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Vignette #1: Alex

A 32 year-old, single Asian male, without children. He has lived alone since he was 25 years-old and has school acquaintances, no identified friends. He is unemployed and he attends a community college. For the past 7-years, Alex has experienced extremely high levels of anxiety, but he cannot identify the source of the anxiety. When Alex is in social situations, he is often terrified about being judged by others and fears that his anxiety will be seen by others. He experiences shortness of breath, heart palpitations, chest pains, he feels wobbly, and has difficulty concentrating. Alex has never received a formal diagnosis.

Alex has poor school attendance that he attributes to his symptoms. Alex stated that he ‘has to’ smoke marijuana (daily) to help ease his symptoms and that he cannot attend a class without first smoking a ‘blunt.’ He stated that he is unable to maintain a job because he would be absent on the days when he thought that employees would have to submit a urinalysis for a drug toxicology screen. Alex stated that he feared that others could smell the marijuana on his clothes.

Although Alex has been in two accidents, that he attributes to “being high,” he continues to smoke marijuana while driving and he drives while under the influence of marijuana. Alex has smoked marijuana since he was 19 years-old and his use has increased over the past 3-years. Alex relies on his parents to help him pay monthly rent and he often borrows money from his parents to buy the marijuana. Alex admits that he needs help but said that he tried being abstinent, but it didn’t help.

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Vignette #2: Delores

A 25-year-old African-American woman, Delores, is brought to the emergency department by the police after being found walking in traffic at a busy city intersection. The police place her on an involuntary commitment (WIC 5150) after she states that ‘the voices in my head’ told her to kill herself. She appeared disheveled, with a flat affect (extremely limited emotional expression), and disorganized thought processes (difficulty articulating a coherent sentence). She answers questions with one-word responses and when asked if she experiences auditory hallucinations she answered “yes,” but is unable to articulate coherently the details of her experience.

Throughout the examination she appears intermittently distracted by internal stimuli; when asked what her experience is in the moment, she states: "They are talking to me." Delores’ family reports that she became increasingly withdrawn after she moved away from home to attend graduate studies at a local university. The family reports that her academic performance in college was above average, but since starting university she has struggled to complete her school work. Since moving, she has also become more isolative: she made no new friends,

stopped talking to her college friends, and maintained only sporadic contact with her family.

Unbeknownst to the family, Delores stopped paying rent and is on the verge of being evicted. The family was unaware that Delores has hallucinatory experiences. Delores reports occasional use of marijuana (2-3X/mo.), but her urine toxicology screen was negative, ruling out a drug-induced psychosis.

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Vignette #3: Cedric

A 46 year-old Caucasian male who is married to Sarah. Sarah and Cedric have been married for four years and they have a 2-year old daughter, Katie. Sarah is a stay-at-home mom and Cedric is a construction worker whose employment is sporadic. He’s been employed with the same agency since they’ve been married for four years. Sarah describes Cedric as being “very moody.`` She describes him as being very sad at times, then very happy, and at times he is so happy that he doesn’t sleep for days and volunteers for as much overtime as he can get.

Cedric stated that beginning in his late teens, he experienced depression, elevated moods, and mania. Although he’s been married for four years, Cedric admitted that during his ‘mood swings’ he often becomes agitated and loses his temper and takes it out on Sarah by physically and sexually assaulting her. However, he states that he’s never lost control with Katie and that he is always remorseful for physically assaulting Sarah. Cedric did not express remorse for sexually assaulting Sarah because, “She’s my wife!”

Cedric stated that during some period of his life he took ‘meds’ for mood regulation, but he dismissed having a mental health diagnosis. Cedric states that he smokes marijuana and drinks whiskey and beer every day and has for “most of my adult life.” He said that it helps him regulate his moods, but sometimes he’s unable to work because he has a hangover, or he is ‘too high’ to work. Cedric admitted that he is at risk of losing his job because of his temper and mood swings and his drug and alcohol use, but he’s unwilling to stop using. He has not told Sarah that he is at risk of losing his job. Cedric reluctantly stated that, “I could use some help with my temper.”

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ANXIETY RELATED SYMPTOMS

Symptoms include high levels of anxiety

Fear in social situations, including being judged or that others will notice his anxiety

Shortness of breath

Heart palpitations

Chest Pains

Feeling wobbly

Difficulty Concentrating

BEHAVIORAL AND FUNCTIONAL SYMPTOMS

Avoidance of social situations

Poor school attendance

Inability to maintain employment

Social isolation ( no friends/ limited acquaintances

Driving under the influence

Continues to use despite negative consequences

Borrows money from parents to support drug use

Reliance on parents for rent and financial support

SUBSTANCE USE SYMPTOMS

Daily use

Increased tolerance

Uses despite having vehicle accidents and loss of job due to a failed urinalysis

Difficulty maintaining abstinence

STAGE OF CHANGE

Contemplation - has admitted he needs help but shows no real commitment to change

No diagnosis for anxiety from a professional

No real plan other than stating he's tried abstinence

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(Olessia, Sheereen, Tiffenii)

Contemplation of Change:

Pre-contemplation

Reasons: Involuntary hospitalization doesn't have any insight into her condition. Family unaware of her symptoms and hasn't asked for any help.

Symptoms:

voices in her head

difficulty forming coherent sentences

one-word responses

appears distracted during assessment

not very emotional

Behavior:

suicidal ideation

found walking around

withdrawn

limited contact with family

struggling academically

stopped paying rent, facing eviction

disheveled appearance