Case Study
Patient Demographic: Name: Roger Clinical Issues: Physical/emotional issues related to trauma Diagnostic Category: Neurocognitive Disorders Provisional Diagnosis: F02.81 Major Neurocognitive Disorder Due to Traumatic Brain Injury, with Behavioral Disturbance Age: 36 Sex Assigned at Birth: Male Gender and Sexual Orientation: Male, Heterosexual Ethnicity: White Marital Status: Married Modality: Individual Therapy Location of Therapy : Outpatient clinic  
Mental Status Exam: The client presents as tired. He reports a mild headache at the intake appointment, which he says is likely due to coming in from the bright day outside. Memory is slightly impaired. Mood is depressed, though he says this is impermanent, and his mood changes within a day, though the depressed mood is more prevalent and longer-lasting.
Presenting Problem: First session The client returned home from Afghanistan last month after separating from the Navy after 12 years of service. He states he is tired of trying to get an appointment at the VA Hospital, so he Googled locations that treat brain injuries, and your office was on the results page. He called to arrange a consultation with you. You have been practicing as a licensed mental health therapist at the outpatient clinic for over a decade, and you have worked with many clients diagnosed with traumatic brain injury. The client complains about difficulty sleeping, bad headaches, and feeling like he is on a roller coaster - feeling happy one minute and then down in the dumps the next. He states that the happy times don't last long, and he is "down in the dumps" most of the time. When asked why he left the Navy, he replies: "Toward the end of my last deployment, I just got sick and tired of everything and couldn't deal with it anymore. I couldn't sleep, was jumpy all the time, and didn't even want to go outside during the day." Now, I'm finally back home, but things only seem worse. My wife keeps nagging me to get a job, my kids look at me like I'm a monster, and nobody understands how I feel. I want to lay in bed all day and drink a couple of beers. I think something isn't right, and I can't take it anymore." Near the end of the session, the client asked what he could expect if a medical professional recommended medication management to treat NCD.  The client discloses experiencing a highly distressing and psychologically damaging event during his military service in Afghanistan. While on patrol with his unit, their convoy was ambushed, and a fellow soldier directly next to the client was seized by insurgents. The client painfully witnessed his peer and friend being brutally beheaded, describing the horrific sight and sounds as permanently seared into his memory. Helplessly observing the brutal murder firsthand left him stunned and overwhelmed with grief and terror at the moment. The grotesque violence and knowing that could have just as quickly been his fate continues haunting him years later.  The constant stress of combat and imminent danger already had the client in a perpetual state of hypervigilance and anxiety during his deployment. He shares that coming to terms with the abrupt, unfair loss of life was a daily reality there. While transporting supplies between bases in a standard jeep convoy, his vehicle triggered an IED explosion or was directly hit by artillery fire. The client was violently jolted and knocked completely unconscious as the blast disabled their jeep. He remained in and out of consciousness for over 24 distressing hours, being evacuated while critically injured to a military hospital. Once stabilized, he was thoroughly examined and diagnosed with a traumatic brain injury concussion along with other shrapnel wounds.  Fourth session You and the client decided to meet for weekly sessions based on his current needs. You have established a trusting relationship with him, and he feels more comfortable knowing that you have experience in working with military populations. You provided psychoeducation regarding the effects of traumatic brain injuries and what he can expect from the counseling process. You were able to instill hope that he could recover emotionally following his injury and learn new skills along with coping mechanisms. He presents for today's session in a depressed mood which he states began the previous night. He reports that his family appears to now better understand what he is going through and they are getting along better. He is still drinking three beers at night to help him fall asleep, and his headaches have decreased in intensity due to finally getting a medication consult from the VA. However, he is still sensitive to light. He shares that he is ready to look for work but is concerned about finding a job and performing due to his ongoing symptoms.  Ninth session Rober arrives elated at the session, appearing happy, talkative, and smiling. He states that he has felt this way for four days now, which has not been the typical length of time or the intensity of his positive mood episodes. He reports that his family relationships are satisfactory, and he has been somewhat successful at his part-time job at the local lumberyard. However, he is angry with his manager, who says he has been too distracted this past week and spends more time talking with customers than working. He is still drinking three beers at night to sleep but reports that he has not had to sleep much this past week and feels "wide awake." He says he is ready to open his own business but isn't sure what he wants to do yet.  Roger reports feeling energized, creative, and motivated over the past several days. He has come up with many new business ideas that he is eager to pursue, including opening a restaurant, starting a landscaping company, and developing a crypto blockchain. Roger stays up late into the night brainstorming ideas and making extensive plans. He feels compelled to act on his ideas immediately and has already taken steps to register business names and research loans. However, the next day, Roger often changes course, dropping previous ideas for new ones that seem even more exciting. His friends notice his frenzied pace in bouncing from idea to idea, worrying he has taken on too much. But Roger reassures them this surge of creativity allows him to see endless possibilities for his future business success. Though well-intended, their skepticism only pushes him to work harder to bring his visions to life.  Roger also mentions experiencing increased sociability and talkativeness lately. He says he has frequently called and texted friends and family to share his business ideas and other excited thoughts. Roger speaks rapidly, his thoughts racing as he tries to get loved ones as enthused as he feels. Though some gently try to interject realistic concerns, he remains unchecked in his ambitious optimism. A few close friends have expressed concern over Roger's intensified pace and plans, but he brushes them off, feeling very optimistic and self-assured about his ideas. Roger's confidence borders on grandiose as he envisions an incredibly successful entrepreneurial future. Attempts by caring friends and family to restrain his inflated self-assurance are met with irritation, as Roger feels unable to focus on anything but chasing his next big idea. He's optimistic that his new crypto blockchain will rival and surpass Bitcoin in a matter of months.
Other Contexts:   The client drinks three beers every night before bed to help him fall asleep. He started this pattern a few years ago after struggling with insomnia and finding it challenging to relax his mind. Though effective at first in inducing drowsiness, he has built up a growing tolerance and now needs to drink three beers minimum to feel any sedative effects. He discloses that he knows consuming alcohol regularly can be unhealthy, but he feels dependent on having those beers to wind down from the stresses of his day and quiet his anxious thoughts enough to get adequate rest.  During his time serving in the military, the client reported smoking cannabis on occasion when it was available. However, he did not enjoy the experience or feel compelled to use it. He mainly partook when offered by peers to be social. Since his discharge five years ago, he states he has not had any cannabis.  The client currently smokes approximately one pack of cigarettes per week, a habit he picked up during his military service as a way to cope with boredom and nerves. He expresses some interest in trying to cut back for health reasons but also shares smoking provides a sense of relief and routine.

Question: Given the client's altered behavioral presentation and the description of several new symptoms since the last session, what factors should you consider?
(A): The client is presently grappling with thoughts of self-harm or suicide.
(B): The client is currently experiencing a psychotic state.
(C): The client is currently in the midst of a depressive episode.
(D): The client is currently in a hypomanic state.

Correct Answer: The client is currently in a hypomanic state.
Explanation: The client's talkativeness at work, lack of need for sleep, elated mood, increased goal-directed activity, and these symptoms lasting for four days suggest hypomania. Therefore, the correct answer is (C)
Competency: intake, assessment, and diagnosis