MENTAL HEALTH ASSESSMENT

Student Name__Alyssa Van Vark____

CLIENT NAME:___K.M___________________ DATE:_______1-22-13________________

I. PRESENTING PROBLEM
Patient is an
older Caucasian female who was admitted onto the inpatient unit at PSJMC on 1-16-13 with diagnoses of
Schizoaffective disorder, Generalized Anxiety Disorder and Major Depression. Patient was brought to the
hospital by ambulance after a call was made by herself saying that she was having suicidal ideations and
overwhelming anxiety. Apparently K.M. has been having increasing depression and anxiety over the past
few weeks due from her not taking her medications. The patient stated when asked about her medications,
"the pharmacy would not fill them" without any further reasoning.
II. SYMPTOMATIC THOUGHTS,
FEELINGS, BEHAVIORS
a) K.M. denies thoughts of active suicidal
ideation or depression
b) Stated she was "hysterical with anxiety"
c) Stated she was "scared to death of going crazy"
d) Felt anxious because she "didn't know what to do with herself"
e)
K.M. stated she was "crying constantly and was irritable
III. LETHALITY (current and prior
suicidal/homicidal ideation, plan, behavior)
K.M. had prior suicidal ideations and a plan prior
to admission. K.M. stated that she was looking for pills to take at both her house and her boyfriend's house
that she could overdose on but was unable to find any. K.M. admitted to having thought about suicide in the
past, but feels as if she would "go to Hell if I committed it and would be in more pain then than I am now".
Patient admits to feeling better now and no longer has any suicidal ideations or plans and is "no longer
feeling depressed". Low lethality risk as per assessment.
IV. FAMILY CONSTELLATION (Including significant events,
partners, divorce, trauma, physical or sexual abuse, mental health or substance issues, economic status, etc.,
attach additional pages if needed, number as 2a, 2b, etc.):
a)
Family Ethno-cultural Background: White-Caucasian; non-hispanic. ChristianCatholic
b) Name, Age, Relationship to
client Genogram
i. Patient claims that she doesn't know the
names or ages of her Grandparents
on either side.
ii. Patient's Dad (B.M.) is deceased, after dying of cancer at age 59.
iii. Patient's Mom (M.M.) is deceased, after dying of a heart attack at age 79
iv. Patient has a sister (S.M.) who is "somewhere in her 50's"
v. Patient
has a brother (M.M.) who is "somewhere in his 40's"
vi. Patient has 2 daughters
(E.M. & C.M) who are both "somewhere in their
30's"
Other Significant Relationships (friends, co-workers, intimate partners):
Patient states that she was married, but got divorced after 11 years and wants "nothing
to do with him". She also admits that she had a boyfriend for 7 years but just recently broke up with him
because "he was a pig". Patient states that she has no friends or family and feels as if she has a limited
social/support network. Patient states that her family wanted nothing to do with her after she was diagnosed
with a mental illness, claiming that her brother, sister and two daughters have abandoned her.
Significant Events (traumas, moves, losses, etc.):
K.M. has been in and out of the psychiatric unit many times ("about every 10 years or so, usually
due to relapses caused by not taking my medications"). Patient stated that she felt she did not have a lot of
friends at school and that she did not like going due to that. Patient said she was bullied off and on
throughout school, and eventually developed Anorexia Nervosa during her high school years. Patient's
father died of cancer at age 59, and patient's mother died of a heart attack at age 79. Patient states that she

was married for 11 years, then got divorced once she became more mentally ill and then she moved back
home with her mom. When her mother passed away, her brothers and sisters disowned her due to them "not
understanding mental illness. It's like they think they will catch it or something". Patient then went on to say
that she had a boyfriend for 7 years but just broke up with him because "he was a pig. All men are pigs",
claiming that he was "dirty, and I didn't want to live like that anymore".
Sexual History (sexual preference, currently active, difficulties, idiosyncrasies, current/past
STDs):
Patient says
that she has no interest in sex or sexual activity of any kind. She claims of never having any sexual
difficulties and is not currently sexually active and that she's "never had any interest in that". Patient denies
any past or current STD's.
V. INTERPERSONAL SUPPORT SYSTEM (describe current supports,
include ability to make/maintain friends, handle conflicts with family, peers, workers):
K.M. says that she doesn't have a big support system at all, but can rely on her friend who she met at
her daughter's pre-school and that she used to be a nun but is now a pre-school teacher. K.M. claims of
having good ability of making friends and says that she gets along better with females versus than males.
Patient claims that she handles conflicts well by often talking about things before they can get out of hand,
but that she noticed that she has a much more difficult time handling conflicts when she is mentally ill.

VI. DEVELOPMENTAL HISTORY (include remarkable developmental circumstances, birth, early

childhood, accelerated or delayed developmental milestones, special educational services, etc.):
Patient grew up at home in Joliet with family (until her father passed away of cancer) and
then she moved out at age 25 when she got married. After 11 years, she got divorced and moved back home
with her mother. Patient claims that she was an average student who got mostly B's throughout school.
K.M. has intact thought process, clear thought content and her memory is intact. Patient denies any delayed
developmental milestones or special educational services.
Education
(highest level achieved, schools attended, LD, BD, communication disorders, accelerated programs):
Patient's
highest level of education achieved is a Bachelor's degree. Patient started college at Joliet
Junior College then transferred to the College of St. Francis where she finished up her Journalism

degree.
Job/Vocational (historical and current, including military):
Patient says that throughout college she worked in retail. K.M. says that she now writes freelance articles off and on and recently wrote a paper about her last relapse called the "Glass Wall" that is
being used "in lots of different places". Patient denies a steady, stable job but says her free-lance articles and
her disability serve her needs.

VII. LEGAL/SOCIAL SERVICE INVOLVEMENT (legal problems, probation officers, community service,
social work involvement through the county or legal system):
List legal problems including arrests and DUIs, providers of services and dates.
Patient has no history of any legal issues and has a good legal current status.
VIII. PSYCHIATRIC HISTORY (includes past therapists, psychiatrists, and hospitalizations for psychiatric
problems):
Past hospitalizations including dates and length of treatment:
Patient said that she has been hospitalized in a psychiatric unit prior to this, and it is usually
every 10 years or so usually due to depression and anxiety related to her not having/taking her medications
as ordered. Patient said her first admission was in 1973, then was admitted in the 1980's, 1990's and then
again in either 2003 or 2004. Patient said her average length of stay is about a week.

Past psychiatrists including dates and length of treatment:

K.M. was unsure of the years that each psychiatrist saw her, but said that she has seen Dr. Cynabaldi,
Dr. Miguel, and Dr. Lazano.
Past therapists including dates and length of treatment:
Patient claims that she "never really had any therapists" but reckons it might help her for the future.
Medications past and present:
a) Effexor 50 mg
b) Klonapin 1mg
c) Ativan
d) Norco
IX. ALCOHOL AND DRUG HISTORY
Past treatments/rehab stays including treatment center, dates, and length of time:
Patient does not have a history of alcohol or drug abuse and denies using these ever at all.
Describe patterns of use/abuse and drink/substance(s) of choice:
Patient does not have a history of alcohol or drug abuse and denies using these ever at all.

Does client smoke? ___X___Yes ______No

If yes, level of use and for how long : About 8 cigarettes per day. Patient said she has been a
smoker since the 80's where she used to smoke about a pack a day.
X. MEDICAL HISTORY
Problem/date of diagnosis/current status:
K.M. currently has Heart Disease and was diagnosed in the 90's. Patient also claims
of having severe arthritis, hypothyroidism and claims of having coronary artery bypass surgery in 1990.
Medications past and present:
Patient was unable to tell me what medications she was on for her
medical conditions, except she knew that she was "on some type of blood pressure pill".
Patient also
says she does not have a primary care doctor that she sees routinely for her medical conditions. Patient did
admit to using the pain clinic often.
Last Physical Exam prior to hospitalization:

Date:__Unknown______________ Physician/NP:__Doesn't have one________________

Significant findings: N/A as patient does not remember her last physical exam.

XI. MENTAL STATUS EXAMINATION:

GOOD is not an answer!!!
1.
Appearance (dress, hygiene, facial expressions, grooming, etc.):
Patient is dressed appropriately for the environment and for her age. Hygiene is not offensive
and her facial expressions react appropriately in that she smiles and laughs when appropriate. Patient seems
to have a flat affect when she is not being talked to or engaged in conversation/activity.
2.
Rapport (cooperative, resistant, aggressive, guarded, etc.):
K.M. is cooperative, coherent, and answers all questions appropriately when asked.
3.
Motor Activity (motor retardation, hyperactive, restless, etc.):
K.M. does not appear to have any motor retardation and her gait is smooth, even. No tremors or ticks
or unusual body movements are apparent. Motor activity appears to be within normal limits.
4.
Speech (relevant, coherent, pressured, retarded, etc.):
K.M.'s speech is relevant and coherent. No evidence of pressured or retarded speech patterns. Patient
answers all questions appropriately when asked.
5.
Thought Process (loose associations, tangential thinking, delusions, hallucinations, etc.):
K.M. denies any suicidal or homicidal thoughts and also denies auditory or visual hallucinations.
Patient's judgment appears to be well adapted for her age.

6.
Mood and Affect (labile, flat, angry, dysphoric, etc.):
K.M.'s mood appears calm and has a slightly flat affect when not being engaged in conversation or
activity. K.M. is anxious to be discharged later today and speaks highly of the new nursing home she has
just been accepted into.
7.
Intelligence Estimate (check off) Below Average_____ Average_X____ Above Average
_____

COGNITIVE FUNCTION:
a. Orientation (person, place, time, contact with reality):
Patient is oriented times 3 to person, place, time and has contact with reality.
b. Attention and Concentration (estimate):
K.M. has a strong attention and concentration span and no apparent issues are noted.
c. Recent Memory (current news, what brought you here, etc.):
Patient was about to tell me about the Inauguration of President Obama yesterday and was
also able to successfully tell me what brought her in to the hospital.
d. Remote Memory (birthday, past presidents, etc.):
K.M. has a strong memory in that she was able to successfully and correctly
tell me her birthday and was able to remember the last 3 presidents.
e. Judgment (What if you found stamped addressed envelope, fire in theater, etc.):
K.M's judgment appear to be intact. When asking her what she would do if she found a stamped
addressed envelope, she said she would "pick up the envelope and mail it". When asked what she
would do if there was a fire in the theater she said she would "leave the theater".
f. Abstraction (proverbs, grass is greener, don = t cry over spilled milk, etc.):
K.M.'s abstraction appears to be well developed. She was able to tell me what the proverb grass is
greener meant in that she responded that it means "you think everything's better that you don't have". When
asked what it meant when you said don't cry over spilt milk, the patient responded that it means, "don't
worry about things that have happened and you can't change them".
g. Calculation (count backward by 7's, start with 100):
Patient was unable to count backward by 7's starting with 100. K.M did not even want to try to
calculate the math in her head, saying "I could maybe do it when I am well, but not when I am ill".
h. Vocabulary (estimate):
K.M's vocabulary is in within normal limits for her age. She did not use slang or vulgar language
and used sensible language/speech.
i. Insight
K.M. showed a very strong sense of insight. She was able to be insightful on why
she's here and what she can do in the future.

XII: IDENTIFY PATIENTS STRENGTHS

During the assessment, I asked K.M. what she thought were her strengths. She responded by saying:
"express myself, writing, and putting make up on".

XIII. MULTIAXIAL ASSESSMENT

AXIS I -- Clinical Disorders and V Codes
1._Schizoaffecive_disorder_
_________
Anxiety Disorder______
_____________________
Depression_________________________________________
4.__________________________________

2.___Generalized
3.___Major

AXIS II -- Personality Disorders and Mental Retardation

1.___None_____________________________________________________________________
2._____________________________________________________________________________
3._____________________________________________________________________________

AXIS III -- General Medical Conditions

1.Heart
Disease_______________________________________________________________
2.__Arthritis___________________________________________________________________________
3.___Hypothroidism______________________________________________________________________
____
AXIS IV -- Psychosocial and Environmental Problems (may include problems with primary support group,
social, educational, occupational, housing, economic, legal, etc.)
1.__Lack of support___________________________________________________________________
2.__Housing
problems_________________________________________________________________
3.__Economic
problems________________________________________________________________
4._____________________________________________________________________________
AXIS V -- Global Assessment of Functioning
Present:____55_________________ (as assessed by you, not from the chart)
Highest GAF over the past year) :____71_________________ (from your interview of the patient. This is
typically higher than the current GAF score)
XIV Nursing Diagnosis, outcomes, and interventions
Anxiety r/t change
in health status secondary to schizoaffective disorder, and threat to self-concept AEB diminished
productivity, expressed concerns, fearfulness, irritability, and feelings of uncertainty.

NOC-- Anxiety self-control-client will identify and verbalize symptoms of anxiety prior to
discharge.
--Coping--Client will identify, verbalize and demonstrate techniques to control anxiety prior
to discharge.
NIC-Assess the client's level of anxiety and psychical reactions to anxiety on a regular basis.
Consider using he Hamilton Anxiety Scale.
--If
irrational thoughts or fears are present, offer the client accurate information and
encourage
her to talk about the meaning of the events contributing to the anxiety.
--Encourage the
client to use positive self-talk such as, "Anxiety won't kill me", "I can do
this one step at a
time" and "I don't have to be perfect".
--Use therapeutic touch and healing touch
techniques when appropriate.
Risk for self-directed violence r/t behavioral cues, emotional problems, history of previous depression and
suicidal ideations, lack of social resources, physical health problems, and mental health problems.
NOC--Depression level--Client will disclose and discuss suicidal ideas if present and seek help
whenever having violent/suicidal thoughts.
--Loneliness severity--Client will maintain connectedness in relationships once discharged.
NIC--Assess for suicidal ideation on a regular basis.
--Assess the
client's ability to enter into a no-suicide contract.
--Be alert for warning signs of suicide ideation or
plans and take suicides notes and threats seriously.
--Observe, record and report any changes in mood or behavior that may
signify increasing suicide risk and document results of regular surveillance checks.
--Assign the patient a room located near the nursing station and search the client and client's
personal belonging for weapons or potential weapons and hoarded medications during hospitalization.

XV Research Article
Kantrowtiz, J.T., & Citrome, L. (2011). Schizoaffective disorder: A review of current research themes and
pharmacological management. CNS Drugs, 25(4). 317-331. Retrieved from EBSCOhost.
Schizoaffective disorder is controversial in the psychiatric community. According to the DSM-IV-TR, "the
fundamental feature of schizoaffective disorder is a continuous period of illness during which criteria for a
major mood disorder coincide with the essential features of schizophrenia" (Kantrowitz & Citrome, p. 318).
Although there are many differing opinions on schizoaffective disorder, it appears that there is common
consensus that most psychiatrists remain dependent on phenomenological descriptions for diagnosing
psychiatric disorders.
It isn't uncommon for people to get confused and misunderstand the differences between schizophrenia and
schizoaffective disorder. According to the research article, the first attempt to examine differences between
the two illnesses was conducted in 1981 (p. 322). Since then, there have been many more studies on the two
illnesses comparing them. In a study which compared the two illnesses, it was discovered that "the
diagnosed schizoaffective disorder, depressed type patients performed intermediately [on a comprehensive
cognitive test] compared with patients with unipolar depression or schizophrenia" (Kantrowtiz & Citrome,
p. 322).
Although the diagnosis of schizoaffective disorder is becoming slightly more recognized, the article states
that "despite recent intriguing work in genetics, neurocognition, and electrophysiology, the diagnosis of
schizoaffective disorder remains controversial..most of which stems from the limited specificity of current
diagnostic schemes, which rely on phenomenological anchors" (Kantrowitz & Citrome, p. 327). The article
also suggested a possible change in the diagnostic criteria for the future which will help differentiate the

diagnoses of schizophrenia, schizoaffective disorder and bipolar disorder. This change, if reviewed and
accepted will make it possible that diagnostic criteria will include genetic, imaging and electrophysiological
components. In conclusion, schizoaffective disorder is a relatively new illness which is recognized by the
DSM-IV-TR, but psychiatrists and clinicians still have an occasional difficulty differentiating between
schizoaffective disorder, schizophrenia and bipolar disorder due to their similar diagnostic criteria.

SIGNATURE:____Alyssa Van Vark__________________ DATE :___1-22-13__________________

Usf/conah/dvb/08/08