Assignment Practicum-Assessing Clients
Demographic information
- M. is a 28-year-old Caucasian male from Detroit. He is a high school dropout and an Employee as Starbucks and was recently separated from his wife, Mary, with who he has lived for the past three years. They have a daughter aged two years. Currently, D. M lives with his parents, who take care of him.
Presenting problem
- M is brought to the emergency room at 2.00 am by close friends and relatives after he was found in the bathroom with a bottle of vodka and an empty pill bottle. He reports having attempted suicide by taking twenty acetaminophen tablets and 15-50mg amitriptyline tables that he found on his mother’s dressing table. He says that he wants to die, and has been forced to come to the hospital against his wish.
History of present illness
D.M.’s mother reports that the evening before, he had been terminated by his employer after being found drinking and smoking marijuana in the storeroom. He had refused to evacuate the premises prompting the management to use force to evict him. On arrival home, he had found his wife and daughter talking to his mother and had become very aggressive and abusive towards the wife, calling her a cheat and a liar. He is reported to have slapped her and sulked off to his bedroom. An hour later, he had gone to the bar and drunk a lot of alcohol and had to be brought home three hours later by his drinking buddies.
Further history reveals that D.M. has, in the past three months, attempted suicide twice and been admitted on both occasions. The first time, he had taken 25 tables to atenolol, and the second time, he had 15 tablets of chlorphenamine. The mother also reports that he has been very disturbed of late, always alone, and sometimes can be heard shouting at a ghostly figure or begging for forgiveness from an unseen person. He has also developed poor appetite and refusal to feed, which has led to significant weight loss. His bedroom is always full of smoke and alcohol bottles.
When probed, D.M. reports that for the past few weeks, he has been feeling a bit under the weather, being generally fatigued almost the whole day and nearly every day. He says that he has feelings of being worthless primarily due to the absence of his wife and daughter, and he thinks that it is his fault that he got separated from them. He also reports having a sense of slowing down of thought, being indecisive, and having recurrent thoughts of death. More importantly, he says that he has lost interest in things that he used to love, such as football, and now finds it easy to use alcohol as a way of drowning the negative thoughts.
Past psychiatric history
- M has a history of mood swings. As the father reports that as a child, he used to cry a lot and would often bang his head on the floor when seeking attention. He often got into fights with other children at school and in the neighborhood and was once referred to a psychiatrist by his class teacher on consultation with the parents. During this episode, he was diagnosed with an unknown mood disorder of childhood, but this was never treated. During his sophomore years, he got into bad company and would often sneak from school to get high with his friends who had dropped out. He has also been in constant arguments with the parents for the past few years but is reported not to have gone violent with them. Apart from the two other attempted suicides, he does not seem to have had any major breakdown.
Medical history
D.M. suffered streptococcal pharyngitis at the age of 14 years and was admitted for three days. At 17, he had a left tibial fracture, which was managed conservatively. However, he was put on dihydrocodeine, which he used for a very long time. He does not have any chronic illness, has never had any surgery, and is not known to be allergic to either medication or food. There is no history of blood transfusion.
Substance use history
D.M.’s substance use started when he was in his sophomore years. He would sneak out to take marijuana. At 17, he started abusing dihydrocodeine that was being prescribed for his leg injury. At 20, he started using cocaine, albeit in small quantities. He is also known to take large amounts of alcohol at ago with a history of loss of consciousness and several developing alcohol withdrawal symptoms.
Developmental history
D.M.’s mother reports that there were no incidences when she was pregnant with him. He was born at term, and cried immediately. He was not taken to the nursery as his weight was 3.2kg. He attained his milestones pretty well, was sitting by 5 months, crawling by 7 months and standing at 11 months. Potty training was done at 24 months. The mother also asserts that D.M. received all his vaccines as scheduled. He started grade one at the same time with his peers and did very well thought early childhood and into teenage.
Family psychiatric history
D.M.’s maternal uncle, a war veteran, had posttraumatic stress disorder, which was managed on benzodiazepines. His father was also treated for generalized anxiety disorder while his paternal grandfather had alcohol dependence and died of liver cirrhosis.
History of abuse/trauma
There is no history of abuse during D.M.’s early childhood. He had a healthy life growing up and was in constant supervision either from his mother or the family’s governess.
Review of systems
On systemic review, D.M. reports fatigue but no fever. There are no visual changes, and his hearing is ok. He denies chest pain or difficulty in breathing but reports feeling nauseated. However, he reports having multiple skin lesions as a result of frequent falls when he is drunk. All other systems are said to be normal.
Physical assessment
On physical assessment, D.M. is in fair general condition but appears drunk. He does not have any respiratory distress and is not febrile. There is moderate pallor and some dehydration though no jaundice, edema or lymphadenopathy. He appears wasted and with poor oral hygiene. No lymph noted palpated from the physical assessment.
Mental status exam
Appearance. The patient appears to be in poor nutritional status and wasted. He is well-groomed but seems nervous and avoids eye contact with the examiner by continually staring at the floor.
Attitude. D.M. seems guarded and not ready to allow his personal life to be shared by the examiner. He is uncooperative most of the time and sometimes seems bored with the discussions and examination.
Mood. The patient is depressed, teary, and responds to most questions directed towards him with short answers such as “ok” and “Don’t know.” He has a limited aviation affect and reports feeling angry and depressed at being forced to come to the hospital (Widera-Wysoczańska, 2016). However, his emotional expression is labile and appropriate to the content.
Speech. D. M’s speech is slowed, forced, and interruptible. The volume is not loud and sometimes he speaks in whispers (Brannon, 2016). The rhythm and expressive intonation are, however, normal. He does not have a high rate of speech and his words are understandable.
Thinking and perception. D.M. presents with logical and goal-directed thought-form. He does not include irrelevant details, although he appears to be circumstantial and lapses into the emotional account of relevant ideas. He does not have flight of ideas or loosening of associations. He also does not have thought preservation, though block or tangentially.
D.M. has intact senses, is alert and oriented in time, place, and person. He also has insight as he reports being depressed a lot and has considered suicide many times and would like to get helped so that he can get better and take care of his family. Besides, he has abstract reasoning, presents with an adequate fund of knowledge, and has intact memory.
Differential diagnosis
Based on the clinical presentation, history and mental state exam, D.M. seems to be suffering from a major depressive disorder. However, the differential diagnoses include the following;
Mood disorder related to substance abuse
- Acute stress disorder
- Schizoaffective disorder
- Hypothyroidism
Case formulation
D.M. presents with a major depressive disorder that appears to be precipitated by being fired from his workplace. Factors that seem to have predisposed him to depression include prolonged substance and alcohol use, separation from his wife and daughter, and having to live with his parents in the same house. The current problem is maintained by excessive alcohol and substance use. However, his protective and positive factors include a loving and caring family and friends who are capable of providing him with the support he needs during the treatment and healing process.
Treatment plan
To effectively manage M.D.’s condition, a therapeutic alliance must first be established and maintained. Following the complete psychiatric evaluation, precipitating and maintaining factors must be identified, together with positive factors that can be used to enhance therapy. Then, the patient’s safety must be evaluated, and this must include factors for suicidal risk (Treating major depressive disorder: A quick reference guide). Eventually, an appropriate treatment setting is established, depending on the client’s clinical condition. Then, functional impairments and quality of life is evaluated and addressed.
Part of planning the patient’s management must also include coordinating with other clinicians, monitoring psychiatric status, and integrating specific psychiatric measurements into the management to evaluate progress. Besides, enhancing treatment adherence through collaboration with the patient and encouraging him to articulate concerns about the treatment approach must be integrated into the whole process. More importantly, education must be provided to the patient and the family.