Johnny Begood: An Evidence-Based Case PresentationPATRICK WARING

CPSY 646

JANUARY 2013

Identifying Information

39-year-old Caucasian male

Referred by his wife for help with explosive outbursts

Lives with his wife and son age 5 and daughter age 2

Also has daughter age 10 from previous marriage

Mental Status Appearance - The client is average in height and

weight. His appearance was consistent with chronological age with some signs of fatigue. He is well groomed.

Mood – He appears mildly unhappy or dysthymic on initial interview.

Affect: The client’s self-report of feeling at fault and being upset over current circumstances is consistent with affective experience and also appeared consistent with observations.

Mental Status

Thought processes: The client’s thought process were very logical

and sequential with good reality testing. His thought processes are generally logical but laden with self-blame, self-doubt, and some other maladaptive thought patterns.

Thought content: The client’s thought content was appropriate to the situation.

Dangerousness to self or others: Denies self-harm ideation, domestic violence or homicidal ideation. In later sessions would admit to using threat of self-harm as a method of gaining attention and/or making sure he was heard.

Sensorium: The client was alert and oriented to person, place, and time and purpose of the meetings

Chief Complaints

client’s chief complaints were:

that he had a “quick trigger” that people saw him as a person easy to anger.

concerned about anger and outburst in front of his children.

Nobody listens to him

he is angry with God for the death of his father prior to his birth.

client states he had to discontinue Fluoxetine, which was prescribed for his

anger and to stabilize his mood Discontinued due to financial concerns and moving to Muncie.

he is concerned that his recent vasectomy has somehow impacted his sexual ability and functioning

affects his general manliness.

been experiencing different expectations than wife regarding the intimate components of their marriage.

Additional Information

Mother in law is very involved in family as social support

Client lacks any social support outside of marriage Client shows tremendous resistance to discussions of

primary family Father died before client was born Mother remarried for 9 months to man with son but

ended marriage after feeling like man was unfair to her son.

Mother was a strong willed and very dominant person and is still a valuable source of support when things go bad at home. Mother will allow client to stay with her.

Additional information

Attends Local Comm College for eventual photography business

Wife also attends same community college Has part time job as computer tech support through temp

agency Often in trouble as home blow ups interfere with work

schedule.

Hobbies are time-lapse photography, making snowflakes Considers his half-brother his only male social connection

but not close connection Shows insight into anger outbursts being undesirable 10 year old daughter is a frequent weekend visitor. After first major outburst during x-mas, pt got and is

taking his Prozac.

Assessment

Presenting Problem Anger, Anxiety, Impulse control, relational conflict and possibly risky and aggressive behaviors.

Specific Definitions of Presenting Problem 

1 Anger with outbursts accompanied by destruction of property, self-defeating actions, and occasional minor physical aggression toward primary partner.

2. Feelings of shame, guilt, and frustration over outbursts that seem to feed into more outbursts3. Feelings of repeating his relationship with his mother with his wife, especially in response to feelings of not being heard or understood.

4. Rigid beliefs about self-concepts of masculinity, the impact of his vasectomy, and his relational ability with both women and men causing moderate anxiety about primary relationship.

Diagnosis 

AXIS I: Clinical Syndromes or Other Conditions That May be a Focus of Clinical Attention: 312.30-Impulse-Control Disorder NOS

V61.20-Parent-Child Relational problems

V61.10-Partner Relational Problems

300.02-Generalized Anxiety Disorder (Provisional)

AXIS II: Personality Disorders/Mental Retardation:

799.9-Diagnosis Deferred 

AXIS III: General Medical Conditions  None reported

DSM Axis IVX Problems with primary

support group (Specify)Communication problems in primary family, overreliance on primary family for social support. Outbursts of anger that may become physical interfere with primary relationships.

X Problems related to the social environment (Specify)

Small primary support group, relies primarily on spouse for social support, the clients states he has trouble making friends

  Educational problem (Specify)

 

X Occupational problem (Specify)

Quit one job for another then quit the new job.

  Housing problem (Specify)  X Economic problem (Specify) Living on student loan money, part

time job and borrowing from parents,X Problems with access to

health care services (Specify)No health insurance, no money for psychiatric medication.

  Problems related to interaction with the legal system/crime (Specify)

 

X Other psychosocial and environmental problems (Specify)

Clients managing strong emotions of any kind.

DSM AXIS 5

Global Assessment of Functioning Scale (Score) 65

Global Assessment of Relational Functioning (Score) 45

A

Treatment Goals-Long Term

Long Term Goals 

1 Eliminate inappropriate displays of anger and self-harming behaviors or simulation of self-harming behaviors.2. The client will gain sufficient insight into his own interpersonal process, including guilt, shame and anger, to be able to benefit and enter couples counseling.3. Identify patterns of thoughts and behaviors which may have been adaptive as a child that are no longer adaptive in the client’s relationships. Replace maladaptive patterns of thoughts and behavior with more adaptive patterns.4. Explore and help the client examine and come to determine his own definition of masculinity.

Treatment Goals Short Term1. Eliminate physicality during periods of anger and/or outbursts

1. Check in each week with client whether any physicality took place in anger; Monitor any possible issues of mandatory reporting. Work on solution focused coping methods to end physicality in anger by the client.

2. Explore early childhood and relationship with mother.

2. Interpersonal exploration of childhood memories and attempt to access repressed memories, as client denies clear memories of mother prior to age 10.

3. Identify patterns of thoughts and behaviors which carry over to present day

3. Examine the adaptive nature of the thought and behavioral patterns for a child versus the patterns of behavior as an adult.

4. Explore the meaning of masculinity.

4. Help the client to define for himself what it means to be a man.

What the literature says about mixed anxiety and impulse control and intermittent explosive disorder http://www.psychologicaltreatments.org/

http://article.psychiatrist.com/dao_1-login.asp?ID=10006061&RSID=55996345638836

http://journals.psychiatryonline.org/article.aspx?articleid=175139

Case Formulation A lack of ability to identify emotions, lack of anger

coping methods, lack of success in attempts to initiate self-change, and repetition of perceived failures of attempts to change have led to social-isolation (especially with other males), overdependence on the primary relationship, low self-esteem and self-worth, inappropriate management of interpersonal relationship building. available may have been. He also is repeating the relationship with his pre-deceased father with other males as he imagines friendships but claims not to know how to relate to males. The need to feel heard tied to unawareness of primary emotions as a child is now being repeated as episodes of anger as a means of drawing attention to the client.

Not quite fish nor foul

Client does not meet criteria for anxiety disorder yet he has features of anxiety like catashrophizing, solely blaming self for both his and partner’s problems, worry about how everything effects partner, how he is perceived by children. His is the only bad example for the children, he sees his poor outburst strategies being repeated by 5 year old son.

Does not meet any of the impulse control disorders clearly either hence the NOS.

Best this counselor can manage is some impulse control issues with some anxiety like features.

How to treat?

Perhaps, best thought of from a CBT perspective that forgets the DSM and instead works on specific problems like Assertiveness of communication skills to combat feelings

of not being heard

Cognitive restructuring of self-blame into understanding in any disagreement both parties are likely to have a role to play

Behavioral treatment of communicating before feels like a “soda bottle that is going to pop”

Reinforcement of safety plan and concrete behavioral methods of preventing episodes of loss of control

Someday in the future, after behavioral strategies are mastered, explore the interpersonal process stuff of mother parallels with wife.

So far with this patient it has been crisis management and anger management skills

Evidence support for medication treatment with either anti-depressants or mood stabilizers is good so continue to reinforce Prozac use

Explore primary relationships vis-à-vis original primary relationship

Expand social supports beyond family

Use Linehan’s communication exercises for increased communication skills

Use CBT approaches to combat maladaptive thought patterns regarding self-blame, self-doubt, anxiety producing changes, surprises, and unexpected events.

Rationale

There is no clear evidence base to work from on impulse control NOS so must draw from lit on typical impulse disorders (gambling, shopping, etc) and explosive disorders. Evidence for anti-depressent usage in explosive disorders. Moderate research support for CBT/ACT/DBT in mixed anxiety disorders, anxiety disorders, and for people with communication difficulties and, hopefully, with someone like this client who seems to feel unheard often will respond to assertiveness training in communication and he already had to some extent.

Case Summary

Prognosis is good.

Patient has made great strides in self-control and behavioral strategies for anger control but needs continued support of these new behaviors

Patient has insight that some of his issues are “deeper” than what we have been able to cover in 10 weeks but will continue to work on that with new counselor

Next counselor could use Linehan’s program of communication skills or similar.

After that and coupled with couples counseling, patient may need to spend some time digging deeper into interpersonal process material, mother issues, and similar material

Estimated time of continuing treatment, 10 weeks of CBT skills and 10-15 weeks of deeper meaning issues-psychodynamic approach. Couples Counseling length unknown.