Diagnosis and Psychiatry Revised 1

Diagnosis and Psychiatry
Name
Institution
Date
Identification: The hospital books have no record of Mr. Alfred. Hence I assume it is his first time to be admitted to a psychiatric facility. Mr. Alfred is a 26-year-old man working on a full-time basis in a local supermarket. He currently cohabits with his girlfriend and plans to make the marriage formal soon.
Date of interview: 25/02/2018
Chief Complainant
Alfred, the 26-year-old male was brought to the facility emergency unit by an ambulance, accompanied by his girlfriend on suspicion that he had taken an overdose of an unknown number of fluoxetine, atenolol, and zolpidem pills in an apparent suicide mission. The medication is believed to have been prescribed for Cate, Alfred’s girlfriend.
Descriptive part
The night before Alfred was brought in he had a violent encounter with his longtime girlfriend. Alfred argued that his girlfriend was no longer committed to the relationship since she spent more time with her friends than with him. As a result, a quarrel broke out leading to a physical fight. Alfred later went to a pub accompanied by Peter, his workmate, where he took a number of beers. Upon returning home, his girlfriend avoided any communication with him which he thought was a reaffirmation that his girlfriend was no longer interested in the relationship. Angered by the reception, he locked himself in the bedroom and took an overdose of the girlfriend’s medication. He then left the empty medication bottles in open display.

A few minutes later Cate walked into the bedroom where he found Alfred laying on the bed with a white substance coming out of his mouth. She saw the empty medication bottles and immediately knew that Alfred had overdosed. Her efforts to get him vomit were in vain hence he contacted the hospital to send an ambulance. I also learned that Mr. Alfred has a habit of consuming alcohol three to four times a week and overindulges on the weekends when he is not on duty. When he overindulges, he occasionally blacks out. One year ago he started using heroin and about six months ago he also started using cocaine.
Summary of meetings
In my first meeting with Alfred, he appeared masculine in his blue polo t-shirt. Like most young people in his age bracket, he was also wearing a pair of black jeans and sneakers. He additionally accessorized his look with a few necklaces and some rings on his fingers. He sat in an awkward position while playing with his fingers. He also couldn’t maintain good eye contact. When responding to inquiries, he spoke impulsively and too rapidly, to the point of losing his breath. Although he could occasionally shout, it was easy to cut him short. His rhythm and tone of voice appeared inconsistent and somewhat abnormal. Although it was easy to understand what he was talking about, I missed a few words due to his fast-paced speech.
Surprisingly, he acknowledged that he is aware of his habit to talk and think quickly and bragged that this is because he is bright, handsome and talented. Nevertheless, subjectively he said that he felt depressed and furious since he was not used to the hospital environment. Objectively he seemed to be unhappy, frustrated, depressed and tense sometimes. Overall, he appeared introverted and emotional considering that he could easily get carried away by emotions when talking about something important to him. For instance, there was evidence of anger, suspicion, and mistrust as he talked about the possibility of his girlfriend having another affair. He also claimed that the hospital was holding him hostage, now that he was okay. Instances of thought blocking, perseveration, the flight of ideas, and tangentiality were also evident.
History of problems
Psychiatric history
Alfred has a past characterized by violent upsurges. His mother confirmed that from a tender age Alfred would knock his head against the wall and other rough surfaces. Moreover, while in elementary school he always got into fights with other kids and sometimes even attacked teachers. For instance, in fifth grade, he knocked down a teacher with a lawn tennis racket. At home, he was equally a troublemaker as he at one point attacked his younger brother and punched him in the face to the extent he had to seek medical attention due to excessive nose bleeding. In high school, he was notorious for bullying younger students. He got into serious trouble when he physically assaulted one student prompting the school to force him to receive counseling from a therapist. He attended five counseling sessions with the school therapist and stopped soon after graduating from high school. Two years ago he attempted suicide after he lost a huge fortune to gambling. He planned to jump from the top of a cliff but got scared when he realized how tall the cliff was. He remained secretive about this attempt and did not bother to seek psychiatric services either.
Family history
Alfred’s family comprises of his father aged 55, his mother aged 50, an elder sister aged 29 and a younger brother aged 21. Alfred’s father is an alcoholic and has twice relapsed from the alcoholics anonymous. Cases of addiction, psychiatric disorders, violence, medical diseases and suicide attempts seem to be common in the family.
Personal history
Alfred was brought up in a big city. As earlier indicated he had a sore relationship with his siblings and parents. Despite being a troublemaker, there is no report of him being a victim of sexual abuse, racism, verbal and physical abuse. Whereas he was a bully in high school, he sometimes scored good grades when he put in the effort. While in high school he was also passionate about sports an almost got a slot on the school’s athletics team. In his final year in high school, he attended part-time classes for drama and drawing.
Alfred had his first girlfriend while in high school, but they broke up soon after graduating because the girlfriend accused him of infidelity. He maintains that he never cheated on his first love something that he says left him heartbroken. Upon graduating from high school, he moved in with a roommate whom he stayed with for about two and half years. He took part-time jobs to sustain himself during which time he also applied to various colleges for admission. However, his applications were rejected due to low high school grades. After two years of moving from job to job he finally landed his current job at a supermarket thanks to the help of a high school friend who works in the same establishment. Around this time he also met his current girlfriend who by then used to work in a nearby grocery. Two years down the line they moved in together. One and half years ago he ran into financial problems because he was spending too much on substance and alcohol. He tried to save his situation by betting all his savings on a soccer team that he supports but the gamble backfired something that contributed to his first suicide attempt. His girlfriend says he is too needy and suspicious. The patient’s current relationship with family members is limited.
Clinical factors (Diagnostic behavior & diagnostic features)
Behavior: In the subsequent meetings with the Alfred remained anxious and depressed for a larger part of all the sessions. He also maintained poor eye contact though as he struggled to concentrate on what I was saying.
Feelings
Mood: Alfred reported feeling depressed, disappointed and angry with her girlfriend since he felt she no longer loved him. He noted, “I am the only who seems to be caring about us, I guess she doesn’t love me anymore.”
Affect: He was tense and frustrated which was visible in his spontaneous and rapid responses. His affect could quickly shift from calm to depression.
Thoughts and memory
Alfred’s memory appeared to be distorted since throughout the sessions he struggled to remember past events. Sometimes I had a feeling that he skipped the important details. He also scored poorly on the spelling tests. For instance, he was unable to give a correct answer to the calculation 8 x 8, stating ’56’ as the answer.
Level of arousal
Alfred’s degree of psychotic defense mechanism was modest owing to the few times he denied responsibility for his behavior. This was evident when he denied responsibility even after physically assaulting a younger high school student. However, sometimes he believed that he was responsible for all the bad things happening in his life.
Clinical formulation
The patient meets the criteria for a core diagnosis of post-traumatic stress disorder (PTSD). According to the National Institute of Mental Health (2016), PTSD refers to a mental disorder that some people suffer from after witnessing a horrific or life-threatening event such as a car crash, death of a relative, natural calamities and much more. Persons who qualify for this diagnosis must show the following symptoms according to DSM-5:
Criterion A; at least one symptom is required
Direct exposure: Alfred was personally involved in an argument with his girlfriend that ended in a physical fight. During the encounter, memories of Alfred’s first break up could have crippled back.
Criterion B: At least one required
Emotional distress after exposure to traumatic reminders: Alfred could occasionally get emotional when talking about the possibility of breaking up with his current girlfriend.
Criterion D: At least two required
Overly negative thoughts and assumptions about oneself or the world: Alfred sometimes reported blaming himself for the problems he experienced.
Negative affect: Alfred also reported feeling unhappy, depressed suspicious, needy and even attempted suicide.
Criterion E: At least two required
Irritability: Alfred could easily get irritated something that began after the argument with his girlfriend.
Difficulty concentrating: As evident from the interviews, Alfred had poor eye contact and struggled to concentrate.
Criterion F: According to this criterion the patient should portray the symptoms for at least one month. Considering that my time with Alfred lasted for about two months proves that Alfred indeed had the symptoms for more than one month.
Criterion G and H also assert that the symptoms lead to distress and they should not be caused by other illnesses, substance use or medication. Alfred meets these criteria because he became distressed after the violent encounter with his girlfriend and there are no reported side effects of the use of medication. The symptoms can also not be attributed to any illness or substance use.
It is important to note that PTSD can affect anyone. Studies indicate that some factors can contribute to chances of someone developing PTSD. A case in point is someone who experiences a tragic event. Such a person is highly likely to have PTSD. Therefore, PTSD is not a sign of mental weaknesses as most of the contributing factors are beyond the victims’ control.
The patient could also be tested for Alcohol/Substance Abuse. According to the Diagnostic criteria, a person who qualifies for this diagnosis must portray at least one of the following conditions within a year.
On and off substance use which leads to failure to meet key duty obligations at home, school or at work. For instance, recurrent absence from work leading to termination (Bressert, 2017).
Recurrent use of drugs or alcohol in environments in which accidents may easily occur such as driving while intoxicated
A history of repeated substance abuse or alcohol-related legal glitches such as arrests for being drunk and disorderly (Bressert, 2017).
Persistent use of alcohol or substance even when there are recurrent interpersonal and social problems wholly or partially resulting from alcohol use.
From the earlier description of Alfred’s history, it is evident that he suffers from substance abuse. He consumes alcohol occasionally coupled with the use of cocaine and heroin. What is more, despite his financial and social problem he has not stopped using drugs, which was a key contributor to the two suicide attempts.
Differential diagnosis; ruled out
Delusional disorder: I ruled out this disorder because Alfred does not have some of the symptoms required for diagnosis.
Communication disorder: Alfred had no communication problem as I could understand most of his words. Also, there is no reported case of autism in the family.
Schizoaffective disorder: No clear symptoms that could suggest that Alfred might be suffering from this disorder.
Principal diagnosis
Post-traumatic stress disorder (PTSD).
Treatment
People like Alfred with PTSD can be treated using the two main available options which include psychotherapy and medication. Psychotherapy or counseling entails having sessions with a therapist. The therapist can employ different approaches to help the patient overcome the problem. However, the most common approach involves focusing on the traumatic event to unearth the core fear associated with the event. Patients can also use medication such as venlafaxine, paroxetine, and fluoxetine to control the levels of depression.
References
Bressert, S. (2017, August 30). Alcohol & Substance Abuse Symptoms – Psych Central. Retrieved from https://psychcentral.com/disorders/alcohol-substance-abuse-symptoms/National Institute of Mental Health. (2016, August). NIMH » Post-Traumatic Stress Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml