Demographics Patient is a Hispanic male, aged 31. He is the father of one son, aged 10. The patient is Puerto Rican, and was born and spent his childhood in Puerto Rico. He came to live in the U.S. at age 11. He now lives in Brooklyn, New York. The patient is separated from the mother of his son. His son lives with his mother. The patient currently lives alone and is unemployed.

Chief Complaint

The chief complaint of the patient is that he is "feeling down and alone recently," and that he also feels separated from his family: "I also haven't seen my son for a while." Clearly he is depressed about his living situation, his prospects, and his health.

History of Present Illness

The patient's present illness is related to drug abuse, of which the patient has a considerable history. Essentially, the patient reports that over the past two weeks, he has felt depressed, can't sleep, has little to no energy, can't concentrate, and can't eat. He does not indicate that has had any major fluctuations in his mood -- no elevations or expansiveness. He does have auditory hallucinations (mumbling voices) but does not have visual hallucinations. He does not state any awareness of have paranoid ideation or ideas of reference. He does not have delusions. He is not currently taking any psychiatric medication but this is only because he has not followed up on his hospital discharge prescription from 7 months prior. Patient's son has been with his mother for the past few months, adding to the patient's increasing isolation and depression. The patient has a poor relationship with his son's mother and that his son has a developmental problem with which the patient would like to help. Not being near his son makes this difficult.

Family Medical and Psychiatric History

The patient's family history consists of 4 brothers and 4 sisters born and raised in Puerto Rico. The large family emigrated to the U.S. when the patient was 11 years old. The patient has indicated that there has not been any history of sexual, emotional or physical abuse in his family.

He has provided no other history of his family, no medical history or psychiatric family history. All that he has affirmed is the number of siblings and their nationality as Puerto Ricans. He has also affirmed that his family does still help to support him financially while he is unemployed, so there is the indication that he still maintains some contact with his siblings/parents.

Personal Medical and Psychiatric History

The patient's medical history consists of two prior hospitalizations, the most recent one being 7 months prior when the patient was demonstrating suicidal tendencies related to drug abuse: he had stepped in front of bus and required medical assistance.

The patient has also received detox and rehabilitation treatment on different occasions, the last occasion following the suicide attempt.

The patient is dependent upon opioids and marijuana.

The patient has Hepatitis B and C, chronic back pain secondary to getting hit by a car, and received back surgery in 2007.

The patient's psychiatric history consists of Mood Disorder diagnosis (DSM-IV-TR), given at the age of 23. The patient has not given any details or specifics regarding his hospitalizations as he is "embarrassed" by them. He has asserted that he has failed to commit to outpatient psychiatric referrals and has not used the prescriptions provided him in the past.

Mood Disorders are little changed from DSM-IV to DSM-V, with a few exceptions: "missing from DSM-V is the DSM-IV entity of mood disorder NOS, which has been replaced with unspecified bipolar disorder and unspecified depressive disorder; people who present with an unclear pattern will have to be designated as one or the other" (Parker, p. 187, 2014). Thus, DSM-V diagnosis for this patient would most likely be "unspecified depressive disorder" as there is little indication of bipolar disorder.

Developmental/Educational/Occupational History

The patient's developmental history is scarce and his educational history consists of a GED. There is no indication of employment history other than that he is currently unemployed.

Social History

The patient's social history consists of being expelled from school in the 11th grade due to smoking marijuana and getting into a fight at school, after which he was hospitalized (he did not give any specific details about this hospital stay or the fight). The patient did go on to earn his GED. The patient affirmed that he was only violent in this fight and was never violent at the hospital. He has spent some...

For the time being he has no job and receives assistance from his family.
Substance Abuse History & Current Use

The patient has a history of substance use and abuse and is currently abusing heroin, using 5-8 bags per day for the past 3 years. He has smoked marijuana occasionally. The patient has undergone multiple detox and rehab treatment for opioid dependence, most recently 7 months prior.

Mental Status Examination

The appearance and behavior of the patient indicated displeasure with himself: he is a Hispanic male who looks his age. He was sniffling and grimacing, but he made adequate eye contact. However, he looked like he was physically uncomfortable with both himself and his surroundings. He was sufficiently groomed, not unkempt, and had no distinguishing feature. His speech was articulate, with a normal rate, volume and rhythm. His English was fluent and his word choices appropriate.

His thought processes were appropriate and linear and he was clearly goal-oriented in his thinking, not wandering. The patient's focus is on obtaining relief from his symptoms of drug withdrawal and he admits that he needs detox.

The patient did indicate perceptual disturbance with auditory hallucinations. He does not demonstrate suicidal ideation nor violent ideation. His mood is depressed, causing him to be anxious and dysphoric. His impulse control is intact. His cognitive functions are oriented to person, time, place and situation; in short, he is not disoriented. His ability to think abstractly is sufficient with his age and education and his attention span is fair. He has insight into his own symptoms and detects the presence of illness and need for rehab. His judgment, however, is poor or soft, given his tendency to relapse.

Diagnosis

The patient suffers from Mood Disorder and Depression.

Therapeutic Intervention Plan

Cognitive-Behavioral Therapy (CBT) would be an appropriate intervention plan for this patient as it has been used to treat both depression and other mental disorders (McKay et al., 2015).

The core concepts of CBT are that it effectively addresses current problems of a patient by helping the patient to change harmful thinking and behavior through deliberate use attention-focusing techniques. The CBT therapist acknowledges that harmful actions sometimes emanate not from rational choice but from a lack of control of passions, or what Aristotle called akrasia -- a softness of the will. By focusing on both behavioral and cognitive aspects of the patient's life, the therapist is able to guide the patient towards overcoming a stimulus-avoidance response characterized by repeated lapses in judgment and relapses into drug abuse, demonstrated by this particular patient. Thus, the core concept of this therapy intervention is to address the relationship between thought and action and help in aligning the two so that there is less risk of relapse do to avoidance issues (Beck, 2011).

Interpersonal psychotherapy might also be beneficial as this orientation allows the counsellor to draw attention to the patient's surroundings -- i.e., how he or she relates to various persons in his or her life (Rogers 2012). To this end, supportive psychotherapy could also be useful. Supportive psychotherapy essentially views every individual's character as a work in process and that structural changes to that work should come from the individual himself rather than from the therapist. Supportive therapy helps the patient to relieve his or her symptoms and to live with them as opposed to attempting to eradicate them from the individual's life over a series of sessions, be they weeks, months or years long. CBT and supportive psychotherapy are somewhat opposite in extremes, but a combination of the two could be useful in this case. Primarily CBT is the recommended main therapeutic intervention because of the diagnosis of mood disorder, drug dependence, and depression. Guidance from a therapist could be crucial in making the difference.

The rationale for CBT is that one's self-awareness and self-concept contribute to one's "acting self" -- but so, too, does one's body (Tsakiris, Haggard, 2005, p. 387). The acting self is part of a response to various factors, both conscious and sensory. In other words, one "acts" on various levels, which may be understood as "automatic" in a sense and as "pre-arranged." The acting self is a composite of one's intellectual beliefs, physical attributes, and will to power.

If one's self-concept is how one views oneself on an intellectual/role-playing plane, and self-awareness is how one interprets one's self (actions, beliefs, etc.), self-esteem is how one views one's emotional self -- whether one feels positive or negative about one's self. In simple terms,…