Mental Status Examination: A Case Study of Lisa

This essay discusses the case of Lisa, a young patient with psychotic symptoms, and explores the use of Mental Status Examination in assessing her behavior and cognition. The examination reveals her distorted perception, hallucinations, and cognitive distortions. Lisa is referred to Mental Health Services for further assessment and management.

Running Head: MENTAL STATUS EXAMINATION
Topic: Mental Status Examination: A Case Study of Lisa
Name
Institute Affiliation

MENTAL STATUS EXAMINATION 2
Introduction
Mental examination is an analogue of physical examinations or consists of a series of
tests and observations of behaviour and perception. In this essay, I have discussed the case of
a young patient named Lisa. Lisa was a young woman with psychotic symptoms. She
reported hallucinations as she heard voices called by an ugly person and recommended that
she protect herself from her boyfriend. Lisa's perception turned out to be distorted because
she could not remember her address and previous medications. After each MSE evaluation,
Lisa was referred to mental health services for further assessment and management.
The series of observation and examination reveals the normal or pathological
behaviour of the patient (Huisingh, Wadley, McGwin, & Owsley, 2018). The structured
assessment of Mental Status Examination comprised of the description of general behaviour,
appearance, level o consciousness, motor, speech activity, thought, perception, cognition,
attitude and insight (Kinuhata, Takemoto, Senda, Nakai, Tsumura, Otoshi, Uchimoto, 2018).
The Mental Status Examination provides a complete assessment of the patient and
provides the direction for further assessment as well as management steps (Palsetia, Rao,
Tiwari, Lodha, & De Sousa, 2018) In the current assignment, Lisa has been found cognitively
or behaviourally unstable. All the associated terminology has been elaborated through the
case of Lisa. The massive body of researchers highlights the effectiveness of the Mental
Status Examination in the psychiatric, neurological or psychological assessment (Huisingh et
al., 2018).
Body
Lisa has been seen Jennie a counsellor in the loco drug services for the last six
months. She had a first to Psychiatric admission last years and was discarded with the
antipsychotic drugs. Lisa is a regular cannabis user and occasional spad user. She recent
moves away from her parents to live with his boyfriend, Jhonner.

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The first encounter of the patient gives the behavioural disturbances and underlying
mental and emotional states (Huisingh et al., 2018). The appearance gives the counsellor an
overall impression of the patient. The physical appearance of the patient includes apparent vs
stated age, unkempt or immaculate grooming, riotous or subdued dress, kyphotic or erect
posture, and furtive or direct eye contact ((Bigler, 2015; Grossman, & Irwin, 2016). The
current case Lisa was found to be unhygienic, hairs were uncombed. Lisa counsellor noted
that she is not looking in her usual self, normally she looks quite smart. When the client
entered the session room, he was very anxious and reluctant to respond to the question. The
counsellor noted that usually, Liza looks smart and active, but currently, she was looking dull
and in unhygienic condition.
Furthermore, Liza sat comfortably n the chair but found to be lost and distracted. She
was wearing a black t-shirt and trousers, and she was assessed to be non-depressed but
agitated. According to the counsellor, Liza appearance was not appropriate that can be
considered as pathology.
The behaviour of the patient plays a significant role in the assessment of Mental status
examination. The verbal and non-verbal both behaviour depict the normal or pathology in the
behaviours of the patient (Huisingh et al., 2018). The eye movement (establishing eye
contact, maintain eye contact) body posture, gesture, hand movement, and distracted
behaviour provides a basis for pathology (Grossman, & Irwin, 2016). In the above Behavioral
Observation was carried out to assess the client interest, abilities and appearance, his verbal
and non- verbal cues. (Demetrius, Magistretti & Pellerin, 2014).
The rationale of Behavioral Observation was to assess the client nonverbal behaviour,
her posture gesture, hygienic condition and how he communicates with or without verbal
communication (Trzepacz, Hochstetler, Wang, Walker, &Saykin, 2015). The client was
observed during the entire session. The client was a young woman with weak physic. She sat

MENTAL STATUS EXAMINATION 4
anxiously on a chair and continued rubbing her arm. The content of his speech was not
coherent; he was taking much time to answer the questions and answers were very brief. In
the current case, Lisa seems restless and agitated; she was continuously fidgeting in her chair.
At times, she was a disgrace and seemed to be respondents towards unseen stimuli. Abnormal
involuntary movements have also been observed in Lisa's behaviour. She found to be
distracted by unseen stimuli. The behavioural observation of Lisa suggested that she has
abnormal and restless behaviour. The activity level of the patient was found to be
inappropriate. The findings of the overall observation showed that he was anxious, fearful,
paranoid and hopeless about his future.
Thought content refers to the presence or absence of obsession or delusional thinking
(Huisingh et al., 2018). The delusion refers to the belief that is not reality based, and distort
the normal thinking pattern (Bigler, 2015). Also, indicate abnormal thinking in the thinking
content of the client. The delusions are not accounted for by any religion or culture and level
of intelligence. The key element of delusion means a degree to which a person is convinced
to that belief even without actual evidence. A person with delusion firmly believes that her
delusions are real. Delusions are neurological, medical and mental disorder oriented such as
psychotic, schizophrenic, delusional, schizophreniform or mixed psychotic disorders, mood
or and substance-induced disorder (Kertesz&Harciarek, 2014). Different types of delusions
have been reported in the literature such as jealousy, persecution, guilt, poverty, love and
nihilism (Grossman, & Irwin, 2016). The delusion of persecutory is the most common type of
delusion, in which a person believes that the erroneously another person is trying to harm
(Kertesz&Harciarek, 2014). Such as Lisa has persecutory or paranoid and delusional
thinking, she feels that Jhonner has been making plans to destroy her. She feels unsafe in the
house. She is trying to protect herself by knife and sleep in the garden shade which is cold

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and dark. She feels that in all the through cameras someone is watching her. She also heard
an unusual voice.
The inability to process information accurately results in psychotic thinking (Putcha,
and Tremont, 2016). The incorrect perception of stimuli and the relevant response considered
to be a critical psychiatric assessment (Putcha, and Tremont, 2016). Hallucinations are the
perceptual disorientation that occurs in the absence of the sensory stimuli. The auditory,
visual, tactile, gustatory, olfactory and cereal are the basic types of hallucination and patient
usually experience and report such hallucination (Huisingh et al., 2018). The sensory system
which is involved in hallucination must be noted for risk assessment (Bigler, 2015).
Hallucinations are the most significant perceptual disturbances, without external
stimuli. The two kinds of hallucination have been reported in the current case, i.e. auditory
and visual. In the auditory hallucination, the patient hears voices that nobody else hears, as
Lisa hears someone calls her ugly, and commands her that she should protect her from his
boyfriend, Jhonner. The visual hallucination seeing objects that are not present, such as Lisa
sees hidden cameras in the entire house. Furthermore, Lisa was experiencing both
hypnopompic and hypnagogic hallucination that depicted she see things in awakening as well
as a sleeping state.
The behavioural observation provided the basis for the risk assessment of Lisa. Lisa
was having the fear that someone is watching her through cameras. She was tried to protect
herself from honour, his boyfriend. She also heard voices that shooter is trying to kill her.
The psychiatrist continued the risk assessment of her behaviour and continued further
assessment questions. The clinical interview was carried out to assess the client problem and
conflicting issues which lead toward drug abuse, paranoid thinking and hallucination
(Huisingh et al., 2018). A clinical Interview is the main tool for gathering information from
client, parents, and other informants (Bigler, 2015). Clinical Interview was done to assess the

MENTAL STATUS EXAMINATION 6
client own insight about his illness and problems which was very helpful to understand her
problems(Grossman, & Irwin, 2016). The client had no insight about the harms of a drug;
rather it’s a source of energy for the client. The counsellor tried to investigate the core belief
behind the illusions, hallucination and paranoid thinking of the client. It was asked by the
client through history taking if Jhonner has hurt her or someone else. The client relied upon
no; Jhonner hasn’t hurt her or even to someone else. Her denial depicted that either she has
no insight about her problem, or must be experienced unconsciously by the Jhonner or family
members. Furthermore, memory and cognition were also found to be distorted as the client
was not able to recall the name of the medicine; she was using in the past. The Lisa reported
all the experiences, apprehensions and problems to the counsellor and it was observed that
there was well rapport built between the client and the therapist.
The results of the above risk assessment revealed that Lisa has a speech problem. She
had cognitive distortion; such as having the inability to recall new address and previous
medication. The orientation of time, space and location where appropriate. The roots of her
paranoid thinking were baseless as it was reported by the client that Jhonner hasn’t hurt her
throughout the relationship. The client also reported that her parents had not developed a
relationship with the patient.
It was also observed that Lisa has more inclination towards self-harm, that could be
dangerous for her and the other petioles as well. In short, speech, cognition, paranoid
thinking, hallucination and agitated behaviour were found in Lisa behaviour and cognition
(Yajima et al., 2014).
The counsellor checked and understood Lisa problem and hypothesised that
 A relapse of their mental illness
 There is a risk of harm to self or others

MENTAL STATUS EXAMINATION 7
Therefore she was recommended for further assessment by the counsellor with the
collaboration of Liza.
After completing MSC, the following was observed
 Speech and Language: Lisa ha Speech and language problem.
 Mood and affect: Lisa was not depressed but showed agitated behaviour.
 Cognition: Lisa does not remember her new address and medication. Orientation: the
orientation of time, space and location were appropriate. Insight and judgment. She
had insight into her illness and treatment.
Mental Health Services were contacted for further assessment.
After the completion of mental status examination, the counsellor asked the patient if
she need help to protect herself from the jhonner or unfamiliar voices. The Lisa reluctantly
answered that yes she needs help and want to protect her from the entire painful situation as
to sleep under the shade in the dark and cold night is hard. The counsellor called the mental
health services and reported all the symptoms to the mental health practitioner. Furthermore,
the counsellor set an appointment with the mental health practitioner for relapse prevention,
assessment and management of the client.
Conclusion
Lisa was a young lady diagnosed with psychotic symptoms. She reported
hallucination as she hears voices that someone calls her ugly and recommend her to protect
herself from Jhonner. Lisa strives for protecting herself and sleeps in a garden shade with a
knife. The MSE was carried out to assess her behavioural and cognitive functioning. The
appearance of Lisa was reported to be unusual; her hairs were uncombed. She was fidgeting
on the chair and continued rubbing her arm. She was found to be distracted for unseen
stimuli. Her speech was coherent, she was taking time to give answers, and her answers were

MENTAL STATUS EXAMINATION 8
very brief. She was lost and responding unusually. Through risk, assessment t was observed
that Lisa has a hallucination that someone is seeing her through hidden cameras. She also
reported auditory hallucination such as someone calls her ugly and recommended her to
protect him from Jhonner. She also reported that Jhonner had inserted some instrument in her
stomach. Lisa's cognition was found to be distorted as she was unable to recall her new
address and medication. After all the assessment of MSE, Lisa was referred to Mental Health
services for further assessment and management.

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