Thursday, November 05, 2009

Psychiatric Assessment -- May 2009

McClendon Center
1313 New York Avenue, NW
Washington, DC 20005
202 745 0073

INITIAL ASSESSMENT

Staff Name: Karen Wood [social worker]

Intake Assessment 5/4/2009

PSYCHOSOCIAL ASSESSMENT

1. Describe the client's family and how the family impacts her/him now. Note significant events and how they affected the client:

Cl grew up in Philadelphia in an intact family. Cl has one older sister. Cl reports his parents died many years ago. Cl's sister lives in New Jersey; Cl speaks with her on the phone but does not often see her.

2. Describe the type of situation in which client lives, both the physical and emotional environment, as well as the neighborhood and the client's ability to navigate it.:

Cl likes his neighborhood. Cl feels capable of navigating the area -- he has lived there for 25 years.

3. Describe the client's peer group, what they have in common, and their shared interests and activities:

Cl reports he has no friends. When asked if he would like to have friends he reported having "mixed feelings" and having been diagnosed with Schizoid Personality Disorder. He reports one close friendship that ended in 1993.
4. Describe the client's spiritual beliefs and practices and how these impact on her/him:

"I gravitate toward the Jewish religion." Cl does not feel connected to organized religion.

5. Describe the client's military history (if any) and note how these experiences might relate to the client's current concerns:

Denies.

6. How does the client spend his/her free time?

Cl exercises for an hour and a half each day. Cl enjoys going to the library, taking walks, and reading (history and biography).

7. What is the client's financial status?

Cl receives SSDI. Cl also receives a housing subsidy and is in a rent-controlled building.

8. Describe the client's sexual history (include orientation, attitudes toward sex and sexuality, past and current sexual behaviors, and safer sex practices if applicable):

Cl denies any hx of romantic relationships or interest in them. Cl corrected himself later in the interview; he had a girlfriend when he was 25. The relationship ended when she wanted to marry and he didn't.

EMOTIONAL/BEHAVIORAL

1. Describe the client's history of emotional and/or behavioral problems (hallucinations, etc.):

Cl reports hx of social isolation and difficulty being around people. Cl reported he had a depressive episode when he was 23 that resulted in a suicide attempt; since then he has had a "low grade depression." Cl denies any SI since that time. Cl reports hx of delusions beginning at age 35. Cl denies any hx of AH/VH, elevated mood, HI.

2. Describe the client's current emotional and behavioral functioning. Note maladaptive or problem behaviors:

Cl was dressed casually and well-groomed. Cl was calm and cooperative during the interview. Cl also gave writer three rather long documents that he had written: a personality profile, a character study, and a written hx of his employment problems. The documents are well written, with appropriate grammar. They are quite clinical, with a great deal of psychological jargon and references to a variety of sources. Cl spoke at an appropriate rate, volume. His affect was blunted, mood euthymic. Cl's thought process was goal directed and logical. Cl denied SI/HI. Cl acknowledged delusional thinking about several past events. Delusions are also evident in the documents he supplied. Cl was alert and oriented x4. His memory appeared intact. I/J fair.

3. List community resources (such as Metro, food pantries, grocery stores, social service agencies, etc.) utilized by the client:

Cl uses a variety of community resources without issue: grocery store, metro, library.

SUICIDAL/HOMICIDAL RISK

Have you ever thought about hurting yourself?

Cl overdosed on elavil at 23 years old. Cl denies any SI after this event.

Have you ever thought about hurting someone else?

No.

Has any family member or significant other ever attempted or committed suicide? If so, who? When? Why do you believe they attempted/committed suicide and how did they do it?

Yes. Cl's niece committed suicide when in college. Cl reports she may have had Bipolar Disorder.

Do you currently have any thoughts of hurting yourself or someone else?

No.

PSYCHIATRIC ASSESSMENT

1. Describe the client's history of involvement with the mental health system, both inpatient and outpatient. Note age and circumstances at onset and significant events since then:

Cl began seeing a private psychiatrist while he was in his early 20's for feelings of social isolation. Cl had been getting services at GW but transferred to DMH in 1996 after GW stopped taking his insurance. Cl reports hx of social isolation and difficulty being around people. Cl reported he had a depressive episode when he was 23 that resulted in a suicide attempt; since then he has had a "low grade depression." Cl denies any SI since that time. Cl reports hx of delusions beginning at age 35. Cl denies any hx of AH/VH, elevated mood, HI.

2. Describe the symptoms of the client's condition and current treatment regimen:
Cl was dressed casually and well-groomed. Cl was calm and cooperative during the interview. Cl also gave writer three rather long documents that he had written: a personality profile, a character study, and a written hx of his employment problems. The documents are well written, with appropriate grammar, They are quite clinical, with a great deal of psychological jargon and references to a variety of sources. Cl poke at an appropriate rate, volume. His affect was blunted, mood euthymic. Cl's thought process was goal directed and logical. Cl denied SI/HI. Cl acknowledged delusional thinking about several past events. Delusions are also evident in the documents he supplied. Cl was alert and oriented x4. His memory appeared intact. I/J fair. Cl currently takes the following medications: Geodon, 20 mg qd; Effexor, 300 mg qd; and Klonopin, 1.5 mg qd.

TRAUMA/ABUSE HISTORY

Check regarding whether the client has been a victim or perpetrator of any of the following:

Domestic abuse (Maltreatment caused by a spouse or significant other resulting in physical or psychological injury):

Victim

Child neglect or abuse (Maltreatment of a child resulting in physical or psychological injury; or the absence of services or resources to meet basic needs):

Victim

Describe any item selected above and give time frames:

Cl reports being physically and verbally abused by his father. Cl also witnessed domestic violence in his family of origin. This is somewhat contradicted by cl's report in his personality profile and character study that he and his father were dominated by his mother.

For the clinician: Is there any evidence of trauma or abuse (bruises, scratches broken bones, etc.)? If yes, does the consumer's explanation for the evidence seem plausible?

No

LEGAL HISTORY

Other (how does that situation relate to the client's condition and how will it impact her/his care and treatment?)

Denies any criminal hx.

EDUCATIONAL/VOCATIONAL

Last grade completed:

College

Describe the client's work and volunteer history, including vocational training; note if the client would like to work again and, if so, what type of work:

Cl as a JD and an LLM. Cl has not worked as an attorney but has worked as a paralegal. Cl's paranoia and delusions led him to believe he was being harassed at work. He made a complaint that was investigated. Cl was fired after the investigation contradicted his reports of harassment. Cl stopped working at 37 after delusions interfered with his ability to work. Cl expresses interest in returning to work but is concerned about his ability to get along with others and possibly being harassed in the workplace.

SUBSTANCE ABUSE ASSESS.

When did you start using? or start your addictive behavior e.g. gambling, shopping, eating, etc?) age? duration? patterns of use? what would you say got you started?

Cl shared that he has had a period of heavy drinking (6 pack/day) in the 90's that ended after two years. He attributed his heavy drinking at this time to a poor relationship with his psychiatrist. He reports that he stopped drinking immediately after seeing a new psychiatrist. Cl does not drink currently. Cl denies any other drug use, with the exception of trying MJ a couple of times.

STR., BARRIERS AND RECOM.

What are the client's strengths?

"My intelligence, my reasoning ability, my creativity. Emotionally I would say i'm a tolerant person."

What are the client’s barriers?

"I'm so . . . I just don't relate to people."

What issues does the client need to address?

Cl would benefit from therapy to address his interpersonal conflict re relationships with others.

What does the client want to accomplish during treatment? Include pertinent recommendations:

Cl would like to receive therapy with Dr. Jama at DMH. Cl would like assistance in maintaining his housing subsidy. The subsidy requires a monthly inspection that has been done by his CSW in the past.

Staff Signature

[signed electronically] 5/4/09 10:29 AM

_____________________________________________________________________________

MED PROGRESS NOTE

Staff Name: Didi Bailey, MD

DATE: 5/15/09

Medication? Somatic Treatment Service Goal:

To be free of psychiatric symptoms on the lowest possible dose(s0 of medication(s).

Algorithm Followed: Depression, Other*
Delusional d/o. Schizoid personality d/o.

Clinical Rating Scales:

POS SX: Anhedonia. Fixed delusions.

NEG SX: Impaired interpersonal relations

AXIS V: 50

Address asterisked items at first Evaluation
*Current symptoms:

Delusions fixed but pt. no longer feels they apply to him currently. Pt. has problems with interpersonal relations.

*Past Psychiatric History:

Always a loner with difficulty making friends. Started psychotherapy after college 1/77-1/78. 6/78-79, 79 returned to initial therapist for summer (then began law school). No treatment again until 1990 when he moved to DC to work. Saw a psychiatrist because he felt he was victim of job discrimination; saw psychiatrist due to his hx. Meds started in 1999 although they were recommended from 1992. Meds have continued to date. No IP stays. Suicide attempt at 23 y/o by Elavil OD; in coma and admitted until stable (almost 1 week).

*Current Medications:

300 mg Effexor QHS. Klonopin 1.5 mg. 20 mg Geodon. OTC Benadryl. 40 mg Zocor for elevated cholesterol.

*Allergies:

DNKA

*Past Medical History:

MVA vs. pedestrian -- coma & concussion & fx L wrist (1991). EEG unremarkable. Pt. noted no changes. Elevated cholesterol. Coma s/p Elavil OD at 23 y/o.

*Family History:

B&R Phila. Both parents deceased. Older sister. Never married. No children.

*Social History:

No military service. Law master's in Intl. Trade Law. (one degree about Law School). PA license as attorney but chose not to have law practice. '86-'91 paralegal Disability from 1991. Exercises daily 1.5 H. Reads. Surfs Internet. Walks. Engages in activities he enjoys. Presented his self-published book.

*Substance Abuse History:

'94-'96 drank up to 6 pack of beer. Coincided with period with a GW Resident he could not stand [Dimitrios Georgopoulos, MD] (but could not transfer per protocol).

*Legal Issues:
None.

SUBJECTIVE FINDINGS:

Appetite: Normal
Sleep: Normal
Side Effects: None
Objective Findings:
Vital Signs: [blank]
Orientation: Person, Place, Time, Situation
Rapport: Appropriate
Appearance: Appropriately Dressed, Appropriately Groomed
Mod: Depressed
Affect: Depressed
Speech: Coherent
Thought Content and Process: Appropriate, Goal Directed, Loneliness
Dangerousness (Describe Below): Not Suicidal, Not Homicidal

Psychomotor Activity: Normal
Insight: Poor
Judgment: Grossly Impaired
Memory:
Immediate: Good
Recent: Good
Past: Fair
General Psychiatric Conditions: Improving
Patient Response to Medication: Partial
*Diagnosis (justify):

Delusional d/o per hx; pt. continues to have fixed belief but knows it no longer applies to him/his circumstances. Major depression, recurrent, severe without psychotic fx's per hx of depressed mood, feelings of otherness, hopelessness that he can achieve happiness in his relationships. Schizoid personality d/o per how he relates to work in general.

Assessment/Pal:

Pt. transfers from Spring Rd. after many years of treatment. Pt. feels hopeless about ever achieving happiness., sameness as he perceives in others. Pt. is delightful and intelligent but appears to have no social skills nor appreciation of his positive assets. Pt. has 1ry care physician. Continue 20 mg Geodon QHS (#30)x1. 300 mg Effexor-XR QHS (#60)x1. d/c Klonopin. Add 2 mg Ativan po QHS. Pt. to request last labs from Walker Jones Clinic.

Staff Signature

[signed electronically] 5/15/09 3:11 PM

1 comment:

Gary Freedman said...

"Pt. is delightful and intelligent but appears to have no social skills nor appreciation of his positive assets."

No appreciation of my positive assets? That doesn't sound like a grandiose narcissist. Wow, did I have HER fooled!