This document presents the results of John Doe’s mental illness assessment histories. The interview was conducted to collect information about the client’s mental health condition. It contained open ended questions about John Doe’s mental history. The first part of this document highlights the assessment histories that will be performed while the second part comprises a summary of the interview findings. Finally, the subjective, objective, assessment, and plan (SOAP) is used to create a treatment plan for John Doe.
Interview Process
As earlier stated, the interview comprised open ended questions that probed John Doe’s mental illness history. The interviewer also observed John Doe’s physical behavior and took concern for any strange actions. Historical statements and indications were grouped into categories and the client’s responses about each category summarized. John Doe’s responses were grouped into historical categories, which include mental health, substance abuse and medical.
Summary of Findings
Demographic findings
John Doe is a male client born on 15th October, 1980. He is a resident of Townsville.
Symptoms
The client’s conditions include anxiety, depression, hallucinations, substance abuse, and sleeplessness.
History of Substance abuse
John Doe currently abuses cocaine and amphetamines. He abuses cocaine and amphetamines by snipping 2-4 grams daily. John Doe is currently under prosecution for cocaine abuse.
Mental health history
John Doe has never been treated for mental illness. The client is not under any medication.
Medical history
John Doe was involved in a bike accident on 18th June, 2014 and received three stitches on his elbow. He does not have a chronic disease.
Socio-economic history
John Doe works with McKinsey as a senior data analyst. He has been married for six years and has a four year old son. John Doe is a Presbyterian and an ardent fan of Manchester United Football Club.
Mental status assessment
During the interview process, the client appeared to be intoxicated from cocaine or methamphetamine. The client reported ecstasy, a feeling of internal satisfaction, and perceived intelligence, power, and achievement. John Doe explained that a cocaine use enhanced his ability and speed in accomplishing data analysis tasks. He explained that an increase in the use of cocaine reduced his ability to concentrate on personal and official tasks. John Doe explained that his unguided use of cocaine took him past the functional level. His cocaine use overtime exposed him to impulsive unsafe actions, including violence and immoral sexual behavior.
The client reported that he experienced momentary paranoid delusional behaviors, which lasted for as long as two months. John Doe explained that his paranoid conditions were caused by cocaine because his reasoning was intact if he abstained from cocaine use for some time (Jarvis, 2011). John Doe explained that intoxication is followed by a sudden depressive feeling accompanied with person is fatigue, sadness, and craving for more cocaine to ease the withdrawal syndrome. He explained that this is the reason he abused cocaine for week-long sprees without pausing. The client recalls an instance when cocaine lost the ability to get him high, which was followed by a severe depressive spell. Although John Doe abstained from cocaine for up to a month, he reported a dysphonic condition characterized by nervousness and anhedonia (Blum, Werner & Carnes, 2012). He explained that these effects lasted for weeks.
Strengths and weaknesses of the Client
The advantage of John Doe’s condition is his intention to respond to the mental illness by engaging in the current support program. The client’s weakness is a combination of previous mental conditions, health problems and financial issues, which may prevent him from completing the current program.
Narrative summary
The results of the interview indicate that John Doe’s mental illness is caused by his substance abuse history. The next section of the report uses the subjective, objective, assessment, and plan (SOAP) to create a treatment plan for John Doe.
Subjective, objective, assessment, and plan (SOAP) for John Doe’s Mental Illness
Subjective
Patient is a 35 year old male, brought to the psychiatric clinic today by his wife, who explains that he has been experiencing depression, anxiety, insomnia, and mild schizophrenia. According to the client’s wife there have been no occurrences of violence and the client has been functioning normally for the past few weeks. The client’s immunizations are current according to clinical data.
Objective
The client’s appearance is appropriate for his age and he is alert and responsive. The client responds to all interview questions but appears to be depressed and anxious. Client also seems unstable and clenches the arms of the chair in his fist.
Assessment
The assessment is designed according to the symptoms of mental illness caused by substance abuse (Barrett & Turner, 2006). John Doe’s toxicology assessment revealed he used cocaine and amphetamines. The client was severely depressed and agreed that he has contemplated suicide. Although he has no recorded history of psychiatric medications, John Doe confessed that he should have visited the psychiatric clinic earlier. The Client’s current psychiatric visit was not preceded by cocaine overdose. John Doe may not complete the program because of his financial status. He previously enrolled in an AA session.
Plan
The plan will be designed and administered by the psychiatric consultant.
References
Barrett, A. E., & Turner R. J. (2006). Family structure and substance use problems in adolescence and early adulthood: examining explanations for the relationship. Addiction, 101(1): 109–20.
Blum, K., Werner, T., & Carnes, S. (2012). “Sex, drugs, and rock ‘n’ roll: hypothesizing common mesolimbic activation as a function of reward gene polymorphisms”. Journal of Psychoactive Drugs, 44(1): 38–55.
Jarvis, C. (2011). Physical examination and health assessment. Philadelphia, PA: Saunders.