Patient’s Name: Algernon Greyson
Date of Evaluation: 25 April 2011
1.Purpose for Evaluation:
This is the first inpatient admission for this 19 year old, single, white male who is a student at UW Madison. He was admitted due to abnormal psychological symptoms with possible danger of starving himself to death. The purpose for the current evaluation is to identify and clarify the nature of the patient’s underlying psychological symptoms and establish a proper treatment plan accordingly. 2.Relevant History and Background:
Name: Greyson, Algernon
Marital Status: Single
Occupation: UW student
•Hears voices all night.
•Believes someone might come in his room and kill him or kidnap him. •Feeling very fearful lately missing classes as a result. •Thinks students are looking at him and judging him negatively. •Believes receptionist talks behind his back and makes “evil” stares. •Suspicions of being talked about behind his back, and criticized alienating his friends for the past 6 months. •Afraid he may be attacked in the bathroom while showering has not showered in a week. •Believes there are people stuck in his house walls thinks they might come out and harm him. •Difficulty distinguishing unreality from reality.
•Flat in his affect.
•Became quieter Hard to extract information.
•Difficulty sleeping at night.
oStarving Won’t go shopping.
•Used to have a good support system of friends.
•Not suicidal, no depressive traits.
•Avoided seeing a psychologist.
3.Assessment Procedures & Findings
The patient was interviewed in a clinical setting. I find that positive and negative symptoms as in schizophrenia are present (detailed symptoms are listed under symptom repertoire). Algernon mainly suffers from delusions and auditory hallucinations. His negative symptoms such as being emotionless and having a flat affect also indicate him having schizophrenia. His delusions impair him to a great extent. He is unable to leave his house, alienates his friends and lacks the capability to take care of himself. His performance has declined. I estimate his GAF at about 23 since he falls in the following category of the GAF scale:
21 - 30 Behavior is considerably influenced by delusions or hallucinations or serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends)
His medical and psychiatric history documents were reviewed and revealed a family history of schizophrenia. Neuropsychological assessments, blood tests, EEG and Computed tomography were carried out. Several psychiatric scales (Structured Clinical Interview for DSM Disorders, Brief Psychiatric Rating Scale, Global Assessment of Functioning and Mini–mental state examination) were also used to establish diagnosis. Neuroimaging and laboratory tests were normal. They did not indicate any physical cause for Algernon’s impairments. However the various psychiatric scales ruled out any other disorders and strongly suggested that schizophrenia is the most appropriate diagnosis. 4.Diagnosis
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1 -month period (or less successfully treated): (1) delusions
(3) disorganized speech (e.g . frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior
(5) negative symptoms, i.e., affective flattening, alogia, or avolition Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a...