Adelle Iusim MS 3 Time of Interview: 10:00 am Date of Interview: January 27, 2012 Place of Interview: Salud Mental, Mayaguez,

Puerto Rico Case Presentation 2 Id: EMS is a 56 year old male who lives in Mayaguez with his wife. He is divorced and he remarried to his current wife of 15 years. He has 2 sons with his first wife a 35 yr old and 29 yr old. He has 2 children from his 2nd wife a 23 yr old and 21 yr old. Patient worked for 15 yrs as an industrial mechanic. Is currently on disability leave. Patient is reliable. Chief Complaint: Me siento triste, sin animo, sin energia, no puedo dormir, desde mas de 2 meses. Present Illness This is a 56 year old male patient with past history of Major Depressive Disorder who is currently taking Paroxetine 40 mg, Divolproex 500mg TID, Xanax 2mg PO HS, Haldol 2mg PO HS. He presents with decreased energy, absence of pleasure, decreased sleep, decreased eating, anxiousness, stress, slowness and hallucinations which call out his name and various faces for 2 months. He also refers irritability and having lots of coraje or anger. He refers having an accident at work 5 years ago where a machine fell on him and herniated several cervical discs. He refers that a month later his mother day and he attributes these causes to the beginning of his symptoms. He states that his wife noticed several changes in his behavior and thought he might be depressed. He decided to seek help at her insistence. The patient denies use of any additional psychiatric medications. He denies current alcohol use, denies current cocaine use. States that he smokes a box of cigarrettes a day and that he smokes marijuana once a day to calm him down. Denies obsessions or compulsions, psychosis, pressured speech, grandiose thoughts, and flight of

ideas, palpitations, intrusive thoughts, agoraphobia, repetitive behaviors, experiencing or being witness of a life threatening event. The patient also denies any suicidal/homicidal ideas. He denies command hallucinations. Past psychiatric history: He refers having similar symptoms to those he is presenting now previously on two different occasions. He refers no psychiatric hospitalizations. Past medical history: The patient has a history of a work accident that herniated C2-C3 which occurred in 2007. Refers hypertension, hyperlipidemia, diabetes mellitus type 2, arthritis, sinusitis and tendinitis. Patient states that he is currently taking Metoprolol of 50mg PO BID, Insulin 75/25 injectable, Ramipril 2.5 mg PO daily, Aspirin.160mg PO daily. The patient has not suffered from seizures, hyperthyroidism, hypothyroidism, or anemia. He refers a catheterization in 2002 and a gallbladder removal 1990. He refers head trauma as a 6 year old child for which he was in a coma for several months but he does not remember the cause. The patient has no known allergies or drug sensitivities. Vaccinations are up to date. Family Medical History: There is a history of hypertension, diabetes and alcoholism in the family. Father is alive and suffers from diabetes, hypertension and alcoholism. Mother is alive and suffers from diabetes. Patient has 2 brothers. The 60 yr old brother is an alcoholic and suffers from hypertension, dyslipidemia and kidney failure. His 52 yr old brother is healthy. Family Psychiatric History: Father has a history alcoholism and committed homicide as well as attempted suicide. The patient refers no other psychiatric conditions in the family.

Social/Developmental History: Prenatal History and Perinatal History: EMSs father was a grocery store manager and his mom was a cashier at a clothing store. He was born in Bronx, NY as an uncomplicated vaginal birth at 40 weeks from a planned pregnancy. Early Childhood: The patient is the second child and has 2 siblings from the same father and mother. He reports meeting his developmental milestones and no illness or traumas during infancy. Middle Childhood: He reports living in the Bronx New York in an apartment in public housing. He states that his father was an alcoholic who verbally, emotionally and physically abused his mother. He refers no personal physical abuse because he would leave the house when his dad was too drunk. He refers that his dad did abuse him verbally and emotionally. He negates any sexual abuse. He states that he had a good relationship with his brothers though they would sometimes get into physical fights. He states that his dad left the house when he was 7 years old and they moved in with his aunt because of their poor economic status. He refers being very poor and having very little clothing, toys and food. He reports liking school because it was an escape from the troubles at home. He reports having a small group of friends. The patient states that at the age of 8 he was removed from his moms care because his older brother accused his mom of abuse. He refers that this was a lie and his mom never hurt them. Late childhood: At the age of 8 his brothers and him where removed from their home and placed in a halfway home in Hicksville, NY. He refers getting into many fights with the children there. He attended school but would cut a lot of class and started smoking cigarettes at

the age of 11. He drinking began drinking and smoking marijuana at the age of 14. He graduated high school when he turned 18 and left the halfway house and moved back to the Bronx. Adulthood: When back in the Bronx he had a series of jobs working in grocery stores and clothing stores. He continued to drink, smoke cigarettes and marijauna. At the age of 21 he meets his first wife and they get married. His first son was born in NY. At 25 he started becoming involved in gangs. He states that it was necessary to be protected otherwise you were vulnerable to be attacked. He states that owned a gun and was involved in many shootings as well as murders. He refers no legal troubles because the police were too afraid to go into those neighborhoods. He read in the newspaper that his dad was suspected of throwing a man off a roof and then tried to kill himself. He began using cocaine at 26 as well as crack on a regular basis. He refers very little contact with his family members and refers to his first symptoms of depression. At the age of 27 their second son is born. He was born with Down syndrome. They decide to move to Puerto Rico where his parents are originally from. They move to Ponce, PR where his mom has some aunts. He begins to work as a mechanic at a friends shop. He refers a tumultuous relationship with his wife with lots of fighting. Patient continues occasional cocaine, alcohol, cigarette and marijuana use. They separate after 4 years of living in Puerto Rico and she moves back to NY with both children. He states that he has symptoms of depression during this time. Patient met his second wife at the age of 31. She was from Mayaguez, PR. He stopped using cocaine and crack. Their first son is born and they move to Mayaguez. Their second son is born 2 years later. The boys are currently 23 and 21. They do not live in Mayaguez but he refers good relationships with them. He refers good relationship with his wife. The patient currently states that he lives alone with his wife and a dog in a house in Mayaguez, PR. He states they have a good relationship and she offers him support. He is currently on disability leave due to the accident he had in a factory 5 years ago. He also

refers that his mom died a few months later. He identifies these as triggers for his current symptoms. He states that he does not see his two sons from his first wife because they are back in the states. He says that the older one who is currently 35 is married, had kids and lives in Alabama. He has not seen them. He states that the younger child with Down syndrome who is 29 lives with his mom and that he talks to him twice a week. He refers getting really stressed and upset because he feels that his ex-wife does not treat him well. He states that she locks him in his bedroom and screams at him at all times. This situation gives him a lot of coraje. He states he does not take cocaine or crack anymore. He refers that he still smokes box of cigarettes a day, drinks the occasional bottle of beer during the weekend and smokes marijuana daily. He also drinks 4 cups of coffee daily. He refers having many confrontational situations with his neighbors. He states that they do not like his dog walking around the neighborhood. He states that they have closed off the areas where he can walk the dog and that he barely takes the dog out because of it. He refers that the situations with the neighbors make him very angry and at times he wants to kill them because of it. He refers no actual plans to kill his neighbors. Mental Status Exam: General appearance, behavior and attitude EMS is a 48 year-old Hispanic male of 5 ft 10 in and 185 lbs. Patient looks his age. At the time of examination, he was well groomed and well dressed. On appearance, there were no signs of tremor or abnormal movements. Patient was cooperative throughout the interview. He maintained eye contact at all times. Speech Articulates clearly, answers questions spontaneously, although at slow rate and speed. Affect Appropriate Mood Depressed

Thought a. Stream Decreased b. Form Coherent, relevant and logical. No formal thought disorder, no new or created words. Questions answered spontaneously and directly. c. Content No general worries or concerns. He denies any delusions, phobias or compulsions. Suicidal or homicidal ideation was not detected. Perception Patient exhibits normal perception. Symptoms, such as illusions, misinterpretations, depersonalization, passivity phenomena, were not elicited. Cognition He was alert and orientated to time and place. He was able to answer questions and recall his past. Insight Poor Judgement Poor

MMSEScored: 30/30

Review of Symptoms y HEENT: Head: No headaches, Eyes: normal vision according to age, Ears: normal hearing according to age, Mouth: no abnormality, Neck: no lumps or swollen lymph nodes y y y y y y y Skin: No rash or other abnormalities Respiratory: No cough, some sputum production Cardiovascular: No palpitations Neurological: No decreased sensation on extremities GI: No pain or other complaints GenitoUrinary: No changes in stool frequency or stool composition. Musculoskeletal: Neck pain

Physical Exam EMS is an alert, active 56 year old male y Vital Signs: o Height is 510, weight 185, BMI: 26.5, BP 125/75, RR 17, no difficulty breathing and no use of accessory muscles. y Skin o Normal skin color, skin warm but appears dry. Nails without clubbing or cyanosis. No rash, petechiae, or ecchymoses. y HEENT o Head the skull is normocephalic/atraumatic (NC/AT). Hair with average texture. Eyes Visual acuity not impaired. Ears acuity good to whispered voice. Tympanic membranes (TMs) with good cone of light. Weber midline. Nose nasal mucosa pink, septum midline; some mucus production, no sinus tenderness. Throat (or Mouth) oral mucosa pink, no softening and inflammation of the gums, pharynx without exudates o Neck Trachea midline, Thyroid isthmus palpable

o Lymph Nodes No cervical, axillary adenopathy y Thorax and Lungs o Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular, no rales, wheezes or ronchi. Diaphragm descends 4 cm bilaterally. y Cardiovascular o Regular rate and rhythm, no murmurs or bruits y Abdomen: o Abdomen is protuberant. It is soft and nontender, no palpable masses or hepatosplenomegaly. No CVA tenderness y Musculoskeletal: o The range of motion is severely decreased in neck. The range of motion and reflexes of other extremities are intact. y Neurologic: o Normal gait. Cranial Nerves normal; full neurologic exam not performed Diagnosis Axis I: Moderate, Major depressive disorder recurrent, r/o Substance induced mood disorder with depressive features Axis II: deferred Axis III: hypertension, dyslipidemia, Diabetes Mellitus 2, disc herniation C2-C3, tendinitis, arthritis, sinusitis Axis IV: interpersonal problems GAF-55 Differential (5) Differential Substance induced Mood disorder with depressive features Positive Pertinent y y y y Irritable Feelings of sadness Anhedonia Trouble sleeping y y y Negative Pertinent Anxiety No suicidal or homicidal thoughts No feelings of guilt and worthlessness

y y y y

Eating less Psychomotor retardation Lack of energy Symptoms developed during or within a month of substance use or withdrawal

Symptoms precede onset of substance abuse

y Major Depressive Disorder , Recurrent y

Symptoms cause impairment

2 or more major depressive episodes Interval >2 consecutive months in which criteria no met for MDD

No suicidal or homicidal thoughts

No feelings of guilt and worthlessness

y y y y y y y Dysthmia y y

Feelings of sadness Anhedonia Trouble sleeping Eating less Psychomotor retardation Lack of energy Duration > 2 weeks
Sadness 2 or more symptoms of depression

Depressed mood for most of the day for more days than not for at least 2 years

Loss of interest and pleasure

Never more than 2 months without the symptoms in 2 years

y y y

Changes in appetite Changes in sleep patterns

Significant impairment in daily functioning

y y

Low self-esteem Feelings of hopelessness

y y Bipolar Disorder

Poor concentration Not directly due to a substance or medication

y y y y

Feelings of sadness Loss of interest Lack of energy Duration > 2 weeks

No symptoms of mania like grandiose, increased goal directed activity, flights of ideas or racing thoughts

y y

No elevated mood No excessive involvement in pleasurable activities with high risk negative consequences

GAD

y y y y

Nervousness Difficulty sleeping Fatigue Irritability

y y y

No trouble concentrating No muscle tension No worries about multiple nonspecific things for a period of > 6 months

Biopyschosocial profile EMS is a 56 year old male who presents with a Moderate, recurrent MDD. Patient is currently compliant with medications. Biological There is a lot of research that shows that early head injury and concurrent observation or personal history of physical abuse predisposes individuals to violent behavior..

Studies show that people who suffered maltreatment as children were twice as likely as those who had normal childhoods to develop persistent and recurrent depression, and less likely to respond well or quickly to treatment for their mental illness. Researchers found that those who had been exposed to violence showed increased brain activity in the anterior insula and amygdala. This builds an enhanced reactivity to a threat cue such as anger. This is a neurobiological risk factor which increases the children's susceptibility to later mental illness like depression. Patient suffered from a coma as a child from an unknown cause since he has had several instance of recurrent depression it is possible that the anatomy and function of his brain was altered during the coma. The anatomy of the four brain regions in the regulation of normal emotions: the prefrontal cortex (PFC), the anterior cingulated, the hippocampus and the amygdala. Any major brain illness or trauma that affects any of these areas could potentially result in a mood disorder. Finally, the patient is taking antihypertensives such as Metoprolol which have been linked with depression. The patients father abused alcohol. When he was younger the patient began abusing alcohol, cocaine and marijuana. There is strong evidence from studies of twins, adoptees, and siblings brought up separately indicates that the cause of alcohol abuse has a genetic component. Depressive symptoms are common among persons diagnosed with substance abuse or substance dependence. Also, the father of the patient attempted suicide which increases his likelihood of attempting suicide. Finally, the patient has had positive results previously taking Paroxetine which is a serotonin selective reuptake inhibitor. Basic science research has demonstrated evidence that links the downregulation or decreased sensitivity of beta adrenergic receptors and clinical antidepressant responses. Evidence has also linked presynaptic Beta-2 receptors because their activation leads to a decrease in the amount of norepinephrine released as well as regulate the amount of serotonin released.

Psychological: Several theories can explain the patients aggressiveness and irritability. According to Ainsworth expanded theory of attachment, he states that children who have parents who are emotionally distant or abusive develop insecure disorganized attachment. These children may react in bizarre ways when threatened and this may be a precursor to severe personality disorder in adolescence and early adulthood. The patient observed and experienced personal abuse and responded by eventually joining gangs and leading a life of crime. Also according t o Freud aggressio n co mes pr imar ily fro m t he red ir ect ion o f t he self-dest ruct ive deat h inst inct away fro m t he se lf and to ward ot hers. While t he pat ient wit nessed much har m in his yout h he int er nalized it and t hen dir ect ed it unt o other. Anot her t heor y by Albert Bandur a st at es t hat people acquire aggressio n, t hrough eit her perso nal exper ience or by o bser vat ion o f ot hers. S ince t he pat ient wit nessed emo t ional, phys ical abuse and personally exper ienced it his exper iences left him predisposed to develop aggressive t endencies t owards ot hers. All o f t hese t heor ies t oget her can expla in t he pat ient s t endencies t owards vio lence and aggr essiveness. Older pat ient s wit h perso nalit y disor ders were found to be four t imes more like ly t o exper ience maint enance or reemergence o f depressive sympt oms. The psychoanalyst Erikson created the theory of epigenetic principles. In this theory he states that each stage must be resolved properly for development to proceed successfully. The patient is currently in the stage of generative vs. stagnation (40-60 yrs). The patient is a 56 year old male who quit schooling after high school. His occupations have not provided him with true generativity and he settled for engagement in random occupations that he described as not challenging. This feeling of personal stagnation may have begun when he fist left the halfway house and felt the need to fend for himself back to the Bronx. He then felt the need to join gangs and commit lots of violent acts in order to survive. He also began a long lifetime use of drugs. The patient referred feelings of

failed expectations in reviewing his past. These earlier feelings could contribute to the development Moderate Recurrent, Major Depressive Illness. Social: EMS currently lives with his wife who was the initial person to notice his symptoms and report changes in his behavior. The patient reports not belonging to any specific community or church or group activity. He reports a tense environment in his neighborhood because of conflicts about the walking of his dog. He reports lots of anger, tension and stress towards his neighbors because of their limitations of his boundaries. The patient has injuries that occurred during a work accident and he has to learn how to live with his new role as a person on disability leave. Patient had his mom die five years ago, which he identifies as a trigger towards his symptoms as he saw her as a support figure. Patient does not have much family support since he is estranged from his dads side of the family and most of his mothers family. He is not in contact with his eldest son that lives in Alabama or his grandchildren from that son. The patient also has stress being contributed because of the situation with his exwife and his Down syndrome child who live in NY. Therein he worries about the maltreatment and safety of his child there. The patient is an avid marijuana and cigarette smoker with possible dependence. These are known depressants and could be contributing to his illness. The patient has several risk factors such as substance dependence, work accident, death of a close family member that together are risk factors that contribute to a large propensity for major depressive illness.

Treatment Plan The treatment plan includes switching the patient from his previous medications to Sertraline 50mg PO AM. Sertraline is a serotonic selective reuptake inhibitor that treats depressive symptoms. Since the patient has a past history of hyperlipidemia, diabetes and hypertension amongst other medical diseases and to rule out other causes of his symptoms labs should

be ordered which include: valproic acid levels, CBC, CMP, VDRL, U/A, TSH, lipid profile, Vitamin-B12, folate and a toxicology screen. The patient should be encouraged to continue his other medications for blood pressure, hyperlipidemia, and diabetes. The patient could also benefit from individual therapy, cognitive behavioral therapy and smoking cessation counseling. Since the patient has been smoking for the majority of his life is extremely important to approach the subject of quitting smoking while keeping in mind that it is imperative to provide him with as much support and help that he needs. Continue encouraging him to continue seeking support from his wife and to allow her to face any stressors together. A major cause for aggressive encount ers is lack o f basic social sk ills. People t hat do not know how to communicat e effect ively adopt an abrasive st yle o f self-expr essio n. A t echnique for reducing t he frequency o f su ch behavior invo lves providing t hese persons wit h t he social skills t hat t hey sorely lack. T herefore social skills t raining might be helpful in add it io n t o t hose t herapies alread y ment io ned.