Mental Health Status Assessment Case Study

Mental Status

Part A: Case Study, Mental Status Checklist, Narrative, Sample of MSE, BDI, BAI

Case Study

Barbara Allen (BA), 39, a female professor at a local university, is brought by the partner who fears that the BA is schizophrenic. BA demonstrates paranoia about what the nurses and doctors and doing and keeps saying that she is being sabotaged by her enemies at her workplace. BA appears to refuse to answer questions initially, but when she does speak, she exhibits disordered thinking and confused speech. Her train of thought rambles briefly and incoherently between ideas. She shows an inability to concentrate; her face expresses a great deal of pain and anguish over her awareness of this inability. She says she does not know what is wrong with her intermittently while also saying that “they” are out to get her, while rising out her seat. Her partner tries to comfort her but by the end of the presentation, BA requires restraints. She “sees” on of “them” at the door and alternately in the room as well as something ominous on the ceiling over her, which causes her to launch into a fit of hysterics. Her partner says that this has been occurring off and on for the past two years but that it has worsened during the past six months because of some stress in her workplace. Diagnosis is schizophrenia.

Word Count: 210

Mental Status Checklist

General appearance—disheveled

Behavior—erratic

Thought process and content—has no consistent train of thought; content is incoherent, rambling, distrustful, paranoid, hallucinatory

Affect—patient requires restraint

Impulse control—poor

Insight—alternating between aware and unaware of self

Cognitive functioning—poor

Intelligence—evident from what partner says but not displayed to any great degree by patient

Reality testing—alternating with pass and failure

Suicidal or homicidal ideation—none

Judgment—poor, hallucinatory, paranoid

Narrative: See Appendix

Sample MSE

The Mental Status Exam found at:

https://athealth.com/wp-content/uploads/2014/03/Mental_status_B8506_03-14.pdf

is similar to the one provided by Sands and Gellis (2012) in the textbook. It provides examples of the type of terminology to use when filling out the examination.

BAI and BDI

The Beck Anxiety Inventory is available at: http://bluemtassociates.com/wp-content/uploads/2011/12/Beck-Anxiety-Inventroy.pdf. The BDI is available at: https://www.psychcongress.com/saundras-corner/scales-screenersdepression/beck-depression-inventory-ii-bdi-ii.

Two reasons self-assessments are beneficial is that they allow the care provider to see the extent to which the patient is aware of symptoms and the assessment also helps the patient to think more about symptoms. So the assessment raises awareness of what the patient is experiencing for both the patient and the provider. Limitations of self-assessments are that they tend to be too subjective, as they are conducted by the patient, and so data is not going to be entirely objective. Likewise, the patient may alter responses out of fear of being perceived as weak.

Part B: Paper

Conducting assessments of clients and patients is required of HUS professionals in order to have a firm idea of the issues and problems troubling the client or patient. In this paper, the reasons that assessments are important tools for HUS professionals will be examined. The merits of conducting an MSE and the value of completing a narrative MSE will also be examined. The rationale explaining the MSE chosen will also be supplied and the reasons that HUS professionals need to comprehensively assess clients in order to properly assist them and why this means they can benefit from using a variety of assessments will be discussed. Finally, a detailed explanation of the reasons the MSE/Mental Status Checklist and other assessments are valuable tools and a detailed discussion of additional important and necessary information that needs to be collected in order to complete a comprehensive assessment of a client so that a reasoned and supported plan of action can be determined will be provided. Specifically, the diagnosis used in my case study will be used as a reference point.

The importance of using assessment in diagnosis and treatment planning for mental health clients in HUS professional settings is based on the idea that the clearer the picture and understanding of the patient’s issues, the more exact the diagnosis can be and the more robust a treatment plan can be developed (De Los Reyes et al., 2015). As Sands and Gellis (2012) point out, the mental health assessment provides data that can be cross-referenced with the DSM-V to allow a suitable diagnosis to be delivered based on the evidence obtained from the assessment. Treatment, then, is based on the diagnosis and formulated according to the needs of the patient.

The merits, in particular, of conducting an MSE are that it is a “key component of a complete neurologic examination” as Grossman and Irwin (2016) point out. It provides greater understanding of the components of the patient’s cerebral activity and which components are affected most by the disorder, and what that means in the larger context of inputs obtained from the patient and other providers of data. The value of completing a narrative MSE is that it puts in more vivid detail the actual experience of meeting with the patient so that the reader can obtain a better understanding in concrete terms and examples of how the patient exhibited specific symptoms. It is more objective and less subjective overall.

Three reasons I chose the MSE provided by LaBruzza in the DSM is that (a) it gives appropriate points for guiding the assessment process, (b) it provides an example of how the process should be employed, and (c) it is extremely thorough and leaves nothing out that might possibly add to the assessment. As Grossman and Irwin (2016) note, the MSE should provide key information that can be used to obtain an overall adequate assessment of the patient. The MSE I have chosen has a lengthy outline to follow and covers extensively several different components that help to develop a good picture of the patient’s mental health. Developing this picture is the most important…