NUR2200 - Mental State Examination: Consumer Assessment Report

This report presents a Mental State Examination (MSE) of a 35-year-old male, Mr. Leroy, who is reluctantly attending a psychiatric appointment. The assessment covers various aspects of his mental state, including general appearance, behavior, speech, mood, thought process, thought conte...Read More

Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN:
Family Name:
Given Name(s):
Address:
Date of Birth:
MENTAL STATE EXAMINATION
General
appearance
The overall general appearance of Mr. Leroy, who is 35
years old presented as nervous. He wore a blue shirt
with an orange cap along with green pants which
indicate that the patient was unable to coordinate his
dressing properly. It might be the case for him where
due to irregulations of the medication, his symptoms are
relapsing. However, his clothes were neat and clean. No
accessaries were observed in his clothes and he
exhibited no birthmarks or tattoos. The patient also wore
loose fitted cloths which might be the indication of
weight loss and improper eating pattern. The patient
looked older than his biological age due to his physical
appearance observed in the video, indicating that the
patient has poor self-care and self-management skills.
The patient also appeared nervous and distracted since
he was not making any eye contact with the interviewer.
The patient was sitting in the kyphotic position which

represents the nervousness of the patient.
Behaviour
During the interview, the patient was sitting in kyphotic
positions and unable to sit in a straight position, indicating it
might be the case that he was reluctant to attend the
interview. The video highlighted that his parents forced him to
imvolve in the interview while he was reluctant to attend it.
He exhibited a lack of eye contact while communicating with
the professional, indicating he might be reluctant or nervous
to make eye contact. The lack of eye contact also indicate a
lack of self-confidence and attention while answering
professionals. While answering the questions, he was
continuously fidgeting his fingers and looking downwards.
The lack of confidence also observed when he was
answering in the short and repeated sentences, indicate the
patient might be anxious and nervous during the process of
conversation.
Speech
While considering the speech, it is crucial to consider the
motor activity of the patient. In this case, listening to
spontaneous speech while the patient relate the answer with
the open-ended questions asked is useful information.
Considering the speech of the patient, he was stammering
multiple times while communicating with the professional

where primary reason can be nervousness and anxiety. The
patient was using repetitive sentences and multiple improper
phrases with a clumsy gesture while communicating with the
professionals, indicating apraxia and aphasia. The frequent
pauses in the conversation while communicating with
professionals also observed in the video, indicating marked
phases of aphasia. Consequently, it was difficult to interpret
the information. The patient had distorted and improper
speech along with improper motor activities, indicating he
was unable to place his thoughts into appropriate sentences.
Mood and
Affect
While the patient was involved in a conversation with the
professional, he responded to the professionals and greeted
her warmly in the initiation of the communication. While he
was unable to communicate in proper phrases, he was
capable of replying to each question with overexcitation. The
patient laughed when he was asked to answer the questions,
indicating disruptive behavior
And disorientation. He was unable to understand the
significance of each question that was asked, indicating
cognitive disruption and reception problems. However, in this
context, it can be said that he was hyperactive in the majority

of the time while he was answering the questions of the
professional.
Thought
process
The thought process of the patient was reflected through his
way of replying to the interviewer. The patient used
fragmented sentences and repeated phrases while
communicating with the counselor, indicating he was having
the flight of idea which he was unable to place in proper
sentences. The continuous insertion of random thoughts also
observed in the patient which further impacted his thought
process. In other words, it can be said that can be mentioned
that the patient experienced an acute confusional state.
Moreover, he was not taking time to understand any of the
questions and the professional repeated each question for
providing a clear idea which might indicate receptive aphasia.
He stated that since he was busy, he was not able to monitor
his accurate sleeping pattern, diet, and nutrition. He gets
approximately three to four hours of sleep which indicates
restlessness that inturn reduces cognitive function. In this
case, diversion of thought process may require immediate

clinical attention.
Thought
content
The patient had false beliefs ( delusion) since he highlighted
that some external forces helped him to form creative ideas
for his business. However, he also mentioned that he did not
hear or see any external forces. In this context, it is crucial to
assess symptoms of the hallucination since he may exhibit
mild to moderate hallucination in the future. The appropriate
intervention and clinical support are to required for the health
professionals to modify his false thought content and provide
him an insight of illusion free life. He also mentioned that he
has a habit of thinking about suicide, indicating suicidal
ideation. The suicidal ideation is a common feature of the
patients who are experiencing mental illness as observed in
this case study where patient exhibited maniac episodes
frequently. Hence, in this case, appropriate therapy and
intervention are required to provide to the patient for the
reduction of suicidal thoughts.
Perception
To understand the wrong or false perception of the patient,
it is necessary to interpret affirmative responses
conservatively so that the perception of the patient can be
identified. While patient did not show any sign of negative

and hallucination which he mentioned during the interview,
he was overconfident and had a false belief ( delusional
thinking) that some external forces helped him to form
creative ideas for his business. This false perception requires
immediate clinical assistance and appropriate clinical
interventions. In this case, unorganized perception may
increase the symptoms of mental illness.
Cognition
To identify the cognitive activity of the patient, it is crucial to
consider the thinking process along with the motor skills of
the patient. The cognition level of the patient can be identified
from the responses he was giving to the counselor where he
mentioned that he was not hearing any voices or seeing
anyone since he was busy. However, the patient also
mentioned the external forces which made him creatively for
his business ideas. In this context, it can be said he may or
may not show cognitive impairment in the future. Moreover,
he was not subjected to any cognitive assessment which can
assess the cognitive ability of the patient. Hence, in order to
identify the cognitive ability of the patient, proper assessment
of the cognitive functions with the assistance of the
professionals are required to conduct

Judgment &
Insight
While assessing the mental state of the patient , it is crucial
to consider the ability of the patient to judge any situation
by understanding impact and significance of it. In this
current context, it can be said that the patient was unable to
understand the significance of the interview and his parents
forced him to attend the interview with the professionals. He
was unable to understand the importance of taking
medicines and he skipped his medication cycle , indicating
he lacks the insight and judgement to understand the
scenario. Moreover, he mentioned that he considered
himself as a busy person and hence he was unable to track
the time and sleeping pattern of the him along with the
eating habits. However, he was terminated from his work
months back because he was shifted to his parent’s home
and he was forced by his parents to go to the interview. He
also unable to judge to his health complications and
signification of the his health condition.

SYMPTOM INTERVENTIONS
Thoughts of
the patient
While, analysing the interview of the patient, it can be stated
that, the patients has the problem of fleeting thoughts that is
thoughts related to the planning of suicide, however, the
individual never takes such steps in reality and it is the only
planning process. According to the study of Kallapiran et al.
(2015), it is reported that,the if such kind of symtoms of the
mental health patients are neglected then it may cause more
serious mental health consequences. This study also
suggestd that, neglegency to such condition may lead to
onset of schizophrenhia among the patients and so it is
suggested that it is very crucial to address such kind of
condition so that any kind of severe consequences can be
prevented.
For managing such conditions, it is the duty of the health care
professionals to refer the patients to the counsellors who can
help the patient to manage such kind of condition. The
counsellor will try to enhance the consciousness of the
patients by invoving the patients in therapies such as
meditation and yoga to make the the thought process of the
pateints in a linear way in stead of the turbulence thoughts.
Onset of linear thoughts in the patient will help the patient to
communicate and think in a coherent manner (Carmel,Rose &
Fruzzetti , 2014).
Another intervention that may help to improve the condition of
the patient is the application of the dilectial behavorial therapy

(DBT). According to the study of Linehan et al.(2015) it is
reported that the Dialectical behavior therapy (DBT) is one of
the most effective therapies for treating the patients with
mental health issues such as anxiety, agitation. It is mainly a
cognitive behavioural therapy that is tries to point out the and
change the negative behaviour and patterns of thinking
among the patients and thereby helps the patient to think
positively. DBT will also help to reduce the suicidal behaviour
and related thoughts among the patients with such symptoms.
There are four parts in DBT and in this case the individual
therapy session will be most applicable for this patient (Panos
et al., 2014).
Therefore, it can be stated that, the above mentioned
interventions can easily be applied to this case scenario and
these will help the patient to mamange the symptoms
presented above.
Mood of the
patient
From the analysis of the case study of the patient, the health
care professionals identified that, the patient had the problem
of euphoric symptoms and thus it can be stated that, the
patient had excessive synthesis of dopamine hormone in his
body. In such condition, generally at first antipsychotic drugs
are used as primary intrervention. Apart from that, various
non-pharmacological therapies can also be used as an
intervention to treat such condition. In such condition, both
can be applied in order to get the maximum benefit or an
mixed therapy that is pharmacological therapy along with the
non-pharmacoligical therapy can be used (Gómez-Romero et
al., 2017).
Accorfimg to the study of Fritz et al. (2015), it is reporte that,
as a non-pharmacological theapy, the use of music
intervention is very effective. The study suggested that,
liseteing of music has a strong and powerful capacity to
create physiological and therapeutic effect on the patients. It
is reported that, the effective nature of the music intervention
is associated with the emotional and physiological
associations created by the music itself during the listening of

music by the individuals (Gómez-Romero et al., 2017). In this
study, the self-made music was used as musical intervention
instrument and this produced music was applied to the patient
as intervention method. The patients who are suffering from
substance related malfunction of the nervouse system, a
huge synaptic gap is reported among those patients and thus
they may face neurological dysfunction thereby cause lack of
self-efficacy among those patients. It is reported that, a
positive behaviour in the patients can cause positive
psychological effect and also improve the quality of life of the
patients as well. The study result showed that, the use of the
self- derived music among the mental health disporders
patients can cause improvement in the symptoms of the
mental health patients. The study result showed that, listening
of recorded music have positively impacted the moods, self-
efficacy of the patients having mental health problems. The
reserchers found positive correlation in between the listening
of music and enhanced self-efficacy and mood of the patient.
Along with the non-pharmacological therapy described
above, antipsychotic drugs should also be given to the
patients as a part of the pharmacological intervention. In this
regard, the use of drug named Aripiprazole may be most
effective as it is considered as primary medications for the
treatment of euphoric symptoms among the patients. This
drug can act on the various receptors such as dopamine,
serotonine , adrenergic, muscarinic acetylcholine and
histamine receptors (Beaulieu,Espinoza, & Gainetdinov,
2015). However, in most of the cases, the drug shows
antagonistic nature in terms of exerting its function on those
receptors. In this regard, it is reported that, the drug acts on
the dopamine receptor (D2) in a negative manner which are
present in the postsynaptic region. Partial agonistic nature of
this drug is reported in case of the D3 receptors and thereby
stops the secetion of Dopamine and the mesocortical
pathway as well. In addition to this, the anatagonistic activity
of the 5HT2A, will help to enhance, the dopaminergic
secretion and thereby helps in the management of euphoric

symptoms among the patients (Gevonden et al., 2014).
Problem of
Sleep
Deprivation The case scenario stated that, the patient had problem in his
sleeping pattern. It can be stated that,lack of adequate
amount of sleep among the patients can enhance the issue of
agitation, anxiety among the mental health patients. Not only
the mental health condition, but the poor sleep timimg and
quality of sleep can also affect the physical health of the
patient with mental health problem. So, it is very crucial to
identify this problem of sleep deprivation in order to prevent
further detoriation of the health condition of the individual
having mental health problems. Accoreding to the study of
Boyko et al. (2013), it is reported that, lack of adequate
amount of sleep is associated with adverse health condition
among the patients with mental health disorders.
As a part of the sleep depribvation management, low amount
of hypnotic drugs can be suggested in case of this patient.
According to the study of McMillan, Aitken and Holroyd-Leduc
(2013), it is reported that, the use of the hyponotic drugs or
sedatives may improve the sleep deprived condition of the
patients. However, it is also quite evidemt that there may be a
few side effects of using such drugs for managing the sleep
deprived condition of the patients.
Another, impporant ntwrvebrin that can help the patients to
cope up with this condition is the use of the
nonpharmacological therapy and such therapies are more
suitable as they have no such kind of negative effect like the
medication therapy. In this context, the use of CBT will be
more effective. According to the study of Geiger-Brown et al.
(2015), it is reported that, the CBT intervention is very
effective in reducing the symptoms of insomnia or sleep
deprivation.This intervention involves combination technique
of cognitive therapy to reduce the maladaptive behaviour and
attitudes regarding sleep deprivation of the patients. The
study result showed that, the use of the CBT in the

management of insomnia, is quite effective. This meta-
analysis study showed that the application of this therapy has
improved the sleep quality fof the patients and there is almost
17 mins enhancement in the overall sleep timing of the
patients.

References
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