Chronological Age: 50
Referral Source: Attorney
Primary Evaluator: X
Secondary Evaluator: X
Testing dates:
Reason for Referral
LC was referred by attorney X who requested information and comments regarding this client’s competency to stand trial and state of mind at the time of the crime.
Presenting Problem
LC is a 50-year-old African American male with a long history of psychiatric problems. He is from the LA County Jail, August 7 through August 15, 20__ and he experienced difficulties adjusting to prison. While in prison, LC was observed to be “agitated, belligerent, demanding and made verbal threats to a custody officer.” He received a CDCR 115 (administrative disciplinary write up), made suicide threats; a stash of medications were found in his cell with two razor blades and he was hospitalized August 7, 20__. According to one progress note on August 6,20__, “I/M states I’ll kill myselflet them shoot me when I try to escape” I/M vacillates between “I don’t want to die’ to ‘I have no more reason to live.’ He voices a plan of suicide by cop.’” He was reported to have stated, “The minute I get a chance to go to yard, I’m going to charge an officer and they will have to shoot me in the fucking back!”
It is noteworthy, the probation report states, “No indication or claim of significant physical/mental/emotional health problems” following the report related to the current matter.
Background Information
LC had three hospitalizations documented in the records reviewed, including Atascadero State Hospital, Vacaville Acute Mental State Hospital, and Cedar Sinai Medical Center. According to last year’s discharge summary, “On the street, the patient was under care of psychiatrists and was living in a program where he had fairly intensive case managers and psychologists.”
Following his discharge to the Enhanced Outpatient program at CSP-LAC, in one of the reports inmate stated “I put my head in a toilet full of fecal matter in hopes of getting endorsed to another prison.” He stopped taking his medications for the same reason. Inmate is unhappy because of not getting enough attention at LAC, but does not want to be in EOP program.
LC was later transferred to Mental Health Crisis Bed in the infirmary when discovered with a noose around his neck after recounting several other suicide plans.
Following a brief transfer to CSP-Corcoraninmate described mood as “good, but little anxious.” He also denied suicidality and homicidality as well as audio and visual hallucinations.
LC has been found smearing feces on his face from his toilet. In addition, there were varied medical visits related to his sleep apnea and other medical conditions. While he was grossly compliant with his treatment regiment in general, he was concerned about a CDCR 115 he had received and the upcoming hearing.
Administered Assessments
The following tests were administered to LC:
Behavioral observations
Short Portable Mental Status Questionnaire (SPMSQ)
Hare Psychopathy Checklist Items
Million Clinical MultiaxialInventory - III
Mental Status and Behavioral Observations
Inmate was observed to be soft-spoken middle aged obese African American male who was cooperative throughout the session. Inmate’s mood was observed to be depressed, with anxiety and psychomotor retardation. He was unable to provide date, date of birth or current president. When asked why he was being evaluated, he responded, “I don’t remember, but voices told me to cuss out a correctional officer Somebody told me I did that.” While the inmate did not know the name of the officer, he stated the charge threatening a peace officer could result in life in prison since he is facing a third strike.
Short Portable Mental Status Questionnaire (SPMSQ)
When asked about various personnel in the courtroom, he stated the judge is “sometimes your friend.” When asked about the difference between a district attorney and defense attorney, he responded, “I don’t know.” When asked about his attorney, he stated, “his job is to defend me, I think.”
LC failed to accurately respond to the majority of the questions resulting in nine wrong answers indicating severe cognitive impairment.
Hare Psychopathy Checklist Items
The PCL-R is a psychiatric tool that is used in establishing a categorical dimension or rather dimensional score of psychopathy. PCL-R uses 20 items whereby each item has recorded on a 3-point scale based on the criteria of the information wanted. The value 0 is designated to any item that is not applicable while value of 1 is assigned to items where it is applicable somehow. A value of two is for the item where the case is fully applicable. PCL-R is necessary for it assesses a number of factors that can be used in predicting risks and establishing rehabilitation probability. (Hare, 2003).
Million Clinical MultiaxialInventory - III
Modifier Indices Configurations
The patient responded well in taking this test and it appeared open and honest. There are no evident distortions. Therefore the results are most likely valid.
Disclosure Level (X)
The patient responded well to the by opening up appropriately. Having not noticed any defensive attitude towards the test, it would be prudent to appreciate that the patient was very cooperative.
Desirability Gauge (Y)
The patient cooperated well with the testing process having no shown any respond to the MCMI items.
Debasement (Z)
The patient reported a number of interpersonal and emotional problems which is an indicator that there were minimal preservations to this test.
Personality Style
8A2A’
There were a mixture of passive compliance and obedience at one time. Sometimes, moody, hostile, and irritable and such people do manifest an irritable and distrustful demeanor; they also are become angry unexpectedly. They are usually stubborn and may feel guilty at certain times. When they feel the guilt, they can sometimes become apologetic at some point. Disillusionment always permeates their lives. They expect disappointments almost all the times. They feel unappreciated and at some point they will feel that they are not fairly treated. They can complain constantly and are persistently lament over their unfulfilled desires. Often, they do have problems with authority and, in case they are employed; they are likely to have serious job difficulties. This patient demonstrated a withdrawn, self conscious, introverted and socially awkward person. Such people try their best to maintain a fine social appearance since they are oversensitive to rejection and do fear negative evaluations. Or, sometimes they totally withdraw from social contacts. Tension, anger and anxiety can be evidenced but all this is due to the fear of rejection and desire to be to be accepted socially. Such people often maintain the social distance with the aim of avoiding rejection and its experience. They are demoralized by the signs of rejection and disapproval from people and thus have the tendency to withdraw from people. In doing so, they minimize their chances of enhancing relationships. As a result, it leads to a state of social isolation though there could be the desire to relate with people. In rectifying this situation, such patients can wear pleasant appearance to conceal their underlying social feelings of rejection.
Additional Personality Disorder Scales
In this section, information is gotten through narrative statements. It may also contain more/additional information on the specific traits.
Schizoid (1)
There are high scores here meaning that the interpersonal relationships are available to some extent. The traits that are helpful in describing scores here include: introverted, dependent, quiet, self-sacrificing, timid, uncommunicative and passive. People of this type are emotionally bland.
Depressive (2B)
The patient demonstrated some traits associated with a depressive personality style but not in sufficient quantity.
Dependent (3)
This patient showed strong symptoms of dependence. This shows that the patient does not have lasting relationships and is likely to erupt into emotional outbursts.
Histrionic (4)
The patient demonstrated signs of the needs for attention, praise and recognition. This can be seen in the extroverted personality
Narcissistic (5)
The patient demonstrated some evidence of narcissistic-like traits. Clinical interview will help establish the exact traits being demonstrated.
Antisocial (6A)
There is some evidence of antisocial traits by the patient. However, it is not easy to establish the specific traits shown and clinical testing will help.
Aggressive/Sadistic (6B)
The patient shows some mild signs of aggressive traits, clinical test will be of good help since it is not easy to establish the exact traits.
.Compulsive (7)
There are very low scores here which translates to no or minimal symptom if any.
Self-Defeating (8B)
There are strong symptoms of seal defeating disorder. However, it is not easy to establish the specific ones and clinical test will be of good help here.
Schizotypal (S)
There are some mild symptoms of schizotypal personality disoder .
Borderline (C)
There is evidence of borderline traits. Though it is not easy to determine which ones shown, a clinical test is better administered.
Paranoid (P)
The patient show strong symptoms of paranoid personality disorder.
Clinical Syndromes
Anxiety (A)
There are several reported symptoms that are directly associated with anxiety. There are high scores on this scale which indicates that there are signs of apprehensiveness, anxious, edgy, and jittery and restlessness. Such patients have the tendency of semantic complaints caused by insomnia, nausea, headaches and cold sweats among others.
Somatoform Disorder (H)
This patient shows strong symptoms of tendencies of somatization.
Bipolar: Manic Disorder (N)
The patient reported manic-like symptoms. Possibly, this could be caused by substance abuse or development of a Bipolar Affective Disorder.
Dysthymic Disorder (D)
There were many signs that were shown by the patient which are associated to depression. These include: self doubts, social withdrawals, apathy, low self esteem, feelings of inadequacy and worthlessness, diminished sense of pleasure amongst other symptoms.
Alcohol Dependence (B)
The patient showed minimal symptoms that can be associated to alcohol dependence.
Drug Dependence (T)
This patiend showed some signs, though minimal signs associated with drug abuse. It is possible that this patient could be using drugs though not in large quantity.
Post-Traumatic Stress Disorder (R)
The patient had acute symptoms of post-traumatic stress disorder.
Thought Disorder (SS)
The patient showed abnormalities consistent with a thought disorder.
Major Depression (CC)
The patient reported major signs of depression which are severe and can cause mental impairment.
Delusional Disorder (PP)
This patient show signs associated with a delusional disorder.
DIAGNOSIS
Axis I:
R/O 314.01 Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type R/O 296.90 Mood Disorder Not Otherwise Specified R/O 313.81 Oppositional Defiant Disorder V61.20 Parent-Child Relational Problem
Axis II: V71.09
Axis III: disturbed mind
Axis IV: problems related to the social environment, problems related to interaction of the legal systems
Axis V: GAF = 40
SUMMARY
LC is a 50-year-old African American male with a long history of psychiatric problems. He is from LA prison and has had problems in adjusting to the prison life. He was observed while in prison issuing verbal threats to the officers in charge. Stash medication was found in his cell with two razor blades. He received a disciplinarian write-up, often made suicide threats. Stash medication was found in his cell and was hospitalized August 7, 20__. His life in prison has proved that he is not consistent on what he says; at sometimes he says “I will kill myself” while at some point he says, “I don’t want to die”. He is also fond of using abusive language. However, according to the probation reports indicated that he had no health problems, “no indication or claim of significant physical/mental/emotional health problems”.
So far, in the records reviewed, LC has been hospitalized thrice. These include Atascadero State Hospital, Vacaville Acute Mental State Hospital, and Cedar Sinai Medical Center. His admission to Vacaville Acute mental hospital could be an indication of a serious distressing situation (Millon, 2008). Furthermore, it was recommended for him to be under care of a psychiatrist always while out in the streets. In addition to this, he was also recommended a program of having fairly intensive case managers and psychologists (Discharge summary).
The recommended measures did not work and after sometime, LC stopped taking his medication because he was not getting much attention. At one time, he was found with a noose around his neck and was hurriedly taken to Mental Health Crisis Bed.
On assessment, there are indications that LC cannot tolerate frustrations thus has a low frustration tolerance. He experiences a serious difficulty in interpersonal relationships. This can mean that LC frequently experiences symptoms of nervousness and anxiety (Millon, 2008). This can have a relationship to his trouble. Additionally, results show that LC can is very combative especially when frustrated, misunderstood and sidelined.
It is like LC anticipates rejection everywhere and anywhere he is. This is what makes him feel that he is not winning people’s attention thus erupts.
General results show that LC is having difficult experiences which translate to the symptoms of anxiety and ADHD which are/have impaired the daily functioning.
These signs are worsened by the daily struggles which make him be sidelined and thus bringing him frustrations.
RECOMMENDATIONS
1. LC requires individual psychotherapy twice in a week. This can be done either by his psychiatrist or by any other clinician who is experienced enough to deal with adults. This will help create hope and of course safe space for LC. He will be able to guide LC whenever need arises and keep him company
2. There is need for psychotherapy for LC’s family for the sense of belonging to dawn on LC and the feeling of love to overcome his frustration feelings.
3. there is need of getting LC safe and comfortable place, if possible at home where he will be all be alone when need, arises. This can also allow for the implementation of meditative tools like deep breathing to help him curb emotional impulsivity.
BIBLIOGRAPHY:
Hare, R. D. (2003). Manual for the Hare Psychopathy Checklist – Revised. Multi-Health Systems
Millon, T. (2008). The logic and methodology of the Millon inventories: personality assessment. In G. J. Boyle, G. Matthews, & D. H. Saklofske (Eds.). Sage handbook of personality theory and assessment. Vol. 2. Los Angeles, CA: Sage
