DEMOGRAPHIC DATA:

This is a voluntary admission for this 26 year old African-American male. This is Brandon's first psychiatric hospitalization. Brandon has been married for 2 years and has been separated from his husband for the past three months. He has currently been living with his sister in Atlanta, GA., where his husband and son reside. Brandon has a two year degree in nursing. Brandon works as an RN. Religious affiliation is agnostic.

CHIEF COMPLAINT:

"I need to learn to deal with losing my husband and son."

HISTORY OF ILLNESS:

This admission was precipitated by Brandon's increased depression and agitation which has been steadily increasing over the past year. In the past three months prior to admission, it was unbearable. He identifies a major stressor of his husband and son leaving him three months ago. Brandon reports that in the past three months since separating from his husband, he has experienced sad mood and fearfulness.

Brandon reports his dedication to working out. He has used a cycle of steroids to increase his body mass. During his most ambitious cycle, approximately 1 year ago, he used testosterone cypionate, 600 mg per week; nandrolone decanoate, 400 mg a week; stanozolol (Winstrol), 12 mg a day; and oxandrolone (Anavar), 10 mg a day. During each of the cycles Brandon has noted euphoria, irritability, and grandiose feelings. These symptoms were most prominent during his most recent cycle, when he felt "invincible." During this cycle he also noted a decreased need for sleep, racing thoughts, and a tendency to spend excessive amounts of money. For example, he impulsively purchased a $2,700 stereo system when he realistically could not afford to spend more than $500. He also became uncharacteristically irritable with his husband and on one occasion put his fist through the side window of their car during an argument, an act inconsistent with his normally mild-mannered personality.

MEDICAL HISTORY:

Brandon is 69 inches tall and presently weighs 204 pounds, with a body fat of 11 percent. He reports that he began lifting weights at age 17, at which time he weighed 155 pounds. About 2 years after beginning his weight lifting, he

began taking steroids, which he obtained through a friend at his gymnasium. His first "cycle" of steroids lasted for 9 weeks and involved methandienone (Methanabol), 30 mg a day, orally, and testosterone cypionate, 600 mg a week, intramuscularly. During these 9 weeks, he gained 20 pounds of muscle mass. He was so pleased with these results that he took five further cycles of steroids over the course of the next 6 years. Brandon exhibits characteristic features of muscle dysmorphia.

PAST PSYCHIATRIC HISTORY:

Brandon was seen on an outpatient basis by Dr. S for a period of two months prior to admission. He was being seen for individual counseling because of the marital problems. Brandon reported to Dr S. that he was using steroids to increase his body mass. He noted that after the most recent cycle ended, he became mildly depressed for about 2 months. Brandon has used a number of drugs to lose weight in preparation for bodybuilding contests. These include ephedrine, amphetamine, triiodothyronine, and thyroxin. Recently, he has also begun to use the opioid agonist-antagonist nalbuphine intravenously (IV) to treat muscle aches from weight lifting. He also used oral opioids, such as controlled-release oxycodone (OxyContin), at least once a week. He uses oral opioids sometimes to treat muscle aches, but often simply to get high. He reports that use of nalbuphine and other opioids is widespread among weight lifters.

FAMILY MEDICAL AND PSYCHIATRIC HISTORY:

Father and grandfather have a history of cardiovascular disease.

PSYCHOSOCIAL AND DEVELOPMENTAL HISTORY:

Brandon reports that while growing up his parents maintained a satisfactory relationship. Father reportedly worked nights and slept during the day. Brandon did not have much contact with his father but now enjoys a close relationship with him. He states he has always had his parents support.

During Brandon's school years, he reports he was an underachiever in elementary school. He denies having had a history of discipline problems or hyperactivity. He states he did well in high school and earned grades of A's and B's. Brandon played football in HS. After completing high school, Brandon furthered his education and earned his license as a registered nurse. He states he graduated at the top of his class from nursing school.

CURRENT FAMILY ISSUES AND DYNAMICS:

Brandon's husband reports that Brandon's difficulties began to get worse a few months ago when he decided to move out of the house due to Brandon's increasing erratic behavior. He moved into his parents' house and Brandon is living with his sister. Husband states that Brandon has been suffering from mood swings where he is "very up" and feeling great, firm in his direction and then within the next few hours, he is often out of control, arguing, throwing temper tantrums, pushing and shoving, and becoming verbally abusive.

Husband describes Brandon as "extremely depressed" now and says Brandon states, "life is over...I wish I was dead...don't send my son over to visit because I don't want him to find my dead body...everything I touch turns to garbage." Husband adds that Brandon suffers from poor self-esteem. In terms of strengths, he is a good father, compassionate, creative, and can be an outstanding person.

Brandonhas been married for 2 years and has recently been separated for the past three months. Brandon and his husband have one adopted son, age 4. Brandon states he feelsinvested as a parent and feels close to his son.

Leisure time activities Brandon has enjoyed in the past include playing softball, reading, playing poker, and watching football.Now his main focus is weightlifting. Brandon states he has several close friends.

MENTAL STATUS:

Brandon presents as a casually dressed male who appears his stated age of 26. Posture is relaxed. Facial expressions are appropriate to thought content. Motor activity is appropriate. Speech is clear and thereisno speech impediments noted. Thoughts are logical and organized. There is no evidence of delusions or hallucinations. Brandon denies any hallucinations. Brandon denies suicidal or homicidal ideation at the present time. His husband has observed a history of notable mood swings. No manic-like symptoms are observed at the time of this examination.

On formal mental status examination, Brandon is found to be oriented to three spheres. Fund of knowledge is appropriate to educational level. Recent and remotememory appearintact. Brandon was able to calculate serial 7's. He reports checking his appearance dozens of times a day in mirrors, or when he sees his reflection in a store window or even in the back of a spoon. He becomes anxious if he misses even one day of working out at the gym, and acknowledges that his preoccupation with weight lifting has cost him both social and occupational opportunities. Although he has a 48-inch chest and 19-inch biceps, he has frequently declined invitations to go to the beach or a swimming pool for fear that he would look too small when seen in a bathing suit. He is anxious because he has lost some weight since the end of his previous cycle of steroids and is eager to resume another cycle in the near future.

increased depression and agitation increasing over the past year

past three months unbearable experienced sad mood and fearfulness.

dedication to working out. He has used a cycle of steroids to increase his body mass.

approximately 1 year ago, he used testosterone cypionate, 600 mg per week; nandrolone decanoate, 400 mg a week; stanozolol (Winstrol), 12 mg a day; and oxandrolone (Anavar), 10 mg a day.

During each of the cycles Brandon has noted euphoria, irritability, and grandiose feelings

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