I

DIAGNOSES:

 

AXIS I: Depressive disorder, not otherwise specified.
            Post Traumatic stress disorder
            Dissociative State

 

AXIS II: Personality disorder, not otherwise specified

 

AXIS III: Healthy Adult

 

AXIS IV: Moderate stress of chronic depressive disorder, having grown up with an abusive, neglected childhood with superimposed substance intoxication.

 

AXIS V: Global assessment of functioning equals 45.

 

Reason: The patient is a 20-year old gentleman who was a direct admit from #$#$ after an overdose on Coricidin and Dextromethorphan.

 

Condition: During the hospitalization, the patient had a brief moment of decompensation where he became violent and began throwing furniture and broke a table, and when he threw a piece of furniture, one of the nurses apparently from report broke her arm deflecting the item of furniture. The patient reconstructed himself most promptly following this very brief episode of violence and has been demonstrating model behavior ever since. His sleep has improved. His appetite is good. He has been demonstrating excellent impulse control. He has no shakes or sweats. He has participated in all aspects of programming and has been social with peers. Patient reports himself to be less depressed and less anxious than upon admission. He denies any suicidal or homicidal ideation and also denies being a risk to himself and others. He denies any auditory or visual hallucinations or delusions. He has no objective signs of psychosis.

 

ADDENDUM: I spoke with the patient’s therapist and social worker and according to reports that during sessions the patient would sometimes have substantial shifts of personality or his presentation, such that the therapist was suspecting that he may have intermittent dissociative states. At the time just prior to his violent spell, I had been in session with him was explaining to him that he would have to be in hospitalization a little bit longer than was anticipated, the patient began to stare off in almost a trance-like state. There were long periods of silence. I was wondering to myself as to whether or not he was in a dissociative state or not.

 

The patient has a long history of childhood neglect and abuse and moved around substantially. There were various and numerous men that has introduced into the household, some men while he was a boy abused him, yet this man demonstrated enormous psychological strength and was able to mobilize his high level of intelligence and was able to despite extremely adverse circumstances graduate from high school, and despite it not being a part of his cultural heritage was able to in a very healthy way enlist into the armed services where he would become a part of a more structured environment.

 

The patients also struggles with the stress of having a girlfriend who is pregnant by him and had been recently introduced to the mood-altering experience of Dextromethorphan, and I believe because of the very early traumata he knew, may actually have posttraumatic stress disorder. When trauma is introduced in the the preschool and toddler and early years of an individual’s life, manifestations of posttraumatic stress disorder are often times variant from the more traditional diagnosed DSM-IV criteria for posttraumatic stress disorder, but yet carry with it many of the attributes that are present. This is why I strongly suspect that he might have PTSD. However, it must not be overlooked, not just alone the trauma that he has experienced , but also the substantial psychological strengths that this young man has and has overcome much. I believe he is a very intelligent, articulate man with much to offer the armed services and the community in terms of being a productive ongoing member and that he has a good prognosis and will thrive with very little attention from some meaningful psychotherapy and ongoing work. I would strongly encourage him to begin our day hospital program or in some programming like that.

 

Signed,

Randy M.D.

Reviews

[Coyote Poetry]

A very good beginning. I like the set-up of this chapter. Giving a real life feel to the story. You got my attention. I will keep reading. A excellent opening chapter.
Coyote

[Calypso]

I like this mainly because I found it to be educational. I don't know much about diagnosing mental illness mainly because I'm a social work undergrad student. Maybe I'll learn this as I work on my psychology minor.