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Part I: Diagnosis
Given the case information, prepare the following: a diagnosis, the rationale for the diagnosis, and additional information you would have wanted to know in order to make a more accurate diagnosis.
Part II: Biopsychosocial Risk and Resilience Assessment
Formulate a risk and resilience assessment, both for the onset of the disorder and for the course of the disorder, including the strengths that you see for this individual.
What techniques could you use to elicit additional strengths in the client?
What interventions can be used to help this patient? (One intervention per diagnosis)
CASE: Scott is a 23 year old white male who presents as quiet and polite, with flat affect. At age 20, he was in church with his family when he started spinning his body around feeling that something was pushing him. After returning home, he felt restless and randomly moved items and furniture around the house. Over a short period of time, his parents noticed that his speech was becoming disorganized and his behavior more erratic. He would sit outside in cold weather with light clothing, sleep in the backyard, and live in his car. At one point, Scott felt he was possessed by demons and needed to purify his body by not eating. He thought that if he lost weight, the demons would have to leave. From the onset of his symptoms until 6 months ago, Scott was hospitalized 14 times as a result of aggressive behavior towards his family. His aggression was usually characterized by shouting randomly and shoving his parents. Once he punched his father in the face. As times, Scott is bothered by his aggressive thoughts and has sufficient insight to recognize that his illness impacts his life.
Scott is currently receiving treatment from a county mental health agency as outpatient. He is seen regularly by a social worker and by a psychiatrist who monitors Scotts medication and coordinates treatment with his primary care physician. Scott is also attempting to become more involved with a day treatment program, but is finding it difficult. Initially, he liked the idea of participating in group activities and having the chance to develop social relationships. Over time, it became stressful for him, and at one point he said he felt the program was evil so he stopped attending. He is trying to attend again, but initially he would go out on the grounds and stay behind the trees. Scott has progressed to being able to come out from behind the trees and sometimes enter the building, but he is still unable to engage in any kind of social interaction. He has been known to wear ear plugs during his entire time at the day program to protect himself from perceived ridicule.
When at home, Scott spends the majority of his time in his room. He no longer watches television or listens to music, activities he previously enjoyed doing. His parents encourage Scott to eat dinner with the family several times a week to foster the social interaction he otherwise lacks. He is notably distracted by his internal stimuli and often talks and laughs to himself. He paces, goes in and out of the house, and picks up and examines imaginary things. His speech is often tangential.
Scott is currently obsessed with children and their safety. He mistrusts his father and fathers in general, although abuse by his father has been ruled out. He mistrusts the Catholic Church because of reports of sexual abuse by priests. He often misinterprets parental behavior as child abuse. On a recent visit to a fast food restaurant, Scott saw a father holding a fussy child. He thought the child was crying because the father was holding the child in a perverted way, and demanded that the father put the child down.
At his intake for day treatment program, Scott told the doctor that his parents and siblings had murdered his friend. In truth, the friend had died of a Heroin overdose. He also reported he hears a voice that is nasty in tone. He stated that the voices do cruel jokes on him, and he laughs or talks back to them. He tries to control the voices by praying. Scott also talks about a presence touching me. He described it as a sharp jolt of terror, as if someone was in the room with him, touching him. The presence comes and goes, and Scott thinks it may be Satan. He also thinks that people are reading his mind and making fun of him.
Recently, Scott has had problems sleeping and is becoming increasingly agitated over the need to organize protests against abortion. His father contacted Scotts social worker and requested that both the social worker and the doctor see Scott to re-evaluate his medications. When Donald was informed of his appointment, he became extremely annoyed and threatened to cut the doctors throat. He left the house on foot, returning several hours later at 2:00 am, cold, tired, and wet from the rain. He agreed to be hospitalized the next day.
Over the course of his illness, Scott has continued to experience periods of depression. During these periods, which last for several weeks, he will sleep at least 12 to 14 hours a day and has great deal of difficulty waking. By his parents report, he eats less, is more withdrawn, more isolated, and less active than other times. His depressed moods are noted by his mother, his social worker, and the psychiatrist. He has described other moods in which he feels like doing a lot of things, but these episodes were short lived and do not meet the criteria for manic or hypomanic states. According to both Scott and his family members, he does not smoke or use drugs or alcohol.
Scott is the youngest of three children. His mother reported that she had a normal pregnancy and delivery with Scott. Scotts older brother is 34 and his sister is 26. His mother works as a nurse, and his father is an engineer. There is family history of mental and mood disorder. Scotts mother is taking anti-depressants, and her brother has bipolar disorder with manic episodes marked by psychosis and a substance use disorder. There is also history of attempted suicides in Scotts mothers family, and a paternal great uncle had a break down.
Scotts parents describe him as a shy child who did well in school. He was diagnosed with depression at age 13 and took antidepressants until he was 20. At age 15, he experienced his first suicidal ideation but made no attempt to take his life. He also reported thoughts of suicide when he was 19 and 20, but never made attempts. Scott graduated from high school with a GPA of 3.6. He attended college for three semesters, earning a 3.1 GPA in his studies. During high school and college, Scott had several jobs. He worked in a vets office for 9 months. He was also employed in retail and as a waiter in several eating establishments, but was unable to stay employed at any of these places for more than a few weeks.
The medications Scott currently takes are cause for concern. His illness has not responded well to medications, even though he is taking many of them. These include Depakote, Zyprexa, Abilify, Geodon, and Risperdal. He experiences undesirable side effects, most notably tremors of his hands, arms, and feet. The health care providers treating Scott would like to have him try Clozapine, described by his social worker as a drug of last resort. This is an unlikely possibility, however, as transition mediations requires the person to be briefly hospitalized. Scott has not been particularly compliant with medication and treatment but is especially reluctant to be hospitalized, feeling that hospitals are evil.
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