Ian Assessment_Cress

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Indiana University, Purdue University, Indianapolis *

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517

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Psychology

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Apr 3, 2024

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docx

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Uploaded by CaptainWaterFox38

1. MENTAL STATUS EXAMINATION The following format for documenting the Mental State Examination is a variation that can be applied by social workers: Domains Type here Appearance and Behavior: Ian is a 31/34 year old Caucasian male of medium stature. He appears to be well-groomed, slightly disheveled but dressed appropriately for the occasion. Client has a cut on his forehead likely resulting from the accident. His posture and eye contact are poor but appears to be otherwise healthy. His expressions are perplexed, and his cooperation is withdrawn and sullen at times when speaking about his family but overall cooperative and polite. Speech: Client speaks at a normal volume, but rate can be fast and spontaneous at times when he appears to be anxious questions about his future. He is articulate. Mood Subjective: Ian reports not knowing how he got to where he is at today, he admitted to gradually “unraveling”. Ian reports difficulty with memory, feeling upset, and trouble thinking as he misses his family. Objective: Ian’s affect is congruent to his mood, he fluctuates between remorseful/sad, anxious and is irritable at times. Risk: There was no evidence of suicidal thoughts/self-harm observed, however Ian is here today due to domestic violence against his spouse and endangering someone’s life from driving under the influence. Ian admits that he is drinking to the point where he cannot control his actions and reports “going crazy” as well as not recalling timeline of events while under the influence of alcohol. Thoughts Form: Ian admits to loss of memory when drinking, difficulty thinking, and going crazy which leads to unpredictable and

irrational behavior. His thoughts during the interview were linear but sometimes rapid and getting off topic as he had to be redirected more than once. Content: Ian expresses disbelief with the charges he is facing and the interactions with social services following the assault on his wife. He is irritated initially when discussing each incident but then switches to remorse. He attributes impulsive behavior to being upset/increased drinking. Beliefs-Overvalued or Delusional: No delusions. Perceptions: No experiences of abnormal perceptions. Cognition: No abnormality found on formal testing. Insight: Ian demonstrates poor insight on his substance use disorder and the impact it has had on his life. He failed to make the connection of alcohol being the common theme to his issues and showed reluctance to reaching out for services through social services. Diagnostic Impressions: Alcohol Use Disorder (Moderate)

2. Level 1 Cross Cutting Symptoms Measure

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