7 Psychiatric Evaluation James is a 26 y/o single, white, male, who is currently enrolled in a graduate program at The College of New Jersey (TCNJ) majoring in comparative literature. CHIEF COMPLAINT:...

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7 Psychiatric Evaluation James is a 26 y/o single, white, male, who is currently enrolled in a graduate program at The College of New Jersey (TCNJ) majoring in comparative literature. CHIEF COMPLAINT: “I am not sure what to do regarding my medication. My current psychiatrist doesn’t really know me and the visits are for 7 ½ minutes. I want to lose weight, but I don’t want my symptoms to return.” HISTORY OF PRESENT PROBLEM: At this time, James is stable and asymptomatic and has no particular psychiatric problem that is troublesome. However, over the past two years, he has gained 130 pounds from his medication - a combination of Quetiapine 300 mg HS and Paroxetine 60 mg QAM. He is 5 foot eleven and currently weighs 310 pounds. In addition to the weight gain, the medication causes him severe fatigue. The weight gain is also causing him to develop physical problems, such as pain in his knees and back. He would like to change his medication, however, is fearful his symptoms may return, especially a compulsion involving reading, i.e., reading a page over and over again with an inability to move forward. He is half-way through a master’s in comparative literature and a return of the compulsion would not allow him to continue in this very difficult program, requiring reading of over 300 pages each week. Last summer, his psychiatrist rapidly reduced the Quetiapine over 8 days, i.e, decreased to 200 mg for 4 days, decreased to 100 mg for 4 days and then discontinued. Simultaneously, his psychiatrist rapidly titrated him up on Lurasidone, i.e., 40 mg for 4 days, increased to 80 mg for 4 days, increased to 120 mg for 4 days. This resulted in him developing severe akathisia. The psychiatrist then put him back on his current medication, telling him that this is the best course of action because he is unable to take the newer, less weight gaining atypical antipsychotics. PAST PSYCHIATRIC TREATMENT HISTORY: James remembers a compulsion of counting steps that developed when he was about 12 years of age. He would have to count stairs whenever he would go up or down them. If he forgot to count, he would have to return to either the top or bottom and start over. Sometimes, he would believe he made a mistake and would have to return to the top or bottom and start over. The stressors he recalls at the time were his father being diagnosed with leukemia and moving to Flemington, NJ, from Hillsborough, and losing his friends. One year later, when James was 13 years old, his father died. The death was very difficult for James, for although his father had many problems, he also loved James very much and in some way, James always felt loved by him. One week after his father’s death, James had an episode of rage and started beating one of his younger brothers and breaking furniture. His mother called the police and he was sent to Fair Oaks Psychiatric Hospital where he had a 3-day stay and was diagnosed with Bipolar Disorder. He was prescribed Depakote, which he believes that he took for a short period of time upon discharge, but then stopped on his own. He remembers he then became very unsatisfied with his body and wonders if he had some form of body dysmorphia, for he began weight lifting compulsively, going to the gym every day and staying for many hours, for the next year or so. He also started playing football. At the age of 14, he started individual psychotherapy with a humanistic-existential therapist who he liked very much. Originally, he was referred by his high school guidance counselor, whom he told about his stair counting compulsions and the death of his father. He did well throughout the next several years of high school. His therapist loved literature and with the therapist’s support, James became an avid reader in addition to playing football. He decided to give up football after finishing his junior year. Within short period of time, he again developed symptoms of anxiety and OCD. He began having thoughts of killing himself as well. Reading, which had become his favorite hobby was impossible. He had a compulsion of having to read the same page over and over again, never able to proceed, thus he had a total loss of enjoyment in reading. He went to a psychiatrist who told him that he did not have bipolar disorder but severe OCD that was strep induced (PANDA) and that made the OCD irregular. He remembers her saying that normal OCD is more consistent and doesn’t go away, where with James, he had more flare-ups. James does not support her theory. Nonetheless, the OCD became crippling, and he was not able to read a book with any enjoyment. His psychiatrist prescribed Fluvoxamine 50 mg, which was gradually increased to 300 mg. Later, Risperidone 0.25 mg BID was added. He had some improvement in symptoms, but gained 20 pounds, which he attributed to the Risperidone, thus he stopped this medication. Although the Fluvoxamine never took the compulsions away completely, it took some of the edge off of his anxiety and decreased the compulsions to a level in which he could function. He graduated high school and went to Seton Hall University, where he did well during his first two year of college. At the end of his sophomore year of college, he weaned himself off the Fluvoxamine. During his junior year of college, he developed severe anxiety and his compulsions of counting stairs and being unable to read reoccurred in full force. He dropped out of college and returned home. When he returned home, he started back with his former psychiatrist and started back taking fluvoxamine. He eventually returned to a Christian College in Georgia and switched majors from English Literature to Religious Studies. He started praying frequently. By his senior year of college, he slept on a blanket on the floor for the whole semester, because he would experience intense anxiety, fear, and discomfort on his mattress, obsessively fixated on blood rushing through his legs and causing the springs to vibrate ever so slightly. He also developed either scrupulosity, a type of OCD characterized by pathological guilt about religious issues, or delusions with a religious content that were manifested with a theme of guilt rather than persecutory or grandiose in nature. He also had obsessive thoughts or possibly delusions that wanted him to self-harm by destroying parts of his body. It is difficult to determine if they were obsessive or delusional in nature and James is trying to understand what happened to him. At this time, his OCD with reading a page over and over again was still intense, and thus, he had major difficulty reading. He also had high anxiety, social problems and an inability to connect to a peer group. He frequently had suicidal ideation and thoughts of self-harm related to his hatred of his body. He was also diagnosed with Asperger’s Disorder and Sensory Integration Disorder because he had an intense response to sounds and tactile vibrations in the floor from people upstairs who would send him into a state of despair. This may have been a type of misophonia, a disorder related to OCD in which the person has sensitivity to certain sounds. He went to a psychiatrist in Georgia and was diagnosed with resistant Major Depressive Disorder and Generalized Anxiety Disorder. At this time, he prayed for three plus hours per day, was extremely introspective, and attended bible study each day. He didn’t know how much of this was what he took in from his father and mother or how much was his own belief system. He was prescribed Clonazapam 0.25 BID and Olanzapine 200 mg. He was institutionalized at Erlanger in Chattanooga, Tennessee, for several days in his last semester. Upon discharge, he went back to New Jersey and was hospitalized at Somerset Medical Center for 24 hours. He stated that was diagnosed with Bipolar Disorder after a five-minute interview and was prescribed Quetiapine 200 mg and Zolpidem 10 mg. He overdosed on Zolpidem after discharge, which he states was a failed suicide attempt. Then, he was admitted to Carrier Clinic, and they kept him on the same medication of Clonazapam and Quetiapine and added Trazadone 50 mg for sleep. He returned to the Christian college in the spring of 2014 and graduated with a BA in Biblical and Theological Studies in May, 2014. After graduation and returning to New Jersey, he starting seeing a new psychiatrist. James wanted to start a master’s program in comparative literature and could not read because of his reading compulsion. The psychiatrist sent him for IQ and learning disability testing and his total IQ result was 156, which is in the genius range, and he had no learning disability. The psychiatrist then increased the Quetiapine to 300 mg and added Paroxetine, 60 mg. Within 3 months, he gained sixty pounds and then 40 more over the past two years. However, on these medications, the reading compulsion went entirely away for the first time in 8 years and he is able to pursue the master’s degree. He fears that if he stops the medication, his reading compulsion will return, however, the excess weight of 130 pounds over his natural weight, his decreasing physical health, and extremely low energy makes working in addition to taking classes, nearly impossible. He needs at least 12 hours a night to function. At this time, he is only taking one course at the College of NJ. PAST & CURRENT SUBSTANCE USE: Patient does not use substances. MEDICAL HISTORY: Patient is obese weight 310 pounds. All lab tests within normal limits. BP 124/80. FAMILY HISTORY: James is an only child born to John and Roberta Hilger on March 15, 1990 in Hillsborough, NJ. John was of German descent and had an undiagnosed mood disorder and experienced rages and mood swings. He was college educated and worked as a music teacher in a middle school and played a number of brass instruments. James describes him as a very high energy, unpredictable, and charismatic man, who could weave a compelling narrative. But, he was also a man who could be easily “set off” and go into rages that were terrifying to James. He was also verbose, had an inflated sense of self and could become very grandiose. James remembers him giving a disjointed, but charismatic sermon at a Christian church. He also remembers him starting a marriage counseling practice, saying he was a therapist, when in fact, he was not. He also was told that his father, in 1988, would constantly recite
Answered 1 days AfterJul 15, 2021

Answer To: 7 Psychiatric Evaluation James is a 26 y/o single, white, male, who is currently enrolled in a...

Arunavo answered on Jul 17 2021
143 Votes
Running Head: HEALTHCARE MANAGEMENT     1
HEALTHCARE MANAGEMENT     3

TREATMENT INTERVENTIONS OF PATIENT SUFFERING FROM OCD AND OTHER MENTAL DISORDER
Table of Contents
Treatment Therapy and Medication    3
References    4
Treatment Therapy and Medication
The patient is having a history of childhood trauma and stress, along with the symptoms of anxiety and OCD right from the age of 12. This kind of behavior is mainly found when a person losses some guidance or does not get that much emotional support that he/ she expects. As discussed by Potik et al., (2020) to treat these kinds of patients the first line of treatment is providing...
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