Adult Mental Health: Mental State Examination Assessment Report

This report presents a Mental State Examination (MSE) assessment of a 35-year-old male, Mr. Leroy, focusing on his re-evaluation of mental state. The assessment covers his general appearance, behavior, speech patterns, mood, thought processes, and content. Key observations include disorganized dressing, agitated behavior, repetitive speech indicative of apraxia, cognitive distress, and delusional thoughts related to business plans and suicidal ideation. The report identifies cognitive impairment, improper judgment, and insight, particularly regarding substance abuse, medication adherence, and sleep patterns. Symptom interventions are proposed, including Dialectical Behavior Therapy (DBT) for cognitive impairment, Cognitive Behavioral Therapy (CBT) for thought process alterations, and music therapy for insomnia. The report also references relevant literature supporting the interventions, such as Baer (2015), Cooper et al. (2016), and Jespersen et al. (2015), highlighting the importance of evidence-based practices in mental health care.

Adult Mental Health Services
CONSUMER ASSESSMENT
Date: Time:
URN:
Family Name:
Given Name(s):
Address:
Date of Birth:
MENTAL STATE EXAMINATION
General
appearance
Mr. Leroy is a 35 years old person came for the re-evaluation
of his mental state. He has been wearing a blue shirt, orange
cap and green pant. This dressing pattern shows his
dressing coordination was not proper. However, his dressing
was neat and clean. His dressing was loose fit that indicates
the weight loss and his statement highlighted he was not
eating properly. His posture and talking style highlighted that
he was excited and agitated, nervous and least interested in
taking this re-evaluation session.
Behaviour
Mr. Leroy was sitting in a round back posture which is
Kyphotic position and highlights the uneasiness of the
person. He spoke with repeated sentences and did not make
any direct eye contact. This condition shows that he was
reluctant and lacking self confidence. During talking he was
moving his hands and looking downwards which indicates
the uneasiness, nervousness and lack of confidence along
with reluctant behaviour.
Speech
Mr. Leroy was speaking with neglecting tone, repetitive
sentences, lack of focus, improper gesture, fidgeting hand
and improper sitting posture. All these aspects were
observed in the video and this highlights apraxia. The patient
was not be able to control or select his movements.

Moreover, he was not accepting this re-evaluation session
positively. Thus, he was using short phrases and also could
not use proper statements as well.
Mood and
Affect
Mr. Leroy has greeted mental health counsellor with warm
tone and answered every question with excitement and
sometimes laughed as well. However, during communication
he could not select proper phrases and used repetitive
sentences, laughed unnecessarily highlighting disruptive
behaviour. Moreover he could not figure out the every
question which highlights his cognitive distress along with
hyperactivity.
Thought
process
Mr. Leroy has answered every question however; the
counsellor had to repeat every question as he could not get
the questions in one goes. He repeatedly stated that he is a
busy person so he could not properly advocate his food
intake and sleeping pattern. He was confused and had to
think to answer every question. He also stated that he
approximately sleep for three to four hours. All these indicate
that his cognitive condition is affected thus he is agitated and
hyperactive.
Thought
content
Mr. Leroy stated that he had been helped by some imaginary
people for his business plans. However, he confirms that he
has not heard or observes any external force. Moreover, he
also stated that he thought about suicide as well.
Perception
Mr. Leroy did not show any kind of hallucinating behaviour or
negativity. However, he had a false belief about imaginary
people helping him in his business planning. He also showed

positive perception about substance abuse that is he thinks it
is normal and not negative at all.
Cognition
Mr. Leroy showed some cognitive impairment as his
perceptions and statements are not matching. He stated that
he has not seen any external forces however; he got ideas
for his business from external forces. Moreover, he could not
select proper sentences for the answering the questions of
counsellor and used short and repeated sentences. All these
indicated his cognitive impairment.
Judgment &
Insight
Mr. Leroy has shown improper judgement and insight about
many aspects such as substance abuse, lack of
understanding about the interview, thinking himself as a busy
person, skipping medication and thinking himself as a fit
person, improper dietary intake and improper sleeping
pattern. All these showed his insight is not adequate and
judgement of many things is improper as well.

SYMPTOM INTERVENTIONS
Cognitive
impairment
According to the video it has been seen that the patient has
issues with speech selection, posture, understanding and
perceptions as well as suicidal behaviour. Moreover, he has
shown delusive perceptions which can also be stated as
cognitive impairment. Based on this assessment of the video
it can be stated that the proper Dialectical Behaviour therapy
(DBT) can be implemented as it helps in identification and
changes the negative thinking pattern (Baer, 2015). It also
helps in elimination of suicidal behaviour and changing the
thought process which relates to his delusive behaviour
(Linehan & Wilks, 2015). Moreover, implementation of health
education process for the awareness development of the
person as well would be helpful. It will help in the process of
understanding and risk evaluation that is self realisation of the
patient.
Thought
process
Delusion of the patient and false perception about diet,
medication, sleep can be changed by effective
communication and grounding the patient with the reality. The
aspect of the thought process changing can be processed by
implementing Cognitive Behavioural Therapy (CBT) (Cooper
et al., 2016). Moreover, the treatment process emphasises
and modifies the emotion and behaviour of the patient along
with proper support for the thoughts (Tarrier & Johnson,

2015).
Insomnia The patient stated that he only sleeps for three to four hours a
day which is below the requirement of an adult human.
Hence, the patient is anxious and also restless which needed
to be addressed for the betterment of the condition of the
patient. The person needs to relax and it can be achieved by
implementing music therapy (Jespersen et al., 2015).
Moreover, the implementation of recreational therapy that is
talking therapy, self realisation development, self monitoring
and also focusing on the life requirements. All these aspects
can be achieved by effective communication and motivation
development of the patient by the implementation of effective
communication (Niess & Diefenbach, 2016). All these
processes would help in the improvement of the sleeping
habit of the patient that is elimination of the insomnic
condition.

References
Baer, R. A. (Ed.). (2015). Mindfulness-based treatment approaches:
Clinician's guide to evidence base and applications. Elsevier.
Cooper, Z., Allen, E., Bailey-Straebler, S., Basden, S., Murphy, R.,
O’Connor, M. E., & Fairburn, C. G. (2016). Predictors and
moderators of response to enhanced cognitive behaviour therapy
and interpersonal psychotherapy for the treatment of eating
disorders. Behaviour research and therapy, 84, 9-13.
Jespersen, K. V., Koenig, J., Jennum, P., & Vuust, P. (2015). Music for
insomnia in adults. Cochrane database of systematic reviews, (8).
Linehan, M. M., & Wilks, C. R. (2015). The course and evolution of
dialectical behavior therapy. American journal of psychotherapy,
69(2), 97-110.
Niess, J., & Diefenbach, S. (2016). Communication styles of interactive
tools for self-improvement. Psychology of Well-being, 6(1), 3.
Tarrier, N., & Johnson, J. (Eds.). (2015). Case formulation in cognitive
behaviour therapy: The treatment of challenging and complex
cases. Routledge.