Application


Identifying Warning Signs

Taken from Patterson, C. W. (1981). Suicide. In Basic Psychopathology: A Programmed Text.

Instructions:
Underline all words and phrases in the following case history that are related to INCREASED suicidal risk. Then answer the questions at the end of the exercise.


HISTORY OF PRESENT ILLNESS

The client is a 65-year-old white male, divorced, living alone, admitted to the hospital in a near comatose condition yesterday because of an overdose of approximately thirty tablets of Valium, 5 mgm, combined with alcoholic intoxication. The client was given supportive care and is alert at the present time.

A heavy drinker, he has been unemployed from his janitorial job for the past three months because of his drinking. He acknowledges feeling increasingly depressed since being fired, and for the past two weeks has had insomnia, anorexia, and a ten pound weight loss. He indicates he wanted to die, had been thinking of suicide for the past week, planned the overdose, but had to “get drunk” because “I didn’t have the guts” [to kill myself]. He is unhappy that the attempt failed, states that, “nobody can help me” and he sees no way to help himself. He denies having any close relationships or caring how others would feel if he committed suicide (“who is there who cares?”). He views death as a “relief.” His use of alcohol has increased considerably in the past month. He denies having any hobbies or activities, “just drinking.”


Past Psychiatric History

Hospitalized in 1985 at Pleasantview Psychiatric Hospital for three months following a suicide attempt after his fourth wife left him. Treated with ECT, he did “pretty good, but only for about two years” thereafter.


Social History

An only child, his parents are deceased (father died by suicide when client was eight years old; mother died of “old age” two years ago). Raised in Boston, he moved to Los Angeles at twenty-one and has lived here since. Completed eighth grade (without any repeat) but quit to go to work (family needed money). Has never held a job longer than two years, usually quitting or being fired because of “my temper.” Usually worked as a laborer. Denies any physical problems other than feeling “tired all the time.” Currently living on Social Security income, he has no other financial resources. He received a bad conduct discharge from the army after three months for “disobeying an order and punching the officer.” He has had no legal problems other than several arrests in the past two years for public intoxication. Married and divorced four times, he has no children or close friends.


Mental Status Examination

65 y.o. W/M, short, thin, grey-haired, unkempt, with 2-3 day-old beard, lying passively in bed and avoiding eye contact. His speech was slow and he did not spontaneously offer information. Passively cooperative. Little movement of his extremities. His facial expression was sad and immobile.

Thought processes were logical and coherent, and no delusions or hallucinations were noted. Theme of talk centered around how hopeless the future was and his wishes to be dead. There were no thoughts about wishing to harm others.

Mood was one of depression. He was oriented to person, place, and time, and recent and remote memory was intact. He could perform simple calculations and his general fund of knowledge was fair. His intelligence was judged average.


Diagnostic Impression

1. drug overdose (Valium and alcohol)
2. Dysthymic Disorder (depression)
3. Substance Use Disorder (alcohol)


QUESTIONS FOR EXERCISE 3

You have interviewed the client, obtained the above history, and now have to make some decisions about the client. He wants to leave the hospital.
 
1. Is he a significant risk for suicide?
2. Would you recommend:
a. discharging him as he wishes and with your concurrence?
b. discharging him against medical advice (A.M.A.)?
c. discharging him if he promises to see a therapist at a nearby mental health center within the next few days?
d. holding him for purposes of getting his psychiatric in-client care even though he objects?
3. Discuss briefly why you would not have chosen the other alternatives in question #2.