in the seventh section of the Mental Status examination training we will learn about interpersonal issues my name is Tom field and I produced and narrated this training series let's return to the overview in this training series we learn very scaffolding process in this section of the training we will learn about intra personal issues and during guided practice we will review effect and mood thought process memory motor speech and interpersonal issues at the conclusion of the eight sections is an end of training tests I encourage you to follow the handout as we progress you can use scrap paper for guided practice if you'd like this also a sheet available for this and there's going to be occasions during guided practice video case studies where a section of the Mental Status examination is not fully evident and on those occasions it is okay to indicate unable to assess the definition of intrapersonal is internally driven behavior there are three facets to interpersonal behavior ego congruence ego centrism and ego strength ego congruence is the individual's appraisal of whether their behavior is consistent or inconsistent with their personality when an individual deplores and expresses remorse for behavior it is inconsistent or dystonic with their personality when an individual defense or justifies their behavior this is indicative that an individual does not find a behavior inherently problematic and thus it is consistent or sinned tonic with their personality the premise here is that behaviors we find acceptable are somehow aligned with our core self or personality and behaviors we find unacceptable are somehow unaligned with our core self charity egocentrism is an individual's narrow focus on themselves often exaggerating their sense of importance in relation to others this was briefly referred to in the interpersonal or sick the section of the Mental Status examination training it includes conceited and grandiose or expansive concepts ego strength is an individual's ability to cope in the face of adversity or impulse if an individual lacks ego strength they often engage in non-productive behaviors that highlight their unstable sense of self and tendency to make matters worse in a self destructive war decompensating the fashion intro punitive splitting or dichotomous thinking and catastrophizing are all examples of problematic or low ego strength let's watch some video case study examples to illustrate those concepts ego-dystonic is described as when an individual does not consider their behavior to be consistent with their core personality let's watch an example I really wish I'd said all those things in this example the client is contrite with a serious facial expression that mirrors their vocal content that they experience regret for things said to their mother the client here doesn't have to say this isn't me this isn't Who I am it's enough for them to say that they regret they express remorse for that behavior that behavior to them is unacceptable or ego-dystonic ego-syntonic is described as when an individual considers their behavior to be consistent with their core personality this can result in externalizing blame to others for problematic behavior I've been drinking since I was like 5 this client smiles while describing their drinking and they mention it as something they've always done since age 5 that they can handle it that they don't know why everybody else has such a problem in other words their drinking seems consistent with their conceptualization of who they really are it is acceptable behavior to them this means their behavior is ego-syntonic conceited is described as egocentric self-important arrogant and proud it's an example of ego centrism and often hides deeper seated anxieties and feelings of inadequacy it can be associated with narcissistic personality let's watch an example see said you had a test coming up this week oh yeah we got a major exam coming up in a couple days I think how's the studying going oh I'm not worried about studying for this how come I know I'm the smartest person in the class by far I mean I'm just I'm just two or three notches ahead of everybody and and I know I'm gonna do fine I mean I'm not worried about it I really need to study this client shrugs with an all pls expression when asked if she has studied for this upcoming test elaborating that she's the quote smartest person in the class by far and doesn't really need to study while this might be true this arrogant presentation to others is often used for bragging purposes or compensating for deficiencies grandiose or expansive is described as a form of ego inflation another example of ego centrism people who are grandiose are expansive believe they can accomplish anything even outrageous tasks it can be associated with manic states found in bipolar disorder let's watch an example so the other night I was I had this like amazing idea I mean it's just it was just like the best idea I've ever had I mean I just felt like I was just so like in tune with everything you know like like just like the creativity of the universe was just like flowing through me right then and you know I stayed up like all night working on this idea and it's gonna be totally awesome it was like this board game and it's gonna be totally like to do with these like principles of economics and it's gonna be amazing like I already know like it's gonna be like like I'm gonna make it like I'm gonna do this and it's gonna be like this humongous hit like it is gonna be a top board game and you know like I've just never seen anything like it I mean monopoly like complete and utter crap compared to my idea with an intense facial expression this person talks about having stayed up all night to work on their idea for a board game the intensity of their facial expression is matched with this sense of urgency and they're ambitious or lofty ideas and it's this intensity that differentiates grandiosity from conceited as an aside staying up all night is a warning sign of mania and grandiosity is probably the most characteristic symptom of bipolar disorder this inflated sense that a person can achieve almost anything intro punitive is described as self division punishing self for unwanted events even if they are not fully responsible it is turning anger inward and can be associated with depression it's all my fault that my daughter isn't speaking to me I'm such a witch I I just I'm I'm so bad to her she just and she tells me that she tells me that all the time and I I'm just the most awful parent but there is I have no parenting skills I need to go to parenting skills because I am such a bad bad bad bad parent really and I you know I just wish she was speaking to me but she's not and it's all my fault it's just it's just all my fault I you know I shouldn't have talked to her that way I really shouldn't have talked her that way I she said I'm a witch and I am one I am awful this clients lack of ego strength is apparent while listening to the verbal content of her speech she says multiple times with a frown on her face that it's all her fault the sense of punishing self for unwanted events even if not being fully responsible is indicative of intro punitive tendencies as an aside the client also mentioned several times that she's such a witch that she has no parenting skills and the multiple occasions of saying these things are suggestive of rumination and rumination can be characteristic of intro punitive behavior in addition to that the client also says several times that she's a bad bad bad person and this vase language also suggests regression and so you can see that when a person doesn't have an integrated a sense of self when they have problems with ego strength they can experience problems in a multitude of areas such as with regression such as with rumination such as with interview 'native tendencies splitting is described as dichotomous thinking and is another example of having low ego strength people who splitting perceive events in absolute terms all-or-nothing black-and-white good or bad they cannot see the gray areas this is associated with borderline personality disorder that's much an example I got caught stealing last week how do you feel about that I'm just such a terrible person it just I just feel like there's just no no way to come back from that you know it's just there's just nothing good about me I'm just entirely bad it just makes it makes me feel like there's just nothing good about me this client focuses on being a terrible person and states that there is nothing good about them feeling entirely good or entirely bad suggests black-and-white thinking and while the person is blaming themselves in a similar way to someone who is interview 'native would do and you can by the way code both in true punitive and splitting they also engage in this black and white or dichotomous thinking and this suggests more even more problematic thinking and behavior because someone who engages in splitting is less likely to be able to tolerate ambiguity which as most of us know is very common to living everyday life catastrophizing is described as dramatically predicting that the worst event is most likely to occur it's another example of having difficulty or low ego strength the person who catastrophize engages in faulty logic and this can be associated with depression and also with histrionic personality let's watch an example I spent that $3,000 and now I'm not gonna be able to pay my electric bill next week and if I can't pay my electric bill then I'm pretty sure my partner is gonna leave because she's told me already that this is the last time she's gonna put up with my spending so I can't pay my electric bill next week I'm not sure I can pay rent in two weeks my partner's gonna leave because I just did this I bought this couch and if my partner leaves then I'm pretty sure all of our friends are gonna still be her friend and I'll be my friend so in this example the person or client engages in faulty logic they start with not being able to afford their electric bill and by the time they're done they have basically predicted that the worst event is going to happen so they begin with not being able to afford their electric bill then state that their partner is going to leave then mention that they fear all of their partners friends will leave them and then essentially they'll be all alone and it's this kind of worst-case scenario that is evident or indicative of catastrophic thinking it's now time for you to try your hand at coding interpersonal issues on the Mental Status examination and the next series of video case studies you're going to code for effect mood thought process memory and consciousness motor speech interpersonal issues and interpersonal issues let's watch the first video case study well I got caught stealing last week how do you feel about that well I really don't think it should be that big a deal I mean I'm I'm just kind of irritated it's been it's big of a deal as it has it doesn't seem to be problematic to you not really I mean the stuff was overpriced anyway and you know that these big stores have so much money they're not gonna miss it I don't see what's wrong with it pause the video now and assess the client for effect mood thought process memory and consciousness motor speech interpersonal and intrapersonal issues this client has a full incongruent effect that is an outward expression of their inner dysphoria they seem to be irritable which indicates to spheric mood we're unable to assess memory at this point in time their motor seems fairly relaxed their speech is regular rate and rhythm in terms of interpersonal they seem dismissive for example the interviewer provides a minor suggestion or direction and the client says not really just kind of shrugging it off as well as for intrapersonal they are ego-syntonic their behaviors ego-syntonic even though they don't say specifically and that's who they are their sense of framing their behavior as being acceptable and blaming it on others saying that the the stores are not really going to miss the items that have been stolen anyway it's indicative of ego-syntonic behavior let's watch the second video case study last week at work I'm I made this terrible mistake I totally misplaced this really important file and I couldn't find it for like 45 minutes luckily I found it right before my boss was supposed to go into this big meeting so he just kind of you know got a little pissy with me and that was it but but I'm totally scared I'm gonna do it again now and if that happens again I mean you know I just can't stop thinking about what might happen I mean if I keep making these these horrible mistakes he's totally gonna fire me and then you know I'm gonna be unemployed I'm not gonna be able to get a reference cuz I've been such a crappy employee here and then you know I mean all I can picture is you know my house going into foreclosure and everybody's thinking I'm like you know this total like slacker and it's just so bad you know I've called in sick to work for the last two days because I just totally know that that's what's gonna happen pause the video now and assess the client for effect mood thought process memory and consciousness motor speech interpersonal and intrapersonal issues this client has a full incongruent effect again they seem dysphoric somewhat irritable in terms of thought process they seem circumstantial in their form of thought and they have racing thoughts the memory we are unable to assess their motor seems relaxed in terms of their speech it does seem slightly pressured which would match the racing thoughts we're really unable to assess interpersonal issues at this point in time and in terms of interpersonal issues we would code catastrophizing because the person moves from saying that they got into some difficulties at work and they're afraid that their house is going to get into foreclosure based on on that the the link there is somewhat tenuous and is a worst-case scenario okay let's review today we learned about ego congruence looking at both ego-dystonic and ego-syntonic behavior we looked at ego centrism and especially examined conceited and grandiose or expansive concepts and also looked at ego strength both intra punitive splitting and catastrophizing forms of low or problematic ego strength and this concludes section 7 of the Mental Status examination training