Referral and Identifying Information - Case Study Example

It also makes him do things he does not want to do by threatening to hurt his sister, and it causes him to be unable to concentrate at school or at work. He worries about the safety of his sister. He acted it out on one occasion, cutting his throat in the bathtub, although he told the doctors it was an accident. The voices and the ambient noises in the environment also disturb his sleeping. He claims not to have a temper. He stays at home where he feels safer. He claims to be a psychic as well, being able to hear what people think, what they are going to do, and their future. He was detained in the psychiatric hospital, but for undisclosed reasons. It was not revealed whether this was the same as the hospitalization caused by the voices. The patient recognizes that he has a problem, and this is the first time that he sought to consult for his symptoms.

Current Life Situation

He is currently single, unemployed, stays at home most of the time, thinks, writes poetry, and feeds animals in the woods. He is closest to his mom and sister Cathy. His other siblings go to school. Currently uses marijuana, and had previous uses of shrooms, LSD, and cocaine. 

Social and Developmental History

The patient is the third out of the six children of his parents. The patient has a history of asthma and takes an Albuterol inhaler for relief.  He claims to skip 5th grade because of his high grades. This prompted his father to pressure him to become a doctor like him. Stressed out because of his father’s cheating, her mother would often drink and would not care about them, leading to, together with the absence of the father, kids being out of control and undisciplined. The family does not talk about problems. He was sexually abused for 4 years by his grandfather’s male business partner. He has two close friends and has had two heterosexual relationships, although each did not last a year. Grandmother committed suicide. He worked as a part-time tutor, and for his grandfather. 

Assessment

Delusional disorder secondary to sexual abuse

Behavioral Observation and Mental Status

Appearance is fair. The patient seems lethargic, suspicious, withdrawn, restless, and paranoid, and he does not maintain eye contact. Speech is loud and pressured. He is dysphoric and labile. He seems confused at times, and his thought process is scattered and loosely associated. He is well oriented to person, place, and time. The patient has auditory and visual hallucinations as well as somatic delusions. His insight and judgment are impaired.

Multiaxial Diagnosis:

AXIS I: Clinical Disorders

Other Conditions That May Be a Focus of Clinical Attention

Diagnostic Code

DSM-IV Name

312.3

Impulse-control disorder NOS

292.9

Cannabis abuse

AXIS II: Personality Disorders

Mental Retardation

Diagnostic Code

DSM-IV name

301. 0

Paranoid personality disorder

AXIS III: General Medical Conditions

ICD-9 CM code

ICD-9 CM name

None

AXIS IV: Psychosocial and Environmental Problems

􀂅 Problems with a primary support group

Specify:

√ Problems related to the social environment

Specify: victim of sexual abuse; substance abuse

􀂅 Educational problems

Specify:

􀂅 Occupational problems

Specify:

􀂅 Housing problems

Specify:

􀂅 Economic problems

Specify:

􀂅 Problems with access to health care

Specify:

􀂅 Problems related to interaction with the legal system

Specify:

􀂅 Other psychosocial and environmental problems

Specify:

AXIS V: Global Assessment of Functioning Scale

Score: 11

Time frame: current

Treatment Plan:

1. Conduct a thorough physical examination, especially the lungs and the heart, to identify any physical injury or pathology brought about by self-infliction or cannabis abuse. These should be treated accordingly.
2. Ask the patient to bring his family or close friends, maybe his mother, sister, or close friend/s, to the therapy sessions for proper education regarding the condition of the patient. Social support is usually vital in encouraging changes in the patient as they facilitate treatment adherence.
3. Do not confront the patient about his symptoms.
4. Include cognitive-behavioral therapy addressing his substance abuse and trauma from the past child abuse.
5. Recommend low-dose anti-psychotics such as pimozide, clozapine, reserpine, or olanzapine only when symptoms arise, so as not to trigger further drug abuse. Increase the dose as needed
6. Consider admission to the hospital once the persistent threat to self or others is established.