SOCW6090
CASE PRESENTATION – PETE
Intake Date: September 2020
IDENTIFYING/DEMOGRAPHIC DATA: This is a voluntary intake for this 28-year-old, single white male. Pete lives with his partner, Tyrone in Portsmouth. He has a bachelor’s degree in social work and is currently employed as an alcohol and drug counselor. He is Irish-American and Catholic. His partner is Native American.
CHIEF COMPLAINT/PRESENTING PROBLEM: “I don’t feel well lately. I’m really depressed”.
HISTORY OF PRESENT ILLNESS: Pete states he is feeling depressed. He has been sad for the past month. His live-in partner of 4 years is talking about ending the relationship because he wants to date others. Pete is concerned that his partner may already be cheating on him. He feels devastated and unable to cope with the loss. This was a complete shock to him. Since the discussion, he has not been able to sleep at night and feels tired during the day. He has a hard time going to work, and has called out sick. Up until the talk of breaking-up, he has never missed a day of work. When he does go to work he has a hard time concentrating and his job has suffered.
There is a significant change in his eating patterns also. He has lost about 15 pounds in the past month. He becomes scared because he is having suicidal thoughts. He does not want to live without his partner. He believes if he was a better partner, he would not be talking about leaving him. He denies any suicidal attempts or plans.
PAST PSYCHIATRIC HISTORY: Pete sought counseling 5 years ago because of feelings of depression. His grandmother died whom he was very close to and three weeks later he went to see a counselor. He was sad all the time and had problems sleeping at night. He did not want to do anything and sat at home and cried. He believes his feelings then are similar to now, but this seems worse. He also lost 20 pounds in a few weeks at that time. He was given medication but doesn’t remember the name. He was in counseling for a little over three months and took the medication for six months.
SUBSTANCE USE HISTORY: Pete reports drinking socially until about one year ago when he started sensing Tyrone pulling away. His use increased from occasional drinks and beers to a more constant nightly behavior. Tyrone has had a few conversations with him about cutting down, and he has reduced drinking on several occasions. Tyrone said he is tired of competing with alcohol.
PAST MEDICAL HISTORY: Pete denies any significant medical problems. He reports recent stomach pains but has not gone to the doctor.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Pete states while growing up he had a good relationship with his parents. His father was employed as an accountant, and mom stayed home and cared for the three children. Pete is the middle child with an older brother and younger sister. The siblings were close when young and have remained close as adults. He was much closer to his mother than father because his father worked a lot. Pete states his grandfather was alcoholic and died of cirrhosis of the liver. Pete denies any other substance use in the family. His sister received counseling for one year but is unsure why. His parents like his partner, and he fears telling them about the potential breakup because they may blame him.
Pete has always done well in school. He has a bachelor’s degree in social work and has thought about law school but now cannot focus on that idea now.
Pete has always had a lot of friends. He was very active in high school and college with academic activities. He has had no desire to talk to any of his friends since his partner began talking of breaking-up. He prefers to stay home by himself. This is his first serious relationship.
MENTAL STATUS EXAM: Pete is a casually dressed male who appears older than his stated age. He was restless during the interview. His affect was flat. His mood was depressed. His speech was hesitant and he spoke in a low voice. He denies any hallucinations or delusions. He admits to suicidal ideation but denies a plan.
Pete is oriented to time, place, and person. His recent and remote memories were good. His judgement and insight were good. When asked about three wishes he replied, “to stop Tyrone from leaving, going back to school, and be happy always.”