Richard is a 41-year-old married, transgendered male who is brought to the crisis stabilization unit (CSU) by the police because of extremely risky behavior. His wife called the police because Richard was on the roof of their home with a gun, shooting into the roof shingles. Richard has been worried for some time that the mortgage balance on the house was too large. Now he was yelling that the house was “killing his spirit,” and that he could not handle it any longer. While he was on the roof wielding the gun, he made gestures as if he was going to shoot himself.
He told his wife he was an inadequate provider for her and their two young children. In your interview with Richard at the CSU, he tells you that for the past week he has been hearing the voice of his deceased father telling him to “kill himself after destroying the house.” This distressed him greatly because, at the time of his father’s death, they weren’t speaking to each other. His mother still blames him for his father’s death.
He recently was fired from his job as a computer analyst. His sleep is reported by his wife to be poor over the past month, with difficulties falling asleep as well as waking up during the night. Also, he is unable to resume sleeping. He has increased alcohol and cannabis intake, drinking up to a six-pack of beer daily and ingesting cannabis gummies.
His children have found him passed out in the basement twice this week while their mother was at work. He has been self-isolating and avoiding family members and friends. His mood is depressed, and he has lost 15 pounds in the past two weeks because of decreased appetite.
His psychiatric history is positive for two past episodes of depression, one at age 22 and the other at age 35, prior to transitioning to a male gender identity. Both episodes resolved after an eight-week course of fluoxetine 30mg and problem focused therapy. He has a family history of alcohol use disorder (father) and major depression (sister).
This are the questions
After viewing the patient interactive information, address the following:
- What important information is missing from the case study?
- Discuss normal developmental achievements and potential vulnerabilities.
- What precipitating factors could be contributing to the current symptoms?
- What is the differential diagnosis?
- Describe the etiology of the primary diagnosis.
- How would you manage this crisis situation?
- What are the nonpharmacologic interventions that would help?
- What are the psychopharmacological interventions that would help?
- Identify safety risks and how they should be dealt with in the treatment plan.
Include current supportive evidence in your responses to the questions. National guidelines should also be considered with treatment plans.
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