Psychiatric Evaluation: Grrr!

[teacherabc]

I am wondering how it is possible to produce a good psychiatric evaluation overnight...HP went to his appointment this morning at VESID and was given his psychiatric evaluation which was yesterday at noon. It took us a long time to read it--literally--handwritten. Maybe I don't much about these types of reports but it seems to be not all that helpful and carelessly done.

In any event, the long shot is, for anyone that interpret this for me:

Axis I: LD NOS (315.9)
PTSD (309.81) vs. Bipolar D/O NOS (296.80)

Axis II: Personality D/O NOS - (301.9) w/ avoidant, schizoid and schizotypal FX's.

Axis III: Denies.

Axis V: $, Social Support, Self Esteem poor

There is no box for Axis IV. At the bottom of the page: Flashbacks; very depressed; Flashbacks and nightmares. I asked HP about that and he said the flashbacks started only since he left for school.

However, the recommendation in the box titled "Current Medication and Therapy)" which he not yet getting is "Individual therapy/conseling to deal with past abuse rx, resultant mood/self esteem disturbance and overall emotional support. Client would benefit from evaluation for ADHD medication as well as an anti-depressant or mood stabilizer." While the doctor might have mentioned a particular drug in the interview he did not mention one in the report.

With regard to the MD's opinion, in relation to training, education, and employment services on the following factors:

A. Interpersonal factors: While living with mother, client seems to decompensate. Mother abusive, demeaning, critical and unsupportive. Settings that are emotionally supportive or use positive reinforcement would be best. Client motivated to complete college and become "self-sufficient." Has done + w/extra support and attention of teachers.

B. Personal Awareness and Motivation: Very low esteem and underestimation of his cognitive and social ability. Practically - math/written expression are relative weaknesses. Client seems motivated to continue education.

C. Functional Limitations
- Response to criticism. Can react with anger and/or isolation w/a lowering of mood, self-esteem and effort.
+Feedback from supervising teacher a +.

Recommend: Individual therapy to enhance self-esteem and social skills. Medical Evaluation for Mood and Attention.

Mental Health Estimate: box marked good is checked
Work ability estimate: box marked good is checked.

Mental Health Status Examination: Most boxes checked for within normal limitations. Specific mannerisms: leg bouncing. Not checked for normal:

Rate/pitch, volume, clarity, spontaneity: comment-Soft tone
Mood: variability, intensity, liability, appropriateness: "OK-seems depressed."

Delusions/paranoia checked as normal but comment: slightly paranoid (underlined)

Language-repeating phrases, naming objects-not checked but I don't think any of the comments below correspond.

Other comments: No SI/HI; no A/V/T/O Hallucinations (?)
A & O x3: Memory WNL

Somewhat blunt affect

Quotes from HP: "Much in imagination-less in real world"

Habit of being annoying, sometimes get hyper and act annoying/bothering, tough to calm me down.

I don't really know how to make heads or tales of this. On the one hand, the doctor diagnoses him with PTSD vs. Bipolar Disorder (what does the versus mean--maybe he doesn't know).

What is Personality D/O NOS with avoidant, schizoid and schizotypal FX's?

Why does he not diagnose ADHD even though he recommends medication for it?

HP had to sit down and read the report right away (I knew he would) and I had to sit down with him and read it line by line--took us hours. He reacted badly to anything the doctor said about his mood or his being depressed. He vehemently denied being depressed. I wasn't going to debate the point, though he obviously is often (not consistently), with some reason. When he saw the possibility of bipolar disorder he flipped out because he was afraid the doctor he goes to upstate will want to prescribe Abilify which he had before and hated. I told him that the diagnosis is unclear, and the doctor was recommending medication for ADHD and mood and, in any case, the doctor upstate would evaluate him himself and that he (HP) would be free, in the event that the doctor suggested Abilify to ask for a different med...

HELP!!!!!

[teacherabc]

This is what I found about the Personality D/O: Avoidant, schoizoid and schizotypal

People with schizoid personality disorder avoid relationships and do not show much emotion. Unlike avoidants, schizoids genuinely prefer to be alone and do not secretly wish for popularity. They tend to seek jobs that require little social contact. Their social skills are often weak and they do not show a need for attention or acceptance. They are perceived by others as humorless and distant and often are termed "loners."

Many believe that schizotypal personality disorder represents mild schizophrenia. The disorder is characterized by odd forms of thinking and perceiving, and individuals with this disorder often seek isolation from others. They sometimes believe to have extra sensory ability or that unrelated events relate to them in some important way. They generally engage in eccentric behavior and have difficulty concentrating for long periods of time. Their speech is often over elaborate and difficult to follow.

Avoidant personality disorder is characterized by extreme social anxiety. People with this disorder often feel inadequate, avoid social situations, and seek out jobs with little contact with others. Avoidants are fearful of being rejected and worry about embarassing themselves in front of others. They exaggerate the potential difficulties of new situations to rationalize avoiding them. Often, they will create fantasy worlds to substitute for the real one. Unlike schizoid personality disorder, avoidants yearn for social relations yet feel they are unable to obtain them. They are frequently depressed and have low self-confidence.

So, which is he? Avoidant and schizoid seem contradictory. To me, knowing him as I do, the avoidant category is the one that seems to fit the best.

[dwolen]

Tacherabc:
1. Most mental health professionals write up their evaluations the same day. This is a routine part of their medical training. It is based on the psychiatric interview.
2. PTSD vs bipolar disorder: often, it takes time, several interviews, to accurately diagnose mental health problems. The psychiatrist did not have enough data to accurately say if the information he obtained was either one or the other. The doctor at the college mental health clinic can continue the process.
3. Psychaitry and mental health has its own subculture of jargon. Just as it is hard for a medical patient to interpret his/her own medical records without a "translator" it is hard for a client and other lay people to understand his/her own psychiatric reports. It is sort of tricky for a client, especially a young one, to interpret his/her own mental health evaluation without understanding a lot about the process of psychiatric diagnosis. I suggest that instead of you continuing to chew over the report with HP, that you advised him to bring it to his next doctor and discuss it with the new doctor. After all, you want HP to benefit from psychiatry, and trust the help he can get. You don't want him to feel distrustful and avoid getting help.
4..HI=homicidal ideation
SI-suicidal ideation
no A/V hallucinations= no auditory and no visual hallucinations.
I don't know what T/O means.

5. I am not a psychiatric nurse or psychiatrist, but in my role as an FNP in an HIV primary care clinic that has a big mental health service, I do read psychiatric reports pretty often. I think that this psychiatric report sounds fairly thorough and it gives me a pretty good idea of what is going on with HP. It sounds sort of consistent with what you have posted about him. All of the diagnoses are helped with psychotherapy, especially CBT. Medications are negotiable, and if HP had a bad reaction to Abilify, he has a right to communicate his experience and discuss other options. He might need a mood stablizers in order to get benefit from medication for ADHD.
6. It is a shame that he was not medicated for ADHD before he did his first semester in college. Did you know that 55% of people medicated for ADHD have complete normaliztion of their symptoms (ie of ADHD)? the othe 20-25 % have some or moderate improvement. If he had been medicated, he might not have had so many problems during this last school term.

[Mayleng]

If he has BP, anti-D or stimulants are not recommended.

[teacherabc]

Thanks Mayleng. I was not going to continue to review the report with HP but I knew I was not going to avoid going over it with him initially; that's his m/o. He did the same thing with the Psychologist's report.

I wish he had been seen by a doctor before the first semester. That wasn't going to happen given the fact that he was living with mom and mom believes that anyone who sees a psychiatrist is crazy and told him not to. Then in the first semester he had medical insurance problems. Now, annoyingly, he has called the clinic, was told someone would get back to him in 24 hours and they didn't but I will have him call again tomorrow.

So, I guess the doctor upstate would have to see him a few times to determine if he has bipolar disorder. My concern is that this would delay giving him meds for his ADHD. I don't want him to waste a second semester and quite honestly, he does not seem like he has bipolar disorder to me. It is difficult to get me to get him to advocate for himself with the doctors and he does not understand why I can't just call them and speak to them--and I explain that there are all sorts of reasons why the psychiatrist (either the one down here or up there) would not be able to talk to me, though it might be difficult for him to make a decision on meds even though he is 19. I have helped to advocate for other people in my life with doctors (e.g., my mom) but I do have no legal relationship with him and it's a psychiatrist, not a regular MD.

[empeg1]

OH, oh, I can tell from the diagnoses that the psychiatrist is "throwing around" that the doc in question is not used to diagnosing patients who have complex PTSD. The above is a different diagnosis and, more important, a different way to treat, than simple PTSD. If HP has "PTSD" from his childhood, the issue would be complex PTSD, due to long term abuse/neglect, typically from childhood. it is truly a different disorder, with a different treatment.

I can see the red flags in the diagnoses the psychiatrist is considering. One, I can't begin to tell you the number of people who a first diagnosed with BPD and then later, when seem by a trauma expert, with complex PTSD. The problem is that the medication for BPD will not help with complex PTSD and can, instead, be detrimental. Ditto with a stimulant for ADHD, as the latter can make anxiety worse. The true tip off was the schizo affective/ schizotypal business.... that is another set of diagnoses often hung on folks with complex PTSD. Humph By hte way, an Axis II diangoses is saying that HP might have a character disorder, often seen as deragatory (and not really treatable). BS!

My guess is that you have a young man who has a significant history of childhood trauma. The latter can affect brain development ( the cortex is all developed after birth), leading to de-regulation of the amygdala (the emptional centers of the subcotrical brain. Symtoms? Emotional dysregulation, difficulty in concentraion and memory, hyperarousal, .... Guess whatcenters of the brain are affected? The hippocampus, te memory senter of the brain and, yep, the prefrontal cotex. oh, where ADD is also thought to be involved. And, my other guess is that HP as difficulty with dissociation..... that is what this doc is skirting aorund with all these possible diagnoses.

Sigh, HP really needs to be seen by a specialist. He is in New York, right? Try to contact the Trauma Center in Mass. You can google the above. Call, Teacherabc, and ask about their services and any referrals they may have in your area. You can also google, ISSTD (International Soceity for the Study of Trauma nd Dissociation. There should be a New York chapter and find out about a second opinion for HP. There should be sliding fee/ Medicaid fudning. I would not have HP make an appointment iwth a therapist at his school until this matter is resolved. A class in trauma, believe it or not, is not required by most state licensing boards or most graduate shcools boards. owever, the field has grown hugely in research and there are well qualifed professionals out there. One must be very careful to find them, otherwise more harm than good can be done, which you just found out by this psych eval.

[teacherabc]

I would like to hear some other opinions because I seem to be getting different ones. Unfortunately, Empeg, I don't think that scheduling an appointment at the Trauma Center is going to be a viable option. I dobut that it could be done as quickly as it would need to be done and things are seriously deteriorating at home such that he may have to go back earlier than planned. It is not an option for him not to go into counseling and see a doctor upstate, though I am seriously thinking that it might be a good idea for me to have tha bility to talk to the doctor--especially since he seems to want me to. The problem is he cannot stay here. I think that would be more deterimental to him than anything else. He is not going to make it another semester without intervention. I don't know what the doctor up there will be like. But he can't be here and he can't do nothing. Devil if you do, devil if you don't.

[dwolen]

As a point of information:
1. People with bipolar disorder can be treated for ADHD but they need to be on mood stabilizing medications first. People with bipolar disorder are also treated with anti-depressants but they, too, need the mood stabilizer medication first.
People with triple diagnoses (bipolar, ADHD and chemical dependency ie substance abuse like alcohol addiction, cocaine or opiate addictions) need treatment for the chemical dependency, bipolar and then, when those are stablized, for the ADHD.

2. Advocating for HP with psychiatric services is possible if HP signs a consent to give the psychiatrist permission to talk to you. Prior to his first appointment, it is perfectly acceptable for teacherabc to "check out" the services and expertise of the clinicians at the mental health clinics he may access to find out the best possible fit.

[Mayleng]

Yup, BP has to be stablized first before any treatment of adhd or depression can happen. If not, the meds for adhd or anti-D can make the BP worse.

[teacherabc]

But it said PTSD vs. Bipolar disorder. What if he has PTSD rather than Bipolar disorder?

[Mayleng]

Well they better figure out which is what.

[dwolen]

PTSD is treatable, too. When a psychaitrist says, "PTSD vs Bipolar DO", it means that more information is needed, via careful monitoring of symptoms and interviewing using the DSM-IV guidelines, to determine the diagnosis. This is the process of differential diagnosis.

There are two main types of bipolar disorder. In bipolar I, the patient has clear cut manic episodes that are hard to mistake for other mood states. I have been around a couple of my patients when they were in full blown, psychotic mania, and it was frightening. In bipolar II, the mania is "hypomania", that is, lower than full blown, psychotic mania. Sometimes, severe, prolonged irritable mood is called hypomania.

PTSD can cause lots of emotional aggitation, too. So, it is best not to jump on a diagnosis when one is not certain.
Clinical differential diagnosis is both an art and science. But at this point in psychiatry, there is no blood test or x-ray to determine the diagnosis as one could use in, say, pneumonia. Although there is no exact, physiologic way to nail down the psychiatric diagnosis, there is research behind the diagnoses in the DSM-IV. As the years go on, there is more and more.

You might want to learn more about this through the NAMI web site: www.nami.org
National Association for Mental Illness.

[teacherabc]

I have never seen HP with a clear cut manic episode. At most, he would have a severe, prolonged irritable mood and I don't think I have even seen that--anything that severe or prolonged. I will look at that website.

[teacherabc]

And another problem that has arisen...there is a waiting list at the clinic. I have to have him call back to find out how long the waiting list is. Unfortunately, there is only one other place in Auburn that takes Medicaid.

[lillian12]

PTSD can be absolutely debilitating, depending on its severity. In its most severe forms it can cause: nightmares on a nightly basis, which greatly disturb sleep, and, therefore, cause many more issues to arise, such as exhaustion and irritability during the day; anxiety attacks; flashbacks; startle reflex, which causes one to jump at loud sounds; days of overwhelming depression; flat moods; inability to concentrate or focus; and inability to see the future or plan for the future. It is quite common for people who have suffered trauma and have PTSD to be dxed with a wide assortment of other disorders. My advice is to treat it as if it's PTSD first, then see what's left over. If he is not showing any signs of mania, I wouldn't consider bipolar. Have you ever dropped a book around him or slammed a door and noticed that he jumped? This is a very, very common characteristic of people with PTSD. In this day and age, everyone who has ever suffered trauma and goes to counseling gets diagnosed with PTSD, which really irritates me. Depression from the death of a loved one or from a personal trauma is a normal, human reaction. PTSD is a disorder, and something entirely different.

[empeg1]

No, teacherabc.

I did not mean that HP should go to the Boston area and see someone at the Trauma Center. I meant that you can call them and find out if they keep a referral list of professionals in NY. Also, check out the Sensorimotor Psychtherapy site, to see if there is a trauma trained professional in upstate NY. Same with the ISSTD site. You want a NY division of ISSTD International Soceity for the Study of Trauma and Dissociation) and a list of therapists who are members. I believe the site has one part that is for "finding a therapist".
What I am afraid of is that HP will be medicated inappropriately with Mood Stabilizers and/or Anti-psychotic medications, which will not only not help Complex PTSD; these meds can make things worse for people with the latter dx. It is also true, that most people with Complex PTSD often are misdiagnosed, over and over, the average in 10 years, before a trauma trained clinician is able to recognize what is happening. If HP sees a counselor and a psychiatrist who misdiagnose him, more mischief can happen to HP then help. Please do some investigating with the sites that I mentioned.
FYI, the schizoid personality business is really about dissociation, a symptom of trauma, not achizophrenia. Humph

[teacherabc]

I am feeling just a little overwhelmed and I am trying hard not to show it in front of HP...The problem is that there are not that many providers in Auburn, period, and only two that take Medicaid. One has a waiting list and he is on it but I have to have him call Monday to see how long it is; he originally called them with me there but they called him back when I was in class teaching and he didn't think to ask that. He doesn't have a car. I am trying to find out if VESID will pay for a private provider because that would expand the options. And while he is willing to get the counseling because my husband and I are being pretty insistent that he has to, he doesn't quite understand why, though he does seem to understand that he probably needs meds and has to go to a psychiatrist to get them. I am guessing that he doesn't like the idea of talking to someone though he does tend to be compliant, even with people he doesn't know.

[lillian12]

Why are you and your husband insisting that he see a counselor?

[teacherabc]

Lillian12, it is rather a long story. I will try to make it short. We are very close to this young man. He has a history of being physically and emotionally abused by his mom (the emotional abuse continues). He had in a shelter previously and been diagnosed with bipolar disorder. He has also been diagnosed with ADHD and has significant learning disabilities. He started college in the fall and while college has gotten his away from mom, the abuser, it has been hard for him. He did not do well his first semester and wants so badly to succeed. He has many emotional problems--few friends, no self esteem. He is often depressed. He has, for the last year and a half, relied solely on me for emotional support. While I love being there for him, most of the time, I am many hours away and he needs more professional support. Insisting may be a bit strong but he means a lot to us and vice versa and in order to get what he wants in life, he needs to get that kind of help. I may be overstating it when I say he does not understand it. I think he does on some level. I think it is perhaps more that he does not like needing to get that kind of help because it makes him feel like he is bad or stupid even though he is far from either.

[lillian12]

Because he is a survivor of domestic violence, you have more options available for counseling. There are shelters that have free counseling for survivors, and he does not have to be in the shelter or have ever been in the shelter to receive this counseling. My advice is to get in touch with the United Way, which contracts the counseling in many of the shelters, and ask them if there is any free counseling in his area. Also, call the shelters directly.

Anyone who is a survivor of domestic violence and who was a victim of it for as long as he has been needs to approach counseling with caution and look for a specialist in survivors of domestic violence. I have done this counseling, and I have had many clients, who came to counseling after seeing psychiatrists and counselors elsewhere, who blamed my clients for the violence, which is particulary true of spousal abuse, or who called my clients liars, when my clients talked about the extent of the violence my clients faced on a regular basis, with the latter being particularly true of survivors of child abuse. For the person who has never survived such treatment in the hands of a loved one, even those who are professional counselors and should understand domestic violence can find it unbelievable that such levels of cruelty exist and that a child can survive such cruelty without having died or gone absolutely mad. But, the resiliency of children is amazing. Truly.

Again, I would start by treating this like PTSD, then see what happens. As long as he is not causing physical harm to himself--suicide attempts, cutting, severe drug or alcohol abuse that could kill him, blacking out and not knowing what he's doing during these times--then he will be fine in "talk therapy." Start there. Find someone who knows about child abuse and PTSD.

[teacherabc]

He did make a suicidal gesture once, a few years ago, when he was in my class. He took a pair of scissors and started to cut his wrists. As a result of that, I told our social worker and he was taken to the hospital on a three day hold right before Christmas. This was really before I got to know him (and I didn't get to know him for a while after that because he was mad at me and didn't talk to me for months). But he has not done that since. Or any of the other things. And it seems pretty clear that VESID can and should pay for the treatment--it is just the mechanics of how. It is remarkable how resilient he is...even though he has lots of issues, the fact that he can get close to people and trust them and that he is so motivated to make something of himself shows how resilient he is. Lots of kids I know have gone through less and have resorted to self destructive or destructive behaviors--dropping out of school, criminal activity, drugs. Although he did come close to dropping out of high school and engaging in criminal activity (he shoplifted, but mercifully got caught early and that was the end of that), that was it.