Example of a Mental Health Assessment and Treatment Plan

Example of a Mental Health Assessment and Treatment Plan

 

Case # 2 – Ryan

 

Diagnosis (using the DSM-IV-TR):

 

Axis I: 304.10 Sedative, Hypnotic, or Anxiolytic Dependence, without physiological dependence

Axis II: V 799.9 diagnosis deferred R/O 312:89 Conduct disorder; R/O 301.7 Antisocial Personality Disorder

Axis III: V 799.9 diagnosis deferred

Axis IV: inadequate social support, discord with others, problems with the legal system, 

Axis V: GAF Score 40

Axis I - Symptoms: When seventeen years old, Ryan reported to a clinician completing a psychiatric evaluation, in a psychiatric hospital, that he “loved PCP or angel dust, and that he would rather be dusted than anything else.” He explained that he would take routine trips to ‘New York City to buy drugs.’ He denied any feelings of ‘nervousness.’ Clinician notated that “This wasn’t machismo; he really seemed unconcerned.” He was discharged from the psychiatric hospital into a drug rehabilitation program. This turned out to be an unsuccessful effort to cut down or control Ryan’s substance use. Clinician notated that Ryan convinced his parents to take him home within four weeks, and Ryan stole his parent’s money and disappeared to go back with his friends and drugs. A few years later, the clinician reports that Ryan has been arrested several times for theft, and that he continues to con his parents for money to buy drugs. Ryan, and the information present, does not report any evidence of tolerance or withdrawal. Ryan’s diagnosis is without physiological dependence: no evidence of tolerance or without withdrawal is present. The Addiction Severity Index will measure predictors of substance dependence, and Laboratory tests are a good screening tool and detector of continual use.

Axis II - Symptoms: Ryan’s records indicate that he was truant from school for several months, at the time he was seventeen, and he was in legal trouble. Ryan accompanied other teenagers to the local cemetery to perform satanic rituals, and a “young man was stabbed to death.” Ryan admits to being at the scene, but he denies stabbing the boy. Ryan admitted to stealing skulls from the graveyard for parties. No emotional concern was displayed by Ryan according to the clinician. No other past information is in the record; as such, the diagnosis is being deferred until records or information is received to do a complete history. Records should include bio psychosocial, medical, educational records, and any history of behaviors that would be abnormal or illegal if performed as an adult or caught. Ryan has a history of doing ‘many’ things that he claims to regret, but the Psychiatric notes state that “he was never truly remorseful for anything.” During the 48 hours that he was monitored and evaluated, the hospital documented ‘several things’ that showed Ryan needed help. Ryan told another patient that he was going to get released, get in trouble, and be sent to prison where this client’s father was. He threatened to rape the patient’s father. This caused the patient to get upset and hit others at the hospital. When confronted about his actions, Ryan explained that “he was bored and that it was fun to upset Ann.” Ryan went on to state, “Why should it bother me? She’s the one who’ll have to stay in this hellhole!” A complete structured interview would confirm or rule out a conduct disorder and antisocial disorder. Ryan can be assessed by administering objective tests of antisocial behaviors, impulsivity, and aggression. 

 

Axis III - Symptoms: The medical diagnosis is being deferred until information is gathered to determine his medical history. An up to date Physical should be performed on the client, because of his repeated drug use. 

Axis IV – Problems or Stressors: Ryan does not have an adequate social support system. His parent’s continue to provide him with a way to buy drugs. He has a history of discord with others, and he lacks empathy for the things that he does to them. He has had numerous problems with the legal system: he has been arrested several times for theft, and he was arrested at seventeen.  

Axis V: GAF Score 40. Ryan has major impairment in several areas of his life.

Potential Causes of this condition/disorder: This is based on the current information that was provided; however, more information needs to be obtained.

Ryan displays antisocial personality traits, and a complete history of childhood behavior should be reviewed to determine if he had a conduct disorder, and currently has an antisocial personality disorder. Dramatic Personality disorders are general caused by family-based stressors and genetic predisposition.

Ryan’s substance dependence is likely due to his personality and Psychopathy. His lack of remorse, need for immediate gratification, and antisocial behaviors. Risk factors that might have played a role in this are deviant peers and initial drug experiences.

Treatment Plan: Referral to a psychiatrist for medications. 

Social Problem Skills and Cognitive Behavioral Therapy – Two visits per week (one individual, one group). Ryan needs to take responsibility for his behaviors, and the effect that they have on others. He would benefit from learning how antisocial behavior is self-defeating, and developing effective coping skills to self-monitor. In one year, Ryan’s progress can be assessed by re-administering objective tests of antisocial behaviors, impulsivity, and aggression to determine if progress has been made and if treatment should be decreased.

Ryan needs to develop a program of recovery that is free from addiction. Ryan’s initial treatment should be in-patient, and then he can transfer to a half-way house, and outpatient care.