Mental State Examination: Reflection on a Case Study of Clinical Depression

Running head: MENTAL STATE EXAMINATION
MENTAL STATE EXAMINATION
Name of the student
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MENTAL STATE EXAMINATION
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Introduction:
This paper intended to provide a reflection upon a case study of ‘Alison’ a 38-year-old
single mother of two, with a current working diagnosis of Clinical Depression. In consideration
of her current situation financially, she is working at a supermarket for meeting her financial
need.
Cues and information:
Considering the current situation of Alison, There are significant stressors present such
as demand of kids for new stuff and games, being overweight, feeling of being useless with kids
and poor interaction with partner, negative life events which facilitate the symptoms. However,
there are some protective factors such as a few good friends who help her out, her kids and her
sister which may improve her wellbeing. She was experiencing symptoms such as appetite loss,
weight loss, trouble sleeping, and tearful, low mood and feeling useless. Hence, she would
require a proper intervention to cope up with her clinical symptoms and improve quality of life.
Processing gathered information:
There are many areas to assess as the etiology of mental health issues has been linked to
a range of factors. Considering the health condition of Alison, The assessment of Alison requires
a biopsychosocial approach (Baranyi et al., 2017). As discussed by Tarafder and Mukhopadhyay
(2018), one of the key features of this approach is mental status examination which is a
structured way of describing a patient’s situation considering the eleven domain. Taking an
insight into the situation, a summary of findings suggested that she was somnolent; she had an
emotional facial examination with tearful eyes, slurred speech and face downward. Her behavior
demonstrated poor eye contact, hand wringing. Cognitively she was conscious but had poor

MENTAL STATE EXAMINATION
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ability to focus, she was quite forgetful and the problem with sleeping and eating. Her speech
was a little slurry, soft and impoverished. Her thought process was tangential with a flight of
ideas. She moved from thought to thought that related in some way. Thought content was devoid
of any classical delusional themes however contained cognitive distortions such as feeling
useless as a mother, feeling of harming herself and not feeling right. She tried to kill herself by
consuming paracetamol. Her affect was dysphoric, anxious and labile. Considering her mood
state, she was feeling the low mood and lack of energy. Perception indicates that there was no
report of auditor visual, false sensory or false belief of environment being unreal. Her level of
insight was fair with moderate judgment level. The questions about her level of risk revealed
static factors such as the relationship with a partner, support from sister and friends, previous
self-harm Current dynamic factors are a misuse of a drug such paracetamol, troubled sleeping
and eating pattern, feeding sick, unhealthy weight, low self-esteem and lack of energy
hopelessness.
Identify the problem:
By analyzing the available data from this broad approach and more specifically from the
MSE, her diagnosis of Depression can be described by the DSM-5 as a major depressive disorder
with mixed features since she did not meet the full criteria for a manic episode (Fried et
al.,2016). DSM 5 is a diagnostic tool published by the American psychiatric association to assess
the mental health status of the client. Considering DSM-5 of depression, low mood, marked
diminished interest in activities, lack of energy, feeling of worthlessness, specific plan for
committing suicide are the symptoms of depression which was observed in the patient (Van
Ameringen et al., 2017). In a review of the risk assessment findings, she is in depression with
low mood and risk of committing suicide.