Name: R., Dottie DOB: 11/3/74

Diagnosis: Axis I: 305.00 Alcohol Abuse

305.20 Cannabis Abuse

295.30 Schizophrenia,Paranoid Type, Single Episode in Full

Remission

Axis II: Schizotypal Personality Disorder, premorbid

Borderline Personality Disorder, premorbid

Axis III: 250.01 Diabetes Mellitus, type II/non-insulin dependent

99.41 Chlamydia trachomatis

Axis IV: Occupational Problems, Severe

Housing Problems, Severe

Economic Problems, Severe

Axis V: Current GAF: 51

Highest GAF Past year: 51

GAF at admission to hospital: 10

GAF at discharge: 45

Dottie R. is a twenty-four year old woman referred for interdisciplinary staffing by a case manager with Vocational Rehabilitation. She has a history of reoccurring problems on the work site and at home. Most recently, Dottie experienced a "psychotic" episode at work and was hospitalized for two weeks during which time she received treatment geared at stabilization of the acute episode. Little is known about Dottie’s family history and she has had no prior hospitalizations. Information available comes from her current therapist, hospital reports, and coworkers. Dottie also has presented some information but the credibility of her reports is questionable. The interdisciplinary team is asked to re-evaluate the diagnosis and compile a comprehensive rehabilitation plan which can guide the provision of community-based services.

Physical Presentation

This client presented as a woman much younger than her stated age. She is estimated as being within the above average range of intelligence. Her dress was prevocative and she was heavily madeup. She demonstrated childlike mannerisms and speech. Ms. R. carried a large brief case which she described as her "safe". She reports carrying all her important papers with her at all times "in case someone needs to know something about me". Her speech was rapid and slightly pressured. She fidgeted in the chair, dominating the conversation with rapid explanations of history, behaviors, and problems.

Thought processes were organized and non-delusional with some bizarre paranoid and compulsive features. She did not appear to be experiencing the effects of substances at the time of this interview. Ms. R. admitted to frequent use of alcohol and marijuana which she uses to make herself "feel better about things" but denies dependency.

Client’s mood at the time of this observation was somewhat elevated and anxious. She admitted to a history of attempted suicides and violent episodes but denied current suicidal ideation.

She states that her current problem is understanding what happened when she "cracked up", "getting the shrinks off her back", and "putting some rattling money back in the pocket." She sees herself as someone who is different from other people, smarter than most people, a loner, and at her best when everyone leaves her alone. She admits to needing other people to help her get her needs met but finds that she can get what she wants most often by giving people what they want and then "dumping them". She explains that she knows more about herself than anyone.

Ms. R. is the youngest of five children. She reports that her family was "a case study in dysfunctional" and she was rarely happy. She attended school beginning in kindergarten but had a high record of absenteeism. She remembers being taught by a neighbor to read when she was four years old and spent a great deal of time by herself reading books which her neighbor provided. She describes herself as a serious child who took care of herself and survived by "doing whatever it took". She reports being physically abused by both her parents, particularly her father, all during her childhood until she was sixteen. At that time she reports being raped by her brother and uncle.

"I decided that I had to get out of that nuthouse packed everything I owned, which wasn’t a lot, into this briefcase and left."

Dottie explains that she lived primarily on the streets, prostituting and peddling drugs to get what she needed. She used much of her money to buy alcohol and marijuana, living in boxcars and alleys.

When Dottie was nineteen, she met a social worker who convinced her that there were "other ways to get what I needed". She allowed the worker to assist her in finding a job doing janitorial work at a large urban church. She was given a small room in the church basement, a meager salary, and free meals. During her employment with the church, she interacted regularly with the Secretary, Pastor, and Custodian who became her advocates with social services, businesses, and the community-at-large. Dottie successfully maintained her employment there for nearly five years, read voraciously, and acquired her GED. She enrolled in computer classes at the local technical college and began making plans to pursue a two year degree in business administration which she planned to use to start her own mail order book business.

Dottie reported experiencing a number of "wild" physical symptoms which began two weeks prior to her hospitalization. She began hearing a loud buzzing in her ears at night which increased in volume and duration until it was troubling her both day and night. She explains that the noise in her ears would not allow her to concentrate on anything and she found herself yelling at others to hear herself over the noise.

"Everybody started to turn on me. They wouldn’t leave me alone. They would beat on my door all night long. I could hear them laughing at me and trying to figure out how to get me to come out of my room. And my head hurt so bad! It was like coming down from a really bad trip. So I started trying to figure out how to get them to leave me alone. I couldn’t believe that they were doing me this way and I figured that they wouldn’t let me just leave. So I started saving up the things I needed to escape. I filled my briefcase with bottles and stuff to use for fuses. I decided to blow the place up. I read up on making bombs and filled the basement with them. Then I went upstairs and told the pastor that I had been living in fiery Hell all my life and wanted him to know what Hell was really like so he could be a better preacher. I told him to come down to the caves of fire and brimstone where I lived if he really wanted to know. I don’t remember much about what happened then but they say that I started tearing things up and throwing things and yelling all kinds of bad stuff. They said I lit a roll of paper from the pilot on the furnace and threatened to burn the place down. They also said I punched the Preacher out. I don’t remember much of that. Next thing I knew I was in the hospital all doped up. That’s pretty fuzzy for me too."

Dottie was taken by ambulance to the nearest Emergency Room and transferred to a psychiatric ward. She was placed on medications (full records not available) including Haldol which she describes as "Lucifer’s drug of choice". Her acute symptoms responded rapidly and well to medication and hospital staff reported seeing improved functioning in all areas. She was then transferred to the State Hospital where she became the model patient with a glowing prognosis. She was given more and more privileges including the ability to travel to appointments without supervision. On the thirty-first day of her hospitalization, she traveled through the gates and left the hospital permanently without official discharge.

Three days later she reinstituted contact with her therapist at the public mental health center. The therapist reports that her functional level has remained consistent with her optimal functioning prior to her psychotic episode and that she is currently refusing to take any medication. Few residual symptoms of schizophrenia are noted except those which may have been present premorbidly.

Dottie is currently living in a homeless shelter and has no immediate plans for securing permanent housing. She reports wanting to find a job and would like to return to the church. The former employer is reluctant to re-employ her without more certainty that she is stable.

Secure a full assessment.

Address symptom relief and medication management

Identify possible housing solutions.

Identify possible benefits available.

Referrals to appropriate community-based services.

Identify and address vocational and educational issues.