Discussion Topic

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DISCUSSION QUESTIONS

Choose one of the following case studies and answer the following questions. The information provided may not be sufficient but it is what is available for you to analyze and conceptualize how you might proceed with the following patients, Case Example A and Case Example B. After reviewing each vignette discuss with colleagues the following questions. There are no single correct answers to the questions, just different approaches to take.

1.In reviewing this chapter, which factors are important to consider for this patient?

2.What additional information would you like to have to be more comfortable in working with this patient?

3.How will you explain your diagnosis and treatment plan in relation to the patient presentation? What treatment options will you recommend and why?

4.What is your initial approach in negotiating treatment for this patient?

5.What medication changes would you want to discuss with the patient and how will you negotiate that with her or him?

6.What time frame do you propose for this plan, and how will you transition with the patient?

7.How will you coordinate care with the other providers working with this patient?

8.After stabilization, which psychotherapeutic approach would you take?

Post your initial response and on a different day respond to one student in your class. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text).

CASE EXAMPLE A

Campus security was called to the dormitory to assess a 19-year-old man who barricaded himself in his room and covered the windows with aluminum foil. His roommate reported that this man hasn’t been attending classes for the past week, hasn’t bathed or eaten, and has been mumbling that the FBI is monitoring all his communications. Security removed the door and took the man into custody and to the community mental health center for evaluation.

History of current episode: Information obtained by interview with the patient and with collateral telephone interviews with each of his parents, his college roommate, and his English professors. This is the first year away from home for this young man, who has been described as an “odd and reserved” person since teen years. Academically he did well his first semester at college, although he has made few friends and does not participate in any social or extracurricular events. His teachers describe him as a bright and quiet student. His parents, who live in a small town over 70 miles away from the college, expressed sadness but not surprise at his behavioral deterioration because they didn’t expect him to be able to cope with the discrepancy of the large college campus compared to his small-town previous experience.

Psychiatric history: Although he has never been hospitalized or had outpatient psychiatric treatment, this young man has been showing signs of emotional and cognitive disorganization since his early teens. During his high school years the patient became more and more aloof, and strange with both his family and friends. At times he would be mute for days at a time, remained in his room and refused to bathe. He said he did not have control over his thoughts and he believed he was possessed. In his junior year of high school his counselor recommended he attend a breakout group to help him learn interpersonal skills and make friends, but he never attended. The summer before going to college his parents asked if he wanted to see a therapist or counselor to talk about transitions but he said he didn’t want to do that and that he wasn’t concerned about living away from his family for the first time.

Medical history: Has had regular preventive care and immunizations through local family practice. In good health, weight proportion to height, denies smoking or alcohol or drug consumption. Broke his left wrist at age 7 years when he fell off his bike. Moderate acne in late teens treated with oral doxycycline for several months. No drug or food allergies. Allergic reaction to bee sting when 10 years old with swelling, shortness of breath, now carries EpiPen.

Family history: Has an older brother, 23 years old, who graduated from college and is now attending graduate school in business administration. Younger sister is 15 years old and in good health. Father is a business executive, has chronic obstructive pulmonary disease (COPD) related to long-standing cigarette smoking. Mother is an Episcopal priest and is in good health. Maternal uncle died at age 49, diagnosed with schizophrenia.

Personal history: Normal pregnancy and uncomplicated childbirth. Was an active and creative child who enjoyed reading, art, and cooking with his mother and grandmother. Parents said he started to become reserved and shy in middle school for no apparent reason. By early teens he seemed socially inept, had few friends, and preferred solitary play. Never interested in romantic relationships or dating in high school and spent most of his time studying or reading fantasy novels. Seemed to be withdrawn and serious, although denied feeling sad, or depressed.

Trauma/abuse history: Mild bullying in middle school, otherwise no apparent trauma.

Mental status examination: Well groomed, neatly attired, cooperative. Polite without motor abnormalities or gait. Moderate eye contact when directly addressed. Alert, mildly sedated, oriented to time, place, person. Attentive during interview and provided accurate albeit minimal history that was corroborated by family members. Based on fund of knowledge seemed of average intelligence. Speech is normal rate and soft spoken and at times mumbled responses to questions. Stated that he hears a soft voice in his head that tells him to “be careful” but offered no other explanation of voices. Denied visual or other perceptual hallucinations. Thought processes are linear and coherent. Reports that he believes people talk about him behind his back and that he is being controlled by unseen forces. Refused to elaborate on these thoughts. Stated that he has never thought of killing himself or anyone else. Described his mood as “fine” and refused to elaborate. Affect is flat. Demonstrates impulse control and alludes to feeling like an automaton. Judgment is reasonable in terms of recognizing consequences of actions.

Current medications: No regularly prescribed medications. Given lorazepam 1.0 mg orally in urgent care when brought in by campus security because of his extreme agitation. Slept for an hour after administration while waiting to be interviewed.

Differential diagnosis: Brief Psychotic Disorder versus First Episode of Schizophrenia. The duration of the episode is greater than 1 day but uncertain if longer than 1 month, and no previous psychiatric hospitalization. Teen years are suggestive of prodromal period of schizophrenia that may be precipitated by stress of independence from family and college experience.

CASE EXAMPLE B

John B. is a 15-year-old man of Sudanese descent who resides with his mother, grandmother, 23-year-old brother, and his brother’s wife. They are all asylum seekers to the United States, having arrived from South Sudan 2 years prior to this. He is seen in this mental health clinic after discharge from an inpatient stay following a suicide attempt by hanging.

Brother found patient hanging by a rope tied to the clothes rod in the closet. Patient was cyanotic with slow pulse and taken to the hospital by ambulance. He was treated in the inpatient adolescent unit for 1 week and discharged to this clinic for an assessment and follow-up treatment. He reported that he has been feeling depressed “for as long as I can remember” with low self-esteem, feelings of hopelessness and being a burden to his family, guilt, and self-hatred. He said he had been thinking about killing himself for several months and has been cutting on his arms in practicing for this. His brother came home from work unexpectedly to find him. He described not fitting in at school and not feeling comfortable in his new home. His brother arranged to bring his mother and grandmother to the United States to flee from the war. His brother was brought to the United States when he was 14 years old under the UNICEF program for rehabilitation of child soldiers, and believes the patient was being recruited to be a soldier before coming here. Patient sleeps less than 4 hours/night with frequent nightmares and refuses to sleep in bed, prefers to sleep under the bed. Has poor appetite. Teachers report he has difficulty concentrating in school and has to take frequent breaks to sit in quiet room with soft music. He has made few friends and gets into fights, both physical and verbal, with other boys. Easily upset by loud noises or changes in routine at school or at home.

Medical history: Patient has no known drug or food allergies. He was treated for malnutrition upon arrival to the United States and remains underweight. He was diagnosed with mild intermittent asthma, triggered by exercise and seasonal allergies. Physical exam also revealed several horizontal scars on the inner surfaces of his left forearm.

Substance use history: Denies alcohol or drug use.

Family history: Father died in war in South Sudan when patient was 4 years old. Raised by mother and maternal grandmother with older brother. Older sister killed in village raid when patient was 5 years old. Unknown paternal history. Mother is 42 years old with unknown health history.

Personal history: Full-term birth without known complications. Attended school intermittently in South Sudan due to civil war. Currently attending special school and mostly fluent in English. Has had behavioral problems in school due to inattentiveness, anger, poor impulse control, and low frustration tolerance. Mother and grandmother do not speak English and are unable to provide description of patient’s behavior at home. Brother works two jobs, as does brother’s wife.

Trauma history: Witnessed his sister and mother being raped and sister’s death. Possible torture prior to coming to United States.

Mental status examination: Thin, lanky young man with multiple scars on arms and back. Clean, casually attired with close-cropped hair. Cooperative and sullen during the assessment. Sits in chair with legs pulled up on the chair and gripping his knees with his arms. Makes moderate eye contact. Alert, oriented to time, place, and person. Memory not formally assessed but appears to be intact based on his ability to accurately relate details from his recent experience. Hypervigilant to the environment and interviewer’s behavior. Linear thinking with abstract reasoning and seems to be of average to above average intelligence based on fund of knowledge. Speech is soft with pronounced accent, regular rate and rhythm. Comprehends English sufficiently to not need interpreter. Thinking process is coherent and goal directed. Thought content is focused on distress of hospitalization. Acknowledges wanting to die but without current plan to kill self and feeling remorseful that he upset his family with his recent attempt. Described his current mood as scared and depressed. Affect is fearful, tearful, and angry. Impulsive previous behavior with poor judgment and belief in limited future. Insight is reasonable in terms of understanding why he is referred to treatment.

Current medications prescribed at last hospitalization:

1. Prazosin 5 mg bid for nightmares and daytime stress

2. Vortioxetine 10 mg daily for depression and anxiety

3. Fluticasone-salmeterol inhaler qd for asthma

4. Theophylline 300 mg qd for asthma

Differential diagnosis: Major depressive disorder with suicidal thinking. Posttraumatic stress disorder.

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