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Individual Case Presentation

Individual Case Presentation. Maggie McGowan. Presenting Symptoms and Problems. 54 year old male, Forensic readmission on Conditional Release; lives at the *** Group Home until CR expires

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Individual Case Presentation

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  1. Individual Case Presentation Maggie McGowan

  2. Presenting Symptoms and Problems • 54 year old male, Forensic readmission on Conditional Release; lives at the *** Group Home until CR expires • Decompensating in the community due to noncompliance with medication; suicidal ideation with a plan; wrote suicide letters to his children stating that he was going to a bar to hang himself • Auditory/visual hallucinations; God and Angels speaking to him; delusions about good and evil • Patient ingested 15 Klonopin pills; Had been telling friends that he killed a sheriff about 15 years ago and was hearing voices telling him that he needed to be punished

  3. Presenting Symptoms and Problems • Presented with depressed mood and flat affect; pleasant and cooperative; heavily sedated; suicidal; “I’m not in the right state of mind.”; drooling; “I suppose I stopped taking Clozaril because I was running into walls.” • Current NGRI status began in 2007 when he stopped taking his medications and began abusing narcotics and becoming increasingly paranoid and delusional; believed that spirits were coming through the window and that he needed to kill them; fired two shots into the wall at a motel; 18 hour stand-off with police

  4. BioPsychoSocial/Spiritual Assessment • Child and Family History: biological parents divorced when he was 24; mother died at age 66; father died at 49 after being hit by a tree; mother remarried; good relationship with step father; older brother (age 58); tense relationship with brother; strained relationship with parents throughout childhood and adulthood; extreme conflict between biological parents

  5. BioPsychoSocial/Spiritual Assessment • Child and Family History: physical abuse by mother and emotional abuse by father; raised without structure or rules; father was an alcoholic and drank heavily; reports that father struggled with mental illness and a history of violence; no family HX of suicide; no health issues as a child; sexually abused by a male peer at age 12 • Education: HS graduate; special education classes; fights in school; multiple suspensions

  6. BioPsychoSocial/Spiritual Assessment • Health Issues: COPD, Type II Diabetes, hypertriglyceridemia, mid thoracic back pain, hypertension, hypothyroidism, hyperlipidemia, GERD, hyperglycemia, and obesity • Marital HX: Married for 5 years. Divorced 3 years ago. Ex-wife is still very supportive. • Children: 1 son (Age 28), who is married with 3 children (ages 8, 10, & 12). • Relationship dynamics: interested in becoming more involved with son and grandchildren; interactions limited per conditional release; regular phone contact; son & grandchildren visit every few months

  7. BioPsychoSocial/Spiritual Assessment • HX of Violence & Legal Status: multiple DV charges, assault charges, disorderly conduct, resisting arrest, contempt of court, robbery, & breaking and entering. Incurred NGRI status due to charges related to discharging a firearm in habitation, felony 2 inducing panic, felony 5 at a Super 8 Motel and the door was pointing the gun towards the walls when he was preoccupied and distraught threatening to shoot others, “spirits”, and himself; Claims he did not want to hurt others but wanted to protect himself from the spirits, which looked like fingers coming through the door.

  8. BioPsychoSocial/Spiritual Assessment • Extensive history of drug and alcohol abuse; drinking heavily & smoking marijuana since age 13; smoked marijuana daily prior to 2007; PCP abuse via IV; HX of hallucinogen, heroine, sedative, amphetamine, tranquilizer, opiate, and benzodiazepine use; abusing Klonopin & Xanax PTA • Multiple suicide attempts: OD on 30-300 mg Seroquel, cutting his throat, OD on combination of drugs • 25thhospitalization to the ODMH System since 1988; HX of poor compliance with treatment in the community • Religion: Christian. Religious preoccupation with delusional, religious beliefs, particularly when decompensated.

  9. Step-father X: Deceased Father X Mother X Strained relationship Positive Relationship Ex-Wife Patient Brother Son Daughter-in-law Granddaughter Granddaughter Grandson

  10. Differential Diagnosis • Axis I: Schizophrenia, Chronic Paranoid Type; PTSD, MDD, severe; Poly-substance Dependence • Axis II: Antisocial Personality Disorder • Axis III: COPD, Type II Diabetes, GERD, Hep C, & obesity • Axis IV: Chronic severe MI, legal issues, limited education, limited social support • Axis V: 25 (upon admission), 45 (current)

  11. DSM-V • Based on the proposed criteria in the new DSM-V, the patient’s primary diagnoses would not be different. • Substance use disorders as opposed to poly substance dependence

  12. Treatment • CBT & DBT • Meet once per week to evaluate psychotic disorder symptoms, identify stressors, and provide education regarding MI and coping skills • Develop and implement plan to use relaxation techniques & coping skills • SA Relapse Prevention Plan • Medication • Group Therapy: Anger Management, DBT Coping Strategies, SAMI, Forensic Group

  13. Initial and Current Treatment Goals • Strengths: Increased insight on need for TX; familiar with CMH services; has housing, income (SSDI), and Medicaid; compliance with TX has increased, work program at ABH • Initial Goals: maintain stability on medications, manage symptoms, learn to control moods, maintain sobriety, deal with legal issues • Current Goals: increase social interactions; maintain stability on medications, voice needs; practice coping skills

  14. Goals • How did you explain treatment goals with the patient and what was his reaction? • Allow the patient to list his personal goals. • Discuss therapeutic goals based on ITP • Cooperative

  15. Sessions • Discuss mood, symptoms, and weekly issues. • Assess symptoms such as delusions, paranoia, A/V hallucinations, SI, & HI. • Discuss coping skills. • Identifies stressors. • Discuss relapse prevention plan. • Discuss psycho-education regarding diagnoses. • Practice relaxation techniques.

  16. Thoughts During Treatment Process • Concern about building rapport in the beginning • Initial anxiety about working with individuals with severe MI • Feeling “stuck”; progress?

  17. Change over Time • More compliant with treatment and medications. • Positive trusting, therapeutic relationship. • Use of coping skills. • More insight in regards to MI & SA. • Continue working on social relationships.

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