MENTAL STATUS EXAM

I. CLIENT’S PROFILE AND HISTORY

Date: December 13, 2023
Name: Alison Wells (can also be addressed as “Alison”)
Address: Not stated and need for further investigation during the follow-up
Birth Date: Not stated Age: 38 Gender: Male Female
Ethnicity: Not stated but based on her accent, color and features, she might be a White British
Marital Status: Divorced
Occupation: Job Role wasn’t specified but mentioned “working in a local supermarket”
Educational Attainment: Not stated
Religion: Not Stated Primary Language Spoken: British English
Date of Evaluation: Not stated in the video but the Psychologist – in – Training evaluated the Px on December
13, 2023

II. PRESENTING PROBLEM:

The patient manifested bad mood, crying, tiredness, low energy, difficulty concentrating, and has had reported for
low motivation, waking up early and difficulty to get back to sleep, hunger loss, weight loss, less enjoyment
(Anhedonia), and decreased enthusiasm in taking care of oneself as symptoms.

II.1 Presenting 4 Ps: Predisposing, Precipitating, Perpetuating, Protective Factors.

• The Predisposing factors that led to Alison’s condition can include social, psychological, genetic, and
sociocultural variables; hence, a detailed validation of the client's family history is necessary for these
components background and for additional assessment.
• The Precipitating factors could be her genetic vulnerability and her family support since she was divorced
to her husband, had an unsupportive boyfriend with two kids who has a lot of demands, although she has
friends and a sister whom she can rely on hence her boyfriend whom she expects to be supportive has
often contact with her while her kids who are attached with her and she’s been taking care of has a lot of
demands she can’t fulfil to.
• The Perpetuating factors that contribute to the condition of Alison are financial and family concerns, since
the company that she’s been working with cut off their wages, it becomes difficult for her to pay the bills
all by herself while dealing with the demands of her two kids. Her relationship towards her boyfriends adds
up the weight.
• The Protective factors that might help Alison to counteract the predisposing, precipitating, and
perpetuating factors are her bravery to seek for professional help despite the heaviness she carries and
the support from her friends and sister who encouraged her to go through.

III. REASON FOR REFERRAL:

Patient have been feeling unwell for “few months” now, her sister observed her and suggested to visit a mental
health professional to assist her in understanding her experiences and dispositions. She reported to experience
feeling like fed up and every morning as she wakes up, everything seems to be black, also sleeping becomes
difficult for her. Even if she got an ample of sleep, she feels like restless and her brain feels likes haven’t taken
a nap. The Patient has had suicide attempt as she mentioned taking 2 strips, about 12 tablets of mentioned
medicine “paracetamol” before going to bed just to sleep and never to wake up anymore. Changes of her mood
and behavior was said to be a pile up negative experiences from her ex-husband 4 years ago, the demands
from her 2 children, Bills and financial shortage, and from her boyfriend who’s been unsupportive to her. As
these manifestations of assumed to be on a depressive state.
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 IV. EDUCATIONAL HISTORY: (Please check all that apply and to which level it occurred)

Level Name of School Learning Behavioral Expelled/ Repeater

Problem Problem Suspended
Nursery Not stated and need
for further
investigation during
the follow-up.
Elementary Grade Not stated and need
for further
investigation during
the follow-up.
High School Year Not stated and need
for further
investigation during
the follow-up.
College Not stated and need
for further
investigation during
the follow-up.
Postgraduate Not stated and need
for further
investigation during
the follow-up.

Comments:
The patient hasn’t mentioned any stories or statements about her educational background but mentioned about
having supportive good friends that she might have met at her neighborhood, or workplace, and maybe at school.
However, despite the lack of information from her educational background given that she got employed to a
supermarket, it is assumed that she might have finished High School or College since it is very common in the
supermarket to hire at least a high school graduate applicant. These lack of information needs for further
investigation to strengthen the background for further assessment and shall be conducted during the follow-up
session.

V. EMPLOYMENT

Employed: Yes No
If yes, indicate employment status (Please check all that apply):

Seasonal Permanent Part-Time Self-Employement

Nature of Work Sales in the Supermarket

Comments: Patient mentioned about her employment but didn’t specifically state her job role and employment
status, she only mentioned that nature of her work. These lack of information needs for further investigation to
strengthen the background for further assessment and shall be conducted during the follow-up session.

VI. FAMILY HISTORY

Father’s Name: Not stated Mother’s Name: Not stated and Number of Siblings: 1
and need for further need for further investigation Birth order of the client: Not
investigation during the follow- during the follow-up. stated and need for further
up. Age: Not stated and need for investigation during the follow-up.
Age: Not stated and need for further investigation during the
further investigation during the follow-up.
follow-up.
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 Occupation: Not stated and Occupation: Not stated and
need for further investigation need for further investigation
during the follow-up. during the follow-up.

Comments: Patient mentioned less about her family background other than her sister (not stated if
older or younger) about her sister’s concern about her. These lack of information needs for further
investigation to strengthen the background for further assessment and shall be conducted during the
follow-up session.

VII. FAMILY MEDICAL HISTORY

Relationship Chronic Neurological Seizure Thyroid Mental
Medical Disorder Disorders Disorders Retardation
Problem
Mother
Father
Siblings
Other Relatives

Comments: Patient mentioned less about her family background. These lack of information needs for further
investigation to strengthen the background for further assessment and shall be conducted during the follow-up
session.

VIII. CLIENT’S MEDICAL HISTORY

(Does the individual report any of the following? Check all that apply and describe below.):

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 Sleep disturbances Adverse reaction to meds Others (please specify)
problems
Hypertension Appetite changes Parasites/scabies/lice
Liver disease Weight changes Pregnancy

Comments:
Patient reported to have difficulty in sleeping and sudden waking up early dawn then difficulty in going back to
sleep. Her lack of rest might be one of the contributing reasons of her weight loss aside from her loss of appetite.

IX. SUBSTANCE USE HISTORY (e.g., alcohol, stimulants, sedatives, hallucinogens, nicotine, caffeine,
etc.):

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

Use Last Use Amount of Use Using First Use
Alcohol Four years ago Glasses of Not stated the Not stated exact 34
wine exact frequency length of time
but according to using but
patient, it was a according to the
night ago, patient it was
Glasses of wine, only a night
and need for before she slept.

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 further
investigation.

Paracetamol Four years ago 2 strips, about Once, 2 strips, Not stated exact 34
12 tablets about 12 tablets. length of time
using but
according to the
patient it was
only a night
before she slept.

Treatment/Recovery History:
Patient haven’t mentioned about her Treatment/recovery History since her intake of the glasses of wine and
overdosed paracetamol intake only happened and was mentioned during a night.

X. CLIENT’S PSYCHIATRIC 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: few months (mentioned by Alison) Duration: Consistent for few months (mentioned by Alison)

Interpersonal (Please provide a brief description of impairment.)

Area Brief description of impairment

Daily Activities Patient has a decrease of interest in daily activities compare to her pre-
depressive state, she often has had used to do a lot with her kids, she used
to go swimming playing but now she just spends the day on the sofa unless
she needs to attend her job. Before, she used to like watching the soaps,
EastEnders or something and now 10 minutes later she’s thinking of
something else. Her communication and relationship with her boyfriend were
changed, he often had a call to Alison and got unsupportive and unhelping to
her situation.
Social Relationships She used to enjoy going out with her friends taking photo. She mentioned
forgetting a Parent evening event.
Living Arrangement No issue on her living arrangement mentioned, but this lack of information
needs further investigation during the follow-up session.

Risk Factors (Check all that apply):

Yes, if yes, please explain:

Suicidal/Self-Harm Patient reported to have taken 12 tablets of paracetamol
Claiming to rest forever and never wake up again. This
statement is a clear manifestation of suicide attempt.
Access to Weapons
Trauma
Neglect/Abuse
Domestic Violence
Legal Issues
Crime/Gang Involvement
Runaway
Inappropriate/Risky Sexual Behavior
Substance Use/Abuse
Cognitive impairment Patient reported that she used to watch soaps or
Eastenders and then suddenly she’s thinking of

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 something. Another statement mentioned is her being
forgetful to some of her routines and her cognition towards
daily routines.
Cultural Isolation
Potential for Victimization
Risk of Homelessness

Remarks:

The change of her behavior and interest to pre-depressive state manifested by weeks of anhedonia and
pseudodementia might be a symptom of a depressive state. This information is still a weak basis for warranting
a disorder, it shall be subject for follow-up and for further investigation to supper the assumptions and
assessment.

XI. MENTAL STATUS (highlight all that apply)

Appearance • Neat • Disorderly • Bizarre • Vivacious

• Others (please specify) ___________________________________
Remarks: Patient looks neatly but her face is pale and down.

Build • Medium •Slim • Athletic • Plump

• Others (please specify) ___________________________________
Remarks: Patient mentioned about her weight loose but still has a plump built, built of
Alison has no relevant manifestation since people has unique built according to
genes and lifestyle.

Posture • Upright •Slumped • Rigid • Atypical

• Others (please specify) ___________________________________
Remarks: Patient seats slumpy, her posture might be a manifestation of her loose of
energy, poor posture might indicate a dysfunction in the pelvis area, although
the patient didn’t mention any issues to her pelvis but this posture should be
consider and be taken care of to assess properly the condition and rule out any
non-related concerns.
Clothing • Casual • Scanty • Baggy •Trendy
• Unfashionable • Sophisticated • Smart • Conservative
• Climate Appropriate • Climate Inappropriate
• Setting Appropriate • Setting Inappropriate
•Age Appropriate • Age Inappropriate
• Others (please specify) ___________________________________
Remarks: Patient dressed appropriately but looks like no regard for fashion or effort to
dressed up better. Her manifestation of this appearance might mean her disregard
to preparing her outlook.

Skin Lesions • Lacerations • Abrasions • Allergies • Lumps

• Burns • Stitches •Scars • Punctures
• Contusions •Others (please specify)
Remarks: No obvious skin lesions that can be seen to the patient since she wore a long-
sleeve top and only her hands and neck can be obviously seen. This lack of information
needs for further investigation to support the assumption and tendency for hidden skin
lesions.

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Eye Contact • Appropriate • Avoidant • Intense • Intermittent
• Others (please specify) ___________________________________
Remarks: Patient manifested poor eye contact and is always down during the entire session. This
behavior might be subject for low self-esteem and energy.

Psychomotor • Normal • Accelerated • Slowed

• Stereotyped • Impulsive •Agitated
• Others (please specify) Seated Quietly
Remarks: Patient seated quietly to her seat with hands together and has a slow energy-like
motion.

Attitude •Cooperative • Argumentative • Guarded

• Hostile • Suspicious • Uncooperative
• Awkward • Detached • Expressive
• Others (please specify) Withdrawn
Remarks: Patient show volunteers little, appears sad and has a flat facial expression.
Mood •Euthymic •Angry • Euphoric
• Apathetic •Dysphoric • Apprehensive
• Others (please specify) ___________________________________
Remarks: Patient clearly manifested a sad and down mood consistently throughout the entire
session.
Affect • Broad • Restricted • Blunted • Flat • Labile
• Others (please specify) Euthymic, Angry, Dysphoric.
Remarks: Patient manifested a down and low energy.
Self Esteem • Fair • Impaired • Poor • Exaggerated
• Others (please specify) ___________________________________
Remarks: Poor self-esteem is also manifested with her poor eye contact and low volume upon
speaking.
Consciousness • Vigilant • Alert • Drowsy • Confused
• Lethargic • Stuporous • Fluctuating
• Others (please specify) Obtundation
Remarks: Patient has difficult to arouse and needs constant stimulation to stay awake. She
may seem confused and unable to participate in the interview
Orientation • Person • Place •Time
Remarks: Patient is well-aware and conscious on the present setting.
Speech Rate
• Normal • Slow • Fast • Pressured
• Others (please specify) ___________________________________
Remarks: Patient speaks slowly with low energy and often has been breathing heavily with
sounds, a significance of heavy feelings and unwell.

Speech Volume
• Normal • Loud •Soft • Monotone
• Others (please specify) ___________________________________
Remarks: Patient speaks inaudibly.

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Language Quantity
•Within Normal Limits • Talkative / Spontaneous
• Expansive • Poverty
• Others (please specify) ___________________________________

Remarks: Patient expressed her feelings in a language that can be understand.

Language Fluency
• Articulate • Considerable • Stuttering • Dissonant
• Others (please specify) ___________________________________
Remarks: Patient repeats syllables and has been difficult to speak directly.

Attention Span •Attentive • Distracted • Hyper focused

• Others (please specify) ___________________________________
Remarks: Patient didn’t manifested inattention.

Thought Process • Logical • Relevant • Goal-directed

• Incoherent • Evasive • Racing
• Blocking • Perseverations • Neologisms
• Others (please specify) Impoverished
Remarks: The person uses words but is very skimpy with them. There are too few ideas,
and thinking is slow.

Memory •Long-Term •Short-Term

Remarks: Patient became forgetful about her daily routine and mentioned to
have watched TV then 10-minutes ago she’s been thinking of something. She
mentioned forgetting the swimming time she should have with her kids and even
the parent evening event.

Hallucinations •Auditory •Visual • Olfactory

• Tactile • Gustatory
Remarks: No Manifestation of Hallucinations.

Delusion • Erotomanic • Grandiose • Jealous

• Persecutory • Somatic • Mixed
Remarks: No Manifestation of Hallucinations.
Suicidality • Ideation • Plan • Intent •Attempt

Homicidal • Ideation • Plan • Intent • Attempt

Remarks: No Manifestation of Homicidal.

Insight • Perceptive • Fair • Impaired

• Others (please specify) ___________________________________
Remarks: Her insight about life becomes miserable that wishes to rest forever, she
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 perceives negatively about her as a mother.
Judgment • Sharp •Fair • Impaired
• Others (please specify) ___________________________________
Remarks: Patient negative view about her life affected her judgments as it also affected
her routines and relationship with other people.

Neurovegetative Dysfunction
Sleep Pattern
• Normal Hypersomnia • Hyposomnia
• Others (please specify) Middle and Terminal Insomnia
Remarks: Patient have reported she finds difficult to sleep and sometimes she wakes up
early dawn and find it difficult to went back to sleep.
Appetite
• Normal • Compulsive • Aversed
• Others (please specify) ___________________________________
Remarks: Patient reported to have loose wait.

Findings and Recommendations:

• Alison has been on the depressive state given all our experiences and the duration it has been with her,
there are clear manifestation of an assumed “Major Depressive Episode” however, some details are
still lacking to come up to a reliable and strong assessment. A follow-up assessment is recommended
to gather other details and assess her improvements.
• For the meantime, it is also recommended to let her and her kids be with her sister and friends since
they’ve become helping and supportive to the condition of Alison.
• The issue on financial problems is quite difficult to deal with since it is the establishment that decides
but as soon as she can manage herself, maybe she can talk to the manager about it or do side hassle
to support her financially.
• For her sleep problems, she may practice breathing exercise (Sheryl Ankrom, 2023), this is to help her
body calm and support proper air flow.

XII. MAJOR DEPRESSIVE DISORDER SYMPTOMS CHECKLIST.

Direction: Under the observation column, put a ✓ when a symptom in each line is observed, and ⨉
if not. Supply remarks if needed.
Depressive Disorders Observation Remarks
1. Five (or more) of the following
symptoms have been present during
the same 2-week period and
represent a change from previous
functioning; at least one of the
symptoms is either (1) depressed
mood or (2) loss of interest or
pleasure. Note: Do not include
symptoms that are clearly attributable
to another medical condition. • Alison reported to have
been lying on the couch
1. Depressed mood most of the day, nearly all day except when
nearly every day, as indicated by needed to attend her job.
either subjective report (e.g., feels She feels sad, crying, and
sad, empty, hopeless) or observation very sensitive even if she
made by others (e.g., appears just a sugar fell off from her
hands.
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 tearful). (Note: In children and
adolescents, can be irritable mood.)

2. Markedly diminished interest or • All she wants is lie down all

pleasure in all, or almost all, activities
down if she has no work,
most of the day, nearly every day (as
indicated by either subjective account she doesn’t have driven in
or observation). sexual activity.

3. Significant weight loss when not

dieting or weight gain (e.g., a change
of more than 5% of body weight in a • She lost weight.
month), or decrease or increase in
appetite nearly every day. (Note: In
children, consider failure to make
expected weight gain.)

4. Insomnia or hypersomnia nearly

every day. • She finds sleeping very
difficult and even
5. Psychomotor agitation or experience waking up early
retardation nearly every day dawn is difficult and going
(observable by others, not merely back to sleep.
subjective feelings of restlessness or
being slowed down).

6. Fatigue or loss of energy nearly

• Manifestation of a decrease
every day.
energy level.
7. Feelings of worthlessness or
excessive or inappropriate guilt (which
may be delusional) nearly every day • She mentioned that she
(not merely self-reproach or guilt feels like a worthless
about being sick). mother to her kids since she
can’t fulfil their demands.
8. Diminished ability to think or
concentrate, or indecisiveness, nearly
• Reported to have difficulty
every day (either by subjective
account or as observed by others).
in concentration, she even
experienced watching TV
9. Recurrent thoughts of death (not then after 10 minutes she
just fear of dying), recurrent suicidal thinks of something else.
ideation without a specific plan, or a
suicide attempt or a specific plan for • Attempted to commit
committing suicide. suicide by taking 12 tablets
of paracetamol all at once.
2. The symptoms cause clinically • Her relationship towards her
significant distress or impairment in kids and partner wad
social, occupational, or other affected by the decrease of
important areas of functioning. her energy and disregard to
daily routine. She even
forgets the parent evening
event.
3. The episode is not attributable to the • Her responses begun few
physiological effects of a substance or months back after she
another medical condition. constantly experienced the
Note: Criteria A–C represent a major pressures from fulfilling her
depressive episode. Note: Responses duty as a mother, her
to a significant loss (e.g., company cut off their wages,
bereavement, financial ruin, losses and her partner isn’t being
from a natural disaster, a serious supportive and helpful.
medical illness or disability) may
include the feelings of intense
sadness, rumination about the loss,
insomnia, poor appetite, and weight
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 loss noted in Criterion A, which may
resemble a depressive episode.
Although such symptoms may be
understandable or considered
appropriate to the loss, the presence
of a major depressive episode in
addition to the normal response to a
significant loss should also be
carefully considered. This decision
inevitably requires the exercise of
clinical judgment based on the
individual’s history and the cultural
norms for the expression of distress in
the context of loss.
4. At least one major depressive episode • No Psychosis manifested.
is not better explained by
schizoaffective disorder and is not
superimposed on schizophrenia,
schizophreniform disorder, delusional
disorder, or other specified and
unspecified schizophrenia spectrum
and other psychotic disorders.
5. There has never been a manic • She haven’t taking any
episode or a hypomanic episode. substances.
Note: This exclusion does not apply if
all of the manic-like or hypomanic-like
episodes are substance-induced or
are attributable to the physiological
effects of another medical condition.

XIII. DIFFERENTIAL DIAGNOSIS

• It is not possible to provide a differential diagnosis because there is insufficient data to support the
client's condition, and more testing and assessment must be completed as soon as possible to
provide a solid foundation for the client's distressing situation.
o Persistent Depressive Disorder F34.1 is characterized by depressed mood, more days than not, for at
least 2 years. If criteria are met for both major depressive disorder and persistent depressive disorder,
both can be diagnosed. (DSM 5-TR) This Diagnosis still needed a follow-up assessment to
support the criteria that needed to be validated.

XIV. INITIAL RECOMMENDATIONS

Further intake interview is necessary, during which the client's life history will be covered as well
as the fundamental data required to complete the client's requirements prior to diagnosis. We
must take into account the 4Ds.

GIDEON DONAIRE-BAYONA December 13, 2023

Psychologist – in – Training

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