CASE STUDY: Mitchell H.
Identifying Information:
Mitchell H. is a 47-year-old divorced Caucasian, male who is currently living in a rural area just outside of a small city. He was evicted last week from a city housing unit after fighting with neighbors. He was arrested for public intoxication and battery. He is now living between family members and friends; primarily his mother (she accompanied him to today’s appointment). The mother reports that her husband (patient’s biological father) is not in favor of patient staying with them, so the current housing arrangement is most likely short-term.
He was referred by the court liaison after being released from jail because the liason believes Mitchell’s presentation is a result of untreated Bipolar Disorder. As part of his agreement with the court he will have a substance use evaluation and psychiatric treatment as deemed appropriate.
His height is 6’2″, Weight 256 pounds. Blood pressure is 142/97 and pulse is 80.
He has Medicaid insurance.
Presenting Problem:
The patient states “I have been depressed all my life.” He reports even before going to jail “I never shut up. I run my mouth constantly. I don’t have a problem with it but it does bother the people around me. I can’t slow down. I can’t sleep but alcohol helps.” His mother reports that he sleeps maybe two or three hours at the most every other night. He does have inflated self-esteem and some grandiosity, specifically talking about being a musician and “I won’t back down from a fight.” He is very talkative with flight of ideas, racing thoughts and easily distracted. He also has a long history of substance abuse with negative consequences that have destroyed relationships and employment opportunities, and resulted in multiple arrests. Most recently he was unable to control his mood and got in an argument with the neighbor. He admits he was drinking alcohol and ended up being arrested for public intoxication, intimidation, and disorderly conduct. He has now been kicked out of his apartment and is homeless, hence the reason he is living with various family members and friends. He was being treated by his PCP with Klonopin and a hypertensive medication, but he now does not have access to those medicines because he is not allowed to go back to his apartment complex.
Past Psychiatric History:
The patient reports he first began counseling at the age of 13 through county family and social services. He was then in a regional hospital for inpatient treatment off and on between 1990 and 1995. He also received outpatient treatment from several different providers. He states he has tried numerous medications but primarily remembers Abilify, Xanax, Lithium, and Seroquel. He was on Methadone through a Methadone Clinic. He states the best medicine that ever worked for him was Lithium. He has one previous suicide attempt and admits to intermittent suicidal ideations without intent or plan.
He does have a long alcohol and drug history. He states he began “using drugs in my single digits.” He states he used every drug imaginable but marijuana has always been his favorite. Most recently he has been using alcohol. He was treated with Methadone for nine years and then quit cold turkey, at which time he began using alcohol. He says that he has used opiates in the form of Methadone for about eight or nine years, which he reports discontinued use since 2013. Currently he describes himself as a trash can addict, saying that he is not really physically dependent on any drugs, but he will use whatever drugs he can get. Sometimes he will use Vicodin and other times he will use K2 or spice. He says that he has used methamphetamine “maybe once in the last three months or so.”
Medical History:
His current medications include Amlodipine (he does not recall the dose) and Clonazepam 1 milligram three times a day. He did have a severe head injury at the age of 13, in which is skull was broken. He also had a traumatic event in which his son attempted to kill him and cut him severely with a knife. He now has chronic nerve damage, bursitis, and is treated for hypertension. He has allergies to Septra and CT dye.
Family Psych History:
The patient has a brother diagnosed with Schizophrenia and a son with Bipolar Illness. Patient does not know if they are being treated, nor which medications they may be prescribed.
Brief Personal History:
The patient was born in a small, rural town in Iowa. His parents divorced when he was 13 years old. He reports a brother was molested by a family member, but he was not. He denies any family trauma. He states he barely made it through high school, but did very well at a state college He was in nursing school but was not able to finish, but did work as a psychiatric technician for several years during nursing school, and he reports having a lot of medical knowledge. He went through a divorce and ended up “losing everything” in 2012, and has not been able to work since. He became severely depressed after this and attempted suicide by hanging.
He has four grown children with whom he does not have much contact. A few years ago, his house burned down and he lost all of his possessions. Since this house fire, his youngest son has been keeping his dog for him and has emphasized he will not give it back until he has stable housing. The patient is extremely attached to his dog and this has caused ongoing feelings of hopelessness.
His mother is his primary support system and wants to help as much as possible, but this causes marital strain because her husband “cannot stand him (Mitchell) being up all night.” Patient does enjoy music and describes himself as an artist and admits he does not like psychiatric medication that decreases his mania, because he believes “it interferes with my artistic inability.”
Mental Status Exam:
The patient was alert and oriented to all spheres. Hygiene and grooming are poor. He was cooperative with all questions. Speech is rapid and pressured. His thought patterns are loose and tangential. He describes his mood as “agitated.” His affect is congruent with this report. He denies any history of psychosis. He does report history of suicidal thinking but emphasizes “none currently.” He continues to be future oriented in conversation. He was able to spell the word ‘world’ forward and backwards. When asked to name five large cities he named New York, Bangkok, Prague, Berlin and Chicago.” He knew the last three presidents. He recalled 3/3 objects immediately and 3/3 after 5 minutes. Proverb interpretation was normal. He voices good judgment stating that he would mail an envelope if he found it on the side of the road.
Formulate a diagnosis by completing the following topics and posting to Blackboard (Bb). Clearly number and label each topic in your response.
- Identify the factors (not diagnoses) that are impacting this patient’s mental health. Be specific and provide supportive data.
- Identify syndromes and provide supportive data.
- Construct differential diagnoses and assign a number (1 to 5) to indicate how closely the patient fits the ideal diagnosis you are considering: 1 = little to no match; 2 = some match; 3 = moderate match; 4 = good match; 5 = excellent match.
- Arrange your differential diagnoses according to a safety hierarchy. Morrison (2024) pages 16-18 – Most desirable, Middle ground, or Least desirable.
- Select the most likely provisional diagnosis for further evaluation and treatment (using a decision tree). Provide supportive data and a rationale.
- Identify other diagnoses that might be co-morbid (coexist).
- Based on the C-SSRS, what is this patient’s level of suicide risk? (Do the best you can in assessing this, with the information provided).
- What are the patient’s risk and protective factors for suicide?