Original subtitles

in this third section of the Mental

Status examination training we will

learn about memory my name is Tom field

and I produced and narrated this

training series let's return to the

overview in this training series we

learned vari scaffolding process in this

section of the training we will learn

about memory and during guided practice

we'll review affect and mood and thought

process at the conclusion of the eight

sections is an end of training test I

encourage you to follow the handout as

we progress you can use scrap paper if

you'd like for guided practice and

there's going to be occasions during

guided practice video case studies where

an element of the Mental Status

examination is not fully apparent and in

those instances it's ok to indicate

unable to assess the definition of

memory is the storage and recall of both

current information known as working

memory and past information memory has

two facets that we're going to explore

in this training amnesia and

consciousness amnesia has two important

facets anterograde and retrograde

amnesia and we'll be exploring these

using examples from the mini-mental

State Exam and consciousness has two

important facets as well dissociation

and regression which we'll be exploring

not explored in this training but

important to assessing consciousness is

orientation orientation has four parts

orientation - time per place person and

situation an orientation to time is an

awareness of day month and year an

orientation took place is an awareness

of current location for example your

counseling office an orientation to

person is an awareness of the clients

own name and your name and an

orientation to situation is an awareness

of why the

is being assessed also explored but not

in a great deal of depth and important

for you to understand is intact memory

this is appropriate short and long-term

storage and recall considered normal or

typical and in instances where the

client seems to be demonstrating fairly

good short-term and long-term memory you

would indicate intact memory in the

Mental Status examination anterograde

amnesia is described as memory loss for

events after the onset of amnesia in the

diagram below the color of the circles

indicates the clients ability to recall

information in anterograde amnesia

the client is better able to recall past

events and here this is illustrated by

the circle being a lighter color then

current events illustrated by the circle

being darker color retrograde amnesia is

defined as memory loss for events before

the onset of amnesia and again using the

diagram below the client is better able

to recall current events indicated by

the circle being a lighter color than

past events the circle being a darker

color to indicate this as an aside it's

worth noting that some forms of memory

problems don't have a traumatic event or

incident that occurs that's the central

circle here for example Alzheimer's

disease does not have a traumatic event

or incident that precipitates amnesia

however even in Alzheimer's for example

a person might be better able to recall

current events than past events or vice

versa and so understanding the

difference between retrograde in' and

tarot grade amnesia is important

so let's explore memory and

consciousness using some video case

studies anterograde amnesia is described

as memory loss for events after the

onset of amnesia again this is

associated with brain injury dementia

and substance abuse and you would assess

for confabulation if the client is

demonstrating anterograde amnesia in

confabulation is defined as an attempt

to justify a false response meaning if a

person gives incorrect information they

may attempt to defend that information

is being correct when it is in fact

false if the interviewer prompts further

or prods further let's watch an example

so I'm going to tell you three words

that I would like for you to try to

remember and repeat back to me okay in a

few minutes okay so try to remember

these in the order in which I tell them

to you the three words are cherry car

shoes so repeat those back to me cherry

car shoes great so let's talk about

something else for a minute maybe we can

go back to before the accident and maybe

talk a little bit about your work oh

yeah sure

before the accident as you know I was

working in the fabric metal down at home

and I'd loved being there because I got

to work with all these different fabrics

I'm a quilter so it's where I went up

you know I would be able to get you know

special pieces of fabric to take home

work on my clothes but anyway so I've

been working at the fabric mill for a

long

time had my position I was moving into a

management role there really enjoyed the

group of ladies that I was working with

everyone got along well on the team we

all you know we were high productivity

in our particular division and so

everything was going really well and I

was moving up making a making a place

for him for myself in my career you know

before and then the accident happened

Wow

sounds like you like working that so

let's return back to those three words

do you remember the three words and the

order in which I told them to you

was there fruit in there one of them was

a fruit

the client is able to recall past events

in fair detail they talk about being a

quilter in a fabric mill and enjoying

that line of work before their accident

but then cannot recall the three words

that the interviewer provided at the

beginning of the segment those three

words were cherry car and shoes the

client therefore has problems with

working memory short-term memory and if

the client has memory loss for events

after the onset of amnesia

they have anterograde amnesia retrograde

amnesia is described as memory loss for

events before the onset of amnesia this

is associated with brain injury dementia

and substance abuse and again you would

assess for confabulation if the client

is demonstrating retrograde amnesia

let's watch an example I'm going to tell

you three words and I want you to try to

remember them in the order in which I

tell them to you those three words are

Apple table and penny would you repeat

those to me sure

Apple table penny great it's moving on

I'd like to ask you a couple questions

about your past would you tell me a bit

about your wedding day Oh wedding you

know it was it was a really long time

ago

hmm maybe it was in this summer I don't

really remember very well that's there

anything about your wedding day that

stands out to you in your mind

I'm sure I had a really nice dress do

you remember what your husband was

wearing for example oh not particularly

probably probably a suit maybe it was

black okay

and returning back to those three

questions that I asked you earlier of

three words I'm sorry do you remember

what the three words were that I had

told to you mm-hmm they were Apple table

and penny you sure those were the three

words yeah oh yeah I'm completely sure

okay great in this example the client

can't recall past events the clinician

asks the client to recall events from

her wedding day which would be

considered a fairly significant day in

someone's life a day that most people

would be able to recall at least some

details about the client can't really

recall when it happened she says maybe

it was in the summer she can't really

recall what she was wearing I think I

was wearing a dress and she can't recall

what her husband was wearing perhaps he

was wearing a suit this inability to

recall specifics about this day

indicates problems with long-term memory

in contrast the client can recall the

three words the clinician gave at the

beginning of the segment Apple table and

Penny and this memory loss for events

before the onset of amnesia rather than

after is indicative of retrograde

amnesia dissociation as a form of

altered consciousness it's a trance-like

state and the client often appears

disconnected from emotions this often

occurs in response to painful emotional

content and can be an Associated symptom

of trauma let's watch an example of

dissociation

I wonder what you're thinking about

right now oh oh I'm sorry um yeah I was

just kind of mmm I don't know just kind

of out there for a second

oh we will we're how long you were

thinking just just a couple seconds it's

been about five minutes really yeah we

were talking about something pretty

difficult to talk about actually really

yeah do you remember what we were

talking about I have no idea I don't

remember you asking me anything

this client suddenly jumps from their

trance-like State at the interviewers

prompt about them being in deep thought

asking what they're thinking about when

they emerge from this trance-like State

they are also unaware of the length of

time they were in that state it was

about a five minute increment and the

client is unaware of that and they have

a lapse in memory they cannot recall

what was being talked about before they

entered the trans-like state and the

clinician reveals that it was content

that's particularly difficult to talk

about meaning it's probably fairly

emotional content this trance-like state

in connection with the lapse in memory

and the clients unawareness of time is

indicative of dissociation and you can

see how this impacts the counseling

relationship if the client is unaware to

talk about difficult emotional content

without going into a trance-like state

and then forgetting what was talked

about before they enter the trance it's

very difficult to make headway on to

some pretty central issues and so the

association is usually an important

symptom to be aware of in counseling

regression is described as a return to a

childlike state

it's another impairment in consciousness

the

person is usually unconscious and

unaware of their aggression and if they

are aware it is usually a symptom of

manipulation rather than true regression

let's watch an example of regression I'm

really scared

what are you scared about this client

says in a childlike voice that they are

quote scared and quote don't want to be

by themselves their childlike high

pitched voice in addition to the

simplistic language used sounds almost

immature almost childlike almost

infantile it's almost like a they they

have somehow returned to a earlier stage

of development clients may also use

language such as I did bad I want to be

a good girl fairly simplistic language

and when that's paired with this

high-pitched childlike voice it

indicates regression it's now time for

some guided practice for you to try your

hand at coding memory and consciousness

in this next series of video case

studies you're going to code affect mood

form of thought and if its present

attention and speed of thought in

addition to memory and for memory you're

going to look at anterograde amnesia

retrograde amnesia dissociation and

regression let's watch the first video

so I've been thinking a lot lately even

hemmond dreams about sort of those war

scenes and remember in particular the

one time when my buddy got shot up

pretty bad and he lost his leg

you seem deep in thought I'm sorry what

pause the video now and assess the

client for effect mood form of thought

attention and speed of thought and

memory this client has a blunted or flat

effect

we can't code congruence here because

it's not fairly apparent with their

effect there are expressed emotion is

congruent or not while talking about the

sadness of losing a friend in war of a

friend who lost their leg we may think

that the client seems depressed and you

could code that here we could also code

unable to assess because of the blunted

or flat nature of their presentation

it's difficult sometimes to code mood

but certainly would not code you thermic

here for thought process we would code

logical because there seems to be

connections made between content there

may be rumination as an aside we don't

know enough about this if they brought

up the the experience of war again and

again and again then we would code that

but we don't have enough information at

this time and for memory we would code

dissociation and we would code

dissociation rather than distractible or

preoccupied here because the client

seems forgetful of what was discussed

there are some memory problems present

they cannot really recall that they were

talking about the war their war memories

when they snap out of that trance and

the client does respond to prompting

with preoccupied the client may not

respond and continue to be immersed

deeply in thought ok let's try another

video case study

I'm going to tell you three words and I

want you to try to remember them in the

order in which I tell them to you the

three words are cherry chair and shoe

would you repeat those to me

cherry chair and shoe great so maybe

let's talk a bit about your college

years how much do you remember about

that well going back to undergraduate I

started in 2000 as a freshman at

University of Washington and majoring in

Psych and I was doing a minor at the

time but I never finished a minor and

was an independent student I look in the

dorm for a while

I lived at my parents for a little while

it was generally I don't always

generally a good time but I think you

know I had some the same sorts of

problems that a lot of students have

sometimes it was difficult my friends

sometimes I wasn't sure what I was doing

with myself socially that kind of thing

what else did you want to know I think

that's about about it it sounds like you

had an okay experience but like most

students there was some things that went

along with that yeah so going back to

those three words that we had talked

about earlier do you remember them in

the order that I told them to you

and I'll actually remember what the

three words were so no sorry pause the

video now and assess the client for

effect mood

form of thought attention and speed of

thought and memory

this clients our fact seems to be full

and congruent they seem to express their

emotion fairly typically or normally in

a way that is not restricted their mood

seems euthymic while talking about their

university years they seem fairly upbeat

they said generally it was a good time

their thought process seems logical they

make obvious connections between content

and their memory seems to be there seems

to be some element of anterograde

amnesia present because they're able to

recall the past events fairly well but

current events those three words they're

asked to recall they cannot recall they

cannot remember so we would indicate

anterograde amnesia okay let's try the

last guided practice video case study

when I get upset I love to snuggle with

my Poochie because he gives me such good

cuddles pause the video now and assess

the client for effect mood form of

thought attention and speed of thought

and memory

this clients FX seems full and

incongruent for example they are smiling

in a way that seems fairly superficial

forced if you will and they talk about

being upset while smiling at the same

time when I get upset and so it seems in

congruent to me their mood seems elated

very very upbeat for being upset for

sure your thymic would also be ok but

they do seem to be almost on top of the

world in some ways their thought process

seems logical they make connections

between content however we don't really

have a lot of information here so it'd

be ok if you had written in unable to

assess I would definitely write in

unable to assess for memory because we

don't know if there are long or

short-term memory problems and in terms

of consciousness we would indicate

regression here because of the clients

high-pitched voice and use of fairly

childlike phrases such as Poochie when

describing their dog ok let's review

today we learned about memory and

reviewed amnesia both anterograde and

retrograde amnesia consciousness both

dissociation and regression and also

briefly went through orientation to time

place person and situation and finally

though it's not written here we also

reviewed intact memory this concludes

section 3 of the mental status

examination training