Psychological_Report

Comprehensive Psychological Report Client: K Gender : Male Date of birth: xx/xx/1922 Marital Status : Widower Employment: Retired Treating clinician: Psychologist Referral Source K is a 75 year old man referred by Pleasant Paddocks nursing home for assistance with managing his depressive symptoms and some socially inappropriate behaviour; mostly nudity. Referral Problem Nurses at Pleasant Paddocks disclosed that K reported having suicidal intentions recently and that they found K sitting naked at the nursing home bus stop last week. Prior to this incident, nurses have also reported they found K unconscious one morning, naked in the corridor with an empty bottle of alcohol in his hands. NOTE: Nudity is forbidden at Pleasant Paddocks. History of Presenting Problem K disclosed that he has been in and out of bouts of depression for some time. More recently he felt his mood and thoughts were becoming “darker”. He stated he had also completely lost interest and pleasure in things he used to enjoy doing. K reported however, after his conversation with a fellow patient, that he decided he had more living to do. K said he remembered what it meant to “Seize the day”. When asked about his nudity, K explained that he had previously joined a nudist group and enjoyed being “free” and feeling “alive”. Substance Use History K did not report having any illicit substance use in the past or at present. He did disclose that he smokes approximately 28 cigarettes a day and if alcohol is available he would drink until he felt intoxicated or “drunk”. Psychiatric and Medical History K has asthma which he treats with ventolin as required. K was previously diagnosed with depression by his treating doctor at Pleasant Paddocks and was prescribed Prozac. He has also been diagnosed with dementia – Alzheimer ’s disease (AD). Previous medical report has indicated that K experiences hallucinations associated with his AD. In addition to the above medical conditions documented in K’s file at Pleasant Paddock, K reported that he was diagnosed with Tourette’s Syndrome (TS) in Poland when he was very young. The symptoms he reported consist of uncontrollable twitches and an uncontrollable urges to touch things with his index finger. He said when he met someone new he often had an uncontrollable urge to touch their nose with his index finger. However, consistent with most people with TS, the symptoms had slowly improved throughout his adulthood. K reported that his uncontrollable urges associated TS had led to some unpleasant events in the past. He provided an example of having been physically assaulted one time after touching someone he just met on the nose, and as a result his skull was split in half. K explained that the scar on his head was from having a steel plate put in between his scalp and skull after the incident. He further disclosed that this steel plate became magnetised after he survived a lighting strike. As a consequence, his head is now magnetic. Another medical condition K reported having in the past was testicular cancer. He was admitted into remission after one of his testicles was removed. Although he no longer has testicular cancer, K disclosed that he was diagnosed as sterile. Family Psychiatric and Medical History K reported that his mother had lead poisoning from working in the mines. He is unsure of any psychological diagnosis, but he explained his mother was obsessed with counting her fingers, often had conversations with people that were not there, and there were times when she mistook him as an intruder and would attack him. K reported no significant psychiatric and medical history for his father. Educational and Vocational History K reported having only attended the first few years of primary school. He disclosed that during that time he had one friend. He said most people at school called him a “Thick”. Together with his friend, they were often bullied by other children. As a consequence, K’s mother took him out of school and home-schooled him herself. K explained his mother was illiterate, but she taught him lots of facts about the world. K showed the therapist the book he had around his neck and said that he had been writing facts he learnt about the world in it ever since. K admitted he carried this book with him everywhere. K informed the therapist that his first job was working as a lumberjack with his father in Poland. Since he arrived in Australia as a migrant, he reported working in many different jobs. He worked at the Spottswood rubbish dump for a while, sold pencils in the streets, worked as a lint picker for some time and he also collected golf balls at a golf club. However, K disclosed that he was “sacked” a lot but he didn’t know why. Life circumstances and important relationships K reported although he enjoyed working with his father and learning facts from his mother when he was a teenager, he did at times wish things were different. He felt marginalised from the rest of their village in Poland. When he was eighteen, K said his family home unexpectedly burnt down (his mother had left the stove on through the night) and he found his parents frozen to death in the nude nearby. Also around this time the Germans invaded Poland and he was forced to flee to Australia as a migrant. When K arrived in Australia he rented a small house with eleven other migrants. He tried his best to assimilate and even changed Pollish name to an English one. K got a job at the Spottswood rubbish dump and he tried to save money by not indulging. K reported he learnt English off a television he found at the dump and discovered more and more facts. K disclosed that he also tried to make friends at his work but he found it quite difficult. It was when he was trying to make friends at work that he was physically assaulted and split his skull in half. K reported that when he was in his late 30’s, early 40’s, his optimism began to crumble while he wondered how he survived so much bad luck. K disclosed that he could not stop thinking about fates horrible dealings, that he felt like he was a victim to the world, powerless, and that he even considered “throwing it all in”. K said during this period of depression he came across a statue with the words “Seize the Day – Carpe Diem” written on it and these simple profound words helped him realised he can change his own world and that is exactly what he decided to do. K stated he stopped believing in fate and “seized the day”, every day, from then on. He reported feeling free and alive. It was then, he joined the nudist group and became vegetarian and joined an animal liberation society. Not long after this, K said he met his wife, who was a nurse at his hospital when he was being treated with testicular cancer. They were soon married and when K was diagnosed as being sterile, they adopted a little disabled girl (limbless). K reported that he quit work to stay home with his daughter and taught her all the facts he knew. K said that those were the happiest years of his life. K disclosed that his wife’s brain unexpectedly clotted and she passed away on his 65th birthday. At present, K reported that his daughter is currently living in United States of America working as a lawyer in her own practice, fighting for the rights of the disabled. K said that he has developed some good relationships at Pleasant Paddocks, especially with his roommate. Assessment A semi-structured interview was used to gather information about the K, the problem and relevant history. Formulation Presentation K is a 75 year old man who recently presented with symptoms consistent with a diagnosis of major depressive disorder. Predisposition K’s mother’s psychiatric history suggests a genetic predisposition for K’s depression. K may also have been predisposed for depression by environmental factors. For example, his mother’s unpredictable behaviours and mistaking him as an intruder, being bullied at school and later at work, may have contributed to the formation of his negative core beliefs of inadequacy, failure, rejection, being unlovable and worthlessness. Precipitation and Perpetuation The initial onset of K’s presenting problems was in his late 30’s, early 40’s, when he first experienced feelings of helplessness and considered “throwing it all in”. More recently, K disclosed that he has been going in and out of dream worlds (previously diagnosed as hallucinations associated with his AD by his treating doctor), and that his depressive episodes were usually precipitated by these “magical” dreams. As K comes out of his dream worlds and back into reality, the realisation of his ongoing stressors (e.g. deterioration of his health, feelings of loneliness) activated his negative core beliefs and these are maintained by maladaptive assumptions (e.g. “I’m powerless”, “I have been a victim to the world all my life”, “I should just throw it all in”). Cognitive distortions (e.g. catastrophising, mind-reading, and all-or-nothing thinking) further contribute to negative automatic thoughts (e.g. “I’m a failure”), leading to depressive symptoms during times of stress, such as post hallucinations or “magical” dream experiences. In addition, K’s deteriorating health condition and the restricted freedom he perceives of having at Pleasant Paddocks (e.g. forbidden to be nude, not allowed to leave Pleasant Paddocks without permission/guardian) has limited and decreased his ability to participate in activities he used to find pleasurable. Together, K’s hallucination-depression cycle and the limited pleasurable activities contribute to the ongoing maintenance of his difficulties. Prognosis Positive factors: good resilience – evident from previous life experiences, desire to learn new facts – motivator/inspiration, holds on to “Seize the Day – Carpe Diem” Negative factors: living away from his only family member (daughter) – feeling of loneliness, deteriorating health condition – grief for loss of health, lack of understanding from people (staff/ & patients) at Pleasant Paddocks in regards to what he has lived through and why he may be behaving the way he is as a result. Diagnosis Axis I 296.33 Major Depressive Disorder, Recurrent, Mild 294.1x Dementia of the Alzheimer’s Type 307.23 Tourette’s Disorder Axis II V71.09 No Diagnosis Axis III None Axis IV Adjustment to life transition, Inadequate social support, Death of wife, Removal from home Axis V GAF= 70 (current) Treatment Plan and Rationale K was referred to therapy for assistance with managing his depressive symptoms and some socially inappropriate behaviour (nudity). The goals of the assessment were to i) provide feedback on case formulation to K and Pleasant Paddocks nursing home and conduct psychoeducation to increase staff’s awareness of the contributing and maintaining factors of K’s presenting problems, ii) increase pleasant activities to enhance behavioural activation thereby alleviating K’s thoughts and beliefs that serve to maintain his depression, iii) and enhancing social support. Description of the treatment process K attended his first therapy session with psychologist at Pleasant Paddocks. The therapist took a client-centred approach during the session to help build good rapport with K. The session focused on building a good client-therapist relationship and exploring and assessing K’s past and present circumstances. K was well engaged and highly motivated to overcome his difficulties as much as possible. Treatment outcome and recommendations If K was only diagnosed with depression, future therapy recommendations may be providing him psychoeducation about depression, and explaining to him (based on cognitive behaviour therapy model) how our body, thoughts, emotions, actions can all interact with our history, culture/society, environment. K may also benefit from assistance with increasing his self-awareness of what situations may precipitate and maintain his depression by working with him to identify and explore these factors. However, as K has also been diagnosed with AD, such therapy strategies may not be effective for K due to his cognitive impairments associated with his AD. After taking into consideration all of K’s life experiences and his current circumstances, it is recommended that staff of Pleasant Paddocks assist K by scheduling more pleasant activities that K finds enjoyable into his days (e.g. K may like to start an animal liberation association within Pleasant Paddocks, possibly giving K permission to be nude an hour a day in a designated area – male only lounge room, his bedroom etc). It is also recommended that staff of Pleasant Paddocks help K engage in some suitable exercises to help improve his mood (e.g. walking, stretching). Increasing pleasant activities and engaging in suitable exercises may also help strengthen his social network within Pleasant Paddock, and increase his opportunity to have more positive emotional experiences that may further assist with alleviating his depressive symptoms.