Presenting Problem

Background Information

Family History

Mental Status

Developmental and Social History

Academic Information

Assessment of Present Functioning - Mental Status Exam

Narrative

Primary & secondary Diagnosis:

Specify if:

Specify Current Severity. Secondary Diagnosis

Rule out Treatment Recommendations , Goals, duration

Thomas is a 56-year-old male who is being evaluated for services after being discharged from a two-week stay in the psychiatric unit of the local hospital Thomas stated that he entered the hospital becausehe became depressed about what he called "obsessive" thoughts and felt that his psychotropic medications were no longer effective.

Thomas has a long history of mental health problems. He was hospitalized several times during childhood and adolescence for what he described as depression and anxiety. He spent most of his school years from 3^rdthrough 12th grades in self-contained special education classes for emotionally disturbed children. He described himself as over anxious and withdrawn during most of his childhood. However, he was a good student and graduated from high school with a Regents diploma. He subsequently entered the navy, in which he served for three years.He suffered a breakdown during his second year of service while he was at sea, fearing that his ship would sink and he had no way of escape. He was subsequently hospitalized when the ship returned to port, and eventually received a medical discharge from the service.

After six months at home, Thomas joined the Merchant Marine service and, again, went to sea, working first out of West Coast Ports, and eventually out of the Port of NY. During his fourth year, a freighter on which he was serving docked in New Orleans to receive cargo Thomas became upset about an interaction with his captain and went on shore leave, during which he became extremely inebriated While drinking in one of the bars along the dock, he began complaining loudly about his ship and captain to some of the patrons. Thomas returned to his ship a few hours later to find it surrounded by police and the entire crew on the dock. The captain had been murdered during an attempted robbery, and the police were questioning all members of the crew regarding their whereabouts and relationships with the captain

After the investigation of the scene was completed, Thomas was one of the crew members who was assigned to clean the area of the ship where the captain had been murdered. It was a gory scene which Thomas found very upsetting as he completed his task. The crime was eventually solved, and the two perpetrators, who were career criminals in New Orleans, were eventually tied and sentenced to life in prison.

When the ship retu^rned to New York, Thomas became convinced that he had some part in the crime. He experienced an overwhelming sense of guilt and fear that he would be eventually arrested. He began hearing voices that said that he had told the preparators how to board the ship and where the captain's safe was located Thomas became convinced that he had helped the crime and that the FBI would eventually arrest bin He became deeply depressed and suicidal, which led to a long hospitalization.pe

During the 25 years of hospitalization, Thomas went through periods of stability, but also was hospitalized numerous times for similar episodes as above. He stopped drinking 20 years ago, and has never used prescription or illicit drugs. Period during which he begins hearing voices again, which he bas named "my boogieman," that rehash the crime, tell him that he purposely left a hatch of die ship to

locked so that the perpetrators could board and sometimes thinks that he was actually present and participated in the murder of the captain. During these episodes, Thomas becomes depressed because of the constant onslaught of the voices, which almost always results in his entering the hospital- He also obsesses about the FBI or Louisiana state police eventually showing up at his door to arrest him.

Thomas has been treated with various psychiatric medications. He is presently prescribed daily regimens of Prozac, Clozaril* Xanax, and Ambien He is very careful to adhere to his medication regimen and recognizes when his thought). lt feel out of control, necessitating that he seek an adjustment in his medications. Thomas has been to work regularly since the murder of his captain. He was employed for a short time 20 to 25 years ago, but each time, became overly stressed and bad to be hospitalized. However, feels a need to "give back." so participates in volunteer organizations that help the community in various ways. He also eventually married and has one son and three grandchildren. Thomas and his wife, who is also chronically mentally ill, are very dependent on one another, and monitor each other's levels Of stress and need for services.

Thomas presented as moderately depressed and discouraged in this evaluation- He was well-spoken and appeared to be of above average cognitive ability- He complained about the "boogeyman" coming back, and his inability to stop thinking about the Climb on his ship. He stated that he was doing better than when he entered the hospital, he reported that he was having difficulty sleeping because the voices in his head wouldn't stop. He would relate his fear of the FBI arresting him to the government attempts at gun control, and stated that he felt that this was aimed at him.

He was able to state the name of where the office was located, but is confused about the day of the week and date. He was also able to provide a very thorough psychiatric and medical history, and his report was corroborated by the discharge report from the hospital- Thomas stated that he was not suicidal when he entered the hospital, but was deeply depressed by the constant voices, and knew that his medications probably needed to be However, he stated that he knew that if he didn't seek help, he could see the suicide as an option for himself Thomas also stated that he knew that he had nothing to do with the crime that occur nearly 30 years ago, but the Boogieman" continually caused Thomas to question his memory of the event.