report

1. 1
Mental Health Consultation
Patient Name: P
Date: 12-16-97
Identifying Data:
Ms. P is a 64 year old, white, female, who was admitted to the on October 2, 1997 from
St. Mary’s Hospital. She was referred for evaluation by her attending physician Dr. B.
Presenting Problem:
Since admission to A, Ms. P has displayed the following problem behaviors: “She always
wants antibiotics and steroids…Is concerned if her temperature is up 10
…Complains of
breathing problems which she consciously exaggerates …Is abusive during physical care…Uses
vulgar language and often curses and swears…Has been seen taking food from her roommates
tray while her roommate was eating…Stands in the hallway screaming at anyone who passes
by…Slams her door when she does not get her way…if you pay attention to her she calms
down.”
A summary of a “Behavioral Treatment Team Meeting” held at A on 12-1-97 includes
the following observations: “It is necessary to be extremely frank with Ms. P in order to be
successful…Ms. P will call the receptionist and disguise her voice in an attempt to get through to
her social worker at unscheduled times”. The summary also includes an excellent behavioral
plan.
This evaluation was requested to clarify diagnosis and offer recommendations concerning
the management of this very difficult resident.
Current medications include: Prednisone 10mg qd, Lasix 40mg qod, and Ativan 1mg q 4 hours
prn.
History:
Available history is vague since Ms. P is evasive about this topic. Little is known of her
social history other than her father was a homebuilder, she has one surviving sister and her
current surname is not her birth name.
Ms. P lived in an adult home for approximately 6 years prior to admission to St. Mary’s
hospital on September 13, 1997. The admission was precipitated by an exacerbation of her
COPD. Once stabilized, she was transferred A. According to the chart, she had been placed in a
nursing home before her last St. Mary’s admission, but left the home AMA following a one-
week stay.
She had “several” psychiatric admissions to the Rochester Psychiatric Center (RPC) and
RGH G1 “several years ago”. In addition, she had a “recent series of inpatient stays” on 4300,
St. Mary’s Acute Psychiatric Inpatient Unit. Ms. P has never followed through with outpatient
mental health treatment nor has she benefited from psychotropic medication. Her psychiatric
diagnosis has consistently been Personality Disorder not otherwise specified or Borderline
Personality Disorder.

2. 2
Her medical history includes: chronic bronchitis, steroid dependency, morbid obesity and
mild CHF. She is an insulin dependent diabetic. She has COPD and is oxygen dependent. She
was a heavy smoker until two months ago when she started using a 21mg nicotine patch. She is
involved in a struggle with Dr. B about tapering the strength of the nicotine patch. She,
evidently, continued to smoke even after she starting using oxygen. According to reports, she
insists on taking antibiotics prophylacticly and constantly pushes for more Prednisone or other
steroid medication.
Mental Status Examination:
I found Ms. P in her room. The room, redolent of spoiled food and overpowering body
odor, was cluttered and chaotic. She was sitting up in bed behind a tray table piled high with
empty soft drink cups and was surrounded by open telephone books which she was examining
with a magnifying glass. She was a grossly obese woman with flat gray eyes and long wild
looking hair. She was breathing oxygen through a nasal cannula and wore a flannel nightgown
covered with old food stains. Her face was very pale and her jowls, which covered her neck,
flushed when she spoke. When I introduced myself, she responded with her opening volley in a
war of wits; “Chenelly! That’s Italian isn’t it; Oh…Oh…Oh…please tell me it is.” Virtually
every subsequent statement was provocative in a playful way and intended to disarm or
intimidate. She was intelligent and articulate. Her speech was fluent, coherent, relevant and
goal directed. She said she was examining the telephone books “to learn something more about
my doctor”. She was suspicious, responding to innocuous questions by exclaiming “I don’t talk
about personal things”. She was also grandiose; “I have a brilliant mind you know”. She was
quick witted turning questions back at me in a conscious effort to put me off balance. Her affect
was labile as she rapidly shifted from anger to graciousness to histrionic pleading. At one point
during the interview, she demonstrated her disapproval by tilting her head back, closing her eyes
and emitting a series of staccato burps; later in the interview she melodramatically demonstrated
her pain by standing and whimpering. There were no signs of psychosis, delirium, dementia or
morbid depression. Biological signs of depression were absent. She was alert and fully oriented
with a clear sensorium. Her insight was absent and her judgment was grossly impaired. Before I
left the room, she wanted to be certain that I understood that if Dr. B refused her medication
demands, she was “going to God” and “the responsibility will be yours as well as his.”
Diagnosis:
Cluster B Personality Disorder with pronounced histrionic, borderline
and narcissistic features.
Conclusions:
Ms. P is not demented or psychotic. She has a severe personality disorder which is
characterized by the following interpersonal style:
1. Ms. P finds the possibility of personal rejection extremely painful and responds to this
fear by rejecting others before they can reject her.
2. Because she lacks a strong sense of self, her self-esteem is dependent on constant
external approval. In the current setting her self-esteem is tied to the amount of time
staff spend interacting with her.
3. Her interpersonal relationships are intense and unstable. Because she needs constant
gratification she over idealizes individuals if they gratify her needs and devalues
those who fail to respond to her demands.

3. 3
4. She resorts to melodramatic theatricality and the exaggerated expression of emotion
to influence others. However, the underlying emotions are shallow.
5. She behaves in ways, which draw attention to herself as a first step towards
manipulating others into gratifying her needs.
6. A grandiose sense of self-importance compensates for underlying feelings of
worthlessness.
7. She seeks special treatment, immediate compliance with her demands and tries to
control others in order to feel important and special and off set her underlying
feelings of inadequacy.
8. She lacks empathy and consequently is unable to identify with the needs and feelings
of others.
9. She tries to make others to feel the need to solve her problems by unconsciously
playing on their need for approval (i.e. if you do what I demand, I will like you and if
you don’t, I will condemn you).
Recommendations:
The approach outlined in the Behavioral Treatment Plan and Dr. B’s efforts to date are
exactly those needed to foster Ms. P’s accommodation to life in the facility. Those approaches
and other recommendations follow:
1. Never allow Ms. P to draw you into an argument or conflict. If she threatens to leave the
facility, simply remind her she is a competent adult and will be permitted to make her own
choices.
2. Never respond to her anger and verbal aggression with anger or rejection. In spite of the
feelings her aggression engenders in you, respond in a calm, matter of fact and professional
manner. When she is verbally abusive, terminate the contact with the following statement: “I
can see you’re not in a mood to speak with me now; I’ll speak with you again later when you
are less upset.” Ms. P will perceive any response by staff other than the above response to be
a victory in a verbal battle.
3. Make expectations for her behavior explicit and always be consistent in your response to her
negative behaviors. Her complaints should be heard by only one individual per shift. When
she complains to another staff member, that staff member should refer her back to the
designated individual. She should be encouraged to put her complaints in writing. It may be
necessary to enter into a contingency contract with her. If that becomes necessary, I will help
staff and the resident draft a mutually acceptable agreement.
4. The designated staff member should schedule contacts with Ms. P during which she can
voice her concerns and complaints. These contacts should be time limited and the staff
member must be available for the scheduled appointments.
5. Mrs. P should be allowed as much autonomy and control over her day to day life as is
possible in an institutional setting. The limits, however, should be explicit and consequences
for exceeding the limits should be equally explicit.
6. Never challenge her suspicions or grandiose assertions but don’t support them either.

4. 4
7. Other than prn antianxiety medication, which has already been ordered, psychotropic
medication would be of little benefit.
8. Her demand for steroid and antibiotic medication should not be acceded to unless Dr. B
believes these medications are indicated. Gratifying her pathological demands leads to a
slippery slope of constant haggling over new and ever increasing pathological demands.
If staff consistently follow the above guidelines, in time, perhaps six months to one year,
Ms. P will make an accommodation to life in the institution. Conflicts and disruptive behavior
will diminish. She will continue to test limits, but if she is not gratified eventually the limit
testing will decrease in frequency and intensity.
Drew Chenelly, Psy.D. Date
Clinical Neuropsychologist