Possession
A BBC Sherlock Extreme AU Story
By
Nana
Chapter 3
Author's Notes: The mental state examination (MSE) is an integral part of a psychiatric evaluation. This fic has not been Brit-picked, and I am not really familiar with the way a Psych evaluation is carried out in the UK. This format is based on the American version, and all mistakes are mine. There is a whole lot more to it, but I just pared the exam down to the most essential parts. Sorry if it becomes too technical at times. A glossary of psychiatric terms can be found at the end of the story.
FRCP stands for Fellow of the Royal College of Psychiatrists.
Technical note: I cannot seem to be able to put a horizontal line (or strikethrough) through certain passages which were meant to be crossed out by JW in his notes. Thus, entries which were supposed to be struck out were "deleted".
From the notes of John H. Watson, MD, FRCP
Mental State Examination of Sherlock Holmes, PhD (a draft including deleted passages):
The patient is a 35 year old male, 6 feet tall, weighing around 200 pounds. Appearance: well-groomed, clean shaven; (deleted-the only feature that may be considered unkempt: the riot of dark hair which appears to be more out of aesthetic considerations rather than neglect or anything suggestive of an underlying problem). He looks healthy and alert, although there is evidence of physical exhaustion. (deleted- Appears younger than his actual chronological age) The patient's physique is slim but there is no indication of any significant weight problem. The skin is very pale but otherwise has good tone. No skin lesions or dental erosions noted. Good personal hygiene: nails kept clean and short, no nicotine stains on fingers, no body odor.
The patient's choice of clothing is appropriate for gender and age. The patient apparently has given careful thought to his manner of dressing: his coat is obviously expensive and the well-tailored suit, black shirt, dark trousers and well-cut shoes speak of his consideration of conventions; (deleted- choice of clothes leaning toward understated elegance, not overly fashion-conscious). Apart from a wristwatch, the patient did not wear jewelry. No skin piercings, scars or tattoos on the face and neck area noted although the patient has yet to undergo a complete physical examination.
The patient exhibited good rapport and was cooperative during the initial interview. There was good eye contact and abnormal eye movements were not detected. The patient's gait and body movements were normal, (deleted- even graceful). Mood: neutral to euthymic. Affect was appropriate, congruent to thought content. He directly approached the problem and exhibited appropriate reaction to certain passages of the interview. The patient did not appear overly anxious. He appears to have good insight: called his "blood hunger" a delusion from the very start. Hesitation was noted on certain parts of questioning, especially when asked about drinking habits. Judgment appears sound.
The patient's speech was spontaneous and articulate. The patient's voice was (deleted- beautiful) pleasant and well-modulated; pacing was normal although a tendency to quickly ramble was noted upon being asked to describe his relations with co-workers. Thought process likewise was orderly and logical, although there is a tendency toward flight of ideas, given the apparent speed of the patient's thinking.
The patient's thought content was problematic mainly on the one delusion of vampirism, bordering on obsession; the delusion appears to be mood-congruent. He denied experiencing hallucinations. There was no apparent suicidal or homicidal ideation (the patient spoke of drinking other people's blood, but not killing them), though impulse control is undetermined and it may be necessary to investigate the patient's thoughts on harming people by drinking their blood in future sessions.
Personal notes (not to be included in patient's file):
SH described chief complaint in more detail and gave personal background information on first interview. Info content generally solid and appropriate. No previous history of mental illness or psychotherapy. Physical health good; finances, housing and attitude toward work all satisfactory. SH is single, never married, no children or family, no religion. Social life strictly work-related, does not appear to desire much social interaction with peers (potential problem? Uncertain at this point if behavior has antisocial or just asocial leanings). Likes to play the violin when he has time. He is clearly very intelligent, and is aware of it. Does not seem to have a problem speaking his mind, has a tendency toward sarcasm. May be a problem for people in contact with him, may need to be explored further.
Also too early to tell at this point, but SH's gaze is not exactly normal. Too intense, watchful (perhaps just wariness on first interview?), seemingly with underlying layers of meaning and emotions not shown up front (clearly a subjective observation and cannot be written down in formal report without factual evidence, but cannot help but feel there is hint of derisive amusement below those colorless depths).
Also uncertain at this point, but a general feeling persists that he is not telling the whole truth regarding his condition/situation. Not exactly lying, but more of deliberate omission of information, which probably will be cleared up in future sessions. Clearly, evaluation for sociopathy may have to be undertaken.
Alarming thought: could he be fabricating his delusion as cover-up of an actual rape attempt in Manchester, with its attendant criminal consequences? Unlikely, as his description of his vampire delusion is probably the most real aspect of entire interview.
But then, Manchester incident and details from interview do suggest sexual repression of some sort but again too soon to formulate judgment, given paucity of actual data. Note to self: must ask Mike sometime regarding what happened to the lady at the center of incident. Based on details gleaned from Mike during lunch: patient just disappeared. No clue as to where SH had gone until he contacted Mike again some weeks later. Mike may not really know underlying details of disappearance. Must ask carefully so as not to give away privileged info.
Overall assessment: SH, despite clearly having some personality issues, appears self-possessed, is extremely intelligent, has good insight and a strong personal drive which (hopefully) will help him overcome his problem soon enough to earn his reinstatement in Mike Stamford's research team.
Note to self: Personal feelings regarding the patient? Irrelevant to the case, but may become a problem if not handled immediately: Why this instant fascination with him?
Glossary of terms: (source: Wikipedia, which also carries an explanation for the performance of the various aspects of the MSE)
Affect –is described by labeling the apparent emotion conveyed by the person's nonverbal behavior, facial expressions, and mannerisms (anxious, sad etc.). Affect may be described as appropriate or inappropriate to the current situation, and as congruent (in agreement) or incongruent with the patient's thought content.
Delusion - defined as "a false, unshakeable idea or belief which is out of keeping with the patient's educational, cultural and social background and held with extraordinary conviction and subjective certainty".
Euthymic - normal non-depressed, reasonably positive mood.
Flight of ideas - A form of talking where a person continues to switch from subject to subject while talking, making it difficult for others to follow the train of thought.