Case Summary
Ben is a forty-six-year-old male who works as a computer scientist at one of the large universities. The patient has been exhibiting unusual tendencies in recent weeks, which has necessitated evaluation at the local hospital. His wife Cindy has to help answer the interviewer’s questions because Ben himself is a hostile interviewee. He does not want to seek any professional help because it is against his will. According to information obtained from his wife, he is easily irritable, moody, and shows increasingly inappropriate behavior and actions.
For instance, in a neighborhood party last Friday, he approached an attractive young neighbor and grabbed her breasts after confirming whether she was having a good time as he was leading to a furious reaction. Ben was not even aware of the ramifications of his actions. She also became angry and struck Ben. The undesirable behavior is affecting his loved ones such that Cindy is embarrassed by the husband’s behavior and says Ben has never displayed such tendencies in the past. Ben has always been kind and respectful and “even a little shy”.
The patient has even started eating his breakfast with his bare hands and also was late for work. He even experienced difficulties organizing his work briefcase. The client makes all sorts of plans, but experiences difficulties following through on them. In the past, Ben has always been cautious, organized and still plans. But yesterday, the client left the car running in the driveway and took the bus to work.
Cindy had enquired from Ben's siblings and learned that he displayed similar tendencies in college when his behavior was peculiar and erratic. He assaulted his roommate, believing that he worked for the KGB. During his college episode, it took eight months for the symptoms to escalate rapidly towards the end. He received some medication by the college psychiatrist, but no further information is available since Ben could not disclose anymore. Among the excuses given for his behavior in college include growing pains and being away from home. The siblings cite no mental illness in the family. However, Cindy has discovered an uncle Mo who died in a psychiatrist hospital 14 years ago.
About six months ago, Ben was involved in an auto accident in which he hit his head on the rear-view mirror. The X-ray at the emergency room resulted in negative findings. The wife was to monitor his situation for the next 24 to 48 hours for any signs of brain injury. Other than a slight headache, Ben exhibited no adverse symptoms. The erratic and irritable behavior started to appear five days ago after nearly six and half months after the accident. He usually works 50 hours a week, earning $130,000 per year. He is an excellent employee and maintains good relationships with his co-workers and friends. Cindy and Ben have been married for about 23 years. Although they have had a few fights, it is a mostly happy marriage. Ben was also a high achieving student in high school, not an alcoholic, experienced no family loss, and is remarkably healthy except for undergoing a tonsillectomy.
Early in the marriage, Ben had a huge fight with the departmental head who he believed was plagiarizing his work. They had to move across the country to find other work with Ben still thinking he had substantial evidence because both of their articles began with the same letter of the alphabet. The wife has also located a disturbing journal that the husband keeps but has not come with it to the interview because it is mostly nonsensical. The initial evaluation concludes the recent episode is brought about by an accident the patient recently experienced when he hit his head on the rear-view mirror.
Clinical Impression (Diagnosis)
907.0 delayed effect of intracranial Injury skull fracture
294.11 (F02.8x) Major Neurocognitive Disorder to Traumatic Brain Injury with Behavioral Disturbance.
Other Factors
V15.81 (Z91.19) Non-adherence to Medical Treatment
V61.10 (Z63.0) Relationship with Spouse
V62.9 (Z60.9) Unspecified Problems Related to the Social Environment
Recommendations
Ben should begin treatment immediately before the eight-month mark. The symptoms escalated in the first episode in college when he assaulted a roommate for believing he was in the KGB. Because six and half months have already elapsed since sustaining a head injury, urgent action will be necessary. The first course of action in the medical treatment is carrying out a Magnetic Resonance Imaging (MRI) scan to determine the extent of the head injury during the accident on the frontal lobes and other parts of the brain. Although the head injury may be mild, and only a small percentage of them progress to severe injuries, the MRI scan will confirm the state of Ben's injuries (Hersen & Beidel, 2012). A clinician with training on dealing with head injuries should reexamine Ben. If there are any concerns, they should document these and recommend treatment procedures appropriate to the patient age. The recommended treatment by the clinician should be followed, including follow-up therapy by an occupational therapist or social worker.
Questions
- Describe how the new information alters the picture presented in the original case study, before submitting the review Ben Part 1 assignment.
The new information alters in the original case study since now the practitioner understands that they may be a history of mental illness in the family tree. In the original case study, the professional does not get a complete picture of the function of the replacement behaviors or any previous medical attention he may have accessed. Before accessing the additional information, the evaluator had difficulty understanding Ben’s behavior except for the automobile accident and stress at work (Tampi et al., 2017). His marriage is doing fine; he is not an alcoholic, works normal hours, has a healthy life, and keeps in contact with friends and family.
However, in the second interview, we understand that Ben has experienced such an episode in the past. We also know that the patient has a history of using some medication issued by the college psychiatrist. We also understand that there is a history of mental illness in the family with Ben's uncle dying in a state hospital for the mentally ill where he had spent 14 years. We understand that Ben is prone to acting irrationally accusing his co-worker of plagiarizing his article because they both began with the same letter of the alphabet. Finally, the additional information alters our view of blaming the accident for Ben’s behaviors but on mental illness such as bipolar. The physician concludes that there are no medical effects from the accident (Weiner & Otto, 2014). The nonsensical journal he keeps also reinforces the notion that Ben may be suffering from some form of mental illness.
- Describe your new diagnostic hypotheses and justify your conclusions.
Clinical Impression
296.89 (F31.81) Bipolar II Disorder DSM-IV-TR hypomanic current episode with moderate symptoms and mixed reactions
V61.10 (Z63.0) Husband-Spouse Relationship problems
F60.69 Disorder of personality and behavior in adult persons
F90.98 Behavioral and emotional Disorder with onset occurring in the college days
V62.9 (Z60.9) unspecified episodes relating to the social environment such as Ben grabbing a female neighbour's breasts at a party
The primary focus of the therapeutic intervention will be on eliminating depression and mood swings in the patient (American Psychiatric Association, 2013). Ben feels his boss his stressing him as well as environmental triggers that are setting off his irritability and aggressive behavior. Ben’s mood disorder is rooted in the challenges he experiences at the workplace as well as other social triggers such as experiencing difficulties with organization. Ben may also have been triggered by the automobile accident such that he may be experiencing fear driving his car. For example, he left it running in the garage and opted to take the bus to work instead. Ben is not experiencing any loss since all his parents are well and alive (First & Tasman, 2004). He also keeps close contact with co-workers and friends going back as high school. I would target conducting sessions with Ben and Cindy since the patient is hostile in the first interviews. I would then graduate to include the family such as Ben’s siblings and parents in subsequent sessions.
- What further diagnostic evaluation do you believe is warranted?
The further diagnostic evaluation I would recommend is the Major Depression Inventory and the Patient Health Questionnaire (Balogh et al., 2015). The tools will help put in context the complete spectrum of Ben's condition. I would also like to meet with Ben's boss and co-workers to gain a better understanding of workplace dynamics.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5thed). Washington, DC: Author. ISBN: 780890425558
Balogh, E., Miller, B. T., Ball, J., & Institute of Medicine (U.S.). (2015). Improving diagnosis in health care. The National Academies Press. Print.
First, M. B., & Tasman, A. (2004). DSM-IV-TR mental disorders: Diagnosis, etiology, and treatment. Chichester, West Sussex, England: J. Wiley.
Hersen, M., & Beidel, D. C. (2012). Adult Psychopathology and Diagnosis. Hoboken: John Wiley & Sons.
Tampi, R. R., Zdanys, K., & Oldham, M. (2017). Psychiatry: Board review. Oxford University Press. Print.
Weiner, I. B., & Otto, R. K. (2014). The handbook of forensic psychology. Hoboken: Wiley. Print.
