IDENTIFYING DATA OF THE PATIENT:
37 year old African American male,
single, never married, 12th grade education , unemployed.
With a primary complaint of "Not
being able to sleep at night, hearing voices and seeing things, depressed and nightmares and flash backs"
He reports feeling anxious and
depressed with worsening symptoms for last year. He reports two prior hospitalizations during
the last year for his depression. He
reports being depressed more now with decreased sleep, decreased energy, decreased
concentration and loss of appetite. He
admitted to feeling hopeless and worthless. He admitted to hearing voices again
about 1 week ago telling him to "go ahead and end it all because it was
not worth it.” He admitted to seeing
little images walking across the room for the last week. Stated the suicidal thoughts comes and go but
he has no plans to harm self. He denies any suicidal ideation now. He denies
any homicidal thoughts now. He
reportedly had some homicidal thoughts.
He stated that he thought about killing some people about 2 or 3 days
ago who were driving in the middle of the road. He reported having some
homicidal threats towards an old supervisor but did not act on them. He denies
any homicidal thoughts towards any one now. Reports he has nightmares and flash
backs every night and sleeps only 2 to 3 hours per night. Urine drug screen
positive for Marijuana metabolites. He is drug seeking for Ativan.
He reports his mother and brother both had problems with mental illness
with his mother hospitalized for her condition.
He reports his brother committed suicide via gun-shot wound (GSW) when
his brother was 52.MENTAL STATUS EXAM: Appears to be of stated age, dressed neat, clean and appropriately dressed with no psychomotor agitation or retardation. Speech was of normal tone, rate and volume. Presented with a depressed and anxious mood and a bright and cheerful affect.
His thought process appears goal
directed with no looseness of association or flight of ideation.
His judgment and insight appear fair. He was Oriented x3 with intact remote and
recent memory. He was able to abstract
on parables and similarities and could name the last three presidents.
DIAGNOSIS
Mood and psychosis secondary to
substance abusePTSD
Hypertension
Problems dealing with substance abuse
Problems dealing with war issues
Victim of war
Unemployed
I find myself asking a lot of questions about this client's information provided. There seems to be information thaat makes me want to continue initial assessment.
ReplyDelete1) Diagnosis: If mood and psychosis are secondary to substance abuse, I would need to know more about his substance use history. The only information about substances are that he tests positive for THC and is seeking Ativan. This information would not typically lead to psychosis or homicidal ideation. Are there other substance involved? How much and how long has he been using? What role does the lack of sleep play in the hallucinations and is his drug use affecting his sleep? Typically THC leads to a more relaxed, stupor like effect. If the diagnosis is correct a thorough SUD eval is needed. I suspect that he would need in-patient SUD treatment based on the diagnosis.
2) PTSD and victim of war: The way it is worded it does not sound like he was military. Is this a refugee from a war zone? At what age did he experience being a victim? What was his experience in the war zone - was he assaulted, raped, tortured? Did he witness atrocities? I would use the CPT or ACT approach to dealing with the PTSD symptoms. He is likely self-medicating so SUD treatment generally comes first. If therapy is congruent with SUD treatment it will be important to monitor any impact of talking about the trauma on his SUD recovery. The best way to deal with nightmares and flashbacks is to be able to talk about his experiences, but that will need to be balanced with his other symptoms so as not to aggravate the hallucinations or sleep loss. Again, getting and keeping him sober takes precedence. Has he had a medication evaluation? Perhaps after he is off the substances medication would be recommended to treat the PTSD symptoms.
3) I would put him in a high risk category for suicide even though he currently denies a plan. Denial of a plan may or may not be the truth. With his history of suicidal thoughts, homicidal thought, being a victim of war, and his brother's suicide he has a lot of markers for high risk. I would develop a safety plan and encourage him to talk about his thoughts and history related to suicide. Were there prior suicide attempts? Careful monitoring would be appropriate while going through detox and recovery.
4) Are there cultural issues? If he is from a war zone outside the US, and if so where is he from, what has he experienced, and what is his cultural view of mental health, substance use, hallucinations, etc.Are his symptoms consistent with a mental disorder common to his culture? I would explore that to find out more
5) His presentation is inconsistent: Bright and cheerful while depressed and anxious. Using Solution Focus I would explore how he is able to be bright and cheerful, what would it take for him to feel bright and cheerful on the inside? If a miracle occurred what would change or what would be different?
6) With hypertension he would need medical evaluation before starting SUD treatment. Would withdrawal present a problem with the hypertension? Is there another medical condition contributing to the lack of sleep and hallucinations? Is he on a medication contributing to symptoms? I would refer for a physical if he hasn't had one recently.
I'm enjoying these blogs. I'm shocked others are not responding. Please keep them up and allow time for them to catch on. I'm learning a lot!!.
Working with combat Veterans who suffer with PTSD I find that substance abuse issues are common. People tend to self-medicate when they are lost. With this client I would begin with a full assessment and rapport building. Male combat Veterans are often left feeling vulnerable and weak due to the stigma attached to therapy. This process is a slow one because it appears he has been avoiding his war traumas. I would eventually talk to him about completing cognitive processing therapy which is very helpful for those who suffer from PTSD. It would help him connect his thoughts and feelings to his maladaptive perceptions.
ReplyDeleteValarie Lopardo, LCSW
Also I forgot to mention; you are absolutely right about medical evals first. We have to make sure there are not medical issues however hypertension often is experienced by those who suffer with PTSD due to their constant high levels of anxiety.
ReplyDelete