Summary of Integrated Treatment Plan for
Facility: --------- --------- Hospital
Date of Admission: 01/01/01
Program: Maximum Security
Legal Status: 17a 582(e)(1)
Psychiatric Security Review Board
Mr. Benjamin Vesper is a 35 year old single white male with a history of Major Depressive Disorder with Psychotic Features. He was initially admitted on two counts remand for competency restoration after an incident in an art gallery where he became disruptive and violent. The Office of Forensic Evaluations (OFE) recommended him not competent, and he was sent here for inpatient restoration. At first, he was highly assaultive to patients and staff in the minimum security Restoration Unit (striking anyone who came within arms’ reach), so he was transferred to the Forensic Division. He was then re-admitted on 00/00/00 and committed to the state’s Psychiatric Security Review Board on 00/00/00 for the charges of Breach of Peace and Assault.
Mr. Vesper is reluctant and guarded to discuss prior psychiatric illness, treatment, or inpatient care. OFE reported prior psychiatric inpatient care in 0000 and 0000 while patient resided out of state. Patient denies prior suicidal ideation, homicidal ideation, auditory hallucinations, or visual hallucinations. He initially denied being depressed, agitated, or having mood changes. However, he appears paranoid, as well as withdrawn and isolative.
He overall is uncooperative and does not answer direct questions. He does not attend recommended groups and has refused to interact with patients and staff who are not Caucasian because he is “afraid of darkness.” This fear seems to manifest itself only when he is anxious, agitated, or upset, or it is discovered that he has refused to take his medication. At such moments he remains fixated on his overvalued ideas about speaking only with Caucasians. This fear seems to coincide with a reoccurring insistence that his first name is not Ben but rather Ishmael.
Initial plan of care included only Benadryl 50 mg prn for sleep. Milieu and psychosocial interventions included group therapy, milieu therapy, and individual supportive therapy.
Mr. Vesper refused to sign any releases of information, so family has not been either identified or contacted. He has been overheard telling peers about his father and grandfather (although social work staff are still waiting for collateral information to confirm that either or both are still living). He also claims he has a conservator who lives in another state, but he refuses to give the unit social worker any information that would allow us to confirm this relationship or contact that person.
Mr. Vesper is delusional and believes he is a visitor at this hospital. Alternately, he believes he has visitors downstairs in the lobby, waiting to transport him to a “real” hospital to address his physical/medical concerns. He denies mental illness and attempts to leave this building and the hospital grounds, claiming that he does not belong here. Because he enjoys art, literature, and especially music, all nursing staff have been instructed to offer him alternative activities to distract him from the exits and engage him in conversation that is pleasurable to him. He has been given a notebook and fine-tipped markers so that he can continue his reported pastimes of journaling and writing letters. The administration is considering our request to grant him supervised access to a typewriter.
Mr. Vesper recently went AWOL for several days and was found squatting in an abandoned house a few blocks from the hospital. When found he insisted that the house belonged to his family. Staff have been unable to corroborate this claim. When campus police brought him back to the unit, he refused to walk, opting to crawl on all fours, even in the restroom. This behavior lasted only a few days, although he spent several weeks sleeping on the hallway floor next to the main exit, insisting he did not want to miss his visitors when they came up to discharge him.
Additional delusions include his belief that he is suffering from a traumatic brain injury (TBI). Reality testing is futile, as any attempt to reason with him causes him to become highly intrusive, loud, argumentative, and even somatic. Under stress, he complains of debilitating pain in various parts of his body, usually his head and skin. His experience of these sensations leads him to complain that this facility is not providing him with appropriate treatment for his “major medical issues.”
Now that his attempts to escape the unit have decreased, Mr. Vesper is currently on Q 15 minute checks for protection of self and others (although he occasionally still insists that “someone is waiting” for him downstairs). His last outburst occurred three weeks ago, when he went downstairs with the fresh air group then tried to exit the building through the main lobby. When security confronted him, he began yelling that he was just a visitor and staff are preventing him from returning to his “real” life. When he refused to return to the unit quietly, additional staff were needed to assist security. Since that time, the only other notable disruption occurred when staff on the unit questioned him about items he was attempting to send in the mail. Mr. Vesper became highly agitated and threatening, to the point of requiring involuntary seclusion. Afterwards, advocacy staff facilitated a mediation, followed by staff education on patients’ rights to use telephones and send/receive mail. No further incidents in that regard.
Mr. Vesper refuses to allow his social worker to locate relatives or friends, nor will he allow her to invite advocates to attend Treatment Plan Reviews. SW continues to invest efforts (in conjunction with Advocacy staff) towards obtaining Mr. Vesper’s written consent to communicate treatment status and discharge recommendations with relatives nearby.
Medical risks include weight loss and malnutrition due to frequent refusal of hospital meals. Psychiatric risks include increased psychotic symptoms and related behavioral problems due to noncompliance with medication, which also places him at risk for assault and aggression (historically).
Mental status exam found his affect to be hostile, with no lability. The reliability of the exam is poor in that his participation was based on an overvalued idea that he must decline aspects of the interview due to provision of care by a non-Caucasian physician. Thoughts are literal and concrete, although thought content involved expression of somatic preoccupations involving skin conditions and headaches. Impulse control was fair, but social judgment is poor as a function of the illness. Lacking insight, he denied that he needed treatment. Also denied any current suicidal ideation, intent, or plans.