Case Study: Adult Mental Health Assessment of Harry's Condition

This report presents a detailed mental health assessment of an 18-year-old male named Harry. The assessment includes a mental state examination revealing symptoms of depression, constricted affect, slow and hesitant speech, and excessive vagueness in thought processes. Harry exhibits delusional thoughts, including the belief of being invisible, and auditory hallucinations. The report outlines a nursing report summarizing the case and recommends interventions such as psychotherapy, interpersonal therapy, relaxation therapy, stimulus control therapy, and cognitive behavioral therapy (CBT) to address his detachment from reality, hallucinations, and symptoms of depression and insomnia. The report references several academic sources to support the assessment and treatment recommendations.

Adult Mental Health Services
CONSUMER ASSESSMENT
Date: 08/09/2018
Time:
MENTAL STATE EXAMINATION
General
appearance Harry is a 18 year old male student study in high school. He is dressed
casual in T-shirt and jeans. The colour of his hair is black and has fair
colour. Patient appears perplexed or tensed.
Behaviour Patient was sitting calmly and have responded to each question,
although he was very cooperative but at the same time he was waiting
for the person to stop asking questions.. He looks nervous throughout
the interview and lack of eye contact at the time of conversation.
Speech Harry's volume of speech was normal. Slow speech rate and hesitant
flow of speech appears.
Mood and
Affect Harry appears to be sad and depressed. Constricted affect, with mood
dysphoric.
Mood depressed and sad, affect congruent.
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Thought
process Excessive Vagueness in thought process. Slow thinking or hesitant. The
thought process of Harry is not clear, there is some vagueness in his
thoughts. His thoughts was less logical and are not consistent.
Thought
content
Harry's thought content includes false beliefs and false sensory
perceptions. An illusionary world was created in his mind. Overvalued
ideas. There is a perceptual disturbance in thoughts of Harry as he
thinks that he can be invisible and no one can hurt him. He is suffering
form delusional disorder.
Perception
Hallucinations. False sensory perceptions are created in mind of patient
due to which he thinks that he can be invisible to others when he wants.
He also thinks that his brother try to harm him but, nothing like that.
Harry made false perceptions in his mind because he is suffering from
Visual type of Hallucination.
Cognition
Patient's current ability to process information was slow. He was fully
aware about the date and time when asked by the assessor.
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Judgement
Patient's ability of thinking and though processing is not good. He is
suffering from Hallucination and delusional disorder due to which false
perceptions is made in his mind that aren't there.
Insight
Patient do not show any insight regarding his illness. He was
completely denial of illness. For eg: When clinician ask to Harry about
his condition, he completely denial his illness.
SYMPTOM INTERVENTION
Feeling
depressed
Psychotherapy: This therapy can be extremely effective treatment in
treating patients who are suffering from depression. In this, clinician
understands the relationship patterns, develop better relations that
assists patient in reducing isolation (Fortinash & Worret, (2014).
Interpersonal therapy: It refers to time limited, discrete and structured
psychological intervention which focuses on interpersonal issues. In
this, patient and therapist work collectively to determine effects of
depression and then seek to decrease symptoms by learn to cope up
with problem areas and attempt to lead a normal life (Grob, (2014).
Sleep or
appetite
changes
(Insomnia)
Relaxation Therapy: It is an observation based theory which states that
insomnia patients often shows high level of cognitive, emotional or
physiologic arousal, during day time or night (Lahelma and et. al.,
(2012). Optimal relaxation methods are used by practitioners to treat
sleeping issues of patients.
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Stimulus Control Therapy: In this, stimulus control instructions are
used for treatment of insomnia (Lee, J. and et. al., (2016). It is
designed to assists patients to develop consistent sleep wake rhythm,
fortify bed as cues for sleep as well as weaken it as cues for activities
which may interfere with sleep. These instructions address various
points including when to sleep, what to do when it is not attained etc.
Detachment
from reality
or
hallucinatio
ns
Psychotherapy: It is the most effective therapy that helps an individual
who is suffering form hallucination or delusional disorder (Perou and
et. al., (2013). The significant factor in psychotherapy is quality of
therapist and patient relationship. It includes gradual but gentle
intriguing of delusional beliefs of client, starting with least important
and smallest items.
Cognitive behavioral therapy (CBT): It is based on an idea that how
we feel, how we act and how we think all interact together. This theory
aims to assist people to be aware of when they think negatively or make
negative interpretations which reinforce distorted thinking. It helps
sufferer to develop alternative ways of behaving and thinking which
aims to lower down their psychological distress (Schmitz and et. al.,
(2012).
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NURSING REPORT
Harry is a young boy who is 18 years old and studying in high school. He dressed
well and appears perplexed. He behaves cooperatively with clinician and answer calmly to
each question asked. Harry believes that nobody can hurt him as he can be is invisible. He
thinks that his brother and patient are not supporting his special powers to be invisible and He
is planning to physically harm him but have not made any plans yet. As per the mental state
examination, Harry is suffered from Hallucination and Delusion problem. He made false
sensory perceptions and false beliefs in his mind. His mood was depressed and excessive
vagueness is found in his thoughts and as per police officials he have portrayed excessive
physical behaviour and may harm the people around. The main symptoms found by mental
state examination includes depression, detachment from reality and Insomnia. In order to
treat this, some therapy like CBT, Relaxation, Stimulus Control Therapy should be given to
patients so that he can overcome this issue. It is recommended to Harry to go through some
therapy sessions so that his psychological distress can be reduced.
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REFERENCES
Books and Journals
Fortinash, K. M., & Worret, P. A. H. (2014). Psychiatric Mental Health Nursing-E-Book.
Elsevier Health Sciences.
Grob, G. N. (2014). From asylum to community: Mental health policy in modern
America (Vol. 1217). Princeton University Press.
Lahelma, E. and et. al., (2012). Cohort profile: the Helsinki health study. International
journal of epidemiology. 42(3). 722-730.
Lee, J. and et. al., (2016). Cohort profile: the national health insurance service–national
sample cohort (NHIS-NSC), South Korea. International journal of epidemiology.
46(2). e15-e15.
Perou, R. and et. al., (2013). Mental health surveillance among children—United States,
2005–2011. MMWR Surveill Summ. 62(Suppl 2). 1-35.
Schmitz Jr, W. M. and et. al., (2012). Preventing suicide through improved training in
suicide risk assessment and care: An American Association of Suicidology Task
Force report addressing serious gaps in US mental health training. Suicide and Life‐
Threatening Behavior. 42(3). 292-304.
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