Patient Assessment: Drug Addiction and Co-Exisiting Issues

5338 words (21 pages) Essay

18th May 2020 Psychology Reference this

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Mental Status Examination (MSE)

Appearance in per as age

As per as her appearance she was looking old, chronological age is 33 years.


In the beginning it was hard to open the line of conversation because she feels a bit hesitate to talk with the male staff after trying 2,3 days she feels comfortable to have a talk. Then finally I was able to build a good relation with her.

Body build

She is short as her height 5”2 weight 98 Kg


Mrs. Tylor (Pseudo name)

She loves jewellery she always wears them.


She loves western dresses, she loves to wear them her favourite colour is pink.

Hygiene and Grooming

She always smells like smoking because she is a smoker she smokes times a day about her hygiene she does not like to take shower every day so she takes shower every after 3 or 4 days so she smells unpleasant.

Facial expression

She is always looks tired and some time she have short breath because she is over-weight she has hard time to do any physical activity. she used to spend whole day on the chair watching TV.

Eye contact

The time when I meet her first she was not even making eye contact when I successfully able to make a good relation with her then she starts making eye contact but she was not able to maintain a continuous eye contact. I make out that she is having darting eye contact.

2. Psychomotor behavior


She used walking frame to walk because of her over weight she walk slow.


When I offered handshake she accepted.

Abnormal movements

She is showing nail biting


She was showing shaky posture

Rate of movements

She was getting agitated frequently.

Co-ordination of movement

She was sowing clumsy movement

Mood and Affect

Appropriateness of mood

She was getting irritate frequently her behavior can’t be predicted as she get upset easily.

Range of affect

She become upset easily and always remains in doubt.

Stability of affect

She is unstable she is having lot of mood swings.

Attitude towards nurse during encounter

The time till I was with her she was very co-operative. Even when I offered handshake she accepted she has warm and co-operative behavior towards me.

Specific mood or feeling

She was seemed always irritable little things can trigger her past and she can become violent so while dealing with her we need to be very conscious about what we speak.

Anxiety level

She has a mild level of anxiety

Rate of speech

She has rapid and jerky rate of speech with low intensity because of low intensity sometime it becomes hard to understand her.


She seems normal but sometimes she was seemed talking to herself.


Attention and concentration

She gets easily distracted while conversation


She got a very good remote memory. She remembers lot of event taken place she even remember the dates of the events but she is not good at recent memory. For example – while talking with her she told her school time story when she was in 12th standard she fall in the love with the someone they both together went to national park during vocations she had enjoyed a lot. Upon asking her that is she had finished her breakfast she was confused and start thinking and she said she don’t know that even she was given breakfast. This shows that she is able to remember remote memory but not the recent.

Abstraction insight into illness

She has insight she wish to join her family once again


She has insight she knows what going around her she know where she is living and all the person around her moreover she is confused about the timings upon asking to guess the current time she said its 9 in the morning but in real it was 2 PM.


Thought pattern

She is good at decision making she know what she is saying and one thing I have noticed while she was telling her school story she was getting confused and try to make up the lines with other idea.


She was suffering from auditory hallucination and having depression also.

Level of conscious

She is responsive to verbal stimuli only she react when anything related to past said 

Case study

Name – Mrs. Tylor

Age – 33 years

Sex – Female

Culture – Tonga


 She got key worker, support worker, community support worker and clinical team. Her family is supporting her as well as.

Presenting complaints:

  1. Causing Fire due to falling asleep while smoking

She is addicted to smoke she smokes a lot, once she about to burn everything because of her confusion she forget that she is still smoking and for her hand the burning cigarette fell down and the carpet caught fire it was so close but she was safe.

  1. Potential of wandering

After having more than 5 cigarettes she becomes more confused and starts wondering. She is too much addicted to the smoke she smokes more than 8 in a day which harm her and make them start wandering.

  1. Aggression-

Because of her confusion she gets easily violent and start abusing who ever in front of her so while dealing with her have to take extra care of what we speak so it won’t trigger her past. to prevent any harm.

History of present illness

Mental illness

She suffering from paranoid Schizophrenia

Physical illness

She is suffering from Asthma and Depression

Past Psychiatric and medical history

She is suffering from Paranoid Schizophrenia and Depression last from 6 years an the same time she has auditory hallucination.

Family history

Because of her over weight she is ignoring physical activities which make her more chances of getting diabetes in future there was no disorder in the family.

Alcohol and substance history

She is addicted to smoke and past history was misusing methaonphetamine a kind o drug.

General appearance

Appearance in relation to age

As mentioned above she was looking older than her real age that is 33 years she loves to wear western cloths mostly she prefer pink color cloths she takes shower after 4,5 days which makes smell like smoky because she is addicted to smoking.

Attitude towards situation/manner of relating

When I first offered her handshake she accepted with smile face which shows that she was was and co-operative she got good insight she knows what is happening around her.


She is obese and always seemed perplexed.


She was very slowly she uses walking frame to walk because of her over weight she become unstable so to maintain stability she used walking frame. She sometimes shows tremors behavior which shows that she is no so confident she is in confusion.

Motor activity

Irritate easily if anything trigger her past.


She has rapid and jerky rate of speech with low intensity because of low intensity sometime it becomes hard to understand her

Mood and affect

She is having depression because of this there are rapid changes in her mood we can see due this we can also predict its affect on her. she sudden become confused which makes her upset and from her face we can see changing expression from normal to sad.

Thought pattern

Because of confusion she sometime stuck and due to confusion she become unable to explain what she want to say so she skip the topic and jump to another topic. During the whole session I noticed she is showing flight of ideas.


She is having auditory hallucination

Sensorium and Cognition:

She is reacting towards verbal as well as touch. She got excellent remote memory but her recent memory is too weak. For example upon asking that what she had have during her breakfast she go puzzled and confused she replied that she don’t even have breakfast. In reality she had breakfast just 5 minutes ago.


She is aware about what is going around her and have ability to take decision and know what kind of disorder she is having which make us to treat her easily and she is co-operative also.

 Diagnosis as per DSM-V:

Her diagnosis involves Paranoid Schizophrenia, Schizoaffective, delusion and drug induced psychosis

  1. Paranoid Schizophrenia “A mental disorder characterized by hallucinations, delusions, disorganized speech and behaviours called Schizophrenia” (Maria Yang, 2013).
  2. Delusional Disorder: A false unshakable belief is called delusion (Psych Central, 2019).
  3. Schizoaffective disorder: “The biggest change to schizoaffective disorder is that a major mood episode must be present for a majority of the time the disorder has been present in the person” (Psych Central, 2019).

Causes- the substance abuse causes her Paranoid Schizophrenia. Other issues such as physical, sexual abuse, feeling of isolation and shame.


Sign showed by her she become violent easily, have auditory hallucination and assaultive behavior also

Symptoms- over thinking, lack of hygiene, delusion, auditory hallucination.

Treatment method

She has to take medication every morning and night if she seemed too much confused or violent then small amount of medication can be given in the afternoon

Dabigatran- she is taking this medication 4Mg Blood thinner. Help to reduces chances of blood clotting. Side effects are stomachache, running nose, rashes.

Haloperidol – 5Mg quantity of this medicine used for the treatment of Schizophrenia some side effects are irregular heartbeat, less or drowsy alerts as compare to current condition.

Epilum- an anti epileptic drug. This tablet used to control the mental illness and mange to bipolar disorder. Side effects feeling shaky , sick and drowsiness.

Psychotherapeutic Method: 

  1. Cognitive behavioral therapy  –

This therapy is a part of the psychotherapy. These therapies help in treatment by boost happiness by manipulating dysfunctional emotion or feeling and behavior. Mrs. Tylor attend the treatment every 2 days a week which effects on her thoughts as well as perception. Motivates clients to have some improvement and challenge the distorted thoughts  (Psychology Today, 2019).

  1. Occupational therapy – Mrs. Tylor is also subject to attend this therapy and the therapist visit her every Fridays. She encourage to do some physical activities so they go for the morning walk and motivates her to follow this every morning and encourage to do ADL activity by herself and motivated to have goal to join gym to lose weight  (The American Occupational Therapy Association, 2019).


Mrs Tylor is a 33 years old lady suffering from Paranoid Schizophrenia and depression. She is addicted to smoking she smokes 5 6 cigarette a day after having more than 4 she starts wandering. She got good remote memory buy she is weak at recent memory she even forget that she smokes or not. She loves to wear pink western dresses her goal is to reduce weight and recovery fast so she can go back home fast. Because of auditory hallucination she got upset and irritated. For the treatment she is getting medicines and number of therapy also.

Task 2

Approaches of recovery-

A recovery approach plays a important role in improving mental health problems and addiction. Recovery is an integrated approach, a client centred approach for clients with mental health problems and drug addiction. This is the best way to control the symptoms and signs of poor mental health.

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Wrap is recovery action plan. Wrap improves their quality of life, enhances their personal accomplishments, helps them achieve their goals and objectives and helps prevent difficult situations and problems. Applying this therapy can help people investigate problems and sad behaviour, and in all cases, the researched responses diminish. If clients with mental health or substance abuse problems cannot make decisions, the wellness plan also includes strategies for dealing with others. Using this approach, the client can feel unique and special. It’s a good way to recover for each client, where client can make choices and express their thoughts about their lives  (Copelan Center, 2018).



2.2              Family therapy –it is one of the type of Psycho-therapy and it main motive is to solve the conflicts between the family member and the client. The best way to improve the relationship of the client with their family is to apply this therapy it has high chances of success. An essential tool to improve long relationship among the client and family the client who is been receiving treatment for mental illness this therapy also help the client to get solve their mental illness as well as addiction issues. To apply this therapy one had to face so many challenges because it is not an easy job as their will be whole family is involved and each member has different set of mind so lot of challenges can be seen during this therapy. This is therapy can be consider as most important therapy in terms of treatment of the mentally ill client because in this the client is getting lot of support and love from the family and the client need these to improve fast. The therapy has to be always governed by licensed mental health professional and clinical social worker  (Postive Psychology program, 2019).

One of my client Mrs. Tylor who is the victim of paranoid schizophrenia and depression she is getting treatment in our facility while reading her notes I found that she had set future goals she want to lose weight and join the once again she loves her family a lot she always seems happy when they come to meet her. As per as my point of view the family already know the risk and the problem of her what she is suffering but the thing is they don’t have any idea or they don’t have any information/strategy to follow when she is showing challenging behaviour such as wandering or irritation or violent if they know these they can provide best support to improve her fast.

She get violent and upset to when she is not able to contact her family for long then this therapy play important role to make her feel comfortable by guiding her to how to deal with others and build a good relationships and able to meet her family.

It is the bet therapy to maintain the healthy and functional family. If anyone in the family is suffering from any mental disorder so the main goal as per as family therapy, family must know the symptoms and have understanding about the illness. This therapy helps the family to improve healthy boundaries and also communication skills among client and the family. The positive result of this therapy can be seen on the client face because she feels happy and better when she met her family  (Postive Psychology program, 2019).


Relapse plays a crucial role in recovery process.


  1. Emotional relapse- emotional relapse is the beginning of the relapse phase in which the client is having mental illness and addiction problems; they are found with emotional issues also which trigger their depression. Client who is already having mental issue and addiction they are found facing so many problems for example stigmatization and discrimination which in result they end up by feeling isolated which make their problem more badly.
  2. Mental relapse- as per as this, client is surrounded with negative thoughts which make them to think that they are suffering from lack of hope and they are not getting any kind of help because they felt that they don’t have any choice which make their treatment hard as well as chances of improvement reduces.
  3. Physical relapse- the end stage of relapse in which client have ideas while comparing performance respect to behaviour.


  1. Learning about the client- the best way to know your client is to read and understand the client medical history involving mental health and addiction issues. After understanding client medical history then you are able to prevent any risk factor in the clients life upon looking warning sign of the client will guide what measures have to take in the beginning which also help to prevent risk. Sometime client become upset as well as seemed uncomfortable because of their past and don’t want to recall that stressful situation again. while identifying the warning sign we have to take extra care about the client trigger factors because it can ruin whole session  (Here to help, 2019).
  2. Taking action – it has three complete set and the sets are building healthy coping style, identifying stressful situation and managing stressful situation. These three steps works together to take any action.

     Building healthy coping style- coping is the part of life one must possess this skills because the person who knows how to deal (cope) stressful situation in life they live healthy so coping is the best part of having a healthy lifestyle. Some of the measures can be used for example daily physical exercise, have balanced diet, proper sleep these factor can have reflect on their health and ability and if anyone got any challenging  situation they can solve easily as they are already prepared. Compared to it if a person have unhealthy diet seems to have more problem for health and mood.

     Identify stressful situation- the major part of the wellbeing is to know how to identify stressful situation. Having proper information about the client then one can able to control the risk factor and the skills gives the ability to solve their stressful condition and problem.

     Managing stressful situation- the ability to manage the stressful condition. The counsellor must possess these skills so they can able to identify about risk and warning sign of the client to manage the problems. There are some practical steps to manage stressful condition which must be followed by the counsellor  (Here to help, 2019).

Task 3

Social justice-


As per as oxford university “Social justice in terms of the distribution of wealth, opportunities, and privileges within a society (Oxford Unitversity Press, 2019).

Two of the main components which are managing healthcare primarily in health care in new Zealand for example equitable healthcare access to all and equity healthcare means giving the resources as per as the client needs.

  1. Equitable healthcare- it means equality among the resources provided which means that the person is getting same number of the resources as well as same cares.

In another words it refers to the equal share of every resource such as equal opportunities equal sharing among the entire position holder there is no special case for the person to get more benefits they get equal number of benefits. However it is depends on the quantity of resource not on the individuals needs.

  1. Equity healthcare- it refers to the justice and the fairness which depends on the individuals needs. First job is to look the person needs then the facility/resources is being provided rather than dividing equally. It aim to check the individual need then give the facilities to the client.

Treaty of Waitangi – (signed in 6 Feb. 1840) (teara, 2019)

The important side of social justice depends upon the Treaty of Waitangi which includes three principal and the principal are 1.Partnership 2.Participation 3.Protection

Treaty of Waitangi is the agreement made in 1840 among British and more than 500 Maori chiefs which resulted in the announcement of British sovereignty ON the New Zealand

The three principle which describe the social justice are below-

  1. Participation- this principal gives the right to the Maori people. The Maori has the equal right and they should involve in all the stages of health and impairment section and the section are planning, health, safety, development of the health and impairment section and decision making.

This principal also encourages the Maori people to take part in the all level of education to learn to improve their health and wellbeing (teara, 2019).

  1. Partnership- it means working together and has equal opportunities. As per as this principal motivates Mori to work together with non Maori which help to make enhance strategy for Maori health in respect to disability as well as health section (schoolnews, 2019).

It also involves the Maori people to take part together with all other groups in the education sector which evolves decision making, planning and development of curriculum. This will improve the Maori health as well as they are getting education they can improve their health condition also because from the education they are getting equal opportunities to take part in the social community and make lifestyle healthy as they know what to do to have a healthy life (schoolnews, 2019).

  1. Protection – it means that protecting Maori culture, knowledge, values. It can be protected by the involvement of the government by treating and giving equal opportunity to the Maori people. To help to save the Maori language they have started Te reo classes in some of the schools (schoolnews, 2019).

Importance of social justice-

It is the second most important measure to prevent illness. The goal of social justice is make the Aotearoa the place where healthy people leave by degrading the mortality rate and making the healthy lifestyle. It also focuses on the malnutrition as well as impairment on the social and economic well being. The key element that is social justice provides hips of opportunities to meet their needs who are the victim of mental illness and physical illness also. Social justice also aims to focus on the needy person who needs support with education or mental health treatment. Then end goal of the social justice is to give everyone an fair treatment in the society.


1. Rapport building skills- it mean making a good relation which is the most important skill and counsellor must have this skill for giving counselling because it plays an important role in session if the counsellor is able to develop a good relation with the client then the whole session will go easy and have positive result. To make the make the client not to feel whakama counsellor can give additional importance to the client having mental and addiction issues so the client will be able to develop the trust and can explain whole things his/her thoughts and the issues. Therefore the counsellor will be able to treat them very well because the counsellor now knows the root of problem so now he can help them to improve easily  (Skill you need, 2019).

2. Empathy- to provide the high standard of care, the person who is dealing with the client treatment procedure must have empathy skill because the client have face stressful condition and they are mentally ill .The counsellor must have this quality it’s like putting yourself in clients shoes mean feeling the pain of the client therefore there is the need of empathy for their treatment. So if the counsellor show empathy towards then it will be easy to deal with the client to make them feel relax and comfortable by understanding the client feeling.

Applying this skill he can make the session effective then the client also thinks that he is her to listen you and able to build the trust so the client express their problems as well as felling and the counsellor can make out the reason why they become mentally upset and can help them in the treatment  (Skill you need, 2019).

  1. Communication skills-

To being an effective counsellor one must have good communication skills. To be a effective counsellor one much listen properly to the client let him explain himself completely then counsellor must describe properly and in a clear tone so client can understand the treatment and what the actual problem is there. In any case if the counsellor lack in communication skills then it can result in negative session and the client may become upset or might be violent and can leave the place. Therefore counsellor always remains mindful while dealing with the client so they feel important and can built trust so they can share the problem. To make to session good and effective counsellor always used these skills  (Skill you need, 2019).


1. Right to have visitor and make telephone- Mrs. Tylor she is having paranoid Schizophrenia. While in the facility she always misses her family she sometime feel crying to because she not able to contact them because she don’t know how to use the mobile she has the right to call them anytime but she need assistant in using mobile when she talk with them she remain happy for whole day but when not she become sad for the day and remain upset. Once I visited her she was laying on the bed and looks tired then I tried to talk with her she dint respond and I offered handshake she refused then I ask her what happen she replied that she have not seen her brother for long time she is missing her brother she want to meet him then I offered you have right to call you can call him and ask him that you wish to meet him as you are missing too much then I helped her to manage the call and her brother said he will be there in the afternoon. She starts smiling and seems excited to meet him. In the afternoon when he arrives she become too much happy and active to and the happiness we can see on her face whole day she was happy and active too.

2. Right for culture identity – every culture has the right to be treated with respect and with dignity. Mrs. Tylor she is an religious lady in her gaol plan she wasn’t to visit The Methodist Church of New Zealand near to the facility every Fridays or sometime she wish to visit on Thursday she had the right to visit. To maintain and remain her attach with the culture our facility managed visit. After having visit she feels relaxed.

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