A patient for whom you conducted psychotherapy for an impulse control

Full Answer Section

Chief Complaint:

"I'm always getting into trouble at school. My teachers say I'm disrespectful and defiant."

History of Present Illness:

Alex has been exhibiting symptoms of ODD for approximately three years. He frequently argues with his parents and teachers, loses his temper easily, and intentionally annoys others. He has been suspended from school multiple times due to his disruptive behavior. Alex denies any suicidal thoughts or plans.

Past Psychiatric History:

• Previous Diagnosis: None
• Past Treatment: None

Family History:

• Mental Health: Father has a history of depression.
• Substance Abuse: Mother has a history of substance abuse.

Social History:

• Relationships: Difficulty maintaining friendships due to his disruptive behavior.
• School: Struggling academically, particularly in subjects that require sustained attention.
• Legal History: No prior arrests or convictions.

Mental Status Examination:

• Appearance: Well-groomed and appropriately dressed.
• Mood: Irritable and easily frustrated.
• Affect: Restricted range of affect.
• Thought Process: Linear and goal-directed.
• Thought Content: No evidence of delusions or hallucinations.
• Cognition: Oriented to person, place, and time. Memory and attention intact.
• Insight: Limited insight into his behavior.
• Judgment: Impaired judgment, as evidenced by his continued defiance of authority figures.

Assessment:

Based on the information gathered, Alex meets the diagnostic criteria for Oppositional Defiant Disorder. His symptoms are significantly impacting his relationships, academic performance, and overall functioning.

Diagnosis:

• Oppositional Defiant Disorder (ODD)

Treatment Plan:

• Individual Therapy: Cognitive-behavioral therapy (CBT) to help Alex manage his anger, improve his communication skills, and develop coping strategies.
• Family Therapy: Family therapy to address family dynamics and improve communication between Alex and his parents.
• Medication: Consider medication, such as a stimulant, to help manage symptoms of inattention or hyperactivity if present.

Follow-Up:

Schedule a follow-up appointment in one month to monitor Alex's progress and adjust the treatment plan as needed.

Sample Answer

Hypothetical Patient:

• Name: Alex
• Age: 15
• Presenting Problem: Oppositional Defiant Disorder (ODD) characterized by frequent outbursts of anger, argumentative behavior, and defiance of authority figures.

Comprehensive Psychiatric Evaluation Note

Identifying Information:

• Name: Alex
• Age: 15
• Date of Birth: 09/01/2009
• Gender: Male
• Race/Ethnicity: Caucasian
• Marital Status: Single
• Occupation: Student
• Referral Source: School counselor