Psychiatric assessment form

Patient evaluated: 2011-12-13

1. ID

Name: DEREK ZEIGER

Marital status: SINGLE
Sex: MALE
Occupation: SERGEANT, U.S. ARMY; UNEMPLOYED
DOB: 1986-01-14
Age: 25
Financial situation: VETERAN; DISABILITY PAY

2. HPI [history of present illness]

(ONSET, DURATION, COURSE)

Why present now/precipitants/stressors?

When it started?
How long it lasts/frequency?
What is it like?
Impact on life?

Patient is returning veteran, subject to mandatory psychiatric assessment upon return. Complains of
backache, unable to walk without extreme pain and visible hobble, isnt sleeping through the night.

Patient admits to recurring intense feelings of guilt surrounding the death of squadron member Arlo
Mackley. Guilt impacts daily functioning, but is intermittent. No apparent pattern to episodic impact.
Patient will not engage in deeper discussion of trauma, past an admittance of the name and of the
death. Difficult to determine impact on his quality of life without acknowledgement of the trauma.

Reports the following stressors:

- Loud noises
- Flashes of bright light
- Color red
- Loud vehicle noises
- The smell of roses
 3. Psychiatric Hx

Previous psychiatric Hx/Counseling/Suicide attempts/Violence:

N/A; first time patient

Previous diagnoses:
None on file

Medications/Tx:
None currently

4. Fam Psychiatric Hx

Psychiatric Dx/Visits/Counseling/Suicide attempts:

None

Substance use:
None

Suicide:
N/A

5. Impression/Formulation

I suspect Zeiger has intense trauma due to the death of his friend, Mackley, and his brain is blocking
the truth of what happened on the day Mackley died. Cant seem to give me a straight account of what
happened during the attack and emotions shift rapidly from happiness to deep self loathing when I
continue to press conversation on that topic.

Concern is that continued repression of these memories will continue to surface in his insomnia and
my irrational surges of rage or other extreme emotion. I recommended further counseling to unwrap
the truth of what happened on April 14th, but patient doesnt seem to think he has any problems worth
discussing. This recalcitrance to talk deeply and honestly about the events that occurred is most likely
another measure by his brain to repress the painful memories.

Shifts uneasily when I ask questions about his family and his life before enlisting. No job currently.
Past experience with tech but seems to lack motivation to integrate back into workforce. No mention of
a significant other. No friends currently in Wisconsin. I voiced concerns about his apparent poor
integration back into his real life, and how he still seems to be living as a soldier and not as a man.
Was again shut down in this path of conversation. His inability to engage with me on any level deeper
than small talk makes it difficult to form an accurate impression of his condition or to begin to provide
some measure of relief.

6. Plan

Treatment:

Biological:
N/A

Psychological:
Patient refused to come in for any more regularly scheduled meetings. Recommended
treatment was CBT-I (cognitive behavioral therapy-insomnia) and continued sessions to discuss
trauma. Also recommended that patient try attending a few informal group therapy meetings hosted
by the VA Hospital as a potentially less threatening form of therapy. Suggestion was also rejected by
patient.
Recommended that patient pursue access to massage services under H.R. 1772 bill. Will
alleviate symptoms of pain in the back and other physical pains mentioned. This was met with more
enthusiasm than the first suggestion.
 Psychiatric assessment form
Patient evaluated: 2012-01-25

1. ID

Name: BEVERLY McFADDEN

Marital status: SINGLE
Sex: FEMALE
Occupation: MASSAGE THERAPIST
DOB: 1968-10-21
Age: 44
Financial situation: PRIVATE INSURANCE

2. HPI [history of present illness]

ONSET, DURATION, COURSE

Why present now/precipitants/stressors?

When it started?
How long it lasts/frequency?
What is it like?
Impact on life?

Patient is a middle-aged woman complaining of episodic visions that include auditory and visual
hallucinations.

Refers to these hallucinations as flashbacks from the Iraq War, brought about by intense emotional
connection with a client of hers who is a veteran. Complains of headache, insomnia, and that she
cannot get the story and the day of the veterans bomb attack out of her head. Beginning to question
what is reality and what is her hallucinations.

Claims it is her responsibility to set the record of what happened in New Baghdad for her veteran
patient straight. Stated that she has seen his fixed tattoo move, and personally manipulated and
changed the tattoo. Stated she feels personally responsible for holding the truth of April 14 inside
her so that it cannot poison the life of the Sargeant any longer.

No apparent stressors, has lost control of when the visions do/do not come. Intense and complete
hallucinations (including all the senses) when they do occur. When she isnt experiencing visions,
patient still complains that she still cant stop thinking about these occurrences and vividly imagining
the scene, even when she isnt a part of it.
Has lost 12 pounds. Physically, appears haggard and worn. Evident that quality of life is negatively
impacted by symptoms described.

For episodic illnesses describe first episode:

1. Onset: Upon meeting massage client
2. Precipitants: Visions originally stimulated by physical contact with aforementioned massage patient;
symptoms have grown in frequency and intensity with no additional pattern
3. Duration: Episodic visions last under an hour
4. Rx response: Self medication with alcohol

3. Psychiatric Hx

Previous psychiatric Hx/Counseling/Suicide attempts/Violence:

Previous grief counseling after death of mother

Previous diagnoses:
Insomnia comorbid with mild depression (complicated bereavement)

Medications/Tx:
None

4. Fam Psychiatric Hx

Psychiatric Dx/Visits/Counseling/Suicide attempts:

None

Substance use:
None.
Single week of binge drinking. Not technically classified as typical substance abuse or dependency.

Suicide:
N/A

5. Impression/Formulation

In my professional opinion, patient is experiencing an extreme form of compassion fatigue that is

presenting with hallucination symptoms as well. Patient is used to playing the compassionate
caregiver--did so with her father and mother while both were dying of cancer. This is a role she
takes great pride in, and as a result, it is a learned response for her to attempt to relieve the pain of
those around her.
Due to the doctor-patient nature of her relationship with her client, her brain is attempting to take the
healing relationship one step further. Beyond healing his physical maladies she attempting to relive
the emotional ones as well. This problem is further complicated by the intense emotional nature of her
clients trauma. I believe his trauma is bringing up her feelings of helplessness that she felt during the
death of her parents. I suspect she believes she can actually save her veteran the way she was
unable to save her mother and father from terminal cancer.

Episodic visions and hallucinations are wreaking havoc on her life. Unable to sleep, eat, or really
function in the aftermath of horrific images of war and searches to find what she describes as the
truth of what happened on that day. Patient describes that these visions/hallucinations became more
and more intense the more time she spent with her client.

Symptoms must be managed to preserve quality of life. I believe talk therapy will provide a measure of
relief as she properly sorts through both the veterans trauma and her own.

6. Plan

Treatment:

Biological:
No need for biological psychiatry. Patients insurance doesnt cover brain imaging. Would
not benefit.

Psychological:
It has been recommended that patient pursue a course of antipsychotic drugs (clozapine) to
calm visual and auditory hallucinations and manage the depression-like insomnia and stress caused
by impact of hallucinations. In addition, cognitive behavioral therapy (CBT) is strongly
recommended. Difficult to ascertain whether episodic visions are early symptoms of a psychotic
breakdown/psychotic mental illness or are triggered by stress. More therapy would be required to
determine if this is a neurological issue or an environmental issue.