This Web site is a component of the SAMHSA Health Information Network
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This Web site is a component of the SAMHSA Health Information Network. |
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Evidence-Based Practices: Shaping Mental Health Services Toward RecoveryWorkbook for Clinical & Practical SupervisorsAppendices
Sample Comprehensive Assessment - Mr. Jones PART 1 - PSYCHIATRIC HISTORY, MENTAL STATUS, AND DIAGNOSIS Client Name: Mr. Jones Reason for admission (chief complaint) as stated by client, family and/or referring agency: “The Sheriff’s Department injected me with germ warfare causing these sores.” History of present illness: Previous Smithville State Hospital records indicate that he was released from a maximum-security forensic unit (release date 8/27/99) after being found incompetent to stand trial for alleged felony assault. He was transferred to Smithville State Hospital for treatment and released on 09/29/99. Mr. Jones was admitted to Smithville State Hospital Forensic Unit in July 1988 after facing charges of aggravated assault. Jones states that, while on the forensic unit, he made suicidal gestures, such as, slashing his neck with a razor blade due to auditory hallucinations. He reported attempting to commit suicide five or six times in jail by slicing his arms with sharp instruments, sticking pins into electrical outlets, overdosing on pills, jumping off things, and setting himself on fire. The client’s first encounter with the legal system occurred in 1975, when he shot a friend in self-defense. After that time, he began to drink heavily and use street drugs. He served time in the Mississippi Department of Correction in 1976 for robbery and again in 1984 for aggravated assault. While in prison for aggravated assault, he was diagnosed with Schizophrenia and placed on Haldol and Sinequan. He reported a good response to Haldol and was described as quiet and cooperative. He is afraid of what might happen if he goes to prison again, and believes that the Mississippi syndicate has a contract out on him for $10,000. The Smithville Police Department records from 6/8/98 indicate that Jones was threatening to cut people with a knife at his apartment. He was found to have three outstanding warrants. Police noticed a strong odor of alcohol. Jones attacked the officers. He was not affected by pepper mace. After being handcuffed, Jones stated that the police were going to burn in a volcano and that he was going to light the fire. Correctional Medical Services notes from August 1998 indicate Jones was treated with Haldol for Schizophrenia, but had been refusing medications. He is described as acutely “decompensated.” He constantly talks about Jesus and devils. He complains about vampires. He refused antibiotics for his impetigo. A letter from Dr. Hidalgo (who saw Jones 10/98) describes Jones as “extremely labile and frequently quite hostile.” He was loud and demanding. He had improved after a recent hospitalization during which he received Haldol, but again decompensated. He was religiously preoccupied and delusional. A court order from 11/9/98 indicates that a jury found him incompetent to stand trial and he was subsequently committed to Smithville State Hospital. A report from Smithville County Jail indicates that Jones was treated with Haldol and Cogentin for paranoid schizophrenia that is complicated by “non-compliance.” The jail indicates that Jones is “very unpredictable and goes through mood swings. He exhibits paranoia and is delusional at times. He thinks that he is Christ and will accuse others of being the devil. He picks hair out of his head and beard and has little round areas of pink skin where he no longer has any hair. He can be aggressive and a couple of days ago, he tried to hit a nurse with his fist. He does not like to wear clothes.” Service system records indicate numerous previous psychiatric hospitalizations, including five admissions to the State Hospital and fourteen to Morgan Medical Center. He has been offered outpatient treatment since 1992. Other past diagnosis includes Psychotic D/O, NOS; Organic Hallucinosis; Adjustment Disorder and Undifferentiated Schizophrenia. He states “I was charged with murder in 1976, but all I did was pull the trigger.” He reports that he has AIDS (a delusion) and stomach viruses from drinking out of toilets. He has 19 past admissions but only four of them longer than two weeks. When asked about substance abuse, he states “I can’t get them enough.” He has numerous self-inflicted scars on his arms. He reports that he hears voices and is Jesus Christ. He believes that he has bugs crawling inside and outside of his body. He also believes that staff have tried to kill him in the past. He is difficult to interview and gives rambling statements. He reports that he is a victim of a conspiracy involving Satan and the Smithville County Sheriff’s Department to infect him with germ warfare. He states that he hears voices of the devil and the Holy Spirit. He reports that this occurs all of the time and that he is not bothered by these experiences. He states that the voice says “stick ice picks in my eye and I’m going to eat you in the microwave.” When asked to elaborate on these symptoms, he became agitated, hostile, and threatening. He will not discuss any other psychotic symptoms. He denies any symptoms of depression but reports two previous suicide attempts by cutting his forearm. He states that he has not been suicidal in many years. He denies any symptoms of mania, panic attacks, or memory impairment. Recently he reports that he is doing poorly, which he attributes to being infected with germ warfare. Treatment goals and individual strengths as stated by the client: Jones states that his goals are as follows:
Jones states that his strengths are as follows:
History of past mental/psychiatric illness: Smithville County Jail (1975) Shot a friend in self-defense. Shortly thereafter, he began drinking heavily and using street drugs. His sister reports that Jones was “never quite right as a child and had lots of problems in school and at home.” She reports that he used to draw funny pictures on everything—”they looked evil.” She feels that his first divorce triggered an increase in ETOH use and led him to the situation where he was arrested after killing his friend. She states that he “went down hill from there.” Department of Corrections (1976-1983) Convicted of armed robbery. Jones spent two months in the Skyview Unit (Psychiatric Unit) and received the diagnosis of Psychotic D/O, NOS during this incarceration. Reports indicate that he would be fighting with “spirits” and was saying that the “devil was coming to get him.” Doctors tried him on Thorazine, which helped to clear up the hallucinations but he experienced a reaction to the medication and was transferred to the medical unit. Reports indicate that he was not restarted on another antipsychotic following this episode. During his time in the community, Jones married again and later divorced. He says that his ex-wife just did not understand him and refused to believe that the “devil would kill them one day.” He stated that they would stay barricaded for days in their apartment to stay safe. He feels that this led to their divorce. Department of Corrections (1984-1988) Convicted of aggravated assault. First diagnosed as having schizophrenia. Reports indicate that Jones had a serious suicide attempt while incarcerated. He was being tormented by voices, which he believed to be the devil telling him that the Mississippi syndicate was coming to cut off both his hands and gouge out his eyes. He self inflicted deep cuts across his jugular veins. He was treated with Haldol and Sinequan. This reportedly helped to alleviate some of the symptoms and decreased the aggressive acts. Smithville State Hospital (4/14/88-7/1/88) Charged with aggravated assault and unauthorized used use of a motor vehicle. During his stay, he received Haldol-D injections, Ativan, and Cogentin. The forensic psychiatrist felt that he was not actively psychotic at the time of the aggravated assault and that he was able to understand court proceedings. He was discharged as competent to stand trial and then convicted of both charges and incarcerated. Jones reports that he was high on “crack” cocaine at the time of the murder and that the scene was related to a drug deal. Department of Corrections (7/2/88-2/1/92) During this period, Jones was incarcerated at the Skyward Psychiatric facility. It is reported that he exhibited “fixed” delusions the entire time he was there, related to the devil trying to kill him. His hallucinations decrease with an “adequate” dose of Haldol-D. His aggressive behaviors decreased as well although he continued to be confrontational with staff as well as other inmates. Staff reports that he suffered several injuries related to retaliation from inmates. He did not actively participate in Substance Abuse Treatment and continued to deny problems in this area. Mireston County MHMR (2/7/92-11/1/93) It is reported that Jones showed up for one after-care appointment, received an injection and did not show up for any other appointments. Mireston County Jail (1993) Felony assault of a police officer. Jones reportedly resisted arrest when being questioned in a “drug-related” situation. The report indicates that he was verbally aggressive stating “that the devil would not receive him tonight and that the police would die for helping the devil.” He reportedly caused extensive injury to one officer requiring several days of hospitalization (i.e. a broken wrist and bruising to the face). Charges were dropped and he was released. Hospitalizations 11/4/93-5/24/98: Morgan Medical Center (11/4/93-11/19/93) In the review of the hospitalizations at Morgan Medical Center and Smithville State Hospital listed above, a significant pattern is noted. Symptoms include Jones verbalizing that, “Vampires from England attack him and he believes he is Jesus.” He is irritable and threatening and believes that Morgan Medical Center barbeques people. Medications that were tried were Zyprexa, Risperdol, Seroquel, and Haldol. It appears that when he was released, there was never any follow-up and housing was an on-going issue. Notes from the hospital indicate repeatedly that he was “non-compliant” with his medications and follow-up. In speaking with the Salvation Army, it was reported that Jones was released to their charity but could only spend three days at a time there per their policy/procedure. The Smithville County Sheriff’s Department reports many “criminal trespass” arrests during this time as well. It appears that Jones’s symptoms are never adequately treated and that trials on the new-generation antipsychotics are short with no supervision upon release from the hospital. In assessing Jones, due to his symptomatology, he is not organized enough to take his oral medications independently or meet his basic needs. His survival techniques included rotating through the hospital, jail, and temporary shelters. His interactions with others were apparently threatening, entitled, and frustrating. Smithville County Jail (6/8/98-11/19/98) While in jail, he was prescribed Haldol-D and oral plus cogentin. He refused the injection. It was reported by staff that he was “arrogant, and believing the devil is in him.” Smithville State Hospital (11/20/98-8/27/99) Committed to Maximum Security Unit after being found incompetent to stand trial for the alleged offense of Assault Causing Bodily Injury/Assault to a Public Servant. It was reported that Jones continued throughout his hospitalization to maintain psychotic symptoms with delusions and hallucinations. He was also described as easily agitated, impulsive, potentially explosive, and unpredictable. He was described as treatment resistant. It was recommended to the court that he would not likely become competent within the near future. His medications included Gabapentin 900mg bid; Ativan 1mg bid; and Risperidone 5mg bid. Smithville State Hospital (8/27/99-9/29/99) Transferred from Smithville State Hospital after the felony charges were dropped for further treatment. Reports indicate that Jones was aggressive and easily agitated towards staff. He was verbally loud and escalated easily. He was also engaging in self-talk and laughter significant for auditory hallucinations. Mental Status Exam: Diagnosis (SCID completed):
Recommendations for Treatment Plan: It is recommended that Jones see the ACT psychiatrist a minimum of every month to monitor symptoms, side effects, and medications. Psychoeducation will be provided by his primary advocate on a weekly basis during med training in order to enable Jones to communicate the need for medication changes. Medications will be monitored daily with continuous monitoring of suicidal/homicidal ideation. Collaboration with the local law enforcement agencies to ensure the safety of the community and staff is maintained. Assertive attempts will be made to change the pattern of hospitalizations/jail/homelessness and to treat symptoms with a new-generation antipsychotic medication. Part 2: Physical Health Current Doctor: Mississippi Family Practice, Smithville Past Medical History: Surgical History: Substance Abuse History: Other Significant Social Factors: Current Medications: Allergies: Family History: Height: 6’2” Weight: 155 Blood Pressure: 120/70 Significant Occupational Exposure: Travel History: Prosthetic Devices: Review of Systems: At physical examination, this patient is alert, active, somewhat cooperative, delusional. Appearance and Nutrition: He appears to be malnourished and underweight. Skin: There are multiple sores on face, neck, and extremities, which are self-inflicted traumatic sores; there is a tattoo on right arm; there is no evidence of major scars. Head: Normalcephalic; face is symmetrical; scalp is normal
except for some sores that are also Eyes: Conjunctivae are pink; scerae are white; pupils are equal, round, they react to light and accommodation; there is no ptosis; there is no nystagmus; the extrocular movements are normal; vision is 20/20 both eyes without glasses. Ears: External ear canals are clean, tympanic membranes are normal; able to hear conversational voices and the vibrating fork. Nose: In the midline; no obstruction. Mouth: Oral mucosa is moist, throat is clear Neck: No enlarged thyroid; no vein engorgement; no palpable lymph nodes; range of motion of the C-spine is normal. Chest: Lungs are clear. Breasts: No masses felt. Heart: Regular. Vascular system: In upper and lower extremities, all pulses are present; there is no evidence of varicose veins. Lymphatic system: There is no evidence of lymphedema or enlarged lymph nodes in groin, axillae or supraclavicular areas. Abdomen: Soft: nontender; no masses felt. Genitalia: Of a male. Anus/rectum: The patient declined to be checked. Pelvic: not applicable. Trunk and extremities: Range of motion of all joints in upper and lower extremities is normal. Neurological exam: Alert and oriented; uncooperative and delusional. Cranial Nerves: Pupils are equal, round, they react to light and accommodation; there is no ptosis; there is no nystagmus; the extraocular movements are normal; facial muscles are symmetrical without weakness; tongue is in the midline with normal movement and the deglutition mechanism is preserved. Motor system: In upper and lower extremities, good muscle strength and development; fine and gross manipulation and grip strength are normal; gait in terms of speed, stability, and safety is normal. Sensory system: Vibration, pain and temperature can be felt. Cerebellar: Finger to nose and tandem gait are normal; Romberg is negative. Reflexes in upper and lower extremities are brisk and symmetrical; no abnormal reflexes found. Personal Routine:Oral Hygiene: Jones reports that he brushes his teeth when he has a toothbrush and toothpaste. His transitory history has affected this area. Shampoo/Bathing: Jones reports that when he has access to facilities, he enjoys being clean and bathes daily. Sleep: “I don’t keep track of time except when the sun rises and the sun sets.” Sexual: Jones reports that he is currently sexually active and prefers “many different” women. He states that he uses a condom each time because he reports that he is HIV positive. (Tests do not confirm this.) He reports that “he learned his lesson” when he had Chlamydia and “practices safe sex ow.” He denies a history of sexual abuse. Substance Use: Jones reports that he smokes at least a pack of cigarettes a day and more if he can get them. He reports that he has smoked since he was fourteen and has no complaints of shortness of breath or persistent cough. He states that he drinks 1-2 caffienated drinks. He states that he drinks alcohol on a daily basis if available and prefers beer. He reports that he enjoys using marijuana and “crack” cocaine and will use it daily if he can access it. He feels that he needs the alcohol and drugs to survive but states he “can cut down when he needs to.” Recommendations: Follow-up with MMB in re: Esophageal Reflux, Non-TB Myobacterium, and sores on head/face. Dental Appointment Part 3- Use of Drugs or Alcohol (SCID Completed) Records and self-report indicate an extensive history of Substance Abuse involving the following: Alcohol: Jones reports that he uses this substance daily if it is available. He has used within the past 48 hours. Use began at the age of 12. Heroin: Jones reports that following the shooting of his friend in 1975 that he tried Heroin several times. He has not used this substance since that time. Sedatives: Jones reports that he has used Dalmane and Seconal after doctors at SMITHVILLE STATE HOSPITAL prescribed it for him. He states that he did not like the effects but that they had a “high street value.” Tranquilizers: He reports using Ativan, Valium, and Xanax. Again he reports that he did not like the effects but that these drugs he was able to sell on the streets. Amphetamines: He reports using prescribed Cylert. Cocaine: Jones reports he would use “crack” cocaine on a daily basis if it were available. He began using this drug in 1988 and has used this consistently when in the community and even times when he has been incarcerated. He reports he has snorted, smoked, and injected. This is his drug of choice. Hallucinogens: Jones reports that he has used LSD, PCP, and MDMA. He has not used these since he has been incarcerated. He stated that he enjoyed the “Ecstasy” and would use this drug again if it were offered to him. Marijuana: Jones reports that he has used this in the past 48 hours. He states that he started using this drug when he was 12. He states that it was readily available because other family members used it. Withdrawal Symptoms: Jones reports that he has experienced flu-like symptoms, gets sick to his stomach, gets confused and possibly experiences visual and tactile hallucinations when forced to quit using the substances of his choice. Use Patterns: Jones reports that he usually uses in the morning with others when he is tense or scared. He feels that he has to use more than he used to and has been unable to hold a job because of his use. (“No one will hire a user.”) He knows that even though use causes his symptoms to increase, he wants to continue to use because that is all he knows. He knows that if he is using daily, he is not able to function as he should but that it helps him to forget and it stops the voices of the devil. He states that he will not be killed if he does not hear them (the voices). Problems Related to Substance Use and Level of Impairment: Cognitive-Jones reports experiencing blackouts, memory problems, and confusion due to use. Affective-No reports of depression following use but reports do indicate an increase in “manic” type symptoms. Tolerance-An increased dose is required to get the desired effect. Felt need-Jones reports a strong desire to use to feel “normal.” Interpersonal problems-He knows that many relationships have focused around use and who has access to the drugs. He reports that he has never had a relationship with someone who did not need to trade something for drugs. He acknowledges that when he has committed all of his alleged crimes, he either has been “drug-seeking” or has owed someone. Aggression-he becomes homicidal when using and experiencing acute symptoms. Vocational-Has not worked since he was 23. Legal-Multiple arrests related to use. Financial-”Most of my money is spent paying back people that I owe.” Treatment and Abstinence History: Jones reports that he has never been treated for alcohol or drug addiction and is only abstinent when he is incarcerated or in the hospital. Family Substance Abuse Assessment: Jones’s sister reports that many of his sisters have suffered severe consequences due to substance use including incarceration, interpersonal problems. She also reports that Jones’ father was ‘drunk’ all the time Motivation/Confidence Rating: Due to the severity of dependence and lifestyle/familial pattern, Jones is not motivated to quit using at this time but is able to verbalize the impact that the use has on his illness. His history shows repeated disturbances of functioning seemingly precipitated by relatively small amounts of alcohol or drug use. Assessment Summary: Jones meets the diagnostic criteria for Polysubstance Dependence. Even though he has experienced extreme consequences due to his use, this has had little impact. This is a learned behavioral pattern of dealing with stressors and has been modeled by family members as a coping strategy. It is recommended that staff work with Jones on developing coping strategies to deal with his stressors/symptoms and to work on environmental changes. It will be of the utmost importance to develop a non-judgmental therapeutic relationship with Jones to help him make better choices. Part 4: Education and Employment Current Daily Structure: Jones reports that he usually spends his day wandering the streets. When he is incarcerated, “my day is planned for me.” He states that he has a hard time doing things because “People are watching me and the devil will come for me if I am out too long.” Education History: Jones graduated from Ball High School in Smithville. He states that he does not have many memories from school. He states that he did not have many friends and struggled in school. People thought I “was weird.” His sister reports bizarre behavior and that he was always drawing evil pictures. She reports that classmates were scared of him because of his constant talk about “the dark side.” Jones is able to read and write but states that he finds it difficult to concentrate to complete something. Military History: He is a non-veteran. Employment History: Jones reports that the only job that he has ever worked was construction. The last time that he worked was in 1975. Recommendations: Jones states that he does not want to work at this time. Staff needs to identify his interests and work with him on “adult role functioning” that is not related to drug use. Part 5: Social Development and Functioning Jones and his sister report that he was born and raised in Mudville, Mississippi. He has nine siblings all of whom are sisters. He is in the middle of the birth order. He feels that he was left to “raise himself.” He states that his dad was “drunk” all the time and that his mother would cry. He stated that his father was in jail several times and that his mother had to live on welfare. He states that his father beat his mother and the children. He states that he does not have any good memories from childhood and that he never had any friends. He graduated form Mudville High School. He states that he liked being alone except when he needed to “satisfy his manly urges.” He states that he and his friends drank beer and smoked pot on a regular basis. That was the only thing we had to do. He states that the only friends he has now are people who owe him. He feels it is not “worth it” to be in a relationship. He has been married two times and divorced. His first wife divorced him after he was caught messing around on her and beating her because she was possessed by the devil. His second wife divorced him, he feels, because she would not believe him when he told her the devil would kill them and would barricade them in the apartment for days at a time. He has three children with whom he has no contact. Culture and Religious Beliefs: Both of Jones’s parents are of African-American descent. When he is asked where he was raised, he states that he was raised overseas. (His sister reports that this is inaccurate.) Jones reports that he is discriminated against by the “white” people and that the KKK is out to get him and that the Mississippi syndicate will track him down and kill him. When asked about religion, he stated that he is Jesus Christ and verbalized how the angels and devils are beneath him when he is all-powerful. Many of his delusional thoughts are fixated around his belief that he is persecuted because of his race and the belief that he is Jesus. Leisure Activities: Jones reports that it is difficult for him to concentrate for long periods so he spends his time walking. He states that he does not watch TV because that is “the way that they gather information on you.” He reports that he will go to a bar to “find him a woman.” Social Skills: Jones feels that if you behave in a threatening manner, you will get what you want. He reports that he gets into fights all the time and the police are always called to handle things. He states that people “piss him off” all the time and that he really does not like anyone. He has multiple arrests related to his aggressive responses. Legal Involvement: See Part 1 of this assessment Recommendations: Due to the majority of his adult life being spent in institutions, extreme paranoia, and his delusional thought processes, Jones does not have the skills to function/interact independently in a community in a successful manner. Staff will need to help him develop coping strategies in-vivo. Due to the negative symptoms related to his illness, Jones is not able to identify “healthy” leisure choices. Staff will help him to identify interests and then help him pursue these choices during weekly 1:1. Part 6: Activities of Daily Living Living Arrangements: Jones is currently homeless. He states that he wants to live by himself in Smithville. He reports that when he is not in the hospital or in jail, he has lived on the streets or has gotten “dive” apartments, staying no longer than a month before being evicted. Prior landlords report that evictions occur due to “aggressive” threats to other tenants, poor upkeep of the apartment, and alleged drug trafficking. Eating Habits/Food Preparation: Due to his extensive history institutionalization, Jones has not been required to prepare his own meals. When he has been homeless, he reports that he will eat whatever he can get. He would like to eat three meals a day with “lots of meat.” He states that he is not able to cook well but can make things like sandwiches and that he can bar-b-que. He feels that he will need assistance in learning these skills. It has been noted that he has been able to trade food items for beer and drugs. Grocery Shopping: During contacts at the store, Jones is unable to complete the task due to his paranoia and unable to prepare a list due to his disorganized thoughts. Diet and Exercise: He has a history of being malnourished due to lack of access to nutritional foods and due to his beliefs that food is poisoned and then not eating. Treatment of paranoid symptoms and monitoring of his eating habits and weight will be of the utmost importance. Grooming: Jones reports that he wants to take daily bathes. He states that he has to take them frequently at times “because there are bugs crawling out of my skin and I have to get them off.” He has infected sores on his skin due to continuous picking at his scalp and face. He requires verbal prompting to remember to use all the grooming items such as shampoo and soap. Laundry: Jones does not know how to use the laundromat facilities and needs physical prompts and reminders to complete the task. He does not like to spend his money doing laundry. He is limited in his clothing and staff will need to assist him in purchasing new clothes. Money Management: Jones’s current monthly income is his SSI check of $509. In the past, when he has received the check himself, he would spend the entire amount in one week primarily on drugs and then present himself in the ER for admission to the psychiatric unit. His payee will now be Guardians Are Us to ensure that his check is spent on his basic needs. He will complete a monthly budget with staff assistance. Housing: Jones will be responsible for housekeeping tasks where he lives. He reports that he has a hard time keeping places clean because he cannot organize well. He states that he cannot get motivated and at least he is not living in a dumpster. Recommendations: Due to the severity of Jones’s symptoms (i.e. paranoia, avolition, poor concentration) and extensive time spent in an institutional setting, he will require extensive support in all areas of ADLs. Jones reports that he would like to stay in one apartment for six months without being evicted. He feels that he will need daily supports to do this in the areas of housekeeping, money management, and apartment maintenance. He also will require on-going monitoring of his diet to assure that he is eating properly. |
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