Mental Health Examination - Case Study Example

Mental Health Name Institution Mental Health Introduction Mental illness is a typical term used to various disorders affecting personal behavior, feelings and reasoning capacity. It is also defined as a clinically major psychosomatic and behavioral condition or pattern that takes place in a person and it is linked to prevailing distress, disability, which increases the risk of disability, pain, death or significant loss. Some of the major mental disorders are classified as internal, personality, mood and psychotic disorders. Studies indicate that one in every five Australians suffer from mental disorder. Nevertheless, some people experience sporadic episodes that may reoccur in their lifespan while others may only experience once or in alternating manner. People suffering from mental disorders risk being rejected or isolated by the community, which further threatens their personal and social wellbeing (Timberlake et al., 2008). Nevertheless, mental disorders can be treated or managed effectively to mitigate the risks and restore the patient’s health. A comprehensive mental health assessment exploits observations and conversation, signs and symptoms, along with the establishment of therapeutic alliance to develop effective monitoring, examination and evaluation tools to monitor the condition of the patient and inform the selection of an effective intervention plan in the treatment or management of mental illness. Background Assessment Andy is a 21 year-old University student. He is currently in his final year of study and lives a shared house with colleagues. A review of his data indicates that he was referred to a psychiatrist by his general practitioner due to his behavior. During the interview, Andy avoided eye contact, anxious, and fidgety since he was looking around the room. He has also been suffering from auditory hallucinations and is paranoid towards his housemates. Andy’s paranoia showed him that the housemates were collaborating with MI5 to target him and poison his food. He also believes that his housemates have planted a chip in his head to assist MI5 to locate him. Andy believed he was in a good mental and physical state and hence the absence of medical condition. Andy admitted that he smoked a significant amount of marijuana, weed, on a daily basis. He appeared to be in a good relationship with the parents as he reported to feeling safe in their presence. Andy also allowed the involvement of the mother towards the end of the interview, indicated a robust bond with his parents. Mental State Examination Appearance Andy was experiencing distress auditory hallucinations and believed that his housemates were working for MI5 to target him, or “get him” as he put it. These thoughts were consistent for about two minutes. He also felt that other people were judging him while the rest were forcing thoughts in his mind. As a result, he was hesitant and anxious of the surroundings as he kept looking around. It appeared as if he was being watched by a hidden person. He appeared to be an isolated person. Behavior He was fidgety, avoided eye contact and occasionally looked around the room as if he was being watched. Andy preferred to isolate himself from others and stay indoors, but also suspected that the housemates were poisoning his foods. He was generally afraid. Therefore, his behavior was restless due to his paranoia towards the surroundings and his housemates. Affect Andy believed that MI5 has planted a chip in his mind so as to track his location. He believed that he had done nothing wrong and wanted the devise in his head removed. This affected his personality by creating an impression that everyone was trying to inflict harm on his wellbeing. This is also one of the reasons that made Andy prefer staying indoors, away from everyone else. Mood His moods are characterized with anxiety, driven by hallucinations. He lives in a constant fear of MI5, how he believes is trying to hurt him despite doing nothing wrong. His is also hesitant as he looks around the room as if he is being watched and a primary target, hence treats everything with suspicions. Speech Andy is not articulate. He maintained the thoughts of how MI5 is targeting him and also experienced auditory hallucinations for about two minutes. These features interfered with his speech, making it incoherent and unsustainable. Thus, his speech is poorly organized and cannot address a single subject in a consistent and coherent manner. Thought Form Andy’s formation is characterized by suspicions, whereby all people are his potential .enemies. Andy acknowledged that he felt safer in his parent’s house but felt guilty of involving them. Andy believed that he was physically fit and well. As a response mechanism, Andy smoked large amounts of weed so as to deal with voice hallucinations. He also tried to use high speed but he could still hear voices. Thus, Andy believed that using a high speed and smoking a lot of weed will save him from hallucination. It is also apparent that he believed that drug and risky behaviors are the primary solutions to his problems such as hallucinations. He also felt guilty if his parents were involved in the treatment, which implies that his drug-associated conduct is assimilated from the college life. The expression of guilt also illustrates that Andy trusted and feared his parents. Thought Content Andy admitted to having a knife and a baseball bat in his room. However, he expressed that he did not want to hurt anybody, even though he was contemplating injuring others but was too afraid of being caught. Andy had suicidal thoughts and took an overdose of sleeping pills. Therefore, his thought content is characterized by violence, suicidal, revenge, fear, suspicion and anxiety. Perception Andy’s perception is overruled by anxiety and hallucinations. For instance, he suspected that his housemates were poisoning his food. He was always looking around the room due to the fear of being caught unaware by the imaginary rival, MI5. Andy treated the rest of the community with suspicion since he did not trust him and ended up isolating himself from the rest of the world. Intellectual functioning Noticeably, his intellectual functioning is affected by the amount of hallucinations experienced. Andy thought that using high speed and smoking a lot of weed could help him stop hearing the voices. This illustrates an intellectual functioning breakdown. Insight and judgment Andy’s insight and judgment are poor. He was in constant fear of being caught by MI5 and other affiliate agents. He looked around the room as if someone was spying on him. Despite being surrounded in by walls, his judgment was impaired as he could not seek comfort for being behind closed doors and not in the open. Andy’s social judgment was also impaired as he constantly suspected everyone and ended up preferring to stay indoors away from the society. Risk Assessment Andy’s condition threatens his wellbeing, the safety of the housemates and the society at large. He has suicidal thoughts and suffers from sleeping pill overdose periods. He had a baseball bat and a knife in his room. A review of his thoughts indicated that he was thinking of harming the housemates and other suspicious people. Since he suffers from poor insight and judgment impairment, Andy could attempt to remove what he alleged was a chip in his brain. This could inflict physical and emotional trauma from the pain of the wounds. A habit of taking an overdose of sleeping pills could also jeopardize his life. Andy could also use the knife and baseball bat to injure suspicious people from his point of view. Other types of risks include violence, compromised self-care, social vulnerability, and poor academic merits. Formulation The mental state of the patient requires advanced or specialized medical attention due to the risks of self-harm, violence, impaired judgment and lack of self-care and poor academic performance due to the prevailing status. Provisional Diagnoses The data gathered indicates Andy suffers from Mood disorders, internal disorders and personality disorders. Need for Referral Towards the end of the interview, he consented the involvement of his mother and possible outside support. Since Andy does not oppose the referral suggestions, his prevailing mental status warrants referral decision so as to manage and treat the existing disorders. Care Plan Intervention and treatment approach requires the utilization of the strengths-based problem solving plans at various levels. Since Andy is an individual system, the intervention emphasizes on a micro-level individual system. Notably, different systems are designed to achieve specific goals depending on the needs and situation of the client. A micro approach strategy targets to restore an individual’s system in attempts to resolve the impending issues. An effective strategy intervention empowers a client to regain control of their mental state and exploit the surroundings to meet their personal needs as a normal human being (Restrepo et al., 2007). A micro-level intervention approach facilitates the client to overcome various challenges that may be contributing to the poor mental state. Understanding the process of navigating around various barriers or contributory factors plays a central role in empowering the client to act independently, without jeopardizing their physical, social, emotional, and psychological stability. The micro-level approach requires one to develop a robust relationship that involves effective power-sharing balance. The treatment requires a profession to have realistic, time-bond and achievable relational goals with the client. For instance, allowing the client to feel empowered and self-determined increases the chances of getting long-lasting results from the resolutions achieved. Dictating the relational terms may discourage the patient from sticking to interventional goals and prescriptions (Lillie-Blanton et al., 2015). For instance, the problem prioritization should be based on the level of addition, in this case marijuana. Apparently, Andy is an addict, in which the observed hallucinations may be contributed by weed-smoking. Compelling Andy to seize from smoking marijuana will decrease the chances of cooperation. Instead, a strategy to reduce the consumption can be used. Nevertheless, the first priority in the intervention plan should focus in dealing with possible withdrawal signs as Andy starts to stop smoking. Perhaps, admission to a rehabilitation institution is appropriate if the level of addiction is relatively high. However, the decision to stop smoking should be based on Andy’s preferences. Since he accepted external help and the involvement of the mother, a marijuana rehabilitation should be considered. Alternatively, medical marijuana should be used as an intervention to reduce the level of dependency on the drug. As a medical intervention, the care plan should focus on providing prescriptions to stabilize the moods and reduce anxieties observed in Andy’s behavior and appearance. Mood stabilizers are likely to reduce the suspicion and hallucinations experienced and hence reduce the risk of suicide, reckless driving and poor performance in school. The access to sleeping pills should also be reduced to address suicidal thoughts from overdose (Weiss et al, 2001). As previously mentioned, an institutionalization referral appears to be in order for Andy due to the risks involved. The data review indicated that Andy contemplates committing suicide through overdose and hurting others with potential weapons at his disposal. As a consequence, institutionalizing Andy will create an enabling environment to take medical prescriptions without the risk of overdose and also inflicting self-harm or threatening his housemates. Correspondingly, allowing Andy to take an academic leave from his university studies for a period not less than six months is paramount. On repeated occasions, Andy expressed that it was safer at home as compared to other areas. Empowering Andy to stay at home as a psychosocial intervention is paramount (Wingood & DiClemente, 2016). Dealing with his insecurities will allow Andy to deal with unrealistic hallucinations and also stick to the treatment and intervention strategies developed. The family should be advised to increase contact with Andy to address his insecurities. He should also be encouraged to mingle with other people, particularly close friends and trusted family members. This will gradually boost his confidence in the society and reduce the amount of time he spends alone indoors (Macionis & Gerber, 2005). Moreover, outdoor activities should be encouraged to address isolation, which encourages anxiety, depression and other mental conditions. As a nursing intervention strategy, the personal preferences of the client ought to be taken into consideration. Cultural values, beliefs and other factors that may affect the personality of the patient ought to be established. Such data is paramount as it assist the care providers to tailor the intervention approach to meet specific needs of the client. When counseling a person, it is vital to obtain their trust first followed by the development of an implementation plan. Therefore, nurse practitioner involved should establish a good communication environment, which will facilitate listening and the exchange of ideas with the client (Boyd, 2012). This makes the patient feel valued and hence develop the willingness of providing critical information without being compelled. Such information is paramount as it improves the quality of the final outcomes. Briefly, mental illness jeopardizes the wellbeing of the client and that of the society. This necessitates the need to develop effective intervention and treatment plans so as to manage or treat the condition and restore the patient’s well-being. Andy is a troubled young adult who is caught in between drug addiction. Smoking weed may be the primary reason why he was experiencing hallucinations. Some of the major risks involved in this case include self-harm, reckless behaviors, and poor performance in the school work. This creates a need for referral so as to manage and treat the existing mental conditions such as anxiety. References Boyd, C. J. (2012)."The antecedents of women's crack cocaine abuse: Family substance abuse, sexual abuse, depression and illicit drug use." Journal of Substance Abuse Treatment 10(5): 433-438. Lillie-Blanton, M., Anthony, J. C., & Schuster, C. R. (2015). Probing the meaning of racial/ethnic group comparisons in crack cocaine smoking. The Journal of the American Medical Association, 269, 993-997. Macionis, J. J., & Gerber, L. M., (2005). Sociology (5th ed.). Toronto: Pearson Prentice Hall. Restrepo, C. S., Carrillo, J. A., Martínez, S., Ojeda, P., Rivera, A. L., & Hatta, A. (2007). Pulmonary complications from cocaine and cocaine-based substances: imaging manifestations. Radiographics, 4, 941-56. Timberlake, E.M., Zajicek-Farber, M.L. & Sabatino, C.A. (2008). Generealist social work practice. A strengths-based problem-solving approach (5th ed.). Boston: Pearson Education, Inc. Weiss, F., Ciccocioppo, R., Parsons, L. H., Katner, S., Liu, X., Zorrilla, E. P., Valdez, G. R., Ben-Shahar, O., Angelletti, S., & Richter, R. R. (2001). Compulsive drug-seeking behaviour and relapse. Annals of the New York Academy of Sciences, 937,1-26. Wingood, G. M., & DiClemente, R. J. (2016). The influence of psychosocial factors, alcohol, drug use on African-American women's high-risk sexual behavior. American Journal of Preventive Medicine, 15, 54-59. Read More