| Mental State Examination |
| General appearance and behaviour |
| Alan is a 17 year-old Irish male of average weight and height. At the time of examination, he was well groomed and dressed. He appeared to be in good physical health. He exhibited no abnormal behaviours or movements. Alan was cooperative throughout the interview. He maintained good eye contact, except when recounting his referral from the Juvenile Liaison Officer and the possibility of charges against him. |
| Speech Alan articulated himself clearly. He answered questions spontaneously, though at a slow rate. He spoke softly throughout the conversation, particularly when mentioning past unhappiness. |
| Affect and mood Alan’s affect was appropriate to situation and consistent with his reported mood. At times he appeared irritable. |
| Thought a. Stream Alan’s thought stream was steady. |
| b. Form Alan did not exhibit any signs of a formal or negative thought disorders. He was able to answer questions spontaneously and directly. |
| c. Content Alan’s conversation was dominated by his anger and distress over the possibility of going to prison for possession of drugs. There was no evidence of delusional thinking or preoccupation beyond what is normal for a person experiencing this possibility of incarceration. |
| d. Perception Alan exhibited normal perception. Symptoms such as illusions, misinterpretations, depersonalisation, were not noted. |
| Cognition Alan was alert and orientated to time and place. He was able to answer questions and recall his past without difficulties. |
| Insight and judgment When questioned about his condition, Alan accepted the fact that his addiction was causing him some problems. He was insistent that he wanted to reduce his substance use rather than abstain. Alan’s insight and judgement were intact. He was able to make the link between his increased cannabis use and the problems in his relationships at home. |
| Action The mental state exam suggested no gross cognitive impairment or perceptual deficits. Based upon the assessment and mental state examination Alan was deemed to be a suitable candidate for CBT. |