MENTAL STATUS EXAMINATION (MSE)

Obsessive-Compulsive Disorder

Part 1. Client’s Profile

Instruction: Please fill up the information needed and mark on the boxes applicable based on your
observations about the client.
Name of the client: Whael Hie Age: Not indicated Gender: Male

Birth date: Not indicated Ethnicity: Not indicated

Address: Not indicated Contact Number: Not indicated

Presenting Problem:

Whael has suffered from obsessive-compulsive disorder for forty years, he is trapped in a world of endless
border symmetry and repetition, his compulsive rituals mean he hasn’t able to work for the past 16 years and
his use rituals cannot be completed until he’s counted 12, lots of 12 on his fingers, it’s a set of numbers he’s
driven to repeat again and again. Everything in his entire house has its own special place and must be
precisely measured exactly positioned. Perfect and keeping everything in the house perfect isn’t easy living
with the other five members of his family, they’re our sons Michel and mark , wife maureen and daughter
joanne who’s learning difficulties mean maureen have even more childcare responsibilities with with granson
julian. Unfortunately for him his anxiety is really bad quite often. His rituals can last for 18 hours a day its
exhausting but he’s driven by all-consuming fear. Whael’s recurrent intrusive thoughts and especially
images of tragic events happening to his family which he feels he has to protect, he was a wide range of
rituals order symmetry and tightness which he feels that he has to do over and over again till he feels
confortable, lots of these rituals that he’s been doing have functioned by avoiding a lot of the thoughts and
images that he has in his mind, he does’t stops thinking about these images that he finds so terrifying. He
feels that he’s protecting his family its safe and comfortable but of course is completely destroying his
family.

Whael really can’t stand still for a moment, for him the simple act of maureen preparing a meal in the
kitchen is an anxiety provoking act of dececration. According to him there is one ritual that his not really
talked about because it could cause this situation to worry his beloved wife and childrens, he done it behind
there backs but he swiped his chest 12 times over and over again. Whael said I’ve actually made myself
absolutely sore and blind blood here I swiped myself 12 times, pulling and pulling well you can imagine
doing that a few number times a day , right now like that I got 12 times it is bad I’m not getting sexual kicks
out of it cause hes fucking painful really painful.

A years ago Whael always thought why he started doing these strange things was being tidy. He remember
that his dad and mom and the other two nurses scort him to the psychiatric unit and he was just diagnosed
exhausted and depressed he was never diagnosed with OCD. He was actually in the hospital into a litte
room and then there is a cable electrons puts in his head then electricity shocking to his brain. He still
pictures that day was the most painful to think about and he won’t even better had to go back to his own
world again, he haven’t tell his parents ever again for a long time he cant tell them because they thought
whael has been cured so for years and years whael lived in silence that’s why they called it mental illness.

Whael has suffered from obsessive compulsive disorder for over 40 years, everything in his house must be
arranged precisely in its own special place he believes his compulsive rituals of order symmetry and counting
will keep his family safe from harm. He must be in control of absolutely everything even everyday noises
make him anxious. Perfect frozen food packs can particularly troublesome him.
 Comtrolling everything at home for him this is the way he controlling the world and keeping his family safe.
He’s OCD has prevented him from leaving the house even for a short time. But now for the first time in over
12 years maureen’s persuaded him to take her to blackpool for the weekend but disturbing his bag will be a
massive problem. He may have a mastered up the courage to move the bag but it’ll take him some to pack the
clothes he placed so carefully. Its been a struggle but whael finally ready to travel, before he leaves the house
he must make a final check to make sure that everything is safe. This is the longest time the client stayed
ways from home in years its early days but atleast he’s managed to get here. Whael intrusive thoughts always
make him overly aware of impending danger . for him a simple trip of the blackpool tower is a suicidal
mission into unknown territory . Its a challenge for whael just to stand in the lift but now hes faced with a
new problem a glass floor 380 feet above the ground. For anyone of us walking over this glass floor might be
tricky but with whael irrational fears working overtime for him it would be an outstanding achievement.
Whael may have mastered the towers headly walk of faith but back in his hotel room. Packing his bag is
proving be a much bigger challenge. You may feel safe in the hotel room but the whole point of being here is
to relax to enjoy being on holiday like everyone. However whael always seems to find something to make
him feel anxious.The holidays is over and back at home again. Whael anxiety levels are already begining to
rise if things inside the house have been disturbed it could take him days to get everything feeling safe again.
Whael simply can’t cope by himself even if it’s only the call of phone line he needs the support of a
counselor to get him through his crisis.

Whael has a rock bottom he needs help badly but after 40 years of obsessive compulsve disorder there is a
hope to cure, he is incredible that he’s a man who had nearly 40 years of OCD and probably make a very
good chance of recovery and one of the difficulties now it is getting access to good services in
psychological treatments. Whael has battled against is obsessive compulsive disorder for more than 40 years
he wants to be free from his rituals and has finally been reffered to one of the country’s leading OCD experts.
The rituals are exhausting and take up all of this time but whael finds comfort in them too.

A. Educational History: (Please check all that apply and to which level it occurred)

Level Name of School Learning Problem Behavioral Expelled/ Repeater

Problem Suspended
Nursery Not indicated    
Elementary Not indicated    
Grade:___________
High School Not indicated    
Year: ___________
College    
Not indicated
Postgraduate Not indicated    

Comments:
 B. Employment History

Employed: Yes No

If yes, indicate employment (Please check all that apply):

 Seasonal  Full-Time Part-Time Self-Employement

Comments: Not indicated in the evidence presented.

Head injury/stroke Thyroid problems Chronic pain (incl. location)  STD

Loss of consciousness  Cancer Enuresis/encopresis Respiratory
problems
 Kidney disease  Diabetes Allergies  Seizures
Heart/vascular problems Sleep disturbances Adverse reaction to meds Others (please
specify)
Hypertension Appetite changes Parasites/scabies/lice
 Liver disease  Weight changes  Pregnancy
C. Medical History (Does the individual report any of the following? Check all that apply and
describe below.):

Not indicated in the evidence presented.

D. Substance Use History (e.g., alcohol, stimulants, sedatives, hallucinogens, nicotine, caffeine, etc.):

Type Date of Last Amount of Frequency and Length of Age of

Use Last Use Amount of Use Time First Use
Using
Alcohol Not indicated Not indicated Not indacated Not Not
indicated indicated

Treatment/Recovery History:
Not indicated in the evidence presented

Comments:

E. Family History

Father’s Name: Not indicated Mother’s Name: Not indicated Number of Siblings:
Age: Age: Birth order of the client:
Occupation: Occupation:

F. Family Medical History : (Please check history of difficulties in the areas noted applicable to family
members.)

Relationship Chronic Neurological Seizure Thyroid Mental

Medical Disorder Disorders Disorders Retardation
Problem
Mother     
Father     
Siblings     
Other Relatives     

Comments: There was no mention of the family's disease.

G. Psychological History

Mental Condition (Please check all mental condition if applies to the client.)

 Mania Depression Anxiety  Mood Swings

 Psychosis Substance Use &Abused Others (Please Specify)

Onset: ________________ Duration: ______________

Interpersonal (Please provide a brief description of impairment.)

Area Brief description of impairment

Daily Activities His used rituals cannot be completed until he’s counted 12, lots of 12
 Until he feels confortable about the arrangement must be in exact
Position.
Social Relationships He is unable to work, he doesn’t have a social life his relationship
With his family is failing.
Living Arrangement Everything in his entire house has its own special place and must be
Precisely measured exactly positioned.

Risk Factors (Check all that apply):

Yes If yes, please explain:

Suicidal/Self-Harm Scratch his self by over and over again because he feels
and thinks about that this behavior is part to his repitative action. _______________________________
 Access to Weapons \
_________________________________________________
Trauma
_________________________________________________
Neglect/Abuse
_________________________________________________
Domestic Violence
_________________________________________________
Legal Issues
_________________________________________________
/Gang Involvement _________________________________________________
Runaway
_________________________________________________
Inappropriate/Risky Sexual Behavior
_________________________________________________
Substance Use/Abuse He drink alcohol every night because for him most
of the nights he feels the need to drink before bed.
aCognitive Impairment
_________________________________________________
Cultural Isolation
Potential for Victimization
_________________________________________________
Risk of Homelessness
_________________________________________________

Comments:
II. Mental Status Exam (Please check all that apply)

Physical Aspect

Appearance: Clean  Well-groomed Disheveled Bizarre Malodorous

Motor: Normal  Decreased Agitated Tremors Tics

Repetitive

Speech: Normal Slurred Loud Pressured Slow Mute

Eye Contact Average Avoidant Intense Intermmitent

Posture Within Normal Limits  Atypical Slumped  Rigid 

Tense

Emotional Aspect

Affect:  Appropriate labile Restricted Blunted Flat

Congruent Incongruent

Mood: Normal Depressed Anxious Euphoric Irritable

Congruent Incongruent

Behavior: Cooperative Evasive Uncooperative  Threatening Agitated

Combative Guarded

Cognitive Aspect

Consciousness: Alert Lethargic Stuporous

Orientation: Person Place Time and day Current situation

Thought Coherent Tangential Circumstantial Loose Paranoid

Process: Concrete

Delusions: Persecutory Grandiose  Referential Somatic  Religious

Hallucinations: Auditory Visual Olfactory Gustatory Tactile

Intellect:
Average Above average Below average

Memory:
Good Poor Recent Poor  Remote
Confabulation

Insight:` Good Fair Poor Limited

Judgment: Good Fair Poor Unrealistic Unmotivated

Uncertain

For self
None  Ideation Plan Intent Attempt
For others
Risk Assessment
 None  Ideation Plan Intent  Attempt

Findings and Recommendations:

Based on a thorough investigation and the use of a battery of tests, this psychologist in training is
able to come up with a preliminary diagnosis. This client has an indication of Obsessive-
Compulsive Disorder 300.3(F42) The client met the criteria of Obsessive-Compusive Disorder
6 out of 7 were met as the documentary carefully explained the causes of anxiety impulse, the
recurrent intrusive thoughts and images. Severe harm and death coming from the family.

Cognitive Behavioral Theraphy is a taking therapy that can help to manage the problems by
changing the way you think or behave. Theraphy may include, for example, anxiety, depression,
but can be useful for other mental and physical health problems.

But cognitive behavioral theraphy is not always effective, especially if symptoms are severe and
the person can’t admit that he or she contributes to serious problems.
.
Medications

There are no medications specifically approved by the Food and Drug Administration to treat
antisocial personality disorder. Doctors may prescribe medications for conditions sometimes
associated with antisocial personality disorder, such as anxiety or depression, or for symptoms of
aggression. Certain drugs are usually prescribed cautiously because they have the potential for
misuse.

JENILYN M. CRUSIT April 9, 2023

Evaluator Date

(Signature above printed name)