MSE Case Study

Mental State Examination (MSE)

Appearance

Joshua Smith (prefers “Josh”) is a 19-year-old Caucasian male, whom lives at home with both parents and two younger siblings in Mandurah, Western Australia. He’s currently 180cm tall and 85kg, but has lost several kilos over the last few months due to decline in personal care including refusing to dine with his family. His skin is pale, he appears un-showered and his clothes are dirty and bloody. Josh is underdressed for winter in shorts, t-shirt and thongs; his hair unkempt. During our current interaction, Josh’s motor behaviour express unconscious emotional conflicts demonstrated by mood changes such as restlessness, irritability, aggression and sadness.

Behaviour

This evening, Josh was brought

into ED via ambulance. Police intervention was required today after Josh locked himself in his room, his parents became concerned with his safety after hearing commotion. Earlier, the family had requested Josh see his GP regarding his recent behaviour.
The clients’ family reports that previously Josh was a happy, outgoing teen, who has increasingly become withdrawn, agitated and antisocial. He recently dropped out of high school, near the start of Year 12 as he was failing all subjects. He is socially withdrawn to the point of shaking when meeting someone new. He told family, he “doesn’t feel relaxed around people anymore”. The family relay Josh lost his close cousin to suicide almost one year ago. Recently, Josh has increasingly referenced his cousin in conversations.
Josh has stopped participating in sports activities or going out with friends. His girlfriend, Michelle, broke up with him, stating he is “Nervy and distant”. Joshua currently works for his parent’s air conditioning business; the family appear pressured as the business is failing. In recent months, Josh has been forgetful and erroneous in his tasks.
Lately, Josh has displayed abnormal activities for himself: irritability, “rocking”, self inflicted cutting, locking himself away in his room and random, physical acts of anger such as breaking glass and banging on furniture. Per intake, Josh’s parents say he’s not a drinker and does not do drugs.
Upon examination the client is hostile, with demonstrated aggressive outbursts such as undoing his wrist dressings and throwing the bandages, as well as kicking the wall. His eye contact is limited and brief, demonstrating flitting ideas and disposition.

Affect, Speech and Mood
With the clients’ recent interactions with police, paramedics and family, Josh appears to have a depressed mood with bouts of anxiety and hostility. Albeit he has been compliant with services to this point.
During examination, the client has burst into tears followed by scowling, then yelling “What can you do for me, how can you help, I just don’t want to be here”. Josh appears to be of negative affect, his speech is pressured and circumstantial although, He has expressed himself clearly. His facial expression and speech mimic his emotional infliction with the outburst.

Form of Thought /Content of Thought
Josh’s comment to his parents “no one understands, I feel so miserable, there is no help for me…I want it all to end” is of suicidal pathos. Josh’s cut wrists demonstrate active thoughts of self harm. Josh’ connection of ideas is linear with a consistent theme of helplessness and negative wane. His thought ideology pertains only to his immediate self, situation or link to his cousins’ suicide, this represents his inability to express himself and process his emotions. He has no apparent delusions.

Perceptual
Examination shows no evidence of hallucinations or perceptual disturbances.

Cognition & Insight
Josh is alert and orientated to time, person and place, but his insight is clouded by his greater situation. Physical evidence of cutting reflects a need to feel pain outwardly. Also his family’s concern, a familial suicide and Josh’s physical escalation in actions identify as markers in several classes of risk factors that increase teen suicidality risks and should be taken seriously (Yen, Weinstock, Andover, Sheets, Selby & Spirito (2013).
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Risk Assessment
Josh exemplified many precipitating and predisposing factors of mental illness in the lead up to this hospitalization, including changes in feelings, thinking and behaviour (Hungerford, Clancy, Hodgson, Jones, Harrison & Hart, 2014, p.460, Table 12.3).

In order for the client to access benefits and utilize resources we first should execute a risk assessment to determine w9hat risks may apply to Josh. From the Mental State Exam (MSE) information gathered, we consider: risk factors, history, triggering factors and protective factors; as well as the client’s current thoughts, emotions and social circumstances to strategize clinical decisions (North Metropolitan Adult Health Service Mental Health,

2010).
“Research indicates that behaviour is often a means of communication” in which we could interpret this “means of communication” ...”as a way of coping” (Murray & Wright, 2006, p. 157). Historically, Josh has trended an escalation in events, such as withdrawal of peer relationships like playing sports, seeing friends (Avoidance of social distress or being misunderstood and emotionally overwhelmed) or the break up with his girlfriend (rejection/abandonment). Incompletion of high school and declination of work performance demonstrate distraction or lack of interest as well as and avoidance of pressured environments with expectations to perform. In correlation, Josh’s low self esteem and behaviour is a congruent reflection of low mood and maybe situational, but reflects the trauma of his cousins’ death at a vulnerable time in his life and the anniversary of death coming to a head (Panjwani, Munira, Dossa & Khadija p.7). All ultimating in his involuntary ED admission. Josh has withdrawn from situations that he has limited coping skills for; A limited ability to tolerate negative states, withdrawing him further and further limiting his support system (Scoliers, Gerrit, Portzky, Madge, Hewitt, Hawton, Wilde & Heeringen, 2009). For Josh, his mechanism of coping has become reliant on acts of self harm behaviour such as cutting, drinking and violence, all under his control. These are the skills Josh will need to change to make his situation better and will be applied to his management plan. (Scoliers, et al., 2009).
Based on the MSE and applying Mental Health Triage Tool, a management tool that determines client acuity (Triage quick reference guide: mental health triage tool, 2013); we can consider Josh to have potential risks that require immediate emergent attention to de-escalate his crisis. The potential risks likely to pose over the next 24 hours include:
1) Risk of suicide:
The client is a current risk of further suicidal behaviour due to the multi-faceted nature of this hospitalisation. Help seeking behaviours and general decline have not led to prior health assessment or access, exacerbating the situation. During examination the client said “What can you do for me, how can you help, I just don’t want to be here”. The use of a “double bind” in Josh’ questioning imply low self esteem conflicting with his comprehension of a positive health improvement (Baumeister, 2013).
Josh’ presenting psychiatric symptoms, age and sex determinants conclude the client to be considered high risk (Triage quick reference guide: mental health triage tool, 2013); with males dying “by suicide at nearly three times the rate of females” (West Australian Mental Health Commission, 2015).

2) Risk of harm to self and others:
At 19 years old Josh is vulnerable, He legally is an adult but may be cognitively debilitated to make decisions presented to him. As a population of risk, if the client feels blamed, judged, or does not comprehend why or how he is in the current situation or environment such as receiving treatment, he may become a safety threat to himself, peers, family or staff. Josh has demonstrated lack of self control with verbal outbursts and physical damage to property and himself. Also, although we have an idea, we do not fully comprehend his behaviour as physiological, induced or mental health related due to the multi-faceted nature of this hospitalisation (Mental Health and Drug and Alcohol Office, 2009).

3) Risk of absconding or failure to comply to treatment:
Josh has factors already stated above. Primarily Josh has depressive symptoms, evidentially: withdrawal from most aspects of support to this point so it would seem he may continue to do so. In general, he has poor help seeking behaviour, a limited support system and possible cognitive inability. Alternatively, Josh may refuse or reluct assessment in an attempt to expedite discharge. Josh fortunately has protective factors that could can reduce impact, or impose positive affect towards his future outcome (Hungerford et al., Table 12.1, p.458), (Robinson, McCutcheon, Browne & Witt., 2016).

The process of risk management planning
 Based on the risk formulation, we should deduct an individual short-term intervention and an immediate management plan, using the bio-psychosocial paradigm; corroborating Josh and his family. Josh should be placed in an area of ED that is safe, quiet and any unsafe items removed (such as belts) from the environment. Josh should be provided with 1:1 companionship or security. Due to Josh being actively suicidal and intoxicated he poses a danger to himself and others, the likelihood of immediate discharge from the emergency department is small.
It is imperative that the client is not discharged without a clear management plan (Mental Health and Drug and Alcohol Office, 2009), Josh should speak with the psychiatric liaison nurse; but as they are not currently available, Josh should speak with a physician and an appointment be made to speak with someone from the mental health agency within 24 hours. To conclude, a written action plan to monitor, treat and record Josh’ progress, be developed with Josh or family offering reference and insight. It should comprise of all aspects of Josh’ mental health including education on risk factors, positive and negative outcomes, resources, services, mental health agencies and individuals offering support and address issues of access, privacy and crisis management. Written prompts pertaining to duration of hospital stay, post discharge and long term management will be provided to Josh, his GP and any referred agency. Psychological therapies are the recommended first line options for the treatment of depression in children and young people” (“Types of treatment for young people” n.d.), therefor medications may not be helpful in this client’s current situation.
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Case Formulation/hypothesis
Abraham Maslow wrote in his 1943 paper "A Theory of Human Motivation", a concept pyramid, outlining the order in which to reach well-being. Each tier reflects fundamentals from basic survival needs, aspects of safety, belonging and self-esteem to finally achievable is self actualization (Jackson, Santoro, Ely, Boehm, Kiehl, Anderson & Ely, 2014).
Presently the client, Josh, is a 19-year-old male whom was brought in by ambulance due to family and police intervention. The clients’ chief complaint is bilateral lacerations to wrists, query suicide attempt with ideations. In this case, the client is at the basic survival tier, in order for Josh to be happy he must surpass this level to improve his quality of life.
Josh is considered a patient of concern due to aggressive outbursts, a lack of self control, verbal ideations followed by physical self harm. Josh lives at home with his parents and siblings, he works at the family’s business. The business is failing and could be considered a secondary trigger to Josh’s behaviors. An unstable future could affect the family dynamic adding multiple stressors on family relationships, home, and financial stability. Josh’ “pyramid base” lacks structure.
The following individual issues also affect the client’s stability, relating to the the hierarchical concept.

One year ago, Josh lost his close cousin to suicide and it appears this death may be the initial cause of Josh’s behaviour. Josh feels intense grief, loss, and per family, appears depressed; Undeveloped coping skills may have caused Josh to compensate, as evidenced by cutting and drinking alcohol.

The client’s family is concerned over perpetuating circumstances and escalating behaviors from negative self referencing to quitting sport and school and acts of helplessness. Josh has become depressed, reclusive and could be indirectly demonstrating a “plan” by pushing the protective factors in his life away. The client’s appearance could indicate preoccupation. The anniversary date of his cousin’s death could be considered the breaking point.

Investigations into Josh’ guilt, destructive behaviors and fear are required in an effort to limit short-term and permanent effects of the patient's wellbeing and in order to prevent

suicide.

Conclusion

Josh is currently in crisis and is considered a patient of concern. The goal, is to prevent suicide and limit short-term and permanent effects of the patient's wellbeing. Josh is young and lacks skills to manage his emotions. With protective factors such as his family, Josh can establish techniques to equip his future approach to life.
A multi-disciplinary approach will guarantee success in Josh’s care. This approach includes treating or identifying the underlying disorder, monitoring Josh and applying agreed restrictions, managing his environment, identifying any gaps; and re-evaluating with Josh and his family to consider new information and adjust accordingly to his condition whilst applying existing hospital policies and protocols.