Introduction
This mental status examination (MSE) assesses important aspects of the Patient’s (Nathanial Ayers) psychological and mental functioning, general appearance, behavior as well as overall demeanor. The decision to undertake the examination has been reached after the patient developed a violent predisposition and exhibited rapid mood swings which pointed toward reinforced deterioration of his mental state. Many sections of the MSE report on the actual observation of the patient’s behavior, actions, and reactions as he interacts with the examiner.
General Description
In terms of physical appearance, the patient appears older for his age and frail-looking, not mentioning that he is casually dressed. In self-care, the patient’s face looks oily and somehow bizarre, and the collar of his yellow jacket is not in position. Although there is no noticeable presence of body odor, his choice of clothes appears wanting considering his age. However, the patient’s overall cleanliness and grooming can be described as fair. The psychomotor activity of the patient can be described as unusual owing to observable gait disturbances (slow gait) as well as the emptiness of feelings during his initial encounter with the examiner. He appears quite agitated but projects an erect body position. The patient demonstrates immature defenses which are characterized by a lack of capacity to make sound judgments when the examiner tries to convince him to get help, not mentioning that he demonstrates externalization within the context of inappropriately blaming the examiner (Mr. Lopez) and other individuals for his problems. In terms of attitude towards the examiner, the patient is defensive and hostile, implying that the expressed feelings are inappropriate.
Mood, Affect & Appropriateness
Mood
The patient shows rapid mood swings, from being anxious and angry to demonstrating remorse for attacking the examiner. The rapid fluctuations in the patient’s emotional state are possibly caused by a chemical imbalance in the brain which triggers the disabling disturbance characteristic of schizophrenic patients.
Affect
The affect of the patient is congruent with his mood if facial expression, tone of voice, and body language are considered. The patient’s facial expression depicts someone anxious, angry and disturbed about some ongoing events. The anger-remorse continuum is further expressed through body language (constant pacing and fighting) and the outpouring of remorse as soon as the examiner runs out of the room. The patient’s voice tone appears harsh from the onset, though he is somehow overpowered by emotions after fighting the examiner (Mr. Lopez). These experiences demonstrate that the patient’s affect is congruent with his rapid mood swings.
Appropriateness of Affect
The emotions demonstrated by the patient (e.g., anxiety, anger, remorse) are expected in his current expressed thought, implying that the patient is demonstrating an appropriate affect.
Speech Characteristics
Fluency and Rate of Production
The patient can be described as verbose in the amount of speech production, intense in the pressure of speech production, and rapid in the rate of speech production. This criterion has been given because the patient does not give the examiner time to respond to various assertions or state his concerns. The patient appears oriented to the fact that talking rapidly and intensely will drive the point home.
Quality of Speech
Although the patient talks a lot, much of the talking is not clear as he keeps repeating some words (uninflected monotonous) to underscore his concerns of being forced to seek help. The rhythm of his speech can be described as jerky, while the volume is mostly inaudible. Also, the speech is mostly impulsive; however, no accent is noted.
Disturbance in Sensory Perception
Hallucinations
There is evidence of false perceptions and inaccuracies that affect the patient’s senses and cause him to hear voices that are not there in reality. On particular occasions, the patient appears disturbed by feeling things that are non-existent in reality, leading him to viciously attack the examiner (Mr. Lopez). These perceptions are very forceful, not mentioning that they appear to come from outside the patient’s self.
Illusions
The patient demonstrates false beliefs or misinterpretations of events by incorrectly concluding that the examiner is plotting to take him away. Although the examiner is intent on having the patient seek help, this intention is perceived differently and leads to a vicious attack.
Disturbance in Thought Process
Clarity of Thoughts
The patient shows brief moments of clarity of thought followed by a demonstration of a vague and somehow clouded thought system, implying that his flow and organization of thought are not consistent.
Process
There is clear evidence of disturbances in the patient’s thought system due to observable flight of ideas, echolalia (repetition of words or phrases), blocking (interruption of thought before an idea is completed, and tangentiality (losing thread of the conversation and never returning to the original point). The disturbance of the thought process worsens as the patient demonstrates more anxiety and anger.
Disturbance In Thought Content
Dangerousness
The patient demonstrates homicidal thoughts as he attempts to harm the examiner (Mr. Lopez) by fighting to resist attempts to be taken to the hospital.
Delusions
The patient holds firmly-held fixed beliefs that the sole intention of the examiner is to take him away from the streets for ill-intended motives. The level of conviction about the validity of this delusion is high judging by how the patient attacks the examiner. This demonstrates a high misinterpretation of the actions of the examiner by the patient and a misguided belief that the examiner (Mr. Lopez) is attempting to control the patient’s life.
Confabulation
The patient sticks to the story that the examiner wants to take him by force even though this is not the correct position.
Distortion of Self Perception
From his actions, it would be true to argue that the patient suffers from derealization for acting in a way that seems to reinforce the fact that he is in a world of his own (e.g., overstimulation, confusion and disorientation).
Distortion of Body Image
From his actions (e.g., lack of awareness of connection, inability to engage with others and the world sensitively and responsibly), it is possible the patient would have reported feelings of loss of body boundaries when exposed to the body experience questionnaire (BEQ).
Cognition
Alertness and level of consciousness
The patient demonstrates a decreased level of consciousness, a heightened level of disorientation, as well as a disproportionate reaction to external stimuli. For example, he appears quite disoriented when the examiner (Mr. Lopez) enters the room only to spring a surprise by punching him hard across the face.
Orientation
The patient seems quite disoriented particularly after attacking the examiner, suggesting possible remorse and confusion of thought. However, initially, the patient seems violently oriented to person (examiner) and situation (thought or belief that the examiner is intent on taking him away).
Memory
When the Mini-mental Status Examination (MMSE) is administered, the patient scores in the impaired range (2 to 3 points below the population norms), particularly in remembering remote events as well as those that occurred within the past few days.
Concentration and Attention
The patient demonstrates obvious concentration, attention, and construction difficulties as he cannot work out simple tasks (e.g., spelling the word “New York” backward) despite his average level of education.
Executive Functions
Intellectual Functioning
The patient demonstrates deficits in the fund of knowledge (he cannot name five U.S. presidents, from present moving backward) and vocabulary; however, he is fairly intelligent judging by his counterarguments on the possibility that he has a mental condition.
Abstract Thinking
The patient’s level of abstraction is somewhat concrete as he can recognize that apples and oranges are fruits and that trees and animals represent nature.
Working Memory and Recall
The patient’s working memory is poor judging by the fact that he no longer lives a productive life and feels comfortable when scavenging on the streets. The patient’s recall can also be categorized as poor as he cannot vividly remember events that occurred some weeks ago.
Activation, Arousal, and Effort
There is an observed lack of activation of cues, implying that the patient is suffering from an inherent disturbance of attention and therefore cannot make reasonable decisions. The patient demonstrates an elevated behavioral disposition and readiness to respond to environmental stimuli (arousal) judging by the way he attacks the examiner (Mr. Lopez) with speed. Lastly, it is evident that the patient is suffering from cognitive fatigue and therefore cannot engage in activities that require sustained attentional effort.
Control
The patient is not able to control aggressive impulses and homicidal ideation judging by the way he savagely attacks Mr. Lopez. From these aggressive impulses, it can be concluded that the patient has lost the capacity to control his emotions.
Internalized Language
There is poor internalization of the patient’s beliefs and attitudes concerning his moral behavior judging by the confrontation with Mr. Lopez and the confused state of mind.
Deconstruction, Analysis, and Reconstruction
The patient’s capacity to deconstruct, analyze and reconstruct elements in the environmental stimuli is concrete, though he does not demonstrate the consistency of thought.
Judgment
The patient’s judgment is fragmented as he fails to make an informed decision when attacking Mr. Lopez. His fragmented judgment has affected his reasoning, which in turn has negatively affected his capacity to make appropriate decisions.
Insight
The insight is poor as the patient does not seem to recognize the presence of any mental illness, not mentioning that he does not appear to realize that his behavior of attacking Mr. Lopez is dangerous.
Reality Testing
The patient seems not to have the capacity to distinguish between the realities on the ground and his internal representations of external events, pointing to chronic psychotic interference and the possibility of suffering from hallucinations, illusions, and delusions.
Summary Of Mental Status
This MSE has been successful in providing the patient’s current mental state as well as the various effects of the mental state on his behavioral and cognitive functioning. The general description demonstrates that the patient looks older for his age and acts bizarrely, possibly due to observed disturbance in his sensory perception and effects of hallucinations, illusions, and delusions. The disturbance of the patient’s sensory perception can be used to explain his rapid mood swings and constant demonstration of anxiety, anger, and remorsefulness, not mentioning that it can also be directly associated with his decreased level of consciousness as well as disproportionate reaction to external stimuli in cognition. It is also possible that disturbances in sensory perception and cognition are to blame for the patient’s vague and clouded thought system, homicidal predisposition, fragmented judgment, as well as lack of capacity to distinguish between realities on the ground and his internal representations of external stimuli.