John is a 48-year-old single white male who lives with his mother. His mother has major neurocognitive deficit and John is her primary caregiver. They live in a small rural town on a large property that John maintains. John has several pet dogs and is always working on several projects at a time on his land, including creating a large walkable maze out of hedges, as well as an adult-sized tire swing. He is vocal about his dislike of his small, poor, and provincial town but feels unable to leave. He has few personal relationships except for one young man, Tyler, who John often hires to help with his projects. He has complicated relationships with nearly everyone in his small town, including local officials. He regularly calls the town clerk, a woman named Faye, to either discuss issues or complain about things. Faye says they used to be close friends but once she got married he “changed” and he became “more negative.”
John completed high school but dropped out of college during his sophomore year although he is clearly an intelligent man. He says he was not successful because he often did not complete the required assignments, saying they were â€œstupidâ€ and preferring to work on his own interests. John describes himself as a loner, never quite fitting in with others, and adds that he is bisexual though he has never had any long-term romantic relationships with men or women. He is by trade a horologist (a person who makes and repairs clocks and studies time). He is one of the few, or perhaps the only, person left in the country who does “fire gilding,” a process that melts mercury and gold together to create gold layers on clocks or other pieces. He also does electroplating, using chemicals including cyanide. He stays up for many hours and sometimes through the night working on clock repairs or related projects. John also describes himself as going through periods of deep depression where he becomes excessively concerned with problems in the world including global climate change or even local injustices such as the criminal charges that his friend Tyler has faced in the past. He has had these mood symptoms at least since adolescence. At these times, John contemplates suicide but has reportedly never made a suicide attempt. He mentions suicide frequently to Faye and Tyler. He does not drink alcohol daily but when he does drink, he tends to binge drink. He denies any illicit use. He describes himself as being in good general health, although he does sometimes experience episodes of vomiting and dizziness. He has never sought any mental health treatment and does not seem particularly interested in treatment, although he acknowledges that other people have expressed their concerns to him in the past.
Based on the information you have, how would you respond to the following questions?
What is your differential diagnosis? Discuss your provisional diagnosis and rule outs.
What, if any, labs, other diagnostics, or referrals might you consider?
Using the Transtheoretical Model, which stage of change do you think John is in? Why? Based on the stage of change you identify, which type of interventions might you do?
- Given Johnâ€™s rural environment and his history, John is likely to interface with primary care before he receives specialty mental health services. If you were a PMHNP working in an integrated care setting, how might you engage John in specialty mental health services? Discuss this in terms of your role and other roles within an integrated treatment team.
Briefly describe one psychotherapeutic modality you would use with John and describe why you selected this therapy.
- Imagine you see John for a five-minute mini-consultation (a â€œwarm handoffâ€) in an integrated care setting. Write a patient risk of John, identifying any risk and protective factors in terms of risk of harm to self and others. Describe any specific steps you might take to decrease his overall risk. What if John refuses any further care? Are there any legal and/or ethical considerations and, if so, discuss these, along with steps you might take to resolve them.