?  (Tolerance)  
—  Have  close  friends  or  rela<ves  Worried  or  complained  
about  your  drinking?  
—  Do  you  some<mes  have  a  drink  in  the  morning  when  you  
first  get  up?  (Eye-­‐opener)  
—  Has  a  friend  or  family  member  ever  told  you  about  things  
you  said  or  did  while  you  were  drinking  that  you  could  
not  remember?  (Amnesia  or  blackouts)  
—  Do  you  some<mes  feel  the  need  to  cut  down  on  your  
drinking?  (K(c)  Cut  Down)  
Cufng  score:  2  or  more  suggests  harmful  drinking  
Source:  Russell,  M.  (1994).  New  assessment  tools  for  drinking  in  pregnancy:  T-­‐ACE,  TWEAK,  
and  others.  Alcohol  Health  and  Research  World,  18(1),  55-­‐61.    
 

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Substance-­‐Related  Mnemonics:  
CRAFFT  -­‐  Youth  
—  C  Have  you  ever  ridden  in  a  CAR  driven  by  someone  (including  yourself)  who  
was  “high”  or  had  been  using  alcohol  or  drugs?  
—  R  Do  you  ever  use  alcohol  or  drugs  to  RELAX,  feel  beOer  about  yourself,  or  fit  in?  
—  A  Do  you  ever  use  alcohol  or  drugs  to  while  you  are  by  yourself,  ALONE?  
—  F  Do  you  ever  FORGET  things  you  did  while  using  alcohol  or  drugs?  
—  F  Do  your  family  or  FRIENDS  ever  tell  you  that  you  should  cut  down  on  your  
drinking  or  drug  use?    
—  T  Have  you  ever  goOen  into  TROUBLE  while  you  were  using  alcohol  or  drugs?    

Scoring:  no  (0),  yes  (1);  total  score  ranges  from  0  to  6  Cut-­‐score:  3  
 
See:  Newton  et  al.  (2011).  Instruments  to  detect  alcohol  and  other  drug  misuse  in  the  
emergency  department:  A  systema@c  review.  Pediatrics,  128,  e180.  

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Mental  Status  Examina@on  (MSE)  

—  Modelled  on  the  Physical  Medical  Exam    
—  Describes  the  persons  current  state  of  func@oning  
(behaviours,  thoughts,  feelings  and  percep@ons)  in  
objec@ve,  non-­‐judgemental  manner.  
—  Here  and  now  that  counts  
—  Cross-­‐sec@onal  in  nature  
—  Can  be  used  in  a  variety  of  ways,  e.g.,  pre-­‐assessment/
intake/screening  and/or  as  part  of  formal  assessment.  
—  Brief  and  long  forms  

In  order  to  complete  an  adequate  MSE,  one  must:  

—  have  knowledge  of  language  of  descrip@ve  

psychopathology  &  phenomenonology  
—  be  able  to  detect  or  elicit  necessary  data  during  the  
assessment  interview  
—  know  how  to  interpret  and  integrate  these  data  in  a  
clinically  meaningful  way  
—  be  able  to  describe  the  findings  in  a  predictable,  
concise,  and  unambiguous  manner.  

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Assessing  Mental  Status  

Observa@on  
—  As  soon  see  person  &  before  speaking  to  them,  begin  to  note  
appearance,  alertness,  arousal,  ac@vity  (behaviour),  affect,  
interac@ons  with  others.    
Conversa@on  
—  Undirected,  casual  communica@on.  While  somewhat  off  guard  &  
unaware  being  assessed.  Enables  assessment  of:  orienta@on,  
speech,  thinking,  aOen@on,  concentra@on,  comprehension,  
remote,  recent,  and  immediate  memory.    
Explora@on  
—  direct  ques@oning  regarding  aspects  of  person’s  internal  
experiences  not  on  display,  such  as  mood,  mo@va@on,  percep@on,  
thought  content,  insight  and  judgment  
Tes@ng  
—  formal  examina@on  of  orienta@on,  memory  &  concentra@on  

PHYSICAL
Appearance Motor Activity
Behavior

EMOTIONAL
Attitude Mood and Affect
COGNITIVE
Orientation Attention and Concentration
Memory Speech and Language
Thought (Form and Content) Perception
Insight and Judgment Intelligence and Abstraction

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How  to  write  a  MSE  

—  Draw  aOen@on  to  key  features  that  describe    client  and  frame  
the  presen@ng  problem  within  context  of  who  the  client  is.  

—  Typically  descrip@on  will  begin  with  statement  about  their  age,  
gender,  rela@onship  status,  referrer  &  presen@ng  problem  (i.e.,  
reason  for  presenta@on  at  service  on  par@cular  occasion)  

—  E.g.,  “Gill,  a  35-­‐year  old  single  woman,  was  referred  by  her  
medical  prac@@oner  who  had  suggested  treatment  for  her  
obesity  that  was  contribu@ng  to  hypertension.”  

Wri@ng  MSE  Report  

Major  headings  of  MSE:  
—    Appearance,  Aftude,  &  Ac@vity  
—    Mood  &  Affect  
—    Speech    
—    Thought  Process  
—    Thought  Content  
—    Percep@on  
—    Cogni@on  (Orienta@on,  AOen@on  &  Concentra@on,  Memory)  
—    Intellectual  Func@oning  
—    Insight  &  Judgment  
 
— Present  concrete  examples  to  jus@fy  every  conclusion  
— Discuss  the  reliability  of  the  material  

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Physical  
—  Appearance:  
—  A  concise  summary  of  client’s  physical  presenta@on  is  given  to  
paint  a  clear  mental  portrait  
—  dress,  grooming,  facial  expression,  posture,  eye  contact,  as  
well  as  any  relevant  noteworthy  aspects  of  appearance  

—  Behaviour  
—  May  make  reference  to:  
—  level  of  consciousness  extending  from  alert  through  drowsy,  a  
clouding  of  consciousness,  stupor  (lack  of  reac@on  to  
environmental  s@muli)  and  delirium  (bewildered,  confused,  
restless,  and  disoriented),  to  coma  (unconsciousness  
—  degree  of  arousal  (e.g.,  hypervigilance  to  environmental  cues  
and  hyperarousal  such  as  observed  in  anxious  and  manic  
states)  
—  mannerisms  (e.g.,  @cs  and  compulsions).  

Exercise:  Appearance  &  Ac@vity  

—  What  are  you  saying  when  you  aren’t  saying  
anything?    
—  What  do  your  clothes,  your  shoes,  your  hair,  your  
taOoos,  your  jewelry,  your  scent,  your  bag,  your  coat,  
your  phone  say  about  you  
—  What  do  you  want  them  to  say  about  you?    

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Physical  (Cont.)  
—  Motor  Ac<vity:  
—  Describe  both  quality  &  types  of  ac@ons  observed  
—  reduc@on  in  level  of  movement  (psychomotor  retarda@on)  
—  slowed  movement  (bradykinesia)  
—  decreased  movement  (hypokinesia)  
—  absence  of  movement  (akinesia)  
—  increased  overall  level  of  movement  (psychomotor  agita@on)  
—  tremor
—  AXtude:  
—  Iden@fiers  may  be  open,  friendly,  coopera@ve,  willing,  and  
responsive  or  closed,  guarded,  hos@le,  suspicious,  passive    
—  Describe:  
—  aOen@veness  
—  responses  to  ques@ons  
—  expression,    
—  posture,    
—  eye  contact,    
—  tone  of  voice  

Appearance  Aftude  Ac@vity  Example  

—  Appearance,  Aftude  &  Ac@vity:  
—  Edward  is  a  white  male,  age  32,  who  appeared  at  least  15  years  
older  than  his  chronological  age.  He  was  unshaven  and  
unwashed  and  wearing  soiled  clothing.  There  was  a  strong  odor  
of  cigareOes  and  alcohol.  Health  appeared  poor,  as  evidenced  
by  difficul@es  breathing,  frequent  coughing,  and  the  
appearance  of  fa@gue.  He  was  easily  distracted,  had  poor  eye  
contact,  open  looking  out  the  window.  He  was  uncoopera@ve,  
open  defensive  and  gave  a  poor  history.  He  refused  to  answer  
many  ques@ons,  responding  with,  “None  of  your  business.”  He  
made  several  comments  Such  as,  “What  right  do  you  have  to  
get  into  my  head?”  He  was  slumped  in  posture  and  grasped  his  
bag  @ghtly  to  his  chest  throughout  the  interview.  

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Emo@onal  
—  Mood  and  Affect:  
—  Affect  (an  external  expression  of  an  emo@onal  state)  is  poten@ally  
observable  
—  Mood  (internal  emo@onal  experience  that  influences  percep@on  of  the  
world  and  behavioral  responses)  require  clinician  to  depend  on  the  client’s  
introspec@ons  
—  Descriptors:  euphoric,  dysphoric,  hos@le,  apprehensive,  fearful,  anxious,  
suspicious  
—  Stability  of  mood  can  also  be  noted,  with  the  alterna@on  between  
extreme  emo@onal  states  being  referred  to  as  emo@onal  lability  
—  Range,  intensity,  and  variability  of  affect  can  be  variously  portrayed:  
—  restricted  (i.e.,  low  intensity  or  range  of  emo@onal  expression)  
—  blunted  (i.e.,  severe  declines  in  range  and  intensity  of  emo@onal  range  
and  expression)  
—  flat  (i.e.,  absence  of  emo@onal  expression,)  
—  exaggerated  (i.e.,  an  overly  strong  emo@onal  reac@on)  
—  Appropriateness  (expression  incongruent  with  verbal  descrip@ons  and  
behavior)  
—  General  responsiveness  of  the  client.  

Mood  &  Affect  examples  

Poor:  
The  pa@ent’s  mood  is  fine  and  her  affect  is  appropriate  but  
angry  at  @mes.  
— In  what  sense  is  her  affect  appropriate?  The  clinician  needs  to  
state  first  what  the  affect  is  and  then  comment  upon  its  
appropriateness  in  terms  of  the  criteria  listed  above.  
Good:  
— When  asked  about  her  mood,  the  pa@ent  became  angry  and  
stated,  “My  mood  is  just  fine,  thank  you!”  Throughout  much  of  
the  interview  she  presented  a  guarded  and  mildly  hos@le  affect,  
frequently  clipping  off  her  answers  tersely.  When  talking  about  
the  nurse  in  the  wai@ng  area  she  became  par@cularly  suspicious  
and  appeared  genuinely  frightened.  However,  there  was  no  
evidence  of  tearfulness  or  lability  of  affect.  

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Cognitive: Orientation
—  A  person’s  orienta@on  refers  to  their  awareness  of  @me,  
place,  and  person  
—  Orienta@on  for  @me  refers  to  a  client’s  ability  to  indicate  the  
current  day  and  date  (with  acceptance  of  an  error  of  a  couple  of  
days)  
—  Orienta@on  for  place  can  be  assessed  by  why  they  have  presented.    
Behavior  should  also  be  consistent  with  that  expected  in  the  sefng  
in  which  they  have  arrived  
—  Orienta@on  for  person  refers  to  the  ability  to  know  who  you  are,  
which  can  be  assessed  by  asking  the  client  their  name  and  about  
the  names  of  family  members  or  friends.  

Cognitive: Attention and Concentration

—  Working  memory  (Baddeley,  1986;  1990)  is  term  now  used  in  
psychology  to  refer  to  constructs  called  aOen@on  &  concentra@on  

—  The  aim  is  to  describe  the  extent  to  which  a  client  is  able  to  focus  
their  cogni@ve  processes  upon  a  given  target  and  not  be  
distracted  by  non-­‐target  s@muli  
—  Digit  span  (the  ability  to  recall  in  forward  or  reverse  order  increasingly  long  
series  of  numbers  presented  at  a  rate  of  one  per  second)  is  a  common  way  
to  assess  these  working  memory  func@ons,  and  normal  individuals  will  recall  
around  6-­‐8  numbers  in  a  digits  forward  and  5-­‐6  in  digits  backwards  
—  “Serial  sevens”  in  which  seven  is  sequen@ally  subtracted  from  100.    Typically  
people  will  make  only  a  couple  of  errors  in  14  trials.  

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Cognitive: Memory
—  MSE  will  typically  assess  memory  using  categories  of  short  &  long-­‐term  memory  
—  Aim  of  the  MSE  is  to  provide  a  concise  descrip@on  of  a  person’s  behavior  and  
screen  them  in  a  manner  that  can  guide  further  assessment.      

—  Recent  or  short-­‐term  memory  

—  ask  about  a  recent  topical  event  or  who  the  President  or  Prime  Minister  is  
—  listen  to  three  words,  repeat  them,  and  then  recall  them  some  @me  later  in  
interview.    Most  people  will  usually  report  2-­‐3  words  aper  20-­‐minute  interval  
—  Visual  short-­‐term  memory  
—  copy  and  then  reproduce  from  memory  complex  geometrical  figures  (such  as  
those  in  the  Rey  Auditory  Verbal  Learning  Test)  
—  Long-­‐term  memory  can  be  assessed  by  asking  about  childhood  events.  

Cognitive: Thought (Form & Content)

—  Form of thought are evident in terms of
—  (i) quantity and speed of thought production
—  (ii) the continuity or connectedness of ideas:
—  Circumstantiality – speech digressive, vague, overdetailed.
I: What seems to be the problem?
C: I’m living with Frank. He told me to throw away all my medication. You know
he’s a mental patient himself. But anyone has to get sick who plays music all
night, smokes dope, and takes drugs.
I: Stacey, why don’t we stay on your problems?
C: Okay. Well last night I called home. My mother wasn’t there, just my sister.
You know she’s dating this black guy and…
—  Tangentiality – logical but digresses from the topic  
 I  really  have  not  felt  good  recently.  My  mood  is  shot,  sort  of  like  it  was  back  in  Kansas.  
Those  were  bad  days  back  in  Kansas.  I’d  just  come  up  from  the  army  and  I  was  really  
homesick.  Nothing  can  really  beat  home  if  you  know  what  I  mean.  I  vividly  remember  my  
mother’s  hot  cherry  tarts.  Boy,  they  were  good.  Home  cooking  just  can’t  be  beat.  

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Cognitive: Thought (Form & Content)

—  Flight of ideas - is non-goal oriented. While answering one
question switches to a new train of thought, often triggered
by a word in the previous sentence as in:
I: What brought you here?
P: 1. I got here by getting on my feet. 2. But I have hurt my feet while jogging.
3. Do you think jogging is good for me? 4. It may not help against heart attack,
aspirin might be better. 5. But I don't like to take drugs. 6. Drugs and crime go
together.
 
—  May show loosening of associations, - logical connections between
thoughts are esoteric or bizarre. -I  love  you.  Bread  is  the  staff  of  life.  
Haven’t  I  seen  you  in  church?  I  think  incest  is  horrible.    

Cognitive: Thought (Content)

—  Delusions  -­‐  profound  disturbances  in  thought  content    
—  client  con@nues  to  hold  to    false  belief  despite  objec@ve  contradictory  evidence,  
despite  other  members  of  culture  not  sharing  same  belief  
—  vary  on  dimensions  of  plausibility  &  systema@za@on  
—  persecutory  (others  deliberately  trying  to  wrong,  harm,  or  conspire  against  another)  
—  grandiose  (exaggerated  sense  of  one’s  own  importance,  power,  or  significance)  
—  soma@c  (physical  sensa@ons  or  medical  problems)  
—  reference  (belief  that  otherwise  innocuous  events  or  ac@ons  refer  specifically  to  the  
individual)  –  they  played  that  song  on  the  radio  to  send  me  a  message.  
—  control,  influence  and  passivity  (belief  that  thoughts,  feelings,  impulses,  and  ac@ons  
are  controlled  by  an  external  agency  or  force)  –  someone  is  pufng  thoughts  into  my  
head-­‐  thought  inser@on  
—  nihilis@c  (belief  that  self  or  part  of  self,  others,  or  the  world  does  not  exist)  
—  jealous  (unreasonable  belief  that  a  partner  is  unfaithful)  
—  religious  (false  belief  that  has  a  special  link  with  God)  

 
 

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Cognitive: Thought (Content)

 

—  Other  Aspects  of  Content  of  Thought:  

—  phobias  (excessive  and  irra@onal  fears)  
—  obsessions  (repe@@ve  &  intrusive  thoughts,  images,  impulses)  
—  preoccupa@ons  (e.g.,  with  illness  or  symptoms)  
—  rumina@ons  –  constant  thinking  about  past  events  or  present  
emo@onal  state  

—  Also  note  suicidal  and  homicidal  thoughts  and  inten@ons  

Content of Thought
—  The  pa@ent  appears  convinced  that  if  the  watch  is  
removed  from  her  right  hand,  the  world  will  come  to  an  
end.  She  relates  that,  consequently,  she  has  not  bathed  
for  three  weeks.  She  also  feels  that  an  army  of  rats  is  
following  her  and  intending  to  enter  her  intes@nes  to  
destroy  “my  vital  essence”.  She  denies  current  suicidal  
idea@on  or  plans.  She  denies  homicidal  idea@on.  
Without  rumina@ons  or  obsessions.  

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Cognitive: Perception
—  Hallucinations:
—  perceptual  disturbance  -­‐  an  internally  generated  sensory  experience  –hear  
(auditory),  see  (visual),  feel  (tac@le),  taste  (gustatory),  or  smell  (olfactory)  
something  not  present  or  detec@ble  by  others  
—  Most  frequent  hallucina@ons  auditory  &  typically  involve  hearing  voices,  
calling,  commanding,  commen@ng,  insul@ng,  or  cri@cizing  
—  Hallucina@ons  can  also  occur  when  falling  asleep  (hypnogogic)  or  when  
awaking  (hypnopompic).  
 

—  Other  perceptual  disturbances  include:  

—  external  world  is  unreal,  different,  or  unfamiliar  (derealiza@on)  
—  self  is  different  or  unreal  in  that  the  individual  may  feel  unreal,  that  the  
body  is  distorted  or  being  perceived  from  a  distance  (depersonaliza@on)  
—  Percep@ons  can  also  be  dulled  or  heightened  

Cognitive: Insight and Judgment

—  Insight - extent to which clients are aware have problem
—  A strong lack of insight can be an important indicator of
unwillingness to accept treatment
—  Insight refers also to an awareness of the nature & extent
of problem, effects of their problem on others, & how is
departure from normal

—  I’m being pursued by spies in red cars. They are trying to
kill me – no or absent insight.
—  I’m hearing voices again. It’s really scaring me. I think I
need to start taking the medication again – good insight

—  Judgment: ability to make sound decisions can be

compromised for a number of reasons
—  are poor decisions result of problems in cognitive
processes involved in decision-making process,
motivational issues, or failures to execute planned course
of action

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Cognitive: Speech and Language

—  Described in terms of:
—  Rate (e.g., slow, rapid)
—  Intonation (e.g., monotonous)
—  Spontaneity
—  Articulation
—  Volume
—  Quantity of information conveyed
—  mutism (i.e., absence of speech)
—  poverty of speech (i.e., reduced spontaneous speech)
—  pressured speech (i.e., rapid speech hard to interrupt & understand)

—  Language includes reading, writing, and comprehension.

—  Disturbances such as aphasia
—  Non-fluent (speech is slow, faltering, or effortful) or fluent

Cognitive: Intelligence & Abstraction

—  A general indication of intelligence can be gained from
the amount of schooling person has had:
—  failure to complete high school indicating below average
—  completion of high school indicating average intelligence
—  college or university education indicating high intelligence
—  Abstraction
—  ability to recognize & comprehend abstract relationships
—  to extract common characteristics from group of objects
(e.g., in what way are an apple/banana or music/
sculpture alike?),
—  interpretation (e.g., explaining proverb such as a stitch in
time saves nine).

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Neuropsych Mental State Exams

—  Focus  is  primarily  on  cogni@ve  func@ons  
 
—  Mini  Mental  State  Exam  (Folstein,  et  al.,  1975);  Copyright  PAR  
—  11-­‐items,  measure  orienta@on,  registra@on,  aOen@on  &  calcula@on,  recall,  
language,  and  praxis  
—  Scores  ranges  from  0-­‐30  and  lower  scores  indicate  greater  impairment  
—  less  sensi@ve  for  cases  with  milder  impairment  
—  scores  influenced  by  educa@onal  level  
—  Cogni@ve  Capacity  Screening  Examina@on  (CCSE;  Jacobs,  et  al.,  1977)  
—  30-­‐item  screener  to  detect  diffuse  organic  disorders;  more  appropriate  for  
cogni@vely  intact  individuals  
—  High  Sensi@vity  Cogni@ve  Screen  (HSCS;  Faust  &  Fogel,  1989)  
—  15-­‐item  scale;  valid  and  reliable  indicator  of  cogni@ve  impairment  
—  Mental  Status  Ques@onnaire  (MSQ;  Kahn,  et  al.,  1960)  
—  10-­‐item  scale  that  shares  the  same  weaknesses  as  MMSE  but  omits  some  
key  domains  of  func@on  (e.g.,  reten@on  and  registra@on)    
—  Short  Portable  Mental  Status  Ques@onnaire  (SPMSQ;  Pfeiffer,  1975)  
—  10-­‐item  scale  for  community  or  ins@tu@onal  residents;  reliable  indicator  of  
organicity.  

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