Mental Health Assessment and Intervention for a Delusional Patient

STUDENT NUMBER:
Student Name: Student Number:
Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN:
Family name:
Given names:
Date of birth:
Sex:
MENTAL STATE EXAMINATION
General
appearance
The patient appeared to be silent, irritated, not-interested in the session.
He appeared to be excited on the onset of questioning.
Behaviour The patient’s behaviour appeared to be silent and dreamy. His
behaviour appeared to be absurd as he went on to answer questions.
While initially he answered the questions patiently, later became
aggressive.
Speech The speech of the patient was rather dreamy and absurd in nature. He
spoke in a delusional manner which reflected his mood swings.
Mood and
Affect
The patient’s mood appeared to be highly fluctuating as he answered to
the questions in the interview. His mood reflected remote connection to
reality. He sometimes reflected violence and conviction to his belief.
Thought process The though process of the patient appeared to be paranoid and
delusional. He had unclear understanding of reality.
Thought content Thought content of the patient was connected to him being invisible and
possessing special powers. He has engulfed in paranoiac thoughts that
appeared totally psychotic in nature.
Perception The perception of the patient reflects distorted mental orientation. His
perception appeared highly confused, psychotic and derision.
Cognition Report by the patient’s mother reflects his incapability in cognitive
capabilities. His decline in cognitive capabilities is seen from
deteriorating school performance, inability to speak appropriately,
perform ordinary human functions.
Judgment The patient seemed to have lack of judgemental capability as is
understood from his speech. He lacks capability to link or draw
connection between discussions or make a logical conclusion.
Insight The patient did not reflect any capability to depict insight regarding his
personality. His delusional and unrealistic speech made at the interview
was the proof.
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STUDENT NUMBER:
SYMPTOM INTERVENTION
Delusion and
mood swings
 Providing companionship to help develop sense of reality and remove
delusion (Kyaga, Lichtenstein, Boman, Hultman, Långström & Landen,
2011).
 Prevention of drug abuse through psychological counselling and
mentoring.
Feeling sad and
detached
 Providing assistantship and company to remove the feeling of
loneliness.
 Guiding through sessions to develop a sense of belonging (Schrank,
Bird, Rudnick & Slade, 2012).
Anger to violence
and paranoia
 Aiding in developing social interactions and removing isolation
(Corrigan, Druss & Perlick, 2014).
 Engaging patient in self-care and engaging in activities.
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