report

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Mental Health Consultation
Patient Name: Multiple Sclerosis Facility: XXXX
Date: 8-6-13 Room: 00
Additional history can be found elsewhere in this chart which will not be repeated here.
Reason for Referral: xx-year-old, white, xxxx, female and Mother of 2 who was admitted on
8-5-13 from XXXX … I was asked to do a PASSAR Evaluation.
Background Information: The primary source of what little information we have about her is
medical, mental health, nursing and social work provider notes from XXXX with references in
those notes to other history; highlights follow:
 Recently at XXXX, XXXX complained that a male staff member raped her. She did not
remember the incident but “somebody in my heart told me about it”. The accusation
occurred after she was told she could not move to the first floor of the nursing home. She
made the same kind of allegation at a previous nursing home.
 Her last psychiatric contact was XXXX in April of this year. She was not admitted and
we do not have a record of that contact. Before that she was at the XXXX Psych Unit for
24 hours in January of 2011; she drank bleach in a suicide attempt, a claim which later
proved to be false. She C/O “crossing over to see the angles” “Later she said she voiced
“psychotic” thoughts to gain admission to XXXX and be “taken care of”.” The
diagnosis at that time was psychotic disorder NOS. We also have no XXXX records.
 Reportedly, she lost custody of her children because of Munchhausen-by-proxy. Her
Mother said XXXX would lower herself to the floor then call life line claiming she fell.
She has a master’s degree in business administration from the University of Phoenix and
a BA from Medaille. In March of 2013, her MMSE was 25/30.
Current Medications: Prilosec, Risperdal 1mg q am and 2mg q pm, Senna
Medical History: GERD, Schizophrenia, Cerebral Palsy, Multiple Sclerosis, Paraplegia.
Mental Status Exam: She was a wheelchair bound woman with long, curly, dark hair and
muscle wasting in her left leg and arm. She was cooperative but paranoid. She was very
concerned about the color of the Risperdal pills she was offered last night. When I explained that
different manufacturers’ pills looked different, she expressed suspicion which I was not sure was
sincere; “then I have to put my safety in your hands”. Her speech was spontaneous, coherent,
relevant and free of dysarthria. Her affect was appropriate. She did not appear depressed. She
said her Mother, her Father, her Grand Mother and her Grand Father all abused her physically
and sexually all of her life “but when I was a child I did not know if it was being done to me or if
I was hearing it being done to my brother”. She asked if I could send her “To Rehab for TBI”
She denied past or current hallucinations.

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Findings and Recommendations: The diagnostic picture here is muddled to say the least. We
should start by sorting out what we know from what we don’t know and what we need to learn.
Also how each of the diagnoses affect her current problem behaviors.
She has Cerebral Palsy without spasticity or mental retardation or an apparent speech and
language disorder. She is wheelchair bound and appears to have the ataxic form of cerebral palsy
thought I did not note any dysarthria. Overall I believe her cerebral palsy is not a direct factor in
her problem behaviors.
Even with the limited data we have available, it is clear that she does not suffer from
Schizophrenia. She does not exhibit any of the following key symptoms of schizophrenia:
a. inappropriate or blunted affect
b. dissociated speech
c. loosening of associations
d. pronounced auditory hallucinations
e. bizarre delusions
f. autism and impaired inability to relate to others.
It is possible that she may have experienced a psychosis with a different etiology in the past.
However, this remains to be seen. There may be no indication for the Risperdal. She does not
have a serious mental illness. As a result, PASSAR may not apply here at all. It is much more
likely that her behaviors reflect a personality disorder.
The available history points in the direction of a histrionic/ borderline personality disorder
which is characterized by: a) difficulty achieving intimacy in relationships b) use of physical
symptoms as an appeal for help c) symptoms which are dramatically described and vague d) a
tendency to alienate others with demands for attention e) frustration in situations that involve
delayed gratification f) actions which are directed at obtaining immediate satisfaction g) a
tendency to become angry, demanding and coercive when needs are not met h) fleeting, shallow
emotions i) a pattern of manipulating others into gratifying needs J) seeing others as the source
of all problems k) a lack of empathy l) unstable emotions m) shifting views of others as all good
versus all bad n) over idealizing individuals if they gratify needs and devaluing those who fail to
respond to demands o) melodramatic theatricality and the exaggerated expression of emotion to
influence others.
Of major concern is the fact that she carries a diagnosis of Multiple Sclerosis and we do not
have any information about this.
The literature indicates that “loss of insight” is the most frequent neuropsychiatric sign in MS
patients. Damage to the callosal pathways leads to an inability to discriminate emotions in others,
which in turn leads to emotional lability in the MS patient. MS related psychosis is possible but
very rare.
In the advanced stages, MS patients can experience a subcortical white matter dementia where
language and general intellectual functions are relatively well preserved. This form of dementia
is subtle and characterized by memory impairment, poor judgment, lack of spontaneity,
perseveration, psychomotor slowing, general dilapidation in cognitive functioning, irritability

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and apathy. Loss of brain tissue in the frontal region may have produced a frontal lobe syndrome
with emotional and behavioral disinhibition and impairment in executive functions including:
1.) abstract reasoning ability.
2.) planning and organizing ability.
3.) social judgment.
4.) problem solving and conceptual reasoning ability.
5.) capacity for self-awareness
A patient with deficits in self-awareness shows an inability to: 1) perceive herself as others
perceive her 2) recognize her internal motivations 3) critique her own behavior
4) accurately identify her strengths and limitations 5.) change a course of action when conditions
change 6.) perceive the long-term consequences of her acts. Most patients with deficits in self-
awareness lose the ability to learn from experience, develop a generally more demanding attitude
and exhibit reduced frustration tolerance. Deficits in self-awareness worsen over time. Denial of
deficits in patients with brain disorder is often manifested as anger towards family members and
others because of institutional placement, which the patient believes, is unnecessary.
We know nothing about the course or severity of her MS not even if it is relapsing-remitting or
progressive. At this point, I am not sure how to interpret her various claims of abuse.
I will provide detailed recommendations as soon as I untangle these diagnostic issues but in
order to do so I will need the following information:
1. Records from the Neurologist who is treating her Multiple Sclerosis.
2. Previous: psychological, neuropsychological, psychiatric, neurological…evaluations.
3. Hospital medical and psychiatric unit discharge summaries.
4. Neuroimaging reports.
Start with XXXX, XXX, XXXX and the xxxxxxx Group then ask family for the names
of other providers of care.
___________________________
Drew Chenelly, Psy.D.
Clinical Neuropsychologist