Assignment 2

CASE HISTORY

1. Identification Data
Name: Juan Rodriguez
D.O.B: 2 February 1988
Age: 34
Sex: Male
Education: High school
Occupation: Construction worker
Marital Status: Married
Family Type: Nuclear
Religion: Christian
Domicile: Chicago
Socio-economic status: Lower middle class
Informant (s): Andy Garcia (Supervisor)
Contact no: 98567324
Source of referral:
Case Examiner: Divia Raina
Case Supervisor: AC

2. Chief Complaints
- “My drinking has increased a lot than before”
- “There have been a few times I injured myself at work, because I was
drinking”
- “I feel like I am working all the time, I am not able to remember the days
off work. It is like a distant memory. Maybe it is the drinking.”
 - “I am not able to restrain my drinking during special occasions or Lent, as
after a couple of hours I crave alcohol and get irritated if there isn’t any
nearby.”
- “I have noticed that when I try to restrain myself from alcohol, I end up
drinking it anyway, most of the time, nearly double the amount I
normally take in”
- “I even walked for 2 miles, when the nearest liquor store was closed. That
is the most determined I have been recently”
- “My wife and I always argue on money matters. She thinks I spend too
much money on drinking, instead of paying the credit card bills. But I
always make it just in time with the payments, she worries for nothing.”
- “She says that I am apparently too drunk to spend time with her and the
kids. I know I haven’t been spending time with my daughters and I miss
it.”
- “I know it looks bad, but I can control it. I know I can. My old man had
the same problem and died.”

As per informant:

- “I am aware that he drinks on the job, but given the heat, I turned a blind
eye”
- “I am now concerned, because he shows up drunk to work and gets into
minor accidents. The last thing I need is one of my guys getting into a
serious accident”

3. History of Presenting Illness

The client reports increased consumption of alcohol for five months. He further
mentions that it began during the summer months, as the heat was intolerable,
he would often consume eight beers while working. Over time he started to
drink at home too, after returning from work. His reasoning being, that he is
often tired and has no energy left to engage with his children and wife. He
reports that alcohol provides that “kick” which energizes him. However, he
mentions that he is unable to recollect his days off work, as they “pass in a blur”
due to the drinking. Moreover, he is unable to restrain his alcohol consumption
during special occasions or religious festivities like Lent, as he would end up
irritated and consume larger amounts of alcohol. Although he reports that his
alcohol consumption does not affect his work productivity, he has often got into
minor accidents.

The predisposing factor could be his father’s alcoholism, as he mentions that his
father went through the same ordeal. The precipitating factors could be his
initial consumption of eight beers while working in the summer months. While
the perpetuating factors could be drinking to regain energy to spend time with
his children.

4. Biological Functioning

Sleeping: Increased

Mr Rodriguez reports that after returning home from work, he spends his time
drinking and watching reruns of “One Day At A Time”, till he falls asleep on
the arm chair. He further mentions that he constantly feels tired, even after
sleeping for long hours. Moreover, he reports that he often “sleeps in” and
rushes to get to work on time.

Appetite: Decreased

Mr Rodriguez reports that his appetite has “taken a dive”, as the alcohol keeps
him quite full. He further mentions that his still eats a little before going to bed
at night, so that he doesn’t have to eat breakfast, while rushing to work, as he
tends to sleep in.
Sexual Functions: Decreased

He mentions that he hasn’t been giving his wife attention for quite some time.
Moreover, he mentions the constant arguing doesn’t help their relationship. He
further adds that his wife mentions that he is always too intoxicated to spend
time with her.

Personal care: Negligent

His clothes appear to be wrinkled, not clean, a few stains were visible and worn
for a quite some time. His hair was not brushed. His nails were chipped and
appeared to have been bitten. It is apparent that he hasn’t showered in quite
some time.

5. Treatment History

In the past, Mr Rodriguez has attended Alcoholics Anonymous meetings on the

behest of his supervisor, Andy Garcia. He attended a few meetings and then
stopped going. Upon questioning, he mentioned that he did not experience any
adverse effects. Moreover, he stated that he found the meetings to be “bogus”
and he was confident that he did not need to attend them. As he could stop
drinking whenever he wanted to. His supervisor then advised to consult a
clinician.

6. Past History of Illness

Medical/Surgical Illness: None
Past Psychiatric History: None

7. Family History

Occupation of father: Construction worker

Occupation of mother: Seamstress

Consanguinity between parents

Mr Rodriguez replied “My parents worked hard, to provide for me. They both
would work long hours, not see each other for quite some time. The only time I
saw them together would be at the dinner table, but they would just be arguing
about money. My father was drinking all the time to cope with the stresses of
work, which took a chunk of money out their earnings. My mother was not
happy with that and tried to reason with him.”

Family members living-dead

Mr Rodriguez replied, “My grandparents (both paternal and maternal) passed
away a long time ago. Same with my great grandparents.”

H/O mental illness in the parents (both paternal and maternal).

Mr Rodriguez replied “None that I know of.”

Treatment details: N/A

Client relationship with parents

Mr Rodriguez had a distant relationship with his parents. As they were often
working, he spent majority of his time alone at home. Knowing that his parents
worked day and night, he would never make any requests and keep the
conversation to the minimum. They never encouraged him to pursue any
extracurricular activities and asked him to stay at home after school. He
mentions that his parents were affectionate “in their own way”. As in they
would sometimes rub his hair, get him new clothes or toys.

Overall Attitude

His overall attitude towards his family, is of distant affection. He loves his
parents, but mentions that they were not present at all. He was alone most of the
time. His maternal and paternal grandparents passed away before he was born.
Rituals: Present

The client mentions that his parents neither started nor engaged in any rituals.
He just had one ritual, that is after returning from school, he would spend two
hours watching television, alone.

8. Personal History
 Perinatal History
 Nature of delivery: Natural birth
 Antenatal, natal and post-natal complications: None
 Developmental milestones: Achieved

9. Childhood History
 Presence of childhood disorders: None
 Client reports to having good relation with friends.
 Client reports to having good relations with peers.

10. Educational History

 Age of entry in school: 4 years old

 Class of entry in school: Kindergarten
 Progress in studies: High School
 Involvement in school: None

Mr. Rodriguez mentioned that his parents never encouraged him to take part in
extracurricular activities. Although he was interested, he never engaged because
he did not want to disobey his parents.

 Relations with authority: Never challenged authoritative personnel, was

afraid to do so. Maintained a relationship of mutual respect.

 Relations with peers: Had a few friends in school. Not in touch with them.
 Disciplinary problems: None
 Failure in any grade: None

 Discontinuation or drop out (with reasons): N/A

11. Occupational History

He started working along side his father, right after he graduated from high
school in 2004. His first job was with a small construction company, where he
worked in tarring old roads. After two years, he was promoted and began to
work on rebuilding old houses and continued till around 2010. Due to the
recession, he lost his job and started to pick up odd jobs, till 2012. In 2012, he
was hired by PG & E as a construction worker and is currently working here.

12. Sexual & Marital History

Sexual activities: Present

Mr Rodriguez was uncomfortable sharing details regarding his sexual history.

He mentioned that in the past six months he has not engaged in any sexual
activity.

Attitude towards sex

“It is a natural phenomenon. It exists and that’s it.”

 Age at marriage: 24
 Parental consent for marriage: Received
 Personality of spouse: The client describes his wife as a “worrier” and tends
to panic over small issues.
 Role allocation between couple: Wife is a cashier at a supermarket
 Sharing of responsibilities and decision making: He and his wife split the
household chores between them. He is responsible for the lawn, laundry,
 dishes, picking up the children from school. While she is responsible for
groceries and overall upkeep of their home.
 Premarital/ extra-marital relations: None

13. Premorbid Personality

Attitude towards self: Poorly and self-critical

Mr Rodriguez feels poorly towards himself. He mentions that he has become
critical of everything of what he has done in the past and in the present. He
mentioned that he was not like this before.

Attitude towards others and world: Neutral

The client reports that he never bothered about this attitude towards others and
the world. Although, he tries to be as pleasant as possible.

Interaction patterns and sociability: Altered

The client mentions that he neither socializes with others a lot nor keeps in
touch. He considers himself a family man, devoted to his daughters and wife.
Now, he realized that he has been spending less time with them and more on
drinking. He and has wife constantly argue about this.

 Sense of responsibility: Decreased

The client reports that his sense of responsibility has not changed. He still goes
to work and “clocks in”. Although he previously mentioned that he arrives to
work late and gets into minor accidents because of his drinking. His supervisor
mentions that he is intoxicated most of the time.

 Attitude towards criticism: Bothered by it.

“Before I was not too bothered by it. I took it in a good manner, as a way to
grow as a person. Now I can’t handle it, because I know I am not doing the right
things, not taking my responsibilities seriously, which is why I expect criticism.
Receiving it now, feels like a stab to the heart”.

 Attitude towards moral values: Unchanged

 Attitude towards adjustment: Unchanged

The client mentions that he is not bothered by making adjustments. As he has
been making adjustments his whole life.

 Attitude towards hobbies/interests: Unchanged

The client mentions that he never had any hobbies before he began drinking. He
was never encouraged as a child to indulge in a hobby.

 Attitude towards substance abuse: Unchanged

The client considers drugs as dangerous, something to avoid. While his views
on alcohol is that it is a “relaxer”, not dangerous.

Diagnostic Formulation for Case History

Juan Rodriguez, 34, cis-gendered, Christian, married, male of low middle socio-
economic status coming from an urban background of Chicago with an
unadjusted premorbid personality with a family history of alcoholism. Comes
with a five months illness characterized by increased alcohol consumption,
inability to cease drinking, loss of interest in interacting with family members,
feelings of irritation when not drinking.
 Mental Status Examination

1. General Appearance

1.1. General Physical Appearance: Unkempt and untidy

Body build: Average

Hygiene: Adequate
Grooming: Neglected
Clothes: Unkempt
Hair: Dishevelled
Posture: Slouched
Fingernails: Negligent

1.2. Touch with surroundings: Present

1.3. Eye contact with examiner: Present

1.4. Facial Expressions: Appropriate, congruent with mood.

1.5. Posture: Slumped

2. Attitude towards the examiner: Co-operative

3. Rapport: Easily established.

4. Motor Behaviour: Retardation

5. Speech

5.1. Intensity: Audible

5.2. Pitch: Normal

5.3. Quality: Clear

5.4. Reaction time: Decreased

5.5. Speed: Very slow

5.6. Coherence: Coherent

5.7. Relevance: Relevant

5.8. Goal directedness: Goal directed

5.9. Rate of production: Pressure of speech

5.10. Deviations: Absent

6. Cognitive Functions
6.1. Orientation
 Time: Present
 Place: Present
 Person: Present

6.2. Attention and Concentration

 Number of days in a month
Accurate response
 Backward counting
Accurate response
 Serial Recall
Inaccurate response
 Digit Forward/Backward
Inaccurate response
6.3. Memory
 Immediate: Present
 Remote: Present
 Recent: Present

For immediate memory, when questioned to name five colors, he was able to
recall immediately.
For remote memory, when questioned about his home address, he was able to
recollect and recite it accurately.
For recent memory, when questioned about his last meal, he was able to recall
and answer accurately.

6.4. Abstract Ability: Conceptual

The examiner had asked the following questions to Mr Rodriguez to test his
abstract ability,

 “What is love?”
 “What is guilt?”

He provided a conceptual answer to both. The first being, a feeling of affection

to anyone or anything. The second being, feeling of a weight on his shoulders.

6.5. Intelligence

 Comprehension: Average
 General information: Average.
 Vocabulary: Average
 Calculation: Average

7. Mood and Affect

7.1. Mood
 Objective: Apathetic
 Subjective: Indifferent

7.2. Affect
 Objective: Congruent to the mood, appropriate to context
 Subjective: Indifferent

8. Thought
8.1. Stream: Normal

Mr Rodriguez stream of thoughts is normal, it is not rapidly changing, blocked

or slow.
8.2. Form: Goal-directed

As the client’s thought form is logical, organized and easily understandable.

8.3. Possession: Normal
8.4. Content: Normal

9. Perception: Normal
The examiner asked the following questions to screen for perceptual
abnormalities.

 “Do you ever see, hear, smell, feel or taste things that are not really there?”
Mr Rodriguez replied, “No not really.”

 “Do you ever feel like the world around you aren’t real?”
Mr Rodriguez replied, “Not really.”

 “Do you ever feel like you have changed or that you don’t recognize the
person you currently are?”
He replied, “No I am quite the same.”

 “Do you think this interaction is real?”

He replied, “Of course, that is a weird question”
It can be understood from the responses that the client does not have any
perceptual abnormalities.
10. Judgement
 Social Judgement: Appropriate
The examiner asked a question which tests client’s social judgement.
 “If you find a wallet on the sidewalk while walking. What do you do?”
He replied, “I would take the wallet to the nearest police station to return it
to its owner.”
This response indicates that the client has sound social judgement.

 Personal Judgement: Appropriate

The examiner asked a question which tests the client’s personal judgement.
 “What would you do if your kitchen catches fire?”
He replied, “I would look for a fire extinguisher and put out the fire.”
This response indicates that the client has sound personal judgement.
 Test Judgement: Appropriate
The examiner asked a question which tests the client judgement in a
hypothetical situation which requires him to take steps.
 “If one of the cinema theatres exits caught on fire, what steps would you take
in this situation?”
He replied, “I would look for another exit and calmly direct everyone
towards the alternative exit, while the usher extinguishes the fire”.
This response indicates that the client has sound judgement in such situations.

11. Insight: Level 2

 Diagnostic Formulation for MSE
Juan Rodriguez, (he/him), 34, cis-gendered, was unkempt and eye contact was
maintained; conscious and oriented to place and person. Rapport could be easily
established. He was able to comprehend the instructions given. His speech was
coherent, relevant and audible. His fund of knowledge was average. Mood and
affect were congruent, he was objectively apathetic and subjectively indifferent.
Cognitive functioning was adequate, His immediate, recent and remote memory
was intact. Has no perceptual abnormalities. Judgement was intact. Insight level
was 2.

Diagnostic Formulation for Case History

Juan Rodriguez, 34, cis-gendered, Christian, married, male of low middle socio-
economic status coming from an urban background of Chicago with an
unadjusted premorbid personality with a family history of alcoholism. Comes
with a five months illness characterized by increased alcohol consumption,
inability to cease drinking, loss of interest in interacting with family members,
feelings of irritation when not drinking.

Provisional Diagnosis: Alcohol Use Disorder

Management Plan
Step 1: Psychoeducation
The clinician would first educate the client on how his alcohol consumption is
affecting his and his loved ones, as his insight level is 2. Moreover, the clinician
might need to provide instances which support the diagnosis of alcohol use
disorder, in order to convince the client that he indeed does have a problem.
Most importantly, to make him realize that he is unable to control his
consumption, as he keeps reiterating the fact that he can stop at any time, but
upon doing so, makes him drink more.

It would be best to involve his loved ones, co-workers and informant during
these sessions, so that they he can hear how his drinking has negatively
impacted them.

Step 2: Motivational Interviewing

This aims at improving and strengthening the client’s motivations for change.
As the client might struggle in accepting that he is has a problem, as the last
time he went to an AA meeting, he did not believe in their philosophy and
called it “bogus”. This technique would help him overcome his ambivalence, set
direct goals for self-improvement and stay motivated to realize them.

In these sessions, the clinician will encourage him to commit to a change, that is
to cease alcohol consumption.

Step 3: 12 Step Program

The clinician can encourage the client to join a 12 Step Program, similar to AA.
Although the client had doubts about such programs in the past, motivational
interviewing could help him understand that this program is essential to bring
the change he desires.