Mental Status Examination

Mental Status Examination In order to thoroughly evaluate, Jason it would be very helpful if a Mental Status Examination is conducted. The MSE would give insight to the examinees thought process, thought content, perception, and cognition. Also, the examiner would be able to document the examinees appearance, mood, and affect. A semi-structural interview style may be the best approach to conduct the MSE. This approach would have standard questions but also give an opportunity for the examiner to build a rapport with the examinee. Therefore, the examiner could create an environment that would promote comfort and ease which should allow the examinee to become less guarded. A review of material that could unveil indicators of potential maladaptive behavior would be useful to enhance the examiners understanding of the examinee. Information such as prior psychological assessments and medical records would be very helpful components in unveiling indicators. This information would uncover any medical or psychological problems previously identified that could have contributed to the examinees behavior. Since it has been revealed that the examinee is taking the medication diazepam, it would be beneficial for the examiner to conduct research on the side effects and its reaction with other drugs. Perhaps, the results from a blood toxicology test would definitively determine all the drugs in Jasons body at the time he was arrested. This drug related information can give valuable indications that could explain the examinees behavior. A review of the examinees family psychological and medical history could give data on hereditary traits that could have added to the examinees behavior. In addition, a review of the examinees criminal record could give a timeline of how Jasons criminal activity progresses or digresses over the years. Thus, a review of the examinees criminal record could give insight to trends in the examinees maladaptive behavior. Other sources of information that could pose as good use are results of an intelligence test such as the WAIS-III and a personality test such as the MMPI-2. The WAIS-III will examine Jasons vocabulary level, abstract thinking, concentration, immediate memory, judgment, alertness to details and a host of other intelligence measures (Kaplan Saccuzzo, 2005). In essence, the WAIS-III will show if Jason is able to act with purpose, to think logically and to deal effectively with his surroundings (Kaplan Saccuzzo, 2005). The MMPI-2, on the other hand, measures Jasons tendency to possess some type of psychopathy. The MMPI-2 is a self- report that examines Jasons level of over concern of bodily symptoms, level of depression, level of over dramatization, level of psychopathic deviates, level of paranoia, level of schizophrenic tendencies, and level of impulse control (Kaplan Saccuzzo, 2005). It should be noted that the MMPI-2 only gives a hypothesis of psychopathy and does not give a diagn osis. An extensive psychological examination would be needed in order to properly diagnosis the hypothesis. Lastly, collateral contacts which is information gathered from individuals closely associated or related to the examinee could give useful information to the examiner. Some of the individuals that could be interviewed are family members, employers, co-workers, friends, and neighbors. By interviewing people in different facets of the subjects life the examiner can get an idea of how the subjects behavior diverges in different environments. In turn this would give the examiner a wholistic view of Jasons psychological state. Provide a possible multi-axial diagnosis (based on all five (5) axes of the DSM-IV-TR) for this individual. In narrative form, describe your differential diagnostic thought process used to reach your hypotheses. What additional information would you need for each of the possible diagnoses in order to confirm your diagnoses and rule out the others? Axis I of the DSM-IV-TR multiaxial assessment lists clinical disorders and other conditions that may be a focus of clinical attention (American Psychiatric Association, 2000). One clinical condition that can be considered is Intermittent Explosive Disorder (Code Number 312.34) (American Psychiatric Association, 2000). This is an Impulse-Control Disorder that is characterized by discrete episodes of failure to resist aggressive impulses resulting in serious assaults or destruction of property (American Psychiatric Association, 2000). The DSM IV-TR states that individuals who suffer from Intermittent Explosive Disorder usually exhibit signs of feeling upset, remorseful, regretful or embarrassed after an aggressive incident (American Psychiatric Association, 2000). It has been reported that Jason has had problems controlling aggressive impulse in the past. The vignette notes that signs of remorse were seen after aggressive incidents in the past such as after Jason threatened his Aunt with a knife it was reported he was remorseful about the incident. Also, after stabbing the victim, Jasons act of covering the body could be interpreted as a sign of remorse. Before Intermittent Explosive Disorder is officially diagnosis other clinical condition should be ruled out. One condition that can be considered is Jason ingestion of several different types of substances in a 24-48 hour time period. The vignette suggests that Jason may have had diazepam, acid, and alcohol in his system at the time of the offense. As suggested previously, a toxicology test will definitively indicate the substances present in Jasons body at the time of his offense. After it has been determined that Jasons behavior was not induced by a reaction to a substance a diagnosis of Intermittent Explosive Disorder can be more confidently suggested. The second axis on the DSM-IV-TR multiaxial assessment lists and describes personality disorders and signs of mental retardation (American Psychiatric Association, 2000). The examiner can explore the possibility of Jason exhibiting signs of Borderline Personality Disorder. The DSM-IV-TR describes Borderline Personality Disorder as a pattern of instability in interpersonal relationships, self-image, and affects and pronounced impulsivity. Jasons parents assert he did not develop stable peer friendships throughout his formative school years. In adulthood, Jason did have a girlfriend and the relationship was described as a stabilizing influence; however the relationship was short-lived. Once Jasons relationship with his girlfriend dissipated he reacted by causing havoc at his grandmothers cottage. It was noted that several cottages were destroyed and vandalized cottages. This outburst of uncontrolled emotion and aggression after a break-up is typical behavior of a person suffering from Borderline Personality Disorder. The DSM-IV-TR states that patients with Borderline Personality Disorder à ¢Ã¢â€š ¬Ã‚ ¦ experience intense abandonment fears and inappropriate anger even when faced with realistic time-limited separation (American Psychiatric Association, 2000). Although the diagnostic criteria for Borderline Personality Disorder gives an onset of early adulthood, Jason may have displayed traits of the disorder in his early teens after the death of his maternal grandfather. It is reported that Jason initiated his use of Marijuana and begin to steal from his parent the same year his grandfather died. This behavior may have been indicative of his inability to handle separation from someone he had idealized which is a characteristic of someone suffering from Borderline Personality Disorder. However, the DSM-IV-TR does specify that young adults with identity problems and that may be involved in substance use could fleetingly display behaviors that might falsely give the impression of Borderline Personality Disorder (American Psychiatric Association, 2000). Therefore, observation and more in depth research on Jason would be needed to definitively diagnosis Borderline Personality Disorder. An analysis of Jasons results from the MMPI-2 could give insight for a more conclusive diagnosis. Another thing to consider in diagnosing Jason with Borderline Personality Disorder is that approximately 75% of individuals diagnosed with the disorder are women. Therefore, Jason being diagnosed with the disorder would place him as a minority and the diagnosis under careful consideration. The third axis on the multiaxial assessment details general medical conditions that could affect ones psychological functionality (American Psychiatric Association, 2000). It has not been reported that Jason suffers from any specific physical condition that could affect his psychological functionality. However, a thorough review of his medical record would be needed to definitively exclude any medical conditional that could have attributed to his behavior. Some of the areas of medical concern would be head injuries and diseases that affect the nervous system. These types of medical conditions are widely known to affect a persons psyche. It is known that some of our emotions are regulated through the frontal lobe of the brain. For example, individuals that have endured an injury to the frontal lobe may have anger management problems or trouble controlling their emotion. The fourth axis focuses on psychosocial and environmental problems such as problems with primary support group, occupational problems, educational problems and economic problems (American Psychiatric Association, 2000). Jason appears to have problems maintaining meaningful relationships. Jasons break-up with his girlfriend could have been a contributing catalyst in his aggressive behavior. This break-up may have disrupted Jasons support system and caused him to have feelings of abandonment. It can be inferred that the abandonment could have caused him to have feelings of instability and lack of control. The examiner would need to discuss Jasons feeling regarding the break-up during assessment sessions in order to confidently report its association with the offense at hand. Another issue that can be explored is Jasons inability to maintain attendance while in formative school which continued into his inability to maintain attendance at a job in adulthood. This inconsistent attendance could be related to Jasons substance use which indirectly affects his ability to productively operate in his social environment. The examiner would need to delve into Jasons substance use and feelings of his self-image to address this issue. The fifth axis quantifies a functionality level the use of the GAF scale ranges from 0-100 with 0 being inadequate information and 100 being superior functioning (American Psychiatric Association, 2000.) Jason shows signs that he could hurt others or herself. He is very coherent of his surroundings. However, Jason has difficulty remembering details regarding the stabbing. The examinee appears to understand place, time and current events. On the other hand, Jason has difficulty being self-sufficient and maintaining a job which is partly due to his substance use. Thus, Jason has a mid-level GAF with a range of 40-60. Legal Theory and Application Using information from the provided vignette, describe the background, current presentation, and behavior of the client from a perspective which takes into consideration theories of offender and/or victim psychology and personality/psychopathology theories to support your position. (Do not simply restate the clients presentation from the vignette. Provide a theoretical-based discussion of the client that will later help guide your suggested treatment approach. For example, if you were going to recommend Gestalt treatment, you would provide a theoretical formulation from a Gestalt perspective in this section). A suitable way to explain the existence of maladaptive behavior such as over exertion of aggression as presented by Jason is through the Diathesis-Stress Model. The word diathesis means, in basic terms, a physical condition that fashions a person more than usually susceptible to certain diseases (Merriam-Websters online dictionary, n.d.). Thus, the Diathesis-Stress Model says that each person inherits certain physical weaknesses to problems that may or may not surface contingent on what stresses occur in his or her life (Eberhart, Auerbach, Bigda-Peyton, Abela, 2011). Thus, the diathesis-stress model would say a person may have a neurotransmitter malfunction but the symptoms of this malfunction will not surface unless some life stressor is presented. A life inflicted stressor could be abuse, neglect or simply disappointment. an informative diathesis-stress analysis when defendants who appear to be functioning fairly well at present are claiming temporary insanity at the time of an alleged offense. Current indications of characterologically limited resources for coping with stress, combined with obviously stressful circumstances or surroundings at the time of an offense, increase the likelihood that a defendant might have experienced a transient episode of cognitive incapacity or behavioral dyscontrol. Conversely, the better the coping resources shown by a defendants current test responses, and the less stress the defendant appeared to be experiencing prior to and during the commission of an alleged offense, the less likely the person would have been at that previous time to suffer a psychological breakdown accompanied by loss of cognitive or volitional capacities. (Goldstein 132) Describe the psycho-legal standards and/or definitions for each of the following: competence to stand trial, risk of dangerousness, and insanity. Identify and describe one or more landmark case(s) for each standard (at least three cases total). Describe the elements or issues that a mental health professional usually focuses on when assessing a persons adjudicative competence, risk and insanity, and any additional items that might be especially important to focus on in the provided vignette. A person is competent to stand trial if there is an understanding of the trial process, the ability to assist counsel for defense, and the ability to make important decisions to waive constitutional rights (Poythress, 2006). The standards of competence were created during the landmark case, Dusky v. United States, 362 U.S. 402 (1960) (Bartol Bartol, 2008). During this case it was concluded that the defendant has to have sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and a rational as well as factual understanding of the proceedings against him in order to stand (Bartol Bartol, 2008). However, since competency can change, if Jason shows signs of incompetency he can be medicated to restore competency even if he does not want to take the medication. This forced medication for competency was established in the court case United States v. Sell (2003),which held that if certain requirements are met, those defendants adjudicated as incompetent to stand trial might be medicated contrary to their will for the solitary resolution of instituting or restoring trial competency (Goldstein, 2006). It should be noted that the case Jackson v. Indiana (1972) established the limitations on the duration of commitments for competency restoration. This court ruling stated that, due process requires that the nature and duration of commitment bear some reasonable relation to the purpose for which the individual is committed. In other words, incompetent defendants cannot be held indefinitely if there is no likelihood that the defendant will be restored and criminal proceedings resumed. T hey can, however, be committed to mental institutions under the civil law (Bartol 161-162). The establishment of criminal responsibility is contingent on the sanity of a person at the time of their alleged offense (Goldstein, 2006). Being sane at the time of an offense can be delineated as being able to recognize the criminality of ones illegal actions and understand the wrongfulness of the behavior (Goldstein, 2006). A Forensic psychologist could examine Jason using psychological instruments that support the right/wrong test for sanity or the Irresistible Impulse test for sanity. The right/wrong test also known as the MNaghten Rule, gives emphasis to the cognitive elements of human beings (Bartol Bartol, 2008). First the person must be aware and know what he or she was doing at the time of the illegal act (Bartol Bartol, 2008). Second the person must know or understand right from wrong in the moral sense (Bartol Bartol, 2008). The right/wrong test has no degrees of incapacity; therefore a person is either right or wrong, with no gray area. On the other hand, the Irresistible Impulse test considers that a person may be aware of the wrongfulness of their conduct, be aware of what is right or wrong in a particular set of circumstances, but still be incapable to do right in the face of overpowering forces from irrepressible impulses ( Bartol Bartol, 2008). In other words, certain circumstances cause the person to uncontrollably commit a crime, almost like a wild beast ( Bartol Bartol, 2008). The court system has established that if a person was not in control of his or her mental processes at the time of the offense, then there are grounds for absolving that person of some or all responsibility for the offense (Bartol Bartol, 2008). However, each jurisdiction differs in the extent they accept both these criteria. (Bartol Bartol, 2008). For example the Official Code of Georgia (O.C.G.A.) 16-3-2 states, A person shall not be found guilty of a crime if, at the time of the act, omission, or negligence constituting the crime, the person did not have mental capacity to distinguish between right and wrong in relation to such act, omission, or negligence. Also, the O.C.G.A. 16-3-3 states, A person shall not be found guilty of a crime when, at the time of the act, omission, or negligence constituting the crime, the person, because of mental disease, injury, or congenital deficiency, acted as he did because of a delusional compulsion as to such act which overmastered his will t o resist committing the crime. These two statutes institute a standard for mitigating circumstances in criminal responsibility and thus ground work for the insanity plea. If it can be established that Jason was in fact suffering from some form of a delusional compulsion then it can be argued that there are mitigating circumstances to his criminal responsibility as established by O.C.G.A. 16-3-3. Bartol and Bartol define risk assessment as the initiative in which clinicians offer probabilities that a given individual will engage in violent or otherwise antisocial behavior based on known factors relating to the individual. (Bartol- criminal behavior ,649). In 1976, the California Supreme Court created what many thought to be the national standard for mental health professionals when a client presents a threat to an identified person. In Tarasoff v. Regents of the University of California (1976), the highest California state court ruled that the psychotherapist of a feasibly violent patient had a duty to protect any person identified as a potential victim ( ). The California Supreme Court ruling brought forth the idea that societys necessity for protection overshadowed a clients right to confidentiality ( ). The Tarasoff case answered the question of what responsibility therapists had to third parties in cautioning them of potential injurious behavior from their clients. However, over the years many states have rejected the ruling in the Tarasoff case. Despite the questionable statutory duty to warn, many practitioners have incorporated the standard set by Tarasoff as a standard of practice. (Bartol- criminal behavior 269) The APA Code of Ethics section 4.05 (2002) gives reference to this idea of a duty to warn by indicating that psychologist may disclose confidential information without the consent of the individual to protect the client/patient, psychologist or others from harm. Research and Evaluation Describe tests or assessment procedures you would employ to address these forensic issues (competence to stand trial, risk of dangerousness, and insanity) (you may refer to these from the Psychological Theory and Assessment Section A. if you already covered them there), and discuss what your anticipated conclusions would be based upon information provided in the vignette. The examiner can use a three prong evaluation to determine if the examinee is competent to stand trial. The first prong evaluates if the person is able to understand the roles of the various officers of the court. The second prong evaluates if the person can understand that he or he is charged with a crime and could possibly go to prison or be put on probation. The last prong evaluates if the defendant can rationally and effectively assist his or her attorney to aid in defense. Numerous assessment instruments have been developed in an attempt to quantify and measure trial competency. One tool that has become popular is the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA) (Steinberg, 2003). This is a forensic assessment instrument created to assess the three abilities thought to be described in the Dusky standard for competency which are understanding, appreciation, and reasoning (Steinberg, 2003). The MaCAT-CA is comprised of 22 items that break down into three subscales to delineate the three abilities before mentioned (Jacobs, Ryba Zapf, 2008). At this time, Jason appears to be competent to stand trial based on the fact he is literate, is able to give written consent for the evaluation, and is able to rationalize that something adversely could happen depending on the courts perception of him. To officially establish competency in Jason the three prong examination as described previously would have to be administered. Risk assessments have two components the raw numbers from an actuarial tool and values (Szmukler, 2003). Numbers refer to the probability that a confrontational occurrence will transpire in a certain period of time (Szmukler, 2003). The methods in calculating these numbers are mathematical and statistical (Szmukler, 2003). Basically numbers are just the results from a risk assessment instrument. A recently developed risk assessment instrument is the Historical/Clinical/Risk Management (HCR-20) scale; developed by Christopher Webster and his colleagues (Webster, Douglas, Eaves, Hart, 1997). The HCR bases its predictive power on three major areas: past or historical factors, clinical or current factors, and risk management factors. The HCR contains 10 historical items, 5 clinical items, and 5 risk management items, for a total of 20 items. The historical items include previous violence, which, as we have learned, is one of the strongest predictors of future violence. Another historica l or H item is young age at first violent incident (Webster et al., 1997, p. 267). In other words, a persons young age at the time of the first violent incident can predict a violent pattern will persist into the future. Early maladjustment at home, at school, or in the community is another predictive H item. Other H items in the HCR-20 are relationship instability, employment problems, substance use problems, and major mental illness (particularly psychotic or mood disorders). Clinical or C items include lack of insight, negative attitudes (antisocial, hostile, angry), and active symptoms of major mental illness (Webster et al., 1997, p. 263). Active symptoms of serious mental illness that include delusional systems characterized by sadistic fantasies and homicidal and suicidal ideation are especially related to violence prediction. Risk management or R variables are related to the future circumstances of the individuals they are evaluating-that is, whether the person being evaluat ed is likely to have adequate housing, meals, daily activities, and finances. Research suggests that individuals without these basics are at higher risk for violence than those who have these needs managed and taken care of. Examples of R items are lack of personal support, noncompliance with remediation attempts, feasibility of future plans, and stress. The researchers of the HCR-20 find that the historical (H) items are the strongest for predicting future violent behavior (Webster et al., 1997), and C items are second strongest (Borum, 1996). The HCR-20 is still relatively new and will need ongoing research before it receives widespread acceptance as a valid risk-assessment instrument. (Bartol criminal behavior 275) Values represent the methods of connecting a value to the risk and deciding what should be done about the potential risk (Szmukler, 2003). Thus, values can be seen as the rate at which violent acts occur in the population of interest. This value is significant to the predictive abilities of any risk assessment instrument. This value is sometimes known as the base rate. Using only the information from a risk assessment tool without considering the environmental factors or population can make an assessment skewed. The base rate takes into consideration the population of which the assessed individual is apart. If the rate of violence in the population is low it should naturally lower the possibility of at risk behavior. A simple explanation for this logic is that the individuals of this low violent rate population may not have ideologies that comprise of violent behavior. This lack of cognitive thoughts of violence and lack of examples of violent acts lower the individuals potential to act violently. Therefore, it is possible that a risk assessment tool that is standardized based on a larger more diverse population can render results that show high risks for violence for an individual in a smaller less diverse population. An overall view of both the raw numbers from the assessment and a consideration of the populations base rate would give a better result in calculating risk assessments. Thus, the risk assessment tool gives a hypothesis or educated prediction for a potential risk and should be completed. The base rate gives direction and depth to the hypothesis. Thus, both components are needed and valuable to the assessment. Develop one empirically supported therapeutic treatment plan for the client in the vignette. Please make sure you identify the name of the theory your treatment plan is based on and summarize the empirical evidence with appropriate citations to support your treatment choice in working with this client. Be sure to discuss the effectiveness and limitations in working with this particular client (including effectiveness/limitations in working with this particular clients background using the above theories and treatment plans) A treatment plan following a Cognitive behavioral therapy model could be used to help Jason with his cycles of aggressive behavior. Cognitive behavioral therapy (CBT) is a therapeutic modality that combines various aspects of several different therapeutic approaches including behavioral, cognitive, rational, emotive, and others. The hallmark of CBT is the assumption that distress is a result of improper or faulty cognitive framing that provides the foundation for self-defeating thoughts that lead to maladaptive behaviors. Over the last couple of decades CBT has been the focus of extensive research aimed at validating its theoretical foundation and therapeutic techniques. Much of the research reports favorable outcomes within a variety of settings as CBT is often considered among the most diverse therapeutic modalities available to practitioners. (Hanser 116) Most research concludes that it has been reasonably successful or shows considerable promise in reducing recidivism in violent offenders and serious repetitive offenders (Gacono et al., 2001). However, one of the major shortcomings of the current research is the overreliance on self-report measures to determine treatment gain (Serin Preston, 2001). Although self-report information is important because it may reflect an offenders self-perception, it is also fraught with many serious problems, especially when administered under duress within a correctional environment. (Bartol 623). Cognitive behavior therapies (CBT) rely on changing individual behavioral patterns by changing the persons thoughts, beliefs, and attitudes. CBT emerged during the past 30 years as a result of dissatisfaction with the theoretical and empirical bases of strictly behavior therapy approach. CBT has become the preferred treatment approach for dealing with certain groups of offenders, including sex offenders, v iolent offenders, and a variety of persistent property offenders. Bonta and Cormier (1999) rightfully note that, The research on the cognitive-behavioural treatment of offenders has led to wide acceptance of this approach as the preferred method for treating offenders. (Bartol 621-622) Interpersonal Effectiveness What factors or cultural considerations would you take into account in rendering diagnoses, case conceptualization, and treatment planning? What other cultural factors may be salient for this client? In a psychological examination for diagnosis and treat culture can have an impact on the exhibition of psychological disorders and the examiners interpretation of the behavior being exhibited. Also, information being gathered from an assessment for diagnoses can be misconstrued if the examiner does not have a good understanding of the cultural social practices of the person being examined. The examiner should obtain as much cultural information on the client as possible before a diagnosis or treatment plan is created. The cultural Also, if the clients cultural background is tremendously outside the realm of the examiners understanding it may be wise to consult with an expert to help reduce the cultural impediment. Some of the issues that affect diagnosis in regards to culture differences are the clinician attitudes, beliefs, and biases. No one is exempt from having bias beliefs, thus an examiner should fully inspect his or her biases before being involved in a psychological assessment. The bias could skew the examiners report and make the assessment invalid. For example if a clinician is diagnosing an individual from a different cultural background and does not have an clear understanding of the customs of that culture then the clinician may interpret some behavior as being adverse. However, the person may just be following the customs of their culture. Thus, multicultural competence is of major importance in case conceptualization. Another cultural impact on diagnosing and creating treatment plans is language barriers. Since language is the primary source of communication the examiner and the client must be able to properly communicate in order to obtain information for the assessment. Language barriers are not just limited to different languages sometimes the examiner and examinee may have different understandings of words or phrases. Of greatest concern to assessment is the notion of conceptual equivalence or whether the underlying construct (construct definition: an image, idea, or theory, especially a complex one formed from a number of simpler elements. ) holds the same meaning across groups. A common example of difficulty is when one group defines (i.e.specific behaviors as mental illness or psychopathology while another group views the same behaviors as normative) and not associated with a cluster of diagnostic symptoms. The APA(American Psychological Association) created a set of guidelines known as the Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists to move towards more multicultural competence individuals. These guidelines aid in recognizing b