Miranda Palmer Substance Abuse Counseling March 19, 2002 Date: 3/12/02 Client Name: Steve Berkowitz Demographic Data: This is a 31-year-old single Caucasian male. He is childless. He lives with his girlfriend in Modesto, CA. He has lived in Modesto all of his life. He has some college education. He is currently employed as a salesman at Radio Shack. Chief Complaint: “My girlfriends gonna be pissed if I don’t do something and my boss is ready to fire me.” History of the Present Illness: Patient grew up in what he described as a “normal mom & dad family.” He has two brothers. At a young age (under 10) he began seeing a private therapist regarding “problems making friends.” Client was a poor historian regarding his previous therapy and brushed off numerous attempts to discuss. At the age of 15 he stopped attending individual therapy. He first drank alcohol at the age of 12 and has been sober for two days. His first experience with illicit drugs was at the age of 13 using marijuana. He reports the use of marijuana continued daily until the age of 18. At the age of 15 he first tried Cocaine. He denies any cocaine use in the last week. Since the age of 16 he has used up to an 3.5 grams a day of methamphetamines. He smoked Crack the year he was 20, but denies any use following. Cocaine and alcohol he reports using 1-3 times a week, but does not report the use of these substances as problematic. He admits his daily use of methamphetamines is a problem, but is unsure of what to do. He reports increasing paranoia, fear, anxiety, racing heart and panting. Usually during a “come down,” (withdrawal) he becomes irritable, sweats, can’t sit still, and is hypersensitive to outside stimuli. Furthermore, he reports increasing problems with memory. The
patient’s relationship with partner does not appears to lack communication, lacks common interests, and is described as a source of financial support. Currently, client reports he is danger of being kicked out. He has no social network outside of drug dealers. He is also in danger of losing his job if he doesn’t improve attendance and sales.
Past History: Steve was born in Modesto, California on November 24, 1970. He reports a normal birth and normal developmental milestones. He was raised with his mother, father, and two brothers. His ethnic heritage is “white.” He describes his home of origin as “ok.” In school his grades were average, but his social skills were greatly lacking. He was sent to a therapist at a “very young age” (under 10). The client “doesn’t make friends easily,” “doesn’t really have anybody close…” He attended college briefly studying psychology, but decided he didn’t like it. The patient reports no military service. His occupational history includes one year at his current job and a past sales job at Orchard Supply Hardware. The patient is currently living with his girlfriend of one year. She is the primary supporter of the couple and is paying for the assessment. He denies any alcohol or drug use by her. His family doesn’t know he is coming in, but he reports they would probably be “excited about it.” He does not report any religious affiliations. He admits to a past DUI offense couples with a charge of intent to sell. He was only convicted of the DUI. In lieu of jail time he completed a weekend diversion program. Client also reports 18 accidents, the most recent being one year ago. Client reports that accidents were spread so as not to affect his holding a driver’s license. The client reports no leisure activities. Medical History: Illnesses: Chicken Pox Hospitalizations: None
Allergies: None Medications at Present: None
Family History Father: Age 65, No reported pathologies. Mother: Age 63, No reported pathologies. Other relatives with significant psychopathology: Brother was an alcoholic currently in full remission 10 years. Mental Status: This a tall, thin, 31 year-old white male. He has a shaved head and blue eyes. He has a sullen, unchanging expression and a pale face. He was dressed in clean blue jeans and a clean white print t-shirt. His sensorium was clear. He was oriented to person, place, and time. His attitude toward the examiner was cooperative, yet he maintained a rigid posture throughout the assessment. His motor behavior was fidgety and restless. He lacked appropriate eye contact. His speech was spontaneous, but at times, he would be confused and correct himself. His range of affect was blunted and his mood appeared anxious as evidenced by his sweating and blushing. His thought processes were productive and goal directed. Suicidal ideation was denied. Homicidal ideation was denied. Disorders of perception reported included hallucinations as recent as two weeks ago. Client did report these hallucinations were during drug use, and that he attributed the shadows and figures he saw and heard to the use of drugs. Delusions were denied. Obsessions and compulsions were denied. The patient exhibited an average level of intellectual functioning. He concentrated well. His immediate, recent and remote memories were somewhat intact. He reports periods of memory loss. He exhibited good impulse control. His judgement was fair. He somewhat insightful about his methamphetamine problem and is great denial about his drinking and cocaine use.
Diagnostic Summary
Date: 3/12/02 Client Name: Steve Berkowitz This is a 32-year-old single white male. He is childless. He lives with his girlfriend in Modesto, California. He has lived in Modesto all of his life. He is a high school graduate and has minimal college completion. He is currently employed at Radio Shack as a salesman. He comes to assessment with a chief complaint of “My girlfriends gonna be pissed if I don’t do something, and my boss is ready to fire me.” The client grew up with mother, father and two brothers. He has had a limited social network and an inability to make friends throughout his life. He was an average student throughout high school and college but was unable to make any friends outside of drug circles. He is currently in a one-year relationship in which his partner is supporting him and his drug habit. He has been dishonest about his level of drug use in the past. He has been drinking and using methamphetamines since his early teens. His tolerance has increased over the years. He has suffered memory loss, panic attacks, and other withdrawal symptoms upon ceasing to use. He uses about an 3.5 grams of crank a day. The client reports currently being under the influence of methamphetamines. He reports poor eating habits at best. He has not seen a physician for a check up in over 10 years. He is currently 110 pounds and six-feet tall. The patient does not appear motivated for treatment and his relapse potential is high after detoxification. He is not psychologically minded and may be unable to open up in a group. He shows marked resistance to treatment. His current recovery environment is moderate. He has no social support system aside from his girlfriend who is often at work. The client is suffering from Amphetamine dependence and social phobia should be ruled out. Axis I: Axis II: 304.40 Amphetamine Dependence with Physiological Dependence. 301.82 Avoidant Personality Disorder
Axis III: Axis IV: Axis V:
None Lack of Social Network GAF = 41 (present)
Problem List Problem 1: Continued use of Methamphetamine. Problem 2: Inability to maintain sobriety outside a structured program of recovery as evidence by client has tried to quit using chemicals many times unsuccessfully. Problem 3: Malnutrition as evidenced by client severely underweight for height and bone structure. Problem 4: Fear of new social situations as evidenced by inability to seek out new social networks outside of dealers. Problem 5: Poor relationship skills as evidenced by client not sharing feelings about his use of drugs and alcohol with his partner. Problem 6: Poor social skills as evidenced by inability to maintain eye contact throughout interview and respond as socially appropriate.