Read the case study 2. Write the assessment based on the case study using template provided (some areas you will need to m

Caniesha:

Caniesha presents as a 30 year old Caucasian female who meets the diagnostic crtieria for F15.20 Amphetamine-type substance use disorder, severe as evidenced by substance is taken in larger amounts over a longer period of time than intended, there is a persistent desire to use, there have been unsuccessful efforts made to cut down/control use, continued cravings, continued use despite having family/social problems, increased tolerance, recurrent use resulting in failure to fulfill major work or family obligations, recurrent use in situations which create a physical hazard and the substance use is continued to avoid withdrawal. Caniesha also has a current diagnosis for Tourette’s Disorder (F95.2) with multiple motor and one or more vocal tics. She was diagnosed at an early age. It is suspected that the Tourette’s Disorder is substance-induced due to Caniesha being exposed to Methamphetamines beginning as an infant. There is also a diagnosis of ADHD which is common with Tourtette’s Disorder.

Caniesha’s parents were heavy Methamphetamine users and Canisha’s maternal grandparents sought and gained custody of Caniesha when she was 7 years old. Caniesha reports her parents were physically and verbally abusive and that she was told her mother used both Meth and Marijuana while pregnant. Caniesha’s was raised by her grandparents but then reestablished contact with her parents upon graduating from high school. She fell back into the drug use lifestyle as an IV user and continued to use with her parents on a daily basis. At age 25, Caniesha gave birth to a baby boy and moved back in with her grandparents so she wouold have help caring for her son. Caniesha continued to use Methamphetamines and left her grandparents babysitting for days while she was out partying. The grandparents reported her to CPS and filed for guardianship of the boy. There is a court order in place keeping Caniesha away from her son except for weekly visits of one hour each under CPS supervision.

Medical: Caniesha reports having a prolapsed heart valve (meaning it doesn’t close all the way) and she suffers from Vasovagal Syncope. Vasovagal syncope (vay-zoh-VAY-gul SING-kuh-pee) occurs when you faint because your body overreacts to certain triggers, such as the sight of blood or extreme emotional distress. It may also be called neurocardiogenic syncope. The vasovagal syncope trigger causes your heart rate and blood pressure to drop suddenly. That leads to reduced blood flow to your brain, causing you to briefly lose consciousness.

. She denies taking medication for either condition.

Other MH: Caniesha reports hearing voices that no one else hears and seeing objects that no one else sees.

Caniesha has a limited support system. Her significant other is also a heavy addict but has undergone residential treatment and she reports he has 60 days clean at this time.

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Alcohol and Drug Assessment and Treatment Recommendations

Client: Dean Public Time: 02:00 p.m. to 04:30p.m..

Location of Evaluation: Online

Gender: ______ Marital Status: _____ Age:39 Ethnicity: Caucasian

Occupation: basket weaver and stick ball champion Social Security: 999-99-9999

Primary Language: Cherokee Current residence: Mental Hospital

Client willingness to participate in the evaluation: Good

Reliability of information: Good Referral Source: Dr. Feelgood

Client’s level of understanding of the nature and purpose of this interview? Good

Clinician informed client of the nature and purpose of this evaluation. Client was also informed that the results of this evaluation would be shared with Dr. Feelgood to make treatment recommendations as well as prescribe medications. Client indicated understanding and agreed to participate in this evaluation. Upon observation of client, information from others (multi-disciplinary team notes and Dr. Feelgood), and internal consistency of information obtained as well as spontaneous comments made by the patient, I believe the information (data) is reliable. The information contained in this report is believed to be an accurate representation of the client’s current level of functioning and typical behavioral patterns. This report only reflects the client’s condition at the time of this evaluation and may not reflect their condition at any later or earlier time period.

Reason for Referral/Chief Complaint/Presenting Problem(s):

Dean Public was referred to this writer by Kirk Feelgood, M.D. and Chief of Psychiatry at Kerrville State Hospital. Focus of this referral will be to assess capacity of overall client functioning in relationship to Bi-Polar Disorder (if applicable0 and Substance Addiction (COPSD). I agreed to meet with Dean Public for an evaluation and assessment.

Behavioral Observations

Upon arrival of clinician for this evaluation, it was noted that client was wearing a pair of worn and tattered blue jeans and a shirt that appeared somewhat smaller than his upper body size. Client is 5ft. 9 inches with a somewhat groomed beard with noted breathing as not labored and he appeared to be calm. Eye contact was easily established. He did appear defocused at times and easily excitable when certain questions were asked. Rapport with the client was easily established with minimal effort. Client cooperated with this assessment and gave appropriate responses and appeared motivated to pay attention and be responsive to this writer’s questioning. This evaluation took 80 minutes. Dean appeared very alert and oriented to time, place, person, and date. He was somewhat anxious during the assessment. Due to high level of functioning it was felt to not explore a mental status exam due to the obvious appropriate mental status and average functioning of this client.

Identifying Information:

Mr. Dean Public is a 39-year-old Caucasian male who is employed at the local restaurant in which employment began in March 20___. He is a basket weaver and state stick ball champion. He is married and has 2 dependent children. Dean reports he has resided in Plainview for the past two years and has lived in the region most of his life.

Medical:

Dean reports no major or chronic illness or medical conditions in his lifetime. He has been hospitalized for appendicitis and ear surgery as a child. No other health concerns noted at this time.

Family:

Dean reports that he has been married twice and has two children ages 10 and 13 from previous marriages. He remarried about 12 months ago. Recently, Dean has lost a child due to premature birth. He is close to his parents and one sister.

Academics:

Dean reports academic equivalency and has had some college. As a young adult he aspired to get a college degree, but went into computer science due to the ability to be paid over 100k annually. Current functioning appears to be high average and at this time patient does not appear interested in job change or re-entry to college.

Religious:

Dean reports religious beliefs and utilizes prayer often.

Legal:

Dean reports major incidents and criminal affiliation with known gang members (Texas Syndicate and Mexican Mafia 13) in which for most of his adult life and up until two years ago Dean has been involved heavily in criminal activity and stayed fort 12 months at a State Jail for possession of drugs, prior DWI, and other arrests as a result of alcohol and/or drugs. Currently he faces a court appearance for Driving While Intoxicated (DWI) in which the charge could be considered a felony DWI. Dean reports fear in returning to a penal institution for fear of dying while incarcerated.

Mental Status:

Dean was oriented to time, place, person and date. Mood was anxious due to external stressors and is a condition he deals with daily as a result of his mental illness (reported as Bi-Polar I, and/or schizoaffective disorder).

Dean is currently and has been treated for Bi-Polar I disorder since 1989 (16 years). He has been hospitalized at least 10 times due to mental health decompensation or to adjust his medications to alleviate the depressed mood, mania, and psychosis.

Currently he is taking Seroquel daily and Xanax as needed to manage his mental condition. Troy is seeing the psychiatrist at Kerrville Plains Center for MHMR on a outpatient basis to treat his mental illness. There is no suicidal or homicidal ideation during this interview. He was a fund of information with no hallucinatory ideation. It should be noted that Dean has a history of suicidal ideation and attempts secondary to psychosis and decompensation during a manic state or when he discontinues his medications as reported “I begin to feel better and believe that I do not need medications.” Dean has cycled over the past 15 years at least ten years where he would be hospitalized for mental competency or become highly dangerous to self or others as a result of quitting his prescribed mental illness medication and medicate self with alcohol and other drugs of abuse (cocaine, crack, marijuana, and alcohol).

Alcohol and Drugs used/abused:

Dean reports the use of alcohol since the age of 15. He uses crack cocaine at times, but reports cocaine is used secondary to alcohol which he considers as his primary drug of choice. Dean has had three prior treatments for chemical dependency and has had some periods of abstinence of 1.5 years, 8 months, and four months. Dean reports that alcohol has caused problems in major areas of his life along with the mental illness that makes any recovery attempt harder than usual. Dean considers himself addicted to alcohol and drug.

Diagnostic Impression:

Dean is a 39-year-old Caucasian male who presents for an evaluation to determine treatment needs by his primary Psychiatrist Kirk Feelgood, M.D. who has exhausted all treatment recommendations that he thought would prove to beneficial to this patient and he could manage the mental illness more successfully.

It is apparent and obvious that Dean has chemical dependency problems that are seriously exacerbated by the underlying mental illness (Bi-Polar) that makes recovery efforts almost non-existent.

In addition, the need for medications to treat mental illness has proven difficult due to taking six years to prescribe the right kinds of drugs and dosages to alleviate the symptoms compounds Mr. public’s problems. It should be noted that individuals who have a co-occurring psychiatric and substance abuse disorder (dual diagnosis) it takes addressing both disorders in an integrated fashion to ensure the possibility of abstinence, mental stability and ultimately recovery from addiction and symptom management of the mental disorder.

Discussion of Differential mental illness diagnosis:

In completing this evaluation, it comes to one’s mind on how to arrive at the correct diagnosis and treatment recommendations.

Based on internal and external data collection for this patient, it is obvious that he has a co-occurring substance abuse and mental illness. There is also evidence due to the lack of sustained recovery in both aspects that both disorders were not treated in an integrated fashion and the treatment failed for one reason or another.

Weighing out the diagnosis of mental illness of mood disorders Dean has experienced depressed, expansive and elevated or irritable mood. Which is not a direct effect of a medical condition? Dean has experienced an expansive mood at least one week in duration substantiating a manic episode. The manic episode is for more than four days and more severe than criteria for a hypomanic episode. In looking at psychotic features dean has psychosis at other times than during a manic phase.

Discussion of Differential mental illness diagnosis: continued

I would believe that he meets and is diagnosed with Bi-Polar I disorder and Rule-Out Schizoaffective Disorder-Bi-Polar type.

In looking at Major Depressive disorder, Schizoaffective disorder, Bi-Polar I, II, and schizophrenia I believe that his symptoms best match and support the following.

Dean’s psychosis is not related to a medical condition and not due directly to substance use/abuse and his psychosis has not lasted for 1 month or more. In looking at Bi-Polar disorder his mania or depression lasts longer than two weeks. Therefore Bi-Polar I is the closet match to his symptoms, collateral reports and Inter-disciplinary case notes.

Discussion of Differential substance abuse/dependence illness diagnosis:

In looking at the criteria to support substance abuse dependence and substance abuse Dean meets the DSM-IV TR diagnosis and symptomology for alcohol and cocaine addiction. Can he be addicted to more than one drug and have a diagnosis of poly-substance addiction? The answer would be no because Dean was not using three groups of substance within the last twelve-month period. Dean meets the criteria of alcohol and cocaine addiction. The criteria to meet dependence as opposed to being “just” a substance abuser is that tolerance and withdrawal symptoms are present during any twelve-month period of evaluation. Dean meets the increased tolerance of cocaine and alcohol due to the statement made by him that, “I use more than I intend too, and it takes more to get the desired affect that it use to.”

Recommendations

Dean would benefit from Intensive Outpatient Counseling (IOP) for 1-6 months depending on need and progression through the IOP. In conjunction with IOP, he would benefit from individual intervention for the co-occurring psychiatric and substance use disorder to ensure that both the chemical dependency and mental illness are treated in a integrative manner. At this point I do not believe that residential treatment would be of better benefit than IOP and Dual Diagnosis treatment combined with AA/NA 3 times a week.

Based on this psycho-diagnostic interview and pertinent information gathered the following appears to be the focus of clinical intervention after review of a differential diagnosis.

Diagnosis:

Axis I Alcohol Dependence, Cocaine Dependence

Bi-Polar I, moderate, with psychotic features, R/O Schizoaffective Disorder, Bi-Polar Type

Axis II deferred

Axis III None

Axis IV a primary support group, employment, legal and family

Axis V 60-71 legal .past 6 months 55

Treatment Plan:

I understand that the treatment recommendations will need to be approved by the inter-multi-disciplinary team and ultimately Dr. Feelgood and Dean the patient.

Treatment Recommendations:

1. Intensive Outpatient Counseling 1-6 months at 9 hours per week.

2. Dual Diagnosis (COPSD) counseling 1-3 hours of individual counseling per week for six months.

3. Have Dean to encourage family to participate in therapy and learn the aspects of his illness.

4. Attend Alcoholics Anonymous 3 times a week with verification.

5. Blood levels for Lithium as needed and prescribed by Dr. Feelgood.

6. Continue to take psychiatric medications and see Psychiatrist as scheduled.

7. Submit to random urine screens by treatment providers and mental health staff.

With the above treatment recommendations Mr. Public could benefit from treatment locally which will allow him to address his dual diagnosis and continue to be a productive member of society and rehabilitate himself.

If I can be of further assistance for Mr. Public, please call me anytime.

I hope the aforementioned information is found helpful and useful in treating his co-morbidity. I appreciate the privilege to evaluate your client and assisting in meeting his needs.

___________________________________ ___________

Date

Student Name

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Treatment Plan Example

Patient Name:________________________________ Date ____________20_________

Strengths:

Weakness:

Therapeutic Goals	Presenting Problems/Needs
1. 2. 3. 4. 5. 6.	1. 2. 3. 4. 5. 6.

Assessment Results:

AXIS 1 :___________________________________________________________

AXIS 2:___________________________________________________________

AXIS 3 :___________________________________________________________

AXIS 4 :___________________________________________________________

AXIS 5 :___________________________________________________________

Plan:

1._________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

4. ________________________________________________________________

Presenting Problem:__________________________________________

Goal #: _________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Client Measurable Objectives	Target Date	Responsible Person/s
Intervention Services	Frequency	Staff /Services that will assist in attaining goals treatment
		Dr. Paul Walker, LCDC, LBSW, LPC-S

GOAL#_________________________________________________________________________________________________________________________________________

Progress/Lack of Progress___________________________________________________

Modification/Rationale_____________________________________________________

Measurable Objective# Progress/Lack of Progress or Modification/s

I have been informed and understand the treatment information contained in the individual treatment plan, including the expected benefits and possible risks involved. I understand that I have the right to refuse this treatment, and I am aware of the potential consequences (if any) of such a refusal.

My signature indicates that I am aware of the consequences (if any), benefits, and course of treatment as well as the diagnosis, costs incurred associated with therapy.

Can Leave blank

_____________________________________________ _________________________

Client /Guardian Signature Date

_____________________________________________ _________________________

Counselor Signature Date

____________________________________________ __________________________

Other Family (if applicable) Date

____________________________________________ __________________________

Other Family (if applicable) Date