Intake, Assessment, and Diagnosis Flashcards

A client presents with a 2-week history of depressed mood, anhedonia, significant weight loss, insomnia, and feelings of worthlessness. Which DSM-5 diagnosis is MOST appropriate?

Answer: Major Depressive Disorder

Major Depressive Disorder requires 5+ symptoms including depressed mood or anhedonia lasting at least 2 weeks, which this client meets.

During the intake interview, a client discloses that they recently lost their job and are struggling financially. The BEST way to document this information is under which assessment domain?

Answer: Psychological stressors and support systems

Financial stress and job loss are psychosocial stressors captured under the social history and stressors domain of a biopsychosocial assessment.

Which structured clinical interview is widely considered the gold standard for establishing DSM-5 diagnoses in research and clinical settings?

Answer: Structured Clinical Interview for DSM-5 (SCID-5)

The SCID-5 is a semi-structured interview designed to yield reliable DSM-5 diagnoses and is considered the gold standard diagnostic tool.

A counselor is assessing a 16-year-old client who reports using alcohol on weekends but denies it causes problems. What is the MOST appropriate next step?

Answer: Administer a validated adolescent substance use screening tool such as the CRAFFT

The CRAFFT is a validated screening tool for adolescent substance use that goes beyond self-report to identify risk and problem patterns.

A client scores 15 on the PHQ-9. What level of depression severity does this indicate?

Answer: Moderately severe depression

PHQ-9 scores of 15–19 indicate moderately severe depression, guiding treatment planning decisions.

Which of the following BEST describes the purpose of a mental status examination (MSE) during intake?

Answer: To obtain a systematic snapshot of the client's current cognitive and emotional functioning

The MSE provides a structured assessment of appearance, behavior, speech, affect, thought, cognition, insight, and judgment at the time of the interview.

A client reports experiencing intense fear of social situations and avoids them due to worry about embarrassing themselves for more than 6 months. Which diagnosis should the counselor consider FIRST?

Answer: Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder is characterized by marked fear of social situations due to fear of scrutiny or embarrassment, lasting 6+ months and causing functional impairment.