“What Do
You Do Next? A Clinical Social Work Discussion”
www.mymsw.info
You
receive an email from a client you have not seen in about two weeks. The email
contents are as follows:
“I
wanted to write and explain a very bad day I had today. Today I was followed to
and from my sister’s house by multiple cars. They were all different in color
with tinted windows. I would make turns and take different routes but it seems
like at every intersection one of these cards was cars was there. I finally got
behind one of them on Main street and when he turned in the McDonald's parking
lot I turned in and confronted him about why he was following me. He said he
had no idea what I was talking about and had it not been for there being kids
and I am assuming his wife in the car I would have beat him or died trying.
I
have no idea who these people are or what they want from me. I just can't seem
to be left alone. All I want is to be left alone. No one following me, talking
to me or asking questions of me.
Right
now is my morning. I cannot fall asleep and I cannot remain asleep. I have
nightmares and intrusive thoughts about getting shot down and crashing right
over Baghdad. I am helpless to do anything about it. I cannot shake these
thoughts from my head.
I
fall asleep around 4 AM and sleeping till about 8 AM. I get about four hours of
sleep a night.
The nightmares make me sweat and when I wake up my heart is racing and I can't catch my breath. I take the medicine I'm prescribed but it doesn't help. I don't know if it's because I've developed a tolerance for it or what but, insomnia, depression, OCD, and anxiety rule my life these past few days. I just want all of this to stop and to be a normal human being again.
I wish I could go to sleep and never wake up.
I wish all this turmoil and mass would be done with and I would be at peace.
I'm cursed to live with the guilt of killing people and also the guilt of not being able to kill enough people to prevent so many injuries during the last 13 years. That's my cross to bear and it's heavy… heavier by the day
Against your advice I listed my house for sale in the moving with my sister if and when it sells if I stay here the demons will fill my days and nights and it will be the end of me.
My
sister, niece and brother promised to leave me alone and let me be to myself.
On Sunday evening, I sat in the garage, door closed and ran my truck for about 10 minutes. All I managed to do was to set off my carbon monoxide detector and give myself a headache. I don't want to die, but I'm not scared of it either.
Sorry to ramble on here but it is easier for me to tell you what's going on in my head here than in person.
The nightmares, intrusive thoughts and always being on edge are killing me. To top all of this off I got a letter that Dr. Smith won't be my psychiatrist anymore. I am scared and worried about this. I'm sure the new doctor will be nice but, I had a rapport with Dr. Smith and now I have to start all over. It's a mess…a total mess. Sorry for bugging you with my issues."
On Sunday evening, I sat in the garage, door closed and ran my truck for about 10 minutes. All I managed to do was to set off my carbon monoxide detector and give myself a headache. I don't want to die, but I'm not scared of it either.
Sorry to ramble on here but it is easier for me to tell you what's going on in my head here than in person.
The nightmares, intrusive thoughts and always being on edge are killing me. To top all of this off I got a letter that Dr. Smith won't be my psychiatrist anymore. I am scared and worried about this. I'm sure the new doctor will be nice but, I had a rapport with Dr. Smith and now I have to start all over. It's a mess…a total mess. Sorry for bugging you with my issues."
Upon
a chart review, you find the following
diagnoses:
Bipolar
I Disorder, Most Recent Episode Depressed, Severe, with Psychotic Behavior.
296.54
Post-Traumatic
Stress Disorder 309.81
The following
medications prescribed are:
Remeron
30 MG
Paxil 30 MG
Seroquel 300 MG twice a day
Lisinopril 20 MG
Klonopin 2
MG twice a day
Ambien 10 MG at hour of sleep.
What do you do next?
There is a lot going on. I think I may first try to contact person by phone however I believe that would be unsuccessful. If I can get in touch with the person than I would ask the person to come in for an evaluation. If I could not make contact I may contact the police to do a wellness check. I would be concerned about the person trying to commit suicide even if not intentionally. Allison, MSW
ReplyDeleteI agree so far, but what about the crash over Baghdad and the killing of thirteen people. do you think he is properly diagnosed?
DeleteI agree with Allison in terms of making contact, having a welfare check if necessary, and getting him in for an appointment as soon as possible. He should be evaluated by a psychiatrist - although he states he is med compliant he also states the meds are not working adequately. Without more history it is difficult to determine if the Baghdad nightmares are PTSD (which I suspect is the primary diagnosis, and the bipolar is the result of PTSD gone wild) or if it is psychotic symptoms. We would need to know if he is a Veteran and had actual war experience to distinguish. My experience is that all of the symptoms can be PTSD manifestations. He might also qualify for a diagnosis of OCD based on the obsessive, delusional thoughts about the cars. I don't really see why he has a diagnosis of BIpolar I apart from the fact he can't sleep. I would need to know about his symptom history to judge that one. As far as treatment planning the things I would focus on would be:
ReplyDelete1) Safety management: The attempt to run the car is a suicide attempt and he needs a safety plan, contract, and intensive support through multiple sessions per week and possible CBRS/PSR provider
2) PTSD desensitization through talking about the trauma, stages of grief, if available EMDR, and processing guilt, shame, powerlessness, and contempt associated with the trauma
3) Dealing with the obsessive thoughts, I like using Acceptance and Commitment Therapy. (Actually had a similar obsessive delusional thought pattern involving cars that responded well to this.) Mindfulness and acceptance decreases the fear and stress related to the irrational beliefs, and values driven action empowers the client to act outside the box of the delusion. It has been very successful for me in the past.
4) The sleep issue is a major concern - it could be contributing significantly to all the other symptoms. I am not qualified to deal with meds, but I would question why he isn't on something like Trazadone to deal with nightmares. Side effects of Remeron include behavior changes, anxiety, panic attacks, trouble sleeping, feeling impulsive, irritable, agitated, hostile, aggressive, restless - all of which he is exhibiting. Same with Paxil. These symptoms need to be reported to the prescribing psychiatrist to determine if change of medication is needed. It would be nice if he could have a transition appointment to bridge the change in prescribing psychiatrists since he has a good rapport with his prior doctor. My office has a prescribing physician in house so I would talk over my concerns with the doctor.
5) I have never tried it, but I would think mindfulness and acceptance would also help with the intrusive thoughts - learning ways to remain calm, grounded, and relaxed when intrusive thoughts come. Once that is established I think I would use some MI to address ambivalent feelings regarding what he had to do and how he feels now having done it. It seems like war vets get stuck in the ambivalence of their role as a soldier, and MI would be a way of helping them resolve the inner conflict. It's almost like they have been forced into change due to their orders as soldiers, and after the fact struggle with the ambivalence of change. They cannot undo their actions, but their guilt and flashbacks are a manifestation to warring emotions.
6) If he does move in with the sister it might be a good thing in the long run with the suicidal tendency. I would recommend a couple sessions with the sister to help her understand the client's needs, enlist her support and assistance for the client, and provide psycho-education she may need.
7) I would implement some form of writing exercise - journaling, letter writing, or symptom checklist and monitoring - as part of weekly sessions. CLient reports he finds it easier to tell about his symptoms in writing so I would capitalize on that!
Nicely done. Very Thorough! What about usng Cognitive Processing Therapy?
ReplyDeletehttp://www.ptsd.va.gov/public/treatment/therapy-med/cognitive_processing_therapy.asp
#4: How would you handle it if you did not have a prescribing physician in your office/Practice?
Followed the link and I like the sounds of the CPT approach. I sounds a lot like mindfulness and Acceptance and Commitment Therapy. I have used both when working with PTSD and find them very helpful. With the new DSM symptom of altered sense of responsibility and guilt (very common in my experience) I find it very important to be able to allow yourself to admit your thoughts and feelings, to experience them and step back and examine them, and finally test them for what you want to believe in light of context, other's perspectives, reality of the, etc. Sounds like this approach is very similar. Thanks for the information!!
ReplyDelete#4) Without a prescribing physician in the office the best you can do is a referral to an outside provider. Unfortunately there is little communication between physician and therapist in such cases, which I find frustrating.. Also private practice physicians don't always appreciate outside input from a therapist. I try to build rapport with any psychiatrist/physician I deal with to help communication. Most often the best I can do is to educate the client on types of medication available so that they can ask their doctor - similar to the tv commercials "Talk to your doctor about xyz medication and see if a prescription would be helpful....."