Mental State Examination Report for Chris

This assignment involves a comprehensive mental state examination report for Chris, who believes he is suffering from schizophrenia. The report covers his general appearance, mood, speech, cognition, perception, and behavior. It also discusses the impact of illicit drug misuse on his cognitive impairment and the potential risk factors associated with his condition. Recommendations include immediate medical consultation, possible job agency referral, and psychological counseling.

Mental State
Examination Report

TABLE OF CONTENTS
Introduction................................................................................................................................3
General appearance....................................................................................................................3
Behaviour...................................................................................................................................3
Speech and language..................................................................................................................3
Mood and affect (feelings).........................................................................................................3
Thought (stream, form, content)................................................................................................3
Perception...................................................................................................................................3
Cognition....................................................................................................................................4
Insight and judgement................................................................................................................4
Formulation................................................................................................................................4
Summary of findings..................................................................................................................4
Action.........................................................................................................................................5

INTRODUCTION
This interview is regarding mental health status of Chris. He has turned up for the
appointment and it is his second time at this interview. The interview is regarding analysis of
condition which further moves towards treatment and wellbeing options available to him.
Chris believes that he is suffering from Schizophrenia. Also, risk factors that can affect the
health of Chris will also be analysed during the process. The interview also involves a risk
assessment and K10 test which will help in discovering some real concerns about the
individual and state of his feelings. Further, risks associated to consumption of drug and
alcohol will be ascertained here.
GENERAL APPEARANCE
The client appeared to be casually dressed.
BEHAVIOUR
Chris appeared to be fidget and had movements more than requirements. However, he
cooperated in the interview and answered all questions that were asked to him.
SPEECH AND LANGUAGE
Chris appeared to have normal tone and pace of speech.
MOOD AND AFFECT (FEELINGS)
He appeared to have signs of being distressed as well as anxious. Further, he also
appeared to be agitated at some point of time as well.
THOUGHT (STREAM, FORM, CONTENT)
He has a belief that people may attack on him if he is in large crowd. He claims that
he hears few voices in his head stating, “Do this” or “Don’t do this,” or “stuff everyone”.
Chris has thoughts about suicide yet it has happened a few weeks ago. He claims that the
thought has just entered in his mind and has not really try to attempt it. It was noted that he
scored high on the K10 test. He scored 41 in it which states that he was at the level of severe
mental disorder (Kessler. n.d).
PERCEPTION
The person has Persecutory delusions where he believes that people may attack him.
This is also considered as auditory hallucinations where he is hearing certain things which are
not actually happening in reality (American Psychiatric Association, 2013). He also watches

unreal incidents as well which can also be termed as visual hallucinations. He avoids large
gatherings of people and claims he does not attempt to go out much.
COGNITION
Chris appears to be alert during the interview. However, sometimes, he forget to take
his medicines. It can be due to the drug and alcohol use as a reason why he forgets.
INSIGHT AND JUDGEMENT
The insight and judgment of Chris was good. He recognises the symptoms of his
mental illness and can link that the hallucinations are aggravated due to usage of drug. He
also sees that alcohol also affects his condition and due to the same, he neglects his
medication. He also admitted that he feels unwell at times. Further, he also stated he is not
sure if he is taking the right medication for his disease or not.
FORMULATION
Chris has an irrational fear of big crowd. He claims that he hears voices. However, it
appeared during the session that he did not hear voices or even see things. It was a week since
he smoked pot and claimed that he still hears voices even when he is not taking marijuana.
He occasionally takes marijuana. However, on the other side, he claims thathe
consumed it a week ago. Moreover, he is also an avid consumer of LSD, Ecstasy at least once
every few weeks. He is also being indulged in taking heroin. Further, he stated that he still
hears voices even when he is not taking marijuana.
Chris has audibly hallucinations for at least 2 years. However, he takes marijuana for
at least 10 years. He uses drugs to escape from reality. He is forgetful or neglect his
medications at times. It is because of his continuous alcohol or drug abuse. He stated that
drugs and alcohol help him to cope with distressing and anxious situations. Chris has been
suffering from schizophrenia and he claimed same at the beginning of interview.
SUMMARY OF FINDINGS
The characteristics of him having schizophrenia are present in the form of delusions
and hallucinations. He is also suffering from catatonic tick symptoms such as avoiding large
crowds of people and delusions (American Psychiatric Association, 2013).
Misuse of illicit drugs and alcohol has affected his cognitive impairment particularly
any aspect of memory due to which he is neglecting his medication with these impairments
where he could get attracted towards forgetfulness (Government of Western Australia, 2013)

He uses those drugs to escape from reality. He states that the marijuana is limited to the
amount to which he can afford further claiming that he does not have much money.
He stated that he is not sure if he is taking right medications and spoke regarding the
same to the doctor. He does not see to the doctor regularly and the last time he visited to the
doctor was a few months ago. In this case scenario, it is apparent that schizophrenia has been
derived from the chronic drug use (Marta Di Forti, 2014). With the drug use, he can be stated
in the condition of Drug-induced Psychosis (Ham, Kim, Chung, & Im, 2017).
As per schizophrenia disorder, there been studies that people suffering from this
condition have a high probability of suicide risk (Bourgeois. Swendsen,, Young 2014). From
the interview, it appears that he has not attempted suicide but has got thoughts on the same. It
appears that he has been categorised in mild suicide risk factor. The thoughts are limited in
nature, and has no plans to act out upon it (Marsh, O’Toole, Dale, Williams, 2013).
ACTION
Chris is required to visit to the doctor as soon as possible, particularly with the
medication he is taking. It is important for him to get involved in new medication course
which can further help in dealing with the issue. While asking him regarding planning a visit
to a doctor, an affirmative reply was received from his side. Chris is also planning to opt for
certain counselling session in the future with the help of psychologists. Also, I have agreed to
link him up to a job agency to help him find work as employment. It can help him in lifting
up his spirits and possibly reduce his feelings of worthlessness and depression. These
sessions as well as counselling from the psychologist can guide him in getting rid of illicit
drugs.