1. HOW TO WRITE Assessment of present functioning

2. DSM Diagnosis

Mr. M has had premorbid symptoms since he was a child. He has exhibited a detached demeanor, which makes developing friendships difficult. At the age of twelve, a psychiatric evaluation revealed a personality problem. Mr. M's mother was diagnosed with cancer when he was 13 and died at the age of 16 after three years of debilitating illness. During this time, Mr. M began weekly psychotherapy that lasted for five years. He had his first psychotic episode at the age of 20 when his father remarried, followed by a second episode with manic symptoms at the age of 22 when his stepmother delivered birth. He lives in a monitored apartment and receives assistance from Supplemental Income and Medicaid.

Despite his decliningacademic performance, he graduated from high school at the age18 and attended college. He failed all of his first-semester classes and returned home, where he was socially isolated and jobless. Mr. M was diagnosed with a mental disorder by a new psychiatrist when he was 19 years old, and psychological testing suggested that he was a "passive-aggressive individual with high anxiety and marked passive-dependence needs."

Mr. M was hospitalized for the first time at age 20, within a week of his father's remarriage. He had grandiose delusions, believed he could fly, and was sexually preoccupied and aggressive. An evaluation of his mental status revealed a suspicious, agitated man with an inappropriate and blunted affect and thought processes characterized by derailment and racing. Mr. M believed he could read minds and that his own thoughts were not always his own. He had vague suicidal and homicidal thoughts but lacked suicidal intent. Medicine was prescribed for him to take 400 mg of chlorpromazine per day, and his symptoms improved somewhat; he was discharged after 3 1/2 weeks.

After Mr. M was released from his initial hospitalization, he began treatment with a new private psychiatrist, enrolled in a day hospital rehabilitation program, and began family therapy. During the next two years in the day program, he was socially isolated, had poor concentration, frequently exhibited aggressive and intrusive behavior, and exhibited depressive symptoms.

He was hospitalized for the second time at age 22 after his stepmother gave birth to a son. His parents placed him in an out-of-state residential program as his symptoms worsened. Mr. M was treated with 40 mg of haloperidol per day and showed modest improvement. However, his diagnosis needed to be revised due to manic characteristics in his presentation. He was prescribed lithium. His symptoms diminished, and he was able to concentrate better. He had a more appropriate affect and was less hypersexual and delusional; however, his concentrationand occasional juvenile impulsivity persisted.

Mr. M was discharged after two months on haloperidol (10 mg/day) and lithium (900 mg/day). His lithium level remained stable at 1 mEq/L. He was assigned in a day program and a program for supervised apartments. Over the next two years, he also continued outpatient treatment with his inpatient patient. He was administered minimal doses of haloperidol(5-10 mg/day) and lithium (900 mg/day) during this time. He was periodically symptomatic, butnever manifestly psychotic.

Mr. M's vocational and social functioning remained marginal after a comprehensive work rehabilitation program. At the age of 23, he was referred to a new day program for continuous social and vocational rehabilitation, in addition to continuing in the hospital's outpatient clinic, an "alumni group," and a family group with his parents. Mr. M had resurrected paranoid symptoms several months later, but mood problems were not evident, thus the new resident reformulated the diagnosis. Haloperidol was increased from 5 to 20 mg/day, and lithium was discontinued, with no discernible improvement in symptoms. Mr. M's paranoid symptoms worsened five months later, and the haloperidol dosage was increased to 20-50mg/day; after two months, his symptoms improved but only slightly. Due to his minimal symptom relief after 2 months, his medication was switched from haloperidol to fluphenazine hydrochloride, with moderate improvement.

Four months later, another resident was assigned to Mr. M's case. Mr. M continued to have "paranoid episodes"' followed by intense anxiety, every 2 or 3 days. His stepmother noticed that his call-home visits had risen in regularity during the previous six months. He claimed he was afraid to leave his flat and shown suicidal ideation, which he disputed. He usually reacted to neuroleptic medications, support, and reassurance throughout these times.