Module 8 Discussion: Case Analysis
Return to Module 8
Jose is a 60-year-old Peruvian male presenting to psych emergency (PES) with complaints of, “If I don’t get my wife out of my house, I’m going to kill myself or kill her.” Pt reported he had put a gun to his head and threatened to shoot himself last week in front of his wife. Pt reports
increased relational conflict with his wife for the past 6 months. He cites conflict with his wife as a major contributor to his instability. Based on Jose’s self-report and clinical assessment by a psychologist, draw a conclusion regarding the most appropriate diagnosis or diagnoses for Jose. In doing so, take into account the additional information.
Pt endorses feelings of hopelessness, lack of interest, anhedonia, crying spells (“I break down crying for no reason”), irritability, agitation and anger (“I see red”), racing thoughts, and sleep
disturbance (“trouble staying asleep”). Pt states he has had a nickname (“They call me flash”). Pt reports he is isolating from others. Pt added that he is dealing with multiple health issues that have contributed to his worsening mood, including chronic back pain and uncontrolled diabetes, for which he inconsistently takes his insulin.
Jose was born and raised in public housing in a poor neighborhood of San Francisco. Pt has a history of child abuse and trauma, a history of molestation and physical abuse, and witnessed his brother die. Pt was molested by a 15 yo male when age 5. Pt’s sister was reportedly “pimped out” by their mother. Pt was “never acknowledged” by his biofa. When age 6, pt reports he saw his older brother upstairs and who apparently fell backward, hit his head, and died in front of him. Pt also reports he almost died on 2 occasions in his life. At age 18, he was shot in the leg, and a separate time he was stabbed. Pt reports increase in trauma symptoms, emotional overwhelm over the past few years. He is thinking more about his past, and this has led to more intense feelings of sadness and anger. Pt endorses periodic flashbacks from the past and nightmares. (“She (wife) hears me yelling, talking in my sleep.”)
Pt reports drinking alcohol daily. He tells me he had MVA when he rear-ended a car on the road 3 nights ago and was charged with DUI. Pt believes that his intoxication was due to taking a sleep aid and “a couple of beers.” He says he does not want to fully quit drinking but does want to cut down. He reports a family history of substance abuse. Sister was “a crack addict.” Mo was addicted to heroin. Pt reports his drinking ETOH has led to incidents of physical violence with his wife. Pt endorses DV in their marriage. Wife has left scratch marks on him. Wife was in custody for DV in the past. Pt was incarcerated for 2 yrs in San Quentin from 1989 to 1991. Pt has a hx of selling drugs and assault w/ a deadly weapon. Pt is married for the past 25 years. Pt has 1 son age 22. Pt does not have a close relationship w/ son. Pt would like to repair his relationship w/ his wife so that she does not leave him. He lacks other supports. Works as a self-employed mechanic.
ROI on file. Writer called wife with pt’s authorization to remove guns from their home. Wife states all guns have been removed from the house. She says she would like to support pt. Pt states, “I was trying to get attention” when asked about putting a gun to his head and threatening to hurt wife.
Pt has been followed for medication by a psychiatrist on and off for 10 yrs, most recently 2 years ago. Pt is currently not on any psychotropic medication.
Suicide Risk Assessment
Suicide: Endorses suicidal ideation
Suicide risk factors include: Acute/worsening/symptomatic mental illness, hx of psychiatric hospitalization, active substance use, impairing impulsivity, access of firearms/lethal means, and older age.
Homicide: Endorses thoughts of harming others, denies intent or plan.
Risk formulation: Pt is clinically judged to be at an elevated acute risk of self harm and elevated acute risk of harm to others.
Risk Assessment Criteria
Formal criteria to be met for inpatient hospitalization includes the following:
The person is a danger to self (suicidal ideation with intent and plan)
The person is a danger to others (homicidal ideation with intent and plan)
The person is gravely disabled (unable to care for self & basic needs)
Please note: This is subjective in nature and requires many years of clinical training. The case analysis provides exposure and practice in this key area of clinical assessment.
Mental Status Examination
Behavior: psychomotor agitation
Demeanor/Manner: cooperative, forthcoming
Speech: somewhat rapid
Mood: depressed, anxious, agitated
Affect: congruent to mood
Thought process: logical
Thought content: endorses SI/HI; denies any AH/VH
Orientation: oriented X 4
Attention: within normal limits
Concentration: within normal limits
Memory: intact recent and intact remote
Fund of Knowledge: normal
Impulse Control: poor
Insight: poor
Judgment: poor
a) Identify clinical issues and concerns that may be affecting Jose and his mental health.
b) What diagnoses best fit the case of Jose using the Axis system?
Axis I
Axis II
Axis III
Axis IV
Axis V
