Mental state exam for youth workers: Thought process and content

Posted on May 9, 2013May 26, 2020 by Aaron Garth

So we are a little over half way in this series. We have been developing an understanding of the core components of a mental state exam so that we can support our young people as best we can. This week I was speaking with a youth worker in one of Victoria’s largest Christian denominations about a mental health conference he was at. I was reminded about how important it is for all youth workers to have a strong understanding of mental health. So far we have discussed how a young persons appearance, behaviour, speech and language, and their mood and affect can provide indicators as to their mental state. Today we discuss how a young persons thought content can provide insight into their current mental health status.

A prime example of maladaptive thought content and process

Thought process

A young person’s thought process can tell you a lot about them. The quantity, tempo and form of thought are keys to understanding the process. A persons thought process can’t be directly observed. It can only be described by or inferred from a young persons speech. Some people may experience their thoughts coming so rapid that their speech seems incoherent. Alternatively an individual may have inhibited thinking, in which thoughts seem to progress slowly with few associations. Are they all over the place or are they clear and consistent. do they have few thoughts or do they keep returning to the same thoughts.

Does the young person include a great deal of irrelevant detail or make frequent diversions, but remains focused on the broad topic. Flight of ideas is typical of mania. On the other hand, young people with depression may have slow or inhibited thinking. Poverty of thought is one of the symptoms of schizophrenia, and may also be a feature of severe depression.

Thought content

When we think of thought content we would describe a young persons delusions, overvalued ideas, obsessions, phobias or preoccupations. To draw out any abnormalities of thought content we need to explore a young persons thoughts in an open-ended conversational manner with regard to their intensity, salience, the emotions associated with the thoughts, the extent to which the thoughts are experienced as one’s own and under one’s control, and the degree of belief or conviction associated with the thoughts.

A delusion is a core feature of psychotic disorders. A young persons delusions may be described as persecutory or paranoid, delusions of reference, grandiose, erotomanic, delusional jealousy or delusional misidentification. Delusions may be mood-congruent (the delusional content is in keeping with the mood), or mood-incongruent (delusional content not in keeping with the mood). An overvalued idea is a false belief that is held with conviction but not with delusional intensity. Hypochondriasis is an overvalued idea that one is suffering from an illness and people with anorexia nervosa may have an overvalued idea of being overweight.

Preoccupations are thoughts which are not fixed, false or intrusive, but have an undue prominence in the person’s mind. Clinically significant preoccupations would include thoughts of suicide, homicidal thoughts, suspicious or fearful beliefs associated with certain personality disorders, depressive beliefs (for example that one is unloved or a failure), or some types of anxiety and depression. A Mental State Exam contributes to risk assessments of young people by including a thorough exploration of any suicidal or hostile thought content. Assessment of suicide risk includes detailed questioning about the nature of the person’s suicidal thoughts, belief about death, reasons for living, and whether the person has made any specific plans to end his or her life.

Stay tuned next week for part six: Perception

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Aaron Garth

Aaron Garth is the Executive Director of Ultimate Youth Worker. Aaron has worked as a youth worker in a number of settings including local church, street drug and alcohol outreach, family services, residential care, local government and youth homelessness since 2003. Aaron is a regular speaker at camps, retreats, & youth work training events and is a dedicated to seeing a more professional youth sector in Australia. Aaron is a graduate of RMIT University and an alumnus of their youth work program. He lives in Melbourne with his wife Jennifer & their daughters Hope, Zoe, Esther, Niamh and son Ezra.

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Mental state exam for youth workers: Mood and Affect.

Posted on May 2, 2013May 26, 2020 by Aaron Garth

So far in this series we have been developing an understanding of the core components of a mental state exam. So far we have discussed how a young persons appearance, behaviour, speech and language can provide indicators as to their mental state. Today we discuss how a young persons mood and affect can provide insight into their current mental health status.

Mood

Mood is described using a young person’s own words. Happy, sad, angry, elated, anxious or apathetic. Many young people may be unable to describe their subjective mood state. Throughout my career I have seen a marked decrease in emotional intelligence in our society. It may take some work to flesh out how a young person feels. There are a number of resources to help young people to articulate their emotions, my personal favourites are mood dudes and the stones. In essence Mood is how young people see themselves in their own opinion.

Emotional intelligence in a squeeze ball

The key to remember about mood is that it is subjective. The young person is the master of their own emotional state. Only they truly know what is going on inside.

Affect

Affect is noted by us when we observe the apparent emotion conveyed by the person’s nonverbal behaviour. Affect may be described as appropriate or inappropriate behaviour to the current situation, and as congruent or incongruent with their thought content. For example, a young person who shows a neutral affect when describing a very distressing experience such as family violence would be described as showing incongruent affect, which might suggest PTSD. The intensity of the young persons affect may be conveyed as normal, blunted, exaggerated, flat, heightened or overly dramatic.

A flat or blunted affect can be associated with schizophrenia, depression or post-traumatic stress disorder. Heightened affect might suggest mania, excitement or anxiety and an overly dramatic or exaggerated affect might suggest certain personality disorders. A young person may show a full range of affect, or a wide range of emotional expression during your assessment. They may move from heightened to blunted or they may only show a single affect.

The key to remember about affect is that it is objective. It is what you observe about a young person. The key here is to be clear about what you are observing and why you believe it means what you believe. For example, “Aaron appeared sad. He spoke slowly, kept eye contact on the ground and cried“.

Stay tuned next week as we discuss part five: Thought process and content.

Aaron Garth

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Mental State Exam for youth workers: Speech and language.

Posted on April 18, 2013May 26, 2020 by Aaron Garth

Over the past few weeks we have been developing an understanding of the components of a mental state exam. So far we have discussed how a young persons appearance and behaviour can provide indicators as to their mental state. Today we look at how a young persons speech can provide insight into their current mental health.

A young persons speech is assessed by observing their spontaneous speech, and also by using structured tests of specific language functions. during this time we are focussed on the production of speech rather than the content of speech, which we will address under thought form and thought content in weeks to come. When observing the young persons spontaneous speech, a youth worker should note and comment on paralinguistic features such as the loudness, rhythm, prosody, intonation, pitch, phonation, articulation, quantity, rate, spontaneity and latency of speech.

A structured assessment by a qualified speech pathologist is a great tool for diagnosing serious difficulties in speech however a basic screening can be performed by an aware youth worker. An assessment of speech includes an assessment of expressive language by asking the young persons to name objects, repeat short sentences, or produce as many words as possible from a certain category in a set time. Simple language tests form part of the mini-mental state examination. In practice, the structured assessment of receptive and expressive language is often reported under cognition which we will discuss in a coming cast.

Language assessment will allow you to recognise young people presenting with aphonia or dysarthria, neurological conditions such as stroke or dementia presenting with aphasia, and specific language disorders such as stuttering, cluttering or mutism. People with autism or Asperger syndrome may have abnormalities in paralinguistic and pragmatic aspects of their speech. Echolalia (repetition of another person’s words) and palilalia (repetition of the subject’s own words) can be heard by young people with autism, schizophrenia or Alzheimer’s disease. A young person with schizophrenia might use neologisms, which are made-up words which have a specific meaning to the person using them.

Speech assessment also contributes to assessment of mood, for example people with mania or anxiety may have rapid, loud and pressured speech; on the other hand depressed patients will typically have a prolonged speech latency and speak in a slow, quiet and hesitant manner.

If you know a speech pathologist or have the opportunity to do some training with one, do it! Aside from appearance speech is one of the most observable ways to notice a persons mental state.

Stay tuned next week for part four: Mood and Affect.

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Aaron Garth

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Mental State Exam for youth workers: Behaviour.

Posted on April 5, 2013May 26, 2020 by Aaron Garth

“Oh Behave!” Austin Powers knew all to well that we toe a fine line as humans when it comes to ‘normal’ human behaviour. When we are doing a mental state exam we are observing the fine line between what our clinical brothers and sisters would call ‘normal’ and ‘abnormal’. Behaviour is an interesting phenomenon for youth workers to observe. It requires us to use our powers of observation and our own self reflection (apparently youth workers can be a little abnormal!) to determine whether a person is doing alright. We need to observe whether the young person is acting in a similar way to how they act most of the time or differently. Whether they are acting similar to their peers or completely different. Behaviour requires us to have an understanding of normal behaviour and abnormal behaviour.

Normal day or abnormal behaviour?

Movements

Tremors, shakes, tics, involuntary movements may indicate a neurological disorder, or they could be the side effects of antipsychotic medication, schizophrenia or drug abuse. If your young person is showing these types of movements it may be normal for them or it might be abnormal. It may be something serious like a neurological disorder or it may just be the effects of the drugs they have used. Your ability to observe this behaviour and refer them out to more specialised support will be key.

This also goes if they are hyperactive, rocking, gesturing wildly, fidgeting or unable to sit still. This may mean they are delirious or manic, or it might just mean they are excited or full of beans. Only your keen observation of their movements and your deep relationship will tell you if something is out of the ordinary or ‘abnormal’.

Level of activity and arousal

A persons level of activity and arousal may also provide insight into their mental state. Are they hyperactive (high action) or lethargic (low action)? An increase in arousal and movement (hyperactivity) which might reflect mania or delirium. An inability to sit still might represent akathisia, a side effect of antipsychotic medication. Similarly a decrease in arousal and movement (akinesia or stupor) might indicate depression or a medical condition such as dementia or delirium.

Of course if you are over aroused and hyperactive you may just be having a birthday, bar mitzvah or a wedding. You may be on a camp and really excited. If your young people are lethargic it may just be the last day of camp, the end of a boring group session or a distressing break-up with a cherished boyfriend. Your keen understanding of your young people will help you to know whether or not it was the red cordial or sad movie that is making your young person behave differently or whether it is something else more insidious.

Eye contact

The eyes are the window to the soul they say, and never more so was this true than whilst doing a mental state exam. Does your young person make good eye contact with the floor? Can they look you in the eye? What happens when they are telling you porky pies??? A persons eye contact can say a lot about their mental state. It can tell you if they are lying. It can tell you if they are psychopathic. It can tell you if they are nervous, sad or depressed. Eye contact is one of the most important behavioural signposts for us as youth workers.

There are of course some caveats to this. If your young persons culture frowns on eye contact for example the aboriginal population in Australia. A young person will not make too much eye contact with an adult out of respect. A young person with eye issues such as having a lazy eye may not seem to be making good eye contact, but it may just be your view.

There is a danger

Behaviour is difficult to observe objectively. Not Impossible, but difficult. Most of us observe others behaviour subjectively. We watch through the lens of what we find appropriate. In some cases this is not an issue. We see someone hit their child with a lump of wood, or a person overdosing or a young person in a relationship with a 40 year old and our observation is that this is abnormal. For the most part this is right. When we start to look at others behaviour we must think about what they are thinking when they do this. Most of us do not behave inappropriately on purpose… too often anyway. There is also a number of theories from a number of very noted behavioural theorists that can help us determine whether a person is normal or abnormal.

Aside from the clear observable issues like shakes, poor eye contact or hyperactivity some peoples behaviour can just be different to us. One of the best way we know of to observe and relate to a person on a behavioural level is DISC. Disc is a quadrant based behavioural analysis tool which can help you to determine if another person is nuts or just in a different quadrant than you. Since doing some training in DISC and using this to view peoples behaviour I have found that my mental state exams (as well as my general observations) have become more clear.

PS. If you observe something that seems out of the ordinary, try to explain what it is. For example, ‘John seemed depressed’, will not get you much help from a clinician. However, if you say, ‘John seemed depressed as he was making poor eye contact, was mumbling and wouldn’t finish sentences’, then you are more likely to elicit a response from clinicians.

We hope this helps. See you next week for part three, Speech.

Aaron Garth

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Mental State Exam for youth workers: Appearance.

Posted on March 21, 2013May 26, 2020 by Aaron Garth

You have heard the saying don’t judge a book by its cover. Well that’s exactly what I am going to ask you to do. In the first part of a Mental State Exam we look at a persons appearance and make some judgements on where they are at because of this. Now the politically correct crowd will say that we shouldn’t judge people. That we should make informed decisions or be understanding of their context. Bollocks! We all make judgements and that is OK! If your Judgement is informed by theory and experience then it is an informed judgement. Do not get all mushy about it. It will not help your clients.

We all notice the appearance of others. What they are wearing, are they groomed, their age, weight or perhaps an odour!!! We make observations about this through the lens of our knowledge of the person, society and our experience. Is that young person with their pants hanging down, hair unkempt and malodorous (my favourite clinical word) just part of the teenage stinky boys club or is there something more to it. What if they usually dress very neatly and wear deodorant?

Appearance is possibly the easiest of the Mental State Exam areas to observe. Has your young person recently gained weight…or lost it? Are they smelly or well groomed? Do they stare at the floor or are they making good eye contact? Can you smell alcohol or perhaps their teeth are bad, could they be abusing drugs? Have they stopped wearing clothes that show off their figure and now wear really baggy clothing? Is it a change in fashion or are they self harming???

There are no easy answers when observing a young persons appearance. I have over reached and missed signs throughout my career. Sometimes it is a gut feeling. For the most part it is time, time, time that will be your guide. Meeting people once gives you some data to crunch, but what if they are just having an off day? The more you observe the better your analysis. Take into account cultural issues and the current context for the young person and you should be fine.

This is only one clue in the Mental State Exam. It is however one of the easiest to practice. Look around when next meeting with a young person and ask yourself about their appearance in every way. Ask yourself why they look the way they do and if this is a positive social step or a negative one. Ask yourself if they appear to have them self together or if there seems to be signs that they are letting themselves go. If there are, it doesn’t necessarily mean panic. It does mean be more observant.

See you next week for part two, Behaviour.

Aaron Garth

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one in four young people will have a diagnosed mental illness: do you know the signs?

Posted on March 14, 2013May 26, 2020 by Aaron Garth

One in four young people will have a diagnosed mental illness in their lifetime. That means one in four young people you come across probably has symptoms of the troubles brewing right before your eyes. As youth workers our training in mental health is limited at best. If oour training is limited then we are severely limited in our ability to support them. Over the coming weeks we will look at a great tool for identifying issues early in a young person… and we all know that early detection leads to the best outcomes for our young people.

One of the best tools I have come across over the years is a Mental State Exam. As a your worker I was initially weary of using another form that put my young people in a “clinical” box. However, as I have used this tool and become more familiar with it I have found that I am able to see minute change in my young people which help me identify potential mental health issues. If you can see the changes early it helps you to support them to get the help they will need.

The Mental State Exam covers eight areas of the person for us to keep an eye on:

Over the coming weeks we will show you how to complete a Mental State Exam, What to look out for and when to refer on to the proper treatment. They are a tool, and like any tool it takes practice to master. That is why we will look at one area per week until we have a good understanding. When we have a good understanding then we can put it in the toolbox and use it when the need arises.

In the meantime here is a short video to whet your whistle.

Aaron Garth

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