DIAGNOSTIC PSYCHIATRIC EVALUATION
Patient Name: Macaroni, Ella
Date of Birth: April 10, 1991
AGE: 16 Years
Date of Evaluation. June 22, 2007
INFORMANTS: Patient; and Biological Parents, Greg and Lila Macaroni
REFERRED BY: Jonathan Abel
Evaluated by: Jess P. Shatkin, M.D., M.P.H.
PRESENTING PROBLEM:
Chief Complaint:
"We're concerned about her lack of attention, moodiness, depression and lack of motivation. She is disconnected, and there seems to be no sense of presence. She seems like an observer, letting things happen to her. Life seems to act on her, but Ella does not seem to act on life. We also feel there is a disconnect between actions and consequences such that she doesn't seem to understand that not studying now will have a direct impact on her immediate future. She also does not recognize her good fortune and is reluctant to commit to success. Finally, she has a pattern of blaming others."
History of Present Illness:
Ella is 16 years of age female with a longstanding history of poor motivation and what parents describe as “disengagement and passivity.” Her parents wish to have her evaluated because of these concerns in addition to poor academic functioning and what they believe may be depression. Parents note that she is frequently lethargic and does not appear to express any passion for her daily activities. Parents are frustrated with Ella's refusals to complete her school work, to plan effectively and demonstrate executive and organizational skills, and to "engage" in her life. Parents report Ella suffers from poor self-esteem and a fear of success such that if she demonstrates her true ability, she fears she will always be expected to perform well, and life will become increasingly difficult. She seems to look for confrontation, per parents, and will sacrifice herself in order to "win" an argument. Parents report that the primary current stressor is likely to be her boarding school, St. Peter’s Academy. Although Ella has been there for seven months, the adjustment has not been easy for her. Her academic performance is also poor which is troublesome.
Regarding mood, parents report that her mood is "stressed, depressed, moody and desultory." Ella herself reported her mood as "okay" during her interview, but noted that she does often feel sad. Neurovegetatively, she sleeps well, about 6-8 hours during the week nights and 10-12 hours on the weekend. She has generally a poor appetite, although she reports having gained three pounds in the past three months. Both parents and Ella report that she suffers from lethargy and poor energy but has difficulty with attention and concentration. Ella's parents deny that she suffers from frank anhedonia, noting there may be a slight decrease in her enjoyment of every day activities. Ella herself notes slightly more anhedonia, reporting that she is simply not passionate about anything at this point and does not get a great deal of pleasure out of her activities. There is no reported hopelessness nor suicidal ideation. Parents do report that Ella has expressed some passive death wishes in the past when angry. There is no history of psychosis or mania.
Parents do not view Ella as anxious, although on occasion she will become overwhelmed with anxiety. Recently, for example, her mother misplaced her wallet while shopping, and Ella became very anxious and distraught. There is no history of separation anxiety, panic or phobias. Historically, Ella has reacted very strongly to certain foods and become nauseous and suffered from diarrhea at times. Parents have wondered if there is a connection to anxiety. All major medical explanations for the GI upset have been ruled out by the primary care practitioner. No history of Obsessive-Compulsive Disorder or social anxiety.
Parents identify three symptoms of inattention, including being poorly organized, losing things frequently, and being easily distracted; but no other symptoms of hyperactivity, impulsivity or inattention were noted. Parents endorse all eight of eight oppositional defiant features, such as frequently losing her temper, arguing, being angry frequently, defying parents' requests, blaming others for things that are her doing, purposely annoying others, being touchy or easily bothered, and spiteful and vindictive. No history of conduct or legal difficulties. No history of motor or vocal tics. There is no evidence of pervasive developmental delay and no history of self-injurious behavior. No history of eating disordered behavior. Parents report that she may have been traumatized by a couple of events. She was bitten by a dog at 3 years of age and had to go to the emergency room secondary to an elbow jam at 8 years of age; however, Ella reports no sequelae from these events, and parents are unable to identify any frank reactive symptoms.
PAST MEDICAL HISTORY:
Her primary care practitioner is Ethan Rose at NYU last seen about one year ago. No current treatment. Ella has no history of head trauma, loss of consciousness or seizures. No surgeries or hospitalizations.
PSYCHIATRIC HISTORY:
She has been seeing Jennifer Ree, an M.A. counseling trainee, since late fall. She saw Frank Burges, M.D. once for an evaluation and was diagnosed with depression. She was given medication, Prozac, by Dr. Burges, which she took for about four days but then discontinued. The reasons for the discontinuation were not entirely clear. Parents reported they were under the impression that Ella suffered a stomachache and so discontinued the medication in consultation with the acute care clinic at St. Peter’s. Jennifer Ree reported that starting the Prozac coincided with a surprise visit from her sister, which was very upsetting, made her anxious, and may have promoted in some way the GI distress. Ella herself reports that she discontinued the medication because it was making her feel more angry and irritable. There was no manic agitation reported, no change in sleep, and Ella denied all symptoms of mania experienced when she took the medication. No history of psychiatric hospitalizations.
MEDICATIONS:
None currently.
ALLERGIES:
No known drug allergies.
SUBSTANCE ABUSE:
Parents and patient deny alcohol, tobacco and drug use.
DEVELOPMENTAL HISTORY:
Mother is P4, G3. First pregnancy was a miscarriage. The patient is pregnancy #3. No difficulties with conception, gestation or delivery. The patient was born by normal spontaneous vaginal delivery at full-term, six days late. No assist was necessary. Mother did take prenatal vitamins throughout the pregnancy but no other medications. Mother had an occasional glass of wine throughout the pregnancy but reports her use was minimal. No use of tobacco or drugs during the pregnancy. Motor, language, toileting and social milestones were all met within normal limits. No history of enuresis.
PSYCHOSEXUAL HISTORY:
Menarche was initiated at 11 years of age. The last menstrual period was last week. Parents note severe mood changes with Ella's periods such that prior to the onset of menstruation, she will become increasingly moody for a few days and will then continue to be “moody” for days into the menstruation. The patient has never used oral contraception. She denies being sexually active. She had a boyfriend briefly who she kissed. Boys are reportedly interested in her. She had never seen an OB/GYN.
EDUCATIONAL HISTORY:
She is currently at St. Peter’s Academy in the tenth grade. Kindergarten through ninth, she attended the Arrow school where she was an average to above-average student. She was never suspended or expelled. She never skipped or repeated a grade. No learning disability was ever identified, although she was never tested. No history of IEP or 504. Currently her grades are passing, but in a few cases she is being quite academically challenged and is having some significant difficulties. Her parents shared with me a letter written by Clive Owens, her Dean at St. Peter’s. Mr. Owens reports that at the Winter Academic Review Committee, the faculty voted to place Ella on one week of academic restriction because of her grade of a 2 in chemistry and have now placed her on “year-end review” for three unsatisfactory grades. Mr. Owens goes on to note that Ella must demonstrate progress in her attitude, effort, conduct and academic performance in order to remain at Andover next year.
FAMILY HISTORY:
Mother, Lila, is 51 years of age. She denies all medical, psychiatric and substance abuse history. Father, Greg, also 51 years of age, also denies medical, psychiatric and substance abuse history. The oldest child, Norma, is 19 years of age. She suffers from scoliosis. The youngest child, Troy, is 12 years of age. He has no reported difficulties. Mother's mother, 78 years old, is possibly depressed, has a history of polio, alcohol abuse and tobacco abuse. Greg’s mother, 75 years of age, suffers from Alzheimer's. Both parents' fathers are reportedly alive and well. Mother notes that she is the eldest of five children, that her first brother and first sister may both be depressed. Father has one sibling, a brother, with no apparent history.
SOCIAL HISTORY:
The family lives in New York City. Ella's hobbies include art, drawing, playing video games, enjoying being with the family, soccer, and squash. Regarding discipline, parents report that they are not united on their approach, and it is often haphazard. They find Ella difficult to motivate and inspire and note that their anger and threats only escalate her behavior. There is no religious study in the family. Mother is a chief marketing officer for a public relations company. Father is an architect, self-employed.
REVIEW OF SYSTEMS:
Negative.
PHYSICAL/NEUROLOGICAL EXAMINATION:
Not indicated.
Lab work including CBC and thyroid panel were within normal limits. Free T4 was 1.0 and TSH was 2.06. These labs were drawn on March 23rd.
COLLATERAL CONTACTS:
I spoke to Mr. Owens on March 20th. He indicated that much of Ella's difficulties have to do with procrastination and overcoming a hurdle of perfectionism. He reported, "She critiques herself so severely that she always feels insufficient. Socially, she on the way to becoming comfortable here. Much of the problems she suffered in the fall had to do with social functioning. She is not a social outcast but does not seem to have strong social contacts at this time. In terms of academics, she has produced some high-quality work when pushed, but the difficulty lies more in completing the work. Chemistry was a particular problem with her, perhaps because of a personality conflict with the teacher who is very strict. Generally, I observe her as being hunched over and withdrawn, more than joyful and bubbly. I have heard from her teachers that she can be stubborn, does not listen well and is sometimes quietly resistant." Dr. Burges and I exchanged voice mails on 3/21/07 but were unable to speak. She noted that when she saw Ella for evaluation on February 26, 2007, she found her to be quite depressed. She prescribed Prozac 10mg with instructions to take one for five days and then double the dose; however, Ella went to the St. Peter’s acute care center after 3-4 days and complained of gastrointestinal distress. The Prozac was discontinued. She only had one visit with Dr. Burges. I requested Dr. Burges’ evaluation but never received it. I spoke with Jennifer Ree on March 22nd. She reports seeing Ella since mid October. Ella referred herself for a therapist, and Ms. Ree was assigned. She reported that Ella came into therapy feeling "overwhelmed and upset, complaining mostly about social issues such as wanting to fit in and being preoccupied with how others would perceive her. That has remained the focus of our work together. If I did not have communication with teachers, I would not even know of Ella's academic difficulties." Since mid January, they have been meeting twice a week. They are engaged in open-ended talk therapy, not CBT. No diagnosis has been given. Ms. Ree is a second year counseling student at the Graduate School of Education at Harvard. Finally, I communicated with Rick Tortelio by e-mail on March 23, 2007. He stated in his e-mail, "The thing is that Ella has to do her homework and her assignments on time. Why this is not happening, I guess is the question. She is a valuable student to the class and school, but when the teacher collects homework and papers, she has nothing to give him. It puts a damper on her participation and engagement in the class and seems to start up a negative spin that can last over a few days until eventually she hands in something. Then, the whole process starts over again on the next assignment."
RATING SCALES:
Ella completed a Children's Depression Inventory (CDI) scoring a total of 26 points, placing her at the 76th T-score or 2½ standard deviations above normal.
MENTAL STATUS:
Generally, Ella separated from her mother easily and engaged with me in my office for over an hour. She was pleasant and had no difficulty discussing a full range of topics including school, home, and personal matters. She was not resistant to our conversation and did not appear defended. She maintained good eye contact. She was dressed appropriately for her age. Her hair continued to fall into her face throughout the session for which she apologized and commented on the need for a new haircut. She was otherwise a well-developed, well-nourished, slender 16 years of age Caucasian female who appeared in no apparent distress and appeared her stated age. She wore orthodontic braces. Her behavior was normokinetic. Her speech was of a regular rate, rhythm and normal volume. Her mood she reported as "Okay…sad at times." Her affect was pleasant, generally full, but tearful at times. The topics around which she became tearful were not consistent but had much to do with being away at school or going back to school. No perceptual disturbances were identified. Thought processes were linear and goal directed. Thought content was devoid of delusions and paranoia. No suicidal or homicidal ideation. Sensorium and cognition was grossly intact. Judgment and insight appeared reasonably good. Impulse control and reliability appeared good.
ASSESSMENT:
Ella is a 16 years of age female with a long history of opposionality and defiance at home and more recent negative mood, which seems to have worsened over the past 4-5 months. She has been in therapy, which has made her feel better, but has not improved her symptoms. She has longstanding difficulties with her parents and is the most difficult of the children at home to manage, but she has never engaged in any severely conduct disordered behavior. She has had a difficult time adjusting socially at school and has few friends remaining from her years at Chapin. She prefers to be at home with family and seems to have withdrawn more from friends and hobbies in the past six months. She has received minimal treatment.
Patient: Ella Macaroni
DSM-IV Diagnoses:
Axis 1: Major Depressive Disorder & Oppositional Defiant Disorder; rule out PTSD, rule out Adjustment Disorder
Axis II: Rule out Learning D/O
Axis III: N/A
Axis IV: Ongoing difficulties at new boarding school (St. Peter's Academy)
Avis V: GAF = 55
Ella's two primary diagnoses, Depression and Oppositional Defiant Disorder, are the most pressing and well-established concerns that we will address in this treatment plan. Parents report eight out of eight persistent symptoms of oppositional and defiant behavior, which are corroborated by reports by patient's teachers. Symptoms of Major Depressive Disorder include moodiness (irritability), depression and lack of motivation, anhedonia, poor appetite and slight weight gain, and inattention. Further evaluation is necessary to rule out the possibility of a learning disorder, regarding her poor performance in school, as she has never been tested before. Additional evaluation may be indicated in the future to rule out the possibility of P.T.S.D., as patient's parents report possible traumatization by 'a couple of events' in the patient's past. Although Ella displayed three symptoms of inattention (including poor organization, losing things frequently, and being easily distracted), no other symptoms of hyperactivity, impulsivity, or inattention have been reported. As such, we may confidently rule out any diagnosis of Attention-Deficit Hyperactivity Disorder. Ella's depression appears to be moderate in severity, in that she sleeps well (about 6-8 hours on weekdays, and 10-12 hours on the weekend), and that although she has a poor appetite, she has gained three pounds in the last three months.
Treatment for Ella's Depression and Oppositional-Defiant Disorder are to go hand in hand. Jess Shatkin, M.D., writes in "Treating Child & Adolescent Mental Illness" that, regarding O.D.D., "Addressing concurrent problems, such as ADHD, depression, anxiety, and learning disorders, often considerably alleviates many of the disruptive behaviors." Given this, it may be safe to assume that addressing Ella's depression first and foremost will help minimize or even eliminate her oppositional behaviors towards her parents and teachers. It may be that Ella has suffered from depression for some time now (concurrent with the reportedly longstanding oppositional behaviors), which has only recently come to light. Corroboration evidence for this comes from the fact that Ella's maternal grandmother ('possibly depressed') has a history of alcohol and tobacco use, and that the mother's first brother and first sister also 'may both be depressed.' Although no definite diagnoses have been established for any of these family members, it may be inferred that symptoms of depression run in Ella's immediate family. Nonetheless, if treatment of depression does not lead to a remission in oppositionality, then Ella's O.D.D. may be treated as a standalone issue - a plan for which will be discussed later.
Psychotherapy Interventions:
It was noted in the psychiatric eval. that Ella has not received CBT for her depression, making a 12-14 week course of CBT strongly indicated at this time. The TADS study of 2004, funded by the NIMH, indicated that the best treatment response for depressed adolescents came from a combination of medication and behavioral therapy, and is the primary basis of my recommendation that Ella be treated with both a course of CBT and an SSRI other than Prozac.
Psychopharmacological interventions:
Additionally, we may consider attempting the use of a different SSRI, perhaps Sertraline, for short-term management of Ella's depressive symptoms. If Ella is a partial responder to Sertraline, then in the absence of any major negative side effects, augmentation with Buproprion or aripiprazole may be attempted. It should be noted that the combination of Buproprion and sertraline carries major risk of drug interactions, namably, an increase in risk of seizures and an increase in blood levels of sertraline, possibly increasing the risk of side effects. As with any combination of drug prescriptions, Ella should be closely monitored by a physician or psychiatrist during the course of this medication treatment.
Ella's parents are currently employed in stable, high-paying jobs (the mother is the marketing director for a public-relations firm, while the father is a self-employed architect), which indicates ample resources - money and insurance - with which to pay for treatment. Based on Ella's psychiatric evaluation, talk therapy with Jennifer Ree, an M.A. counseling trainee, has made Ella feel better, although it has not improved her symptoms of depression. Additionally, the 10mg Prozac prescription written by Dr. Frank Burges caused adverse mood and G.I. reactions, as self-reported by the patient, which makes it unlikely that either parents or patient will consider another attempt at using Prozac for management of depressive symptoms.
Additional psychopharm. treatments to consider:
Any consideration of 'stronger' treatments for Ella's depression should be viewed with extreme caution. In the course of treatment, if Ella fails to improve with her schoolwork and social functioning, tricyclic antidepressants may be tried, plus augmentation if a partial response is observed. Failing that, an MAOI may be used; if all else fails, electroconvulsive therapy may be used as a last resort. Any of these treatments should only be considered if there is a. no improvement following combined cognitive-behavioral therapy and SSRI medication and b. a lowering in GAF.
If Ella's oppositional-defiant behaviors do not improve despite an improvement in depressive symptoms, then they may be treated as stand-alone issues. Following Shatkin's recommendations in Treating Child and Adolescent Mental Illness, Multisystemic Therapy (MST) may be employed, in addition to the use of an antidepressant such as Abilify. If Ella were younger, Parent Management Training or Parent-Child Interaction Training might be employed, but as the patient is 16 y/o, she falls well outside of the age range where such interventions are indicated. Antipsychotics and other medications for O.D.D. are not indicated at this time, as Ella has no history of legal or disciplinary issues at school.
Educational/Academic interventions:
Academic interventions, such as a 504/IEP plan, may be considered at this time if, following testing, a learning disorder is diagnosed. Receiving extended time on exams, as well as having homework and assigned projects modified to her individual learning needs, could prove quite beneficial to Ella's education. However, it does not seem like this treatment path is likely to be needed; Ella's academic performance at The Arrow School between kindergarden and ninth grade was average to above average, and it is unlikely that any private school would miss any obvious learning disorders in that great span of time. In all likelihood, cognitive-behavioral therapy will help alleviate Ella's tendency towards procrastination and perfectionism, improving her school performance to the level that is expected of her at St. Peter's Academy.
Protective factors:
Ella has a number of protective factors working towards a favorable treatment outcome. Firstly, her family is willing and able to pay for any treatments that are indicated (given their employment). Secondly, she was an average/above average student at her previous school, and is receiving passing grades at her current school. Thirdly, although some of her family members may have had major depressive disorder or dysthymia, none of them were so affected by it as to cause any hospitalizations or suicide attempts. Lastly, Ella has never had legal or disciplinary troubles at school as a result of her oppositionality. All of the above seem to indicate that, given the interventions recommended above, Ella may see a dramatic, sustained improvement in her social and academic functioning.
Timeline of treatment:
1. 10 week course of Sertraline for management of core symptoms of depression, plus augmentation with Buproprion if partial responder.
2. 12- to 14-week course of CBT for long-term management of depression
3. 5-week trial of TCA therapy if GAF continues to decline, with no response from SSRIs
4. Multisystemic therapy for treatment of O.D.D. if behavioral issues do not resolve following an improvement in symptoms of depression.
DIAGNOSTIC PSYCHIATRIC EVALUATION
Patient Name: Lee, Andre
DATE OF BIRTH: December 19, 1990
AGE: 15 Years
DATE OF EVALUATION: May 16, 2006
INFORMANTS: Patient and Biological Parents, Marie & Neil Lee
REFERRED BY: Rob Canes, M.D.
Evaluated by: Jess P. Shatkin, M.D., M.P.H.
PRESENTING PROBLEM:
Chief Complaint: Per Patient: "Recently I started dating this girl, and we decided that we love each other and want to get married. In my head, I heard something say, ‘kill her.’ I had just nearly finished this book, House of the Spirits, by Isabel Allende, and after a while, the voice changed to ‘kill Amy,’ my girlfriend's name, not just ‘kill her.’ It hurts to think about it. I have been having images of her dying in my arms. I know that I would never do it because I love her. Another voice says, ‘but you love her, cut it out!’ That is the good voice, and that's my voice".
Per Father, Neil: "I feel guilty because of language that I've used in the past with Marie. I've had problems in the past, and I've started to internalize this stuff." Per Mother, Marie: "I just didn't want to wait to see what is going on. Andre is so in love. He's afraid he's not worthy of his girlfriend. He's always been very sensitive and over the past few years, a lot has happened. For example, we've lost our apartment in Manhattan and moved to Queens. I think that he's tired and depleted."
History of Present Illness: Andre is a 15 years of age white male who has had a recent upsurge in sadness over the last nine days prior to our visit with complaints initially of command auditory hallucinations telling him to kill his girlfriend. He recently finished the book House of the Spirits by Isabel Allende and had not had any of these thoughts or experienced any of these images prior to reading the book. Mother contacted Dr. Rob Canes, MD, a physician, with whom she worked in the past, and he recommended the evaluation here. They requested an urgent evaluation. On evaluation, Andre noted that he has had no symptoms of this sort in the past. He stated that when he was younger, he had recurring dreams about his mother falling into a pit and dying, but no other such fearful images.
He has had no change in his activities of daily living, i.e., his showering, eating, dressing, social activities and schoolwork continue to be coming along nicely. He recently received a report card just a day or two before our appointment indicating some of the best grades he has ever received. Mother reported she feels that Andre is simply exhausted and that this book is too intense for him and should have not been recommended by the school. Although the patient initially reported auditory hallucinations hearing a male's voice and a whisper telling him to "kill her, kill Amy," he reports that he is now able to control the voice and stop thinking about it for extensive periods of time. He reported feeling relieved during our appointment because he had not heard the voice in about half a day. He stated, "I can block it, but I could hear it if I want to." He described the voice as emanating from within inside his head. He denied thought insertions, thought withdrawals, thought broadcasting and ideas of reference. He denied visual, tactile and olfactory hallucinations. He denied paranoia and suicidal & homicidal ideation. Upon further questioning, he described the auditory hallucinations as voices within his head, then his own voice, and then ultimately as we continued to discuss the symptomatology, as his own voice and his own thoughts.
He was quite often tearful during the evaluation. He described that his mood is "guilty about having these thoughts. I want to tell Amy that I love her. I want to be honest with her and tell her that I'm having these thoughts." Neurovegetatively, he has been sleeping about seven hours at night with perhaps more on the weekend. He has had periods of time when he has only slept for about five hours at night, sometimes for weeks on end; but during these days, he stays up awake because he is doing schoolwork, and he will often nap for two hours during the middle of the day. He has no difficulty falling asleep, describes a normal energy level, has a good appetite and good attention and concentration, and parents concur. There is some moderate anhedonia over the past nine days secondary to guilt about his girlfriend, but no hopelessness. He reported, "I don't think I'm depressed. I've been the happiest I've ever been for the past four months since I met Amy." There is no indication of manic symptoms. He is now often staying up late to talk to his girlfriend on the phone and do his studies, but again still sleeping seven hours at least within each 24 hour period (including nighttime sleep and naps). Otherwise, no increase in risk taking behavior, no change in talkativity, distractibility or goal-directed changes.
Regarding anxiety, there is no history of somatic difficulties, phobias or separation anxiety. He has reported one panic attack in the past 10 days, but none prior; and there is no fear of having another panic attack. Regarding possible symptoms of obsessionality, he reports fear of his parents dying and the periodic fear of his mother falling into a pit or getting lost (e.g., his prior recurring dream as a child). He stated with regard to his mother, "I feel I need to protect her. I feel bad for her sometimes and that I'm losing time with her." There were otherwise no ascertainable obsessive-compulsive symptoms.
He denied symptoms of ADHD, oppositional defiant and conduct difficulties, and parents concurred. He did have three episodes of shoplifting as a child, but there have been no sequelae from that. No history of tics or Tourette's. No evidence of pervasive developmental delays, self-injurious behavior, physical, emotional or sexual abuse, or eating disordered difficulties.
PAST MEDICAL HISTORY:
His primary care practitioner is Dr. Schwartz. He last saw him about one year ago. He is not currently receiving any treatment. He had surgery and is status-post tonsil and adenoidectomy and a hernia repair. He did have a febrile seizure at 4 years of age with loss of consciousness. He had an EEG at that time and also six months later, which showed no abnormalities. No history of head trauma.
PSYCHIATRIC HISTORY:
He has never seen a therapist, never been psychiatrically hospitalized, never been seen by a psychiatrist or been on any medication.
CURRENT MEDICATIONS:
Advil 400 mg p.r.n. for headache. He takes Advil about every two weeks. No vitamins or herbal medications or dietary supplements other than Chinese tea he has been drinking with his girlfriend since about January. He says he urinates more when he drinks the tea, but otherwise has no difficulties.
ALLERGIES:
No known drug allergies.
SUBSTANCE ABUSE:
The patient reported that he does not smoke tobacco, that he does not use drugs or alcohol. He has tried alcohol on occasion with friends, but he has never used to any significant degree. There is no history of other drug use or intravenous drug use.
PSYCHOSEXUAL HISTORY:
He has never had sexual intercourse. He has had a few girlfriends prior to Amy. He and Amy have decided they will not have intercourse for at least a few years. They are kissing and doing some petting. No history of pregnancies or sexually transmitted diseases. No reports of sexual malfunction.
DEVELOPMENTAL HISTORY:
Mother is P5 G4. The first pregnancy resulted in an abortion. Andre is the fifth pregnancy. He has three male siblings. Mother reported she had gestational diabetes with all pregnancies. She was insulin-dependent with up to 10 injections a day during her pregnancy with Andre. She was not on bed rest, however. She did not otherwise take any medication and did not use tobacco, alcohol or drugs during the pregnancy. Motor, language and toileting milestones were all reportedly within normal limits.
EDUCATIONAL HISTORY:
The patient is a tenth grader at Bates High School. His grades, according to the April 2006 progress report that his mother gave me, range from 87 at a low to 95 at the high end, most grades falling within the 90s. He has no history of repeating or skipping grades, no history of suspensions or expulsions, and no history of Special Education. He has no 504 or IEP plan. He is typically described as an A/B student.
FAMILY HISTORY:
Father, Neil, is 55. He has a history of depression with psychosis approximately seven years ago. He was treated with Wellbutrin, Risperdal, Mellaril and Haldol at various times. He was ill for about three months but has had no difficulty since that time. Mother, Marie, is 54. She continues to have insulin-dependent diabetes mellitus. She was depressed subsequent to her husband's depression and was treated with Remeron and Wellbutrin for about six months. Andre has three brothers. Brian is 23 and has no reported difficulties. Eddie, 26, has a seizure disorder, is currently on anticonvulsants, has made one suicide attempt, and was psychiatrically hospitalized as an adult for 7-10 days. James, who is 29 and who has a history of anxiety, has been treated with medication in the past. Both father and mother have first cousins with chronic paranoid schizophrenia; mother's is a first cousin once removed. Mother also has a first maternal cousin with pervasive developmental delay or possibly Asperger's. Father reports that he drinks alcohol off and on and has drunk up to 18 drinks a day. He says he is currently drinking more and more, perhaps even almost every day. He acknowledged trying to cut down. He acknowledged being annoyed by others' comments about his drinking. He denied guilt or ever having used alcohol as an eye opener.
SOCIAL HISTORY:
The family lives in Flushing in Queens. The patient takes an express bus and a train to school daily. They previously lived in Manhattan until one year ago. They lost their apartment because it was lower income housing that was bought and changed ownership. The patient's hobbies include playing on the computer, playing chess, and reading. He has good friends. He has had friends since first grade. Amy is his first real girlfriend. He was raised Jewish and had a Bar Mitzvah. Neil, his father, teaches history at a public school. Mother, Marie, is a nurse and teacher. His social engagements are described as quite healthy.
REVIEW OF SYSTEMS:
Negative.
PHYSICAL EXAMINATION:
Blood pressure 122/70. Pulse of 80 and regular. Height 67". Weight 216 pounds. His head was normocephalic and atraumatic. His neck was supple. No lymph nodes were noted. Chest exam was clear to auscultation. No CVA tenderness. Heart demonstrated SI and S2 auscultated, regular rate and rhythm with no murmurs, gallops or rubs. Abdominal exam was nontender and nondistended. Positive bowel sounds in all quadrants. No hepatosplenomegaly. Extremities showed no clubbing or edema.
NEUROLOGIC EXAM:
Cranial nerves II through VII were intact. Pupils were equally round and reactive to light and accommodation. Extraocular muscles were intact. Motor exam 5/5 bilaterally throughout. Tone was within normal limits. No tremor. Sensory exam was intact to soft touch bilaterally throughout. Deep tendon reflexes were 2+ at the patella and brachium bilaterally. Cerebellar exam was intact to rapid alternating motion and finger-to-thumb. Gait within normal limits. Negative Romberg.
MENTAL STATUS EXAM:
Generally, Andre was cooperative and friendly with the examination. He was appropriately dressed and slightly husky, a bit overweight. Otherwise he appeared healthy. He was pleasant and easy to engage. His behavior was normokinetic, but notable for crying frequently when talking about his symptomatology and demonstrating a great deal of guilt for thinking these thoughts. Speech was of a regular rate, rhythm and normal volume. His mood he described as alternately guilty and sad. Affect: Largely appears guilty and sad, does have numerous moments when he smiled and appeared to have full affect. No perceptual disturbances identified. Thought processes perseverative on his guilty feelings and worries. Thought content: No delusions or paranoia, notable obsessions regarding his girlfriend (worrying about these thoughts of harming his girlfriend) but no other obsessions were identified. No suicidal or homicidal ideation. Sensorium and cognition were grossly intact. Judgment appears good. Insight moderate. Impulse control and reliability appears good by history.
COLLATERAL INFORMATION:
Life History Form completed by mother is consistent with the history reported. Andre has been increasingly anxious and distraught, concerned about thoughts he has had about these feelings with a fear that he cannot control his thoughts or make them go away. Mother notes that he is crying easily and having trouble forgiving himself for these thoughts. He reported to his mother "I know the thoughts are preposterous, but they scared me". Otherwise, the Life History Questionnaire demonstrates no findings of concern.
ASSESSMENT:
Andre is a 15 years of age white male with no known psychiatric history or major medical problems. He presents for this evaluation after nine days of increasingly worrisome thoughts prompted by reading a book for school. He believes that he and his girlfriend will be married in the not too distant future. He is in love with her. They have been dating for four months. These thoughts have scared him so much that he feels depressed at this time, and although not concerned that he will act on these thoughts, he is terribly worried that there is something wrong with him. There appears to be no substance use or abuse and no true psychosis. He is clearly anxious and troubled. He has good social support. He is doing well academically and has a family who clearly loves and supports him.
Patient: Andre Lee
Axis I: Depression with psychosis
Axis II: N/A
Axis III: N/A
Axis IV: command auditory hallucinations instructing patient to kill his girlfriend
Axis V: 85
Andre Lee is a 15 year old Caucasian Male with a family history of depression with psychosis (father), of suicidality (brother), and of paranoid schizophrenia (Mother's and Father's first cousins). As such, his presenting symptoms of extreme sadness and command auditory hallucinations are to be taken into account with full context in mind. That said, Andre has no prior psychiatric history; he has never seen a therapist, never been psychiatrically hospitalized, and has never seen a psychiatrist of been on any medication. Furthermore, during his mental status examination, he had a full affect, and had no delusions, no paranoia, and no suicidal/homicidal ideation. Given that Andre's daily activities, showering, eating, dressing, social activities and schoolwork all remain unchanged over the past nine days - since the beginning of his symptoms - we may assign him a GAF score of 85-90. His social engagements are described as 'quite healthy', and he came to the Child Study Center promptly upon the onset of auditory hallucinations. All of the above are prognostic indicators of a good treatment outcome.
I am hesitant to prescribe any form of treatment for Andre at present, firstly due to the brevity of his symptoms, secondly due to the mildness of his symptoms (they do not, at present, affect his social or academic standing), and thirdly because his parents may not be able to afford costlier forms of treatment; it was reported that they had recently lost their apartment in Manhattan and had to relocate to Queens. Lastly, Andre's symptoms began immediately after reading a novel, "House of the Spirits" by Isabel Allenda, and were unprecedented. As such, no immediate course of treatment seems necessary; if anything, a careful observation of Andre over the next few weeks, with a possible follow-up, would be recommended. If the patient and his parents insist on some form of treatment, a form of psychotherapy (CBT or perhaps DBT) could help Andre better cope with his hallucinations, by improving his reality-testing skills, and help him deal with his feelings of guilt and inferiority. Because no problems were reported with his relationship towards his mother and father, family-based interventions are not indicated. Likewise, because Andre's reality-testing skills appear to be intact, and because no suicidal or homicidal ideation has yet been reported, psychoparm. interventions are unecessary at this time. Similarly unnecessary would be any educational, academic or vocational interventions: Andre's latest grades are some of best he has ever received, and there is nothing to suggest a learning disorder of any kind. If there is a school psychologist that Andre can talk to as needed throughout the school day, I would reccomend that he go see him/her whenever worries about these hallucinations arise. Again, careful, continuing observation of the patient is essential over the next several weeks/months, as his family history casts hallucinations in a particularly worrying light, but that - and CBT/DBT - are the only treatments indicated at this time.
Treatment plan:
1. Observation of Andre by parents & school psychologist (if available), with follow-up calls by psychiatrist at CSC for 3 months
2. 12 week course of CBT if symptoms of psychosis do not improve, plus atypical antipsychotic medication (Risperidone) if suicidal or homicidal ideation presents & persists, or if command auditory hallucinations persist & begin to interfere with patient’s day-to-day functioning
