Psychiatric Evaluation
Patient Name: *REDACTED* Dean
Date: 7-11-1989
DoB: 10-13-1972
Age: 17
Sex: F
Gender: M
Accompanied By: Bud Dean
Relationship to Patient: Father
Patient Signature: đ„đ¶đâŽđ đâŻđ¶đ
Chief Complaint and Duration:
Patient was admitted into therapy due to an incident concerning their home life. They arrived at school one day with severe bruising on their arms and legs. The patient grew agitated with the faculty when asked about the injuries. Between loud noises reported by neighbors the night prior and the severity of the injuries in question, the court believed the patient was being mistreated by their guardian at the time and was lashing out at school as a result.
The duration of the symptoms is hard to pinpoint due to so many of the patientâs previous schoolâs being out of state and required to disclose information. But, it appears the patientâs symptoms of noticeable neglect and abuse as well as acting out among peers start around the age of nine. A traumatic experience seems likely to be involved.
Symptoms and Concerns:
The Patient appears to go through intense bouts of mania where they become out of touch with reality, unreasonably irritated or aggressive, or disturbingly energetic and wired. They also appear to exhibit major mood swings between optimism and high energy behaviors along with severe depressive symptoms. (These in tandem with each other make a bipolar diagnosis likely)
Patient experiences blackouts in memory when asked about their father and his treatment of them. Saying they âcanât quite seem to remember.â This could also be general avoidant behavior from the patient. They also experience vivid traumatic memories and hallucinations of their deceased mother and her passing. Romanticizing her memory and growing volatile and hyper emotional when people question the pedestal they put her on in spite of her having been dead for over 8 years now. (PTSD likely.)
Patient is highly charismatic but severely antisocial. Most teachers report they went their entire six weeks in their class without speaking. Some kids not even knowing their name. They are highly anti-authority and prone to lashing out at teachers and adults in extreme manners. Theyâre also callous and donât seem to comprehend guilt or responsibility for how their actions hurt others.
Mental Health History:
The patient reports no previous mental health diagnoses or treatment. They state that while this is the first time they are being treated for these symptoms theyâve been going on for âas long as they can rememberâ
Family History:
The patient states that their mom killed herself when they were young out of some form of depressive episode.
Social Support System:
The patient noted no friends and no intentions of making any friends. They live a lifestyle consistently moving around due to their guardianâs work and find it hard to connect with others because of it. Their relationship with their dad is proven to be a taboo subject.
Coping Strategies:
The patient copes in a severe and unhealthy manner. They used to self-harm but are now two years clean. Instead, they use 7-Elevenâs Slurpee slushies to chase a similar feeling to self-inflicted injury.
Goals for Treatment:
The patient has no specific goals for treatment and proves upset to even be in treatment at all. Thinking the courtâs ruling to have made their life âworse than it was before.â
Dr. Watersâ Notes:
- The patient is female, but dresses in a masculine manner and wants to be addressed as a man, demanding to be called âJasonâ so for the sake of the notes, Iâll oblige him.
- Jason is without exaggeration, one of the most troubled youths Iâve encountered in my many years of working with troubled teens.
- Highly eccentric and charming on the surface but emotionally unstable, manic, and disturbed once he gets to really talking with you.
- Heâs very apprehensive about adults and people being in power over him. Resenting and opposing authority at every turn. This is likely due to his own fatherâs actions and control over his life that heâs begun to lash out at any authority figure in the place of lashing out at his father.
- Jason has a history of violent thoughts and tinkering with bombs but passing it off as a part of his dadâs work when questioned on it. His father confirmed while he does help out with work but he also experiments with them in his free time. He claims he has no intentions of going through with harming others but is also deeply unaffected by other people being in harmâs way.
- He also has a fascination with fire and likes watching the flame on his lighter as it âbrings him warmth in a cruel and cold world.â
- Goes through severe mood swings. Some days heâs optimistic about his ability to make a good future for himself in spite of his own cynicism and hyperactivity. Other days, heâs melancholic and daydreaming about âdying like his momâ like that is a release or pleasant fantasy to him.
- Has a warped sense of humor and is often smiling and joking about things dark and tasteless to most.
- Seems incapable of expressing emotions genuinely without his guard up. Heâs often smiling while he cries or acting like he can turn his own feelings off the minute they inconvenience him.
- Likes controlled pain, for example the feeling of a brain freeze. Jason finds the feeling of being in control of something appetizing due to his feelings of helplessness in his own motherâs death, being thrown from state to state often, and his fatherâs control over his life.
I would strongly advise for Jason to be put on a form of antipsychotic or mood stabilizer and to be kept in consistent therapy under thorough watch and observation by teachers at school. He is likely a danger to himself and others and should be on upmost watch at all times.
- đłđ. đđđđđđ
(Request a copy of this file is transferred over to Westerberg High.)
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