MENTAL STATUS EXAM AND SYMPTOM CHECKLIST

Obsessive Compulsive and Related Disorders

Part 1. Client’s Profile

Instruction: Please fill up the information needed and mark on the boxes
applicable based on your observations about the client.
Age: specific age wasn’t specified
Name: Hugh Turner but he is on early 50’s Gender: Male
Birthdate: Not stated, for further
investigation Race: German Ethnicity: British English
Address: England Contact Number: Not stated, for further investigation.
Presenting Problem (include predisposing, precipitating, perpetuating, and protective factors):

Predisposing Factors- Hugh was clinically diagnosed with depression, this happened when he was in the military. An
electroconvulsive session was initiated with Hue and there he might developed the predisposing biological
factor. This has no psychological predisposing factor narrated about the client or to his family. Hugh
wasn’t expressive about his past diagnosis with depression.

Precipitating Factors- The client was clinically diagnosed with depression during his younger years. It was also narrated that he
was consistently continuing to drink alcoholic liquor. Hugh has a cognitive distortion, a belief that if he will
not keep the world under his control, there might harm that will come to him and his family (narration:” If I
don't do these rituals, I find great harm to one of my children, either my grandchild's going to be kidnapped,
my wife is on a bike the tankard or a wagon come inside of her bus a lot or knocked over by. Michael might
get stabbed; Mark, my fear he may go in the ring and they meet Maureen Bassett we're going to be the one I'll
keep on shooting may the temple and his head or something like that” delusion of persecutory. He also believes
that he has two identities: Hugh Turner and the little person.

Perpetuating Factors- The client has a recurring theme of death that might come to him and his family. Isolation is also a
perpetuating factor of the client.

Protective Factors- A good Biological protective factor of the client is that his family has no psychiatry history. The client also has
a good support system from his family.

A. Educational History: (Please check all that apply and to which level it occurred)
Name of Learning Behavioral Expelled/
Level Repeater
School Problem Problem Suspended
Not stated and need for
further investigation
Nursery during the follow-up.
Not stated and need for
further investigation
Elementary during the follow-up.
Not stated and need for
High School further investigation
Year: _________ during the follow-up.
Not stated and need for
College further investigation
Year: _________ during the follow-up.
Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
 Not stated and need for
further investigation
Graduate during the follow-up.
Not stated and need for
further investigation
Postgraduate during the follow-up.
Remarks/observations:

In this portion of the assessment, client lacks for information and this is subject for follow-up to support the continuation of
background check gathering of data.

B. Employment History
Employed Yes No
If yes: Seasonal Full-time Part-time
Self-employed Yes No
Remarks/observations:

The client’s dysfunction hinders him from working. He only isolates himself at home and do his routine just to secure that he feels
the safety of him and his family.

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
C. Medical History (Check all that apply and describe below)
Head Injury/Stroke Chronic Pain
Loss of Consciousness Enuresis/Encopresis
Kidney Disease Allergies
Heart/Vascular Problems Adverse reaction to medicines
Hypertension Parasites/Scabies/Lice
Liver Disease Pregnancy
Thyroid Problems STD
Cancer Respiratory Problems
Diabetes Seizures
Sleep Disturbances Others (specify):
_______________________
Appetite Changes

Weight Changes

Remarks/observations:

Client has poor detail on his medical history. This lack of information is subject for further investigation during the follow-up session.
His sleep disturbances were observed since he narrated that as the family were asleep, he continues to do his intensive obsession
overnight.

D. Substance Use History

Amount of Frequency Length of Age of
Type Last Use
Last Use of Use Time Using First Use
Not stated and
need for further
investigation
Just like drinking during the
Whiskey Last night A glass Once a day a water. follow-up

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
Treatment/Recovery History:

The client experienced to undergo to electroconvulsive session, it didn’t end well, rather it might be one of the predisposing factors
of the development of his disorder.

Remarks/observations:

Substance use history and Treatment/Recovery history wasn’t narrated by details but it suffices the assessment as to the data needed
to conclude the factors is strong and is subject for consideration.

E. Family History
Mother's Name: Not stated and need for No. of Siblings: Not stated and need
Father's Name: Not stated and need for further investigation during the follow- for further investigation during the
further investigation during the follow-up up follow-up
Birth order: Not stated and need for
Age: Not stated and need for further Age: Not stated and need for further further investigation during the
investigation during the follow-up investigation during the follow-up follow-up
Occupation: Not stated and need for
further investigation during the follow-up Occupation: Not stated and need for further investigation during the follow-up

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
F. Family Medical History
Chronic Medical Neurological Seizure Thyroid Mental
Relationship
Problem/s Disorder/s Disorder/s Disorder/s Disorder/s
Not stated
and need for Not stated and Not stated and Not stated and
further need for further need for further need for further Not stated and need
investigatio investigation investigation investigation for further
n during the during the during the during the investigation during
Mother follow-up follow-up follow-up follow-up the follow-up
Not stated Not stated
and need for and need for Not stated and Not stated and
further further need for further need for further Not stated and need
investigatio investigation investigation investigation for further
n during the during the during the during the investigation during
Father follow-up follow-up follow-up follow-up the follow-up
Not stated Not stated
and need for and need for Not stated and Not stated and
further further need for further need for further Not stated and need
investigatio investigation investigation investigation for further
n during the during the during the during the investigation during
Siblings follow-up follow-up follow-up follow-up the follow-up
Not stated Not stated
and need for and need for Not stated and Not stated and
further further need for further need for further Not stated and need
investigatio investigation investigation investigation for further
n during the during the during the during the investigation during
Other Relatives follow-up follow-up follow-up follow-up the follow-up
Remarks/observations:

Family Medical history wasn’t narrated by detail. This lack of information is subject for further assessment during the follow-up
session.

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
G. Psychological History
Mental Condition
Condition Onset Duration
Mania
The client was clinically diagnosed The duration wasn’t descriptively narrated
Depression with depression 40 years ago and is subject for further investigation.
The duration wasn’t descriptively narrated
Anxiety 40 years ago. and is subject for further investigation.
Mood Swings
Substance Use 40 years ago. Every night
Others (specify):
Delusion 40 years ago. Every day for 40 years
Interpersonal
Area Brief Description of Impairment
His isolation to the community and choice to stay home and exercise his obsession;
he counts until 12 to make him feel relief, measure the objects and corners of their
Daily Activities house to secure that everything is organized and he do these everyday that lasts for
hours.

The client was reported to have no social life.

Social Relationships

Living Arrangement The client isolate himself inside his house. His routine rotates inside it.

Risk Factors (Check all that apply):

If yes, please explain:
Suicide/Self-Harm
Trauma
Neglect/Abuse
Domestic Violence
Legal Abuse
Gang Involvement
Runaway
Inappropriate/Risky Behaviors
The client was still on his alcoholic routine. He drunk a glass of whiskey every
Substance Use/Abuse night just like drinking a glass of water.
His choice of not going out his house and stay on his routine which are keeping
order of everything thinking that it would sav his family, rather this cultural
isolation puts his family wanting them to distant from him for a while just to breath
Cultural Isolation and have some peace space to roam around.
Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
 Potential for Victimization
Risk of Homelessness

Remarks/observations:

The client has been manifesting minimal risk factors for the reason that his compulsions are driven for him and his family’s safety.
Also, his actions and behavior has no observance of harm for him and his family since all these are maintaining order inside the
house.

Part 2. Mental Status Exam

Physical Aspect
Clean Well-groomed Disheveled
Appearance
Bizarre Malodorous

Normal Decreased Agitated

Motor
Tremors Tics Repetitive

Normal Slurred Loud

Speech
Pressured Slow Mute

Eye Contact Average Avoidant Intense

Intermittent
Posture Normal Atypical Slumped
Rigid Tensed
Emotional Aspect
Appropriate Labile Restricted

Affect Blunted Flat Congruent

Incongruent

Normal Depressed Anxious

Mood
Euphoric Irritable Congruent
Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
 Incongruent

Cooperative Evasive Uncooperative

Behavior Threatening Agitated Combative

Guarded

Cognitive Aspect
Consciousness Alert Lethargic Stuporous

Orientation Person situation Place Time and day

Current

Coherent Tangential Circumstantial

Thought Process
Loose Paranoid Concrete

Persecutory Grandiose Referential

Delusions
Somatic Religious

Auditory Visual Olfactory

Hallucinations
Gustatory Tactile

Intellect Average Above average Below average

Good Poor Recent
Memory
Remote Confabulation

Good Fair Poor

Insight
Limited

Good Fair Poor

Judgment
Unrealistic Unmotivated Uncertain

For self

None Ideation Plan

Intent Attempt
Risk Assessment
For others

None Ideation Plan

Intent Attempt

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
Remarks/observations:

Client has manifested symptoms of severe anxiety on controlling and keeping things under his control jus to feel the safety of him
and his family. These compulsion for routines, isolation to the community, and intense fear led his dysfunction, deviances, and
distresses that affect his health and the peace of his family.

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
 Part 3. OCD (Obsession) Checklist
Instructions: Check all that apply. Distinguish between current and past symptoms. Tick "N/O" if the symptom is not observed.
Current Past N/O Aggressive Obsessions
Fear might harm self
Fear might harm others
Violent or horrific images
Fear of blurting out obscenities or insults
Fear of doing something else embarrassing*
Fear will act on unwanted impulses (e.g., to stab friend)
Fear will steal things
Fear will harm others because not careful enough (e.g. hit/run motor vehicle accident)
Fear will be responsible for something else terrible happening (e.g., fire, burglary
Current Past N/O Contamination Obsessions
Concerns or disgust with bodily waste or secretions (e.g., urine, feces, saliva Concern with dirt or
germs
Excessive concern with environmental contaminants (e.g. asbestos, radiation toxic waste)
Excessive concern with household items (e.g., cleansers solvents)
Excessive concern with animals (e.g., insects)
Bothered by sticky substances or residues
Concerned will get ill because of contaminant
Concerned will get others ill by spreading contaminant (Aggressive)
No concern with consequences of contamination other than how it might feel
Current Past N/O Hoarding/Saving Obsessions
(indicate)
Current Past N/O Religious Obsessions (Scrupulosity)
Concerned with sacrilege and blasphemy
Excess concern with right/wrong, morality
Other:
Current Past N/O Obsessions with Need for Symmetry and Exactness
Accompanied by magical thinking (e.g., concerned that another will have accident unless
things are in the right place)
Not accompanied by magical thinking
Current Past N/O Miscellaneous Obsessions
Need to know or remember
Fear of saying certain things

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
 Fear of not saying just the right thing
Fear of losing things
Intrusive (nonviolent) images
Intrusive nonsense sounds, words, or music
Bothered by certain sounds/noises*
Lucky/unlucky numbers
Colors with special significance
3 superstitious fears
Other:
Current Past N/O Somatic Obsessions
Concern with illness or disease*
Excessive concern with body part or aspect of
Appearance (eg., dysmorphophobia) *
Other:

Part 4. OCD (Compulsions) Checklist

Instructions: Check all that apply. Distinguish between current and past symptoms. Tick "N/O" if the symptom is not observed.
Current Past N/O Checking Compulsions
Checking locks, stove, appliances etc.
Checking that did rot/will not harm others
Checking that did not/will not harm self
Checking that nothing terrible did/will happen
Checking that one did not make a mistake
Checking tied to somatic obsessions
Other:
Current Past N/O Repeating Rituals
Rereading or rewriting
Need to repeat routine activities jog, in/out door, up/down from chair)
Other:
Current Past N/O Counting Compulsions
Counting number 12
Current Past N/O Ordering/Arranging Compulsions
Knives in the driver, stuff displays in the sala, grocery items.
Current Past N/O Hoarding/Collecting Compulsions

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
 Indicate
Current Past N/O Miscellaneous Compulsions
Mental rituals (other than checking/counting)
Excessive list making
Need to tell, ask, or confess
Need to touch, tap, or rub*
Rituals involving blinking or staring*
Measures (not checking) to prevent: harm to self-harm to others terrible consequences
Ritualized eating behaviors*
Superstitious behaviors
Trichotillomania*
Other self-damaging or self-mutilating behaviors*
Other:

Findings and Recommendations

Differential Diagnosis:

Anxiety Disorder
Recurrent thoughts, avoidant behaviors, and repetitive requests for reassurance can also occur in anxiety disorders. However, the
recurrent thoughts that are present in generalized anxiety disorder (i.e., worries) are usually about real-life concerns, whereas the
obsessions of OCD usually do not involve real-life concerns and can include content that is odd, irrational, or of a seemingly magical
nature; moreover, compulsions are usually present and usually linked to the obsessions. Like individuals with OCD, individuals with
specific phobia can have a fear reaction to specific objects or situations; however, in specific phobia the feared object is usually much
more circumscribed, and rituals are not present. In social anxiety disorder, the feared objects or situations are limited to social
interactions or performance situations, and avoidance or reassurance seeking is focused on reducing feelings of embarrassment.

Major Depressive Disorder

OCD needs to be distinguished from the rumination of major depressive disorder, in which thoughts are usually mood-congruent and
not necessarily experienced as intrusive or distressing; moreover, ruminations are not linked to compulsions, as is typical in OCD.

Psychotic Disorder
Some individuals with OCD have poor insight or even delusional OCD beliefs. However, they have obsessions and compulsions
(distinguishing their condition from delusional disorder) and do not have other features of schizophrenia or schizoaffective disorder
(e.g., hallucinations or disorganized speech). For individuals whose OCD symptoms warrant the “with absent insight/delusional beliefs”
specifier, these symptoms should not be diagnosed as a psychotic disorder.

Recommendations:

The client has manifested a clear symptoms and behavior of a person with obsessive-compulsive disorder.
Treatment
Treatment for obsessive-compulsive disorder might not produce a recovery. However, it can assist in managing symptoms so that they
don't interfere with your day-to-day activities. The severity of your OCD may determine whether you require more rigorous, long-term,
or continuous treatment.

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”
OCD is primarily treated with medication and psychotherapy. Talk therapy is another name for psychotherapy. Combining the two
therapies often yields the best results.

Psychoanalysis
Many OCD sufferers find that cognitive behavioral treatment (CBT), a kind of psychotherapy, is helpful. As part of CBT therapy,
exposure and response prevention (ERP) entails gradually exposing you to an object of fear or preoccupation, like dirt. Then you
discover how to break free from your obsessive routines. ERP requires work and repetition, but if you can control your obsessions and
compulsions, you might live a happier, more fulfilling life.

A few mental health medications may be able to manage OCD obsessions and compulsions. Antidepressants are usually used initially.
The Food and Drug Administration (FDA) has approved the following antidepressants for the treatment of OCD:

• Fluoxetine (Prozac) for children and adults seven years of age and up.
• Adults and children 8 years of age and older should take fluvoxamine (Luvox).
• Adult-only use of paroxetine (Paxil).
• For adults and kids six years of age and up, sertraline (Zoloft).
• Adults and children ten years of age and up should take clomipramine (Anafranil).

GIDEON DONAIRE-BAYONA
Psychologist In-Training

December 15, 2023

Date

Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.”