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Read case studies and answer the following questions
CASE EXAMPLE B
John B. is a 15-year-old man of Sudanese descent who resides with his mother, grandmother, 23-year-old brother, and his brother’s wife. They are all asylum seekers to the United States, having arrived from South Sudan 2 years prior to this. He is seen in this mental health clinic after discharge from an inpatient stay following a suicide attempt by hanging.
Brother found patient hanging by a rope tied to the clothes rod in the closet. Patient was cyanotic with slow pulse and taken to the hospital by ambulance. He was treated in the inpatient adolescent unit for 1 week and discharged to this clinic for an assessment and follow-up treatment. He reported that he has been feeling depressed “for as long as I can remember” with low self-esteem, feelings of hopelessness and being a burden to his family, guilt, and self-hatred. He said he had been thinking about killing himself for several months and has been cutting on his arms in practicing for this. His brother came home from work unexpectedly to find him. He described not fitting in at school and not feeling comfortable in his new home. His brother arranged to bring his mother and grandmother to the United States to flee from the war. His brother was brought to the United States when he was 14 years old under the UNICEF program for rehabilitation of child soldiers, and believes the patient was being recruited to be a soldier before coming here. Patient sleeps less than 4 hours/night with frequent nightmares and refuses to sleep in bed, prefers to sleep under the bed. Has poor appetite. Teachers report he has difficulty concentrating in school and has to take frequent breaks to sit in quiet room with soft music. He has made few friends and gets into fights, both physical and verbal, with other boys. Easily upset by loud noises or changes in routine at school or at home.
Medical history: Patient has no known drug or food allergies. He was treated for malnutrition upon arrival to the United States and remains underweight. He was diagnosed with mild intermittent asthma, triggered by exercise and seasonal allergies. Physical exam also revealed several horizontal scars on the inner surfaces of his left forearm.
Substance use history: Denies alcohol or drug use.
Family history: Father died in war in South Sudan when patient was 4 years old. Raised by mother and maternal grandmother with older brother. Older sister killed in village raid when patient was 5 years old. Unknown paternal history. Mother is 42 years old with unknown health history.
Personal history: Full-term birth without known complications. Attended school intermittently in South Sudan due to civil war. Currently attending special school and mostly fluent in English. Has had behavioral problems in school due to inattentiveness, anger, poor impulse control, and low frustration tolerance. Mother and grandmother do not speak English and are unable to provide description of patient’s behavior at home. Brother works two jobs, as does brother’s wife.
Trauma history: Witnessed his sister and mother being raped and sister’s death. Possible torture prior to coming to United States.
Mental status examination: Thin, lanky young man with multiple scars on arms and back. Clean, casually attired with close-cropped hair. Cooperative and sullen during the assessment. Sits in chair with legs pulled up on the chair and gripping his knees with his arms. Makes moderate eye contact. Alert, oriented to time, place, and person. Memory not formally assessed but appears to be intact based on his ability to accurately relate details from his recent experience. Hypervigilant to the environment and interviewer’s behavior. Linear thinking with abstract reasoning and seems to be of average to above average intelligence based on fund of knowledge. Speech is soft with pronounced accent, regular rate and rhythm. Comprehends English sufficiently to not need interpreter. Thinking process is coherent and goal directed. Thought content is focused on distress of hospitalization. Acknowledges wanting to die but without current plan to kill self and feeling remorseful that he upset his family with his recent attempt. Described his current mood as scared and depressed. Affect is fearful, tearful, and angry. Impulsive previous behavior with poor judgment and belief in limited future. Insight is reasonable in terms of understanding why he is referred to treatment.
Current medications prescribed at last hospitalization:
1. Prazosin 5 mg bid for nightmares and daytime stress
2. Vortioxetine 10 mg daily for depression and anxiety
3. Fluticasone-salmeterol inhaler qd for asthma
4. Theophylline 300 mg qd for asthma
Differential diagnosis: Major depressive disorder with suicidal thinking. Posttraumatic stress disorder.
1.In reviewing this chapter, which factors are important to consider for this patient?
2.What additional information would you like to have to be more comfortable in working with this patient?
3.How will you explain your diagnosis and treatment plan in relation to the patient presentation? What treatment options will you recommend and why?
4.What is your initial approach in negotiating treatment for this patient?
5.What medication changes would you want to discuss with the patient and how will you negotiate that with her or him?
6.What time frame do you propose for this plan, and how will you transition with the patient?
7.How will you coordinate care with the other providers working with this patient?
8.After stabilization, which psychotherapeutic approach would you take?
