1 Kaiser has my whole visit history incl. notes available now! Awesome!! (Except it sucks that right-click doesn't work, making it require multiple clicks to access anything—maybe there's a way to cheat with the developer tools?)
3 Katherine Walker's notes from 12 August—
5 > Zachary Davis is a 28 Y male who returned to focus on addressing symptoms involving: gender dysphoria
6 > *Updated Clinical Status/Relevant History/Active Abuse-Trauma Concerns/Treatment Response:
7 > Zachary in after a long hiatus wanting to talk about his gender issues. He reports that he finds the best explanation for his own gender issues is "autogynephilia" which is described "an erotic interest in the thought or image of oneself as a woman".
8 > This concept is highly controversial in the LGBT community for many reasons and when he talks about it to others he feels their disapprobation. Zack belongs to a philosophical group (Less Wrong, his Tribe) that is devoted to getting as close to absolute truth as possible, so it is important to him to make a distinction between the experience of a transwoman and that of a genetic woman. I talked with him about my own beliefs of people falling on a continuum but he is fixed on wanting to have a socially and politically correct and yet entirely accurate label for his experience. He would like to try hormones but is once again afraid of rejection by caregivers who espouse the more conventional beliefs at the current time regarding gender identity. Zack is very intelligent and will admit that he tends to over think things, but continues to put himself through a great deal of angst about these issues.
11 > JULIE MARIE AYOOB RN at 8/19/2016 1:27 PM
12 > Zachary Davis is a 28 Y patient assigned male at birth who identifies as: pt exploring gender identity, said still identifying as male
13 > Preferred name: Zachary
14 > Preferred pronouns: he/him
17 > Patient is inquiring about the following: hormones, is interested in trying them for a few months to see if they fit with his gender identity
18 > Date started transitioning: not yet
19 > Is the patient currently on hormone therapy? No
21 (That's not how I remember that conversation!)
23 1 September office visit with Daniel Geer LCSW
25 Pt. presents stating that he has been thinking for the past year about starting HRT to experience a feminine hormonal environment and to experiment with a more androgenous appearance. Pt. is clear that he does not ID as female or non-binary and does not want to transition. Pt. with strong political and intellectual views about gender. IDs as having Autogynephilia. Pt. knows this term is often rejected by the TG community, seen as a sx of gender dysphoria, or a phase for TG women but feels strongly that this term best describes him. Pt. hopes for a closer approximation of the female experience, emotionally and physically. Pt. would like to experience some breast growth and have a more androgenous look, experience what it it like to have a female hormonal environment. Pt. wonders about the social implications of being on HRT, eg. "What if not comfortable"?, "What if look weird"?, "Others might stare"? Pt. has gathered info on the internet and in talking with TG women friends in Berkeley where he lives. Pt. states that going on HRT would be an experiment and that it might be only for a few months but is determined to try either through the medically supervised route, or by getting hormones elsewhere. Pt. with some knowledge of the medical risks/benefits but could use more informing on this. Pt. does not seek any other gender affirming services or surgeries.
27 Pt. involved in an "internet subculture", online group based in Berkeley that is his main support. They interact online but also see each other in person. Pt. feels he can talk with them about most anything. In terms of his ID with Autogynephilia, he only talks 1:1 with some of his closest friends. He states that they often "agree to disagree.
28 Positive coping includes: talking to supportive friends, reading, being sure to get enough sleep
29 Negative coping to avoid includes: not getting enough sleep, avoid reading scary things
31 Pt. reports first awareness of autogynephilic feelings at around ages 12-13. Pt. states, "I could cherry pick and create a TG narrative" eg. asked for a few stereotypically feminine toys, was sensitive, not esp. masc, but on the whole states was not GNC. Pt. notes that he did some cross dressing as a teen, sexual fantasy revolved around being and feeling female. Pt. cont. to cross dress, esp. likes using breast forms. Pt. states this is mostly erotic but sometimes not. At age 18 pt. read about autogynephilia online and states it immediately fit for him. Prior to that had been a "gender abolitionist", often protesting that girls/boys should not be divided for sports/gym. Pt. states that from age 15 to 22 tried to use the name ZM but states "it was a disaster", gave up as felt always was correcting people. Pt. is happy when read as female on the phone. Pt. has been told by other TG women that he seems trans but pt. does not ID with this. Pt. states he is male but with the persistent fantasy of being a woman but resists the common language used today to describe trans experience.
33 Pt. not in a rel. Longest dating exp. was a few months with a poly friend with whom he was in a fractional rel., now they are just friends.
34 Pt. states that technically he is a virgin, attempted intercourse x3 but could not maintain an erection.
35 Mostly attracted to cis women but open to TG women.
38 Born in Wisconsin but moved as a baby to Ca. and grew up in Concord and Walnut Creek.
39 Mo. lives in WC, states they are on good terms, gender and sexuality are unspoken topics.
40 Fa. lives in Dublin, good terms and as above they do not discuss gender/sexuality.
41 Pt. has one older sis. who lives in Boston, they are on good terms but not close.
42 School- pt. states he hates school but did almost finish college with a degree in Math.
43 Works as a computer programmer in SF, likes it. Recently has been distracted by gender/sexuality issues so hard to focus. At this job x2 and 1/2yrs.
44 Moved to Berkeley last yr. and has really enjoyed the "geeky" community of people he has found there.
45 Lives with a roommate who is also a friend that he can talk to about gender/sexuality.
47 ASSESSMENT/RECOMMENDATION AND ACTION:
48 Pt. to return for f/up MH visit to discuss further the implications of starting HRT, further clarify goals
49 Wr. to contact MH txst at K/Ant. re. her sense of pt. plan for HRT (pt. gave verbal consent for this in session today)
51 13 September office visit with Daniel Geer LCSW
53 Pt. returns for contd consultation re. HRT.
54 Starts by presenting wr. with the book, "Men Trapped in Men's Bodies" as wants wr. to understand his experience.
55 Pt. cont. to state that he has been thinking for the past year about starting HRT to experience a feminine hormonal environment and to experiment with a more androgenous appearance. Pt. reports that for the last two mo. he has been more obsessed with gender and starting HRT such that it has been harder to focus/concentrate at work.
56 Pt. is clear that he does not ID as transgender, female or non-binary and does not want to transition to another gender. Pt. with strong political and intellectual views about gender. IDs as having Autogynephilia. Pt. knows this term is often rejected by the TG community, seen as a sx of gender dysphoria, or a phase for TG women but feels strongly that this term best describes him. Pt. somewhat concrete in his insistence that he is male in that he has a biologically identified male body and upset thinking that TG women are "delusional" about being women, thinks his way of thinking is the right way. Pt. became emotional and loud at times when talking about the current culture around gender and transition. When directed to focus on his own experience he was calmer. Pt. is excited about the idea of starting HRT but clear that he sees it as an experiment, that he would stop if the effects became uncomfortable.
57 With HRT pt. hopes for a closer approximation of the female experience, emotionally and physically. Pt. would like to experience some breast growth and have a more androgenous look, experience what it it like to have a female hormonal environment.
58 Pt. does wonder about the social implications of being on HRT, eg. "What if not comfortable"?, "What if look weird"?, "Others might stare"? Pt. has gathered info on the internet and in talking with TG women friends in Berkeley where he lives. Pt. states that going on HRT would be an experiment and that it might be only for a few months but is determined to try either through the medically supervised route, or by getting hormones elsewhere. Pt. with some knowledge of the medical risks/benefits but could use more informing on this. Pt. does not seek any other gender affirming services or surgeries.
59 Pt. understands that some of the effects of HRT are not reversible, eg. breast growth. Pt. seems to both not want to transition because it would be "impossible", difficult, but also because he does not feel that his persistent fantasy of being a woman makes him a woman but rather autogynephilic.
60 Pt. notes that he is attracted to women, would like to be in a rel. with a woman but feels that his very high standards will make this difficult. Pt. states that he already has some erectile dysfunction (has not been able to have penetrative sex) but has not been very motivated to tx this with therapy or meds. Does masturbate/ejaculate most days and likes the sexual function he has. Function is the same with partners as it is solo. Pt. does not feel he will be bothered by decreased sexual function on HRT.
61 Pt. has a large circle of online and in person TG women friends that he is able to talk with about his experience. Even though most do not agree with his use of the term and ID of autogynephilic, they accept him. Many tell him that many trans women start out with his way of thinking but ultimately do transition.
62 Worked with pt. on finding language that he both feels is true for him, but also not so inflammatory as to cause conflict and distress for himself and others he interacts with. With discussion pt. states the the term "trans-feminine" could be acceptable to him.
63 Pt. is both excited and nervous re. the idea of starting HRT.
68 Pt. returns for contd consultation re. HRT. Plan at last session was to refer for HRT after today's session after consultation with MST Team.
70 Starts today by stating that he does not feel stable enough right now to start HRT. Pt. states he has been more depressed and anxious and in particular has not been able to get work done at his programmer job as he is obsessed with mainstream thinking re. gender and his disagreement with the thinking that autogynephilia is a sx of gender dysphoria. Pt. opposes the mainstream narrative of TG women as being women in the wrong body. Pt. states he wants to be more stable from a MH perspective before "tinkering with my body chemistry".
72 Pt. cont. to state that he has been thinking for the past year about starting HRT to experience a feminine hormonal environment and to experiment with a more androgenous appearance. With HRT pt. hopes for a closer approximation of the female experience, emotionally and physically. Pt. would like to experience some breast growth and have a more androgenous look.
74 Pt. cont. to be clear that he does not ID as transgender, female or non-binary and does not want to transition to another gender. Pt. with strong political and intellectual views about gender. IDs as having Autogynephilia. Pt. knows this term is often rejected by the TG community, seen as a sx of gender dysphoria, or a phase for TG women but feels strongly that this term best describes him. Pt. somewhat concrete in his insistence that he is male in that he has a biologically identified male body and upset thinking that TG women are "delusional" about being women, thinks his way of thinking is the right way. Pt. again became emotional and loud at times when talking about the current culture around gender and transition. When directed to focus on his own experience he was calmer. Pt. cont. excited about the idea of starting HRT but clear that he sees it as an experiment, that he would stop if the effects became uncomfortable.
76 Asked pt. what he attributes his hyper focus on this issue and upset to. Pt. states he took an online ASD test (58 Qs) and scored 1.8 Standard Deviation toward ASD and believes he may be on the spectrum. Pt. recognizes that he does not have good social skills and needs to work on his emotional intelligence. Pt. recognizes that the way he comes across to others and in online communication is often not helpful. Pt. hopes that by advocating for those men with his experience around gender that he could help other young people understand themselves in a way that is different than the mainstream narrative for trans women.
78 Worked with pt. on some strategies to decrease focus on this topic. Pt. suggested taking a month break from thinking about it at all. Wr. suggested using tools at work to prevent him from going online, using a timer for focused work. Suggested the use of "focused worry" times and deferring worry/thinking about this at other times. Pt. with plan to take a month off from focusing on gender issues.
80 Informed pt. that wr. will be leaving Kaiser after mid. Nov. Offered appmt. to pt. in Nov. but he declines stating he prefers to take some time to stabilize on his own, then call back for HRT consult. Informed pt. he would need to have an appmt. with MH provider again prior to HRT consult referral to assure that he is in a stable place emotionally (as he also identified as being important). Pt. became upset when wr. tried to frame the appmt. as a supportive/check-in vs. a gatekeeping appmt. as pt. referred to it as. Ultimately pt. agrees with plan to call back to see another MH provider here for check in before referral for HRT.
83 LISETTE ROSE LAHANA LCSW at 12/8/2016 12:45 PM
85 Discussed case with director Dr. Susanne Watson and way in which his gender narrative is atypical and how he connects to the concept of autogynephilia. Explored ways in which pt's neurodiversity may be impacting his ability to think about desired gender changes and communicate to therapists. Discussed long term gender issues for patient and his perception of gender and how for some pts on the spectrum, experiencing hormonal changes is important, and something that cannot be imagined. Watson and Lahana discussed importance of having pt meet with MST team providers to check in periodically once he is on hormones to discuss impact on his feelings and how changes are impacting him. After next session with Lahana pt either will continue with Watson at MST or with Lahana at UNC depending on pt's preference.
87 LISETTE ROSE LAHANA LCSW at 12/19/2016 3:41 PM
89 ADULT PSYCHIATRY FOLLOW-UP – THERAPIST
93 Zachary Davis is a 28 Y male who returned to focus on addressing symptoms involving: Zack Davis is a 28 Y single, Caucasian patient assigned male at birth who identifies as male and autogynephilic, uses he/him pronouns, returning to focus on: desire for HRT start.
95 *Updated Clinical Status/Relevant History/Active Abuse-Trauma Concerns/Treatment Response: This is the second return visit with this patient who has already been assessed by Daniel Geer over the last two mos. for HRT as well as had a return visit with Daniel Geer also focusing on HRT readiness.
97 "Zach" Zachary still wanting to be on female hormones, feels concept of autogynephylia defines them. Wants to be on hormones to feel what it is like to have them in his body and experience emotional changes and what women feel. Pt still reporting angry at past 10 years being "lied to" by transgender community," being told their experience as an autogynephilic person is not valid. Zack had to be redirected to talk more about hormones and what they are looking for in hormones rather than focusing on political issues. Attempted to have Zack focus on how the political issues impact him personally. Pt talking about some regret for knowing he had gender issues 10 years ago but because he was feeling he wanted to be a female, felt he was told he was autogyniphilic so that meant he was not transgender and merited hormonal interventions. Pt reports has been quite distracted by gender issues this year and had a hard time focusing at work.
99 Discussed changes to expect on estrogen using KP informational handouts (informed consent forms) and went over which changes patient is most interested in. Pt focused on wanting the emotional changes, being more in touch with emotions, feeling more balance. Also hates having facial hair, pt feels "gross" about facial hair coming in after a few days. Plans to have hair removal out of pocket.
100 Pt still not sure how will feel with breast development. Wants to wait and see and stop if does not like development or if gets in way of social life. Pt has enjoyed wearing breast forms in the past. Encouraged pt to continue wearing breast forms as much as possible over the next 6 mos. to practice and make sure he wants breast development.
102 Pt also shared he has a number of feelings typical of trans women such as a desire to live as a woman full time but feels that it is "impossible" and would be "a lie" as he was born and socialized as a male. Feels it would be a lie to try to convince others he was a female. He reports he functions socially ok as a male and does not feel he can change that. Feels socially transitioning would be "impossible" and scary. We discussed that there may be small changes to his physicality over time, such as hair removal, that may make him feel more comfortable. He liked the idea of looking more androgynous over time. I also talked with him about some people who make very slow transitions, who feel terrified at first, but over time, sometimes 5-10 years or more, move into the female gender role. Pt reports envy for friends who "get to transition" He repeated three times during the session, "I've been wanting this for fourteen years" (referring to hormones and having his body change to a female body).
104 When discussing estrogen versus anti androgens he was clear in wanting a more conservative approach and liked the idea we discussed which was to go on estrogen first. I shared he could go on anti androgens first to cut off tesosterone, or estrogen without testosterone. He feel the issue isn't testosterone in his system that bothers him but rather not having estrogen in his system that is.
105 He understands that he will stay in close communication with Dr. Slovis and Dr. Watson about how it feels to be on estrogen and anti androgens can be included in his treatment plan over time. Pt is aware of trans women in his community that have only been on estrogen to transition.
107 Discussed keeping a regular log about feelings related to gender starting this week. Encouraged Zack to write about feelings related to body changes, emotions, feelings about body without clothing on, social experiences related to gender.
109 Pt and I went over treatment plan. Offered the option for him to be seen in adult psychiatry and see me in Union City or to be seen at KP Oakland Adult Psychiatry for generalist therapy. Pt does not want to commute to see me. Pt wants to continue in MST clinic and see Dr. Watson for follow up about how he is doing after he start hormones and track his response to changes on hormones.
110 I prepared him that appt will likely be within the next 2 mos. time after some changes begin.
112 Pt open to biological children, doesn't care if children are his but would want them to be genetically tested for intelligence as embryos, "sperm is cheap" Pt prepared for sterility on estrogen/anti androgens.
114 Pt reports today wants to focus on work to help him feel more grounded after this session. Feeling relieved and happy he is moving forward toward hormones.
115 Has friends he can call who are supportive and good for him to talk to if needed.
117 Status of target symptoms: According to Zachary, since the last visit these symptoms have been unchanged.
121 *Compliance with the treatment plan has been excellent
123 *CONSULTATION / TEST RESULTS
124 Reviewed pertinent consultation reports / psychological tests results: n/a
125 If Yes, reports / results reviewed:
128 * (Current clinically relevant)
129 Mental Status Examination: Behavior: psychomotor agitation and fidgety, deep breaths, hands over face at times, appeared upset
130 Mood: anxious and irritable
132 Thought Processes/Associations:difficulty talking about own experience apart from theory
134 *Updated Risk Assessment:
139 Risk of self harm is acutely Low and chronically Low.
140 Risk of harm to others is acutely Low and chronically Low.
147 1. MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, MILD F33.0
148 2. SCHIZOTYPAL PERSONALITY DISORDER F21
149 3. GENDER DYSPHORIA, OTHER SPECIFIED F64.8
154 *Psychosocial and Contextual Factors: no current problems
157 Treatment Interventions used in the session:
158 -Reviewed, reinforced and/or revised goals, -Reviewed treatment options, including risks/benefits of each, based on treatment progress and updated goals, -Insight-oriented, supportive therapy, and empathic listening and -Pertinent psychoeducation about impact of estrogen on body and social life
160 *Treatment Goals updated with the patient:
161 -Other: Assess for hormone start
162 Help pt clarify gender goals
163 Decrease anxiety and lack of concentration related to gender issues
165 *Recommended Treatment Options and next contact agreed upon with patient:
167 Individual therapy: SEE DR. WATSON IN 7-9 WEEKS FOR FOLLOW UP, PT AGREED
168 Continue, with next in-person appointment on (date)
169 No future appointments.
172 Other: Pt does not want group tx though we discussed going to group
173 Medication Treatment:
174 Not recommending a medication evaluation at this time. This option may be considered in the future.
176 No future appointments.
178 *Other Interventions Recommended: SEE DR. SLOVIS TO BEGIN ESTROGEN TX
180 Reviewed with Zachary Davis the following interventions relevant to his/her goals (indicate any options recommended, as well as patient’s response):
182 -No additional interventions recommended at this time.
185 JENNIFER LYN SLOVIS MD at 12/27/2016 10:28 AM
186 Zach (preferred name now) comes in - very well read and knowledgeable about hrt.
187 Patient visit for hormone therapy for transgender care.
188 Has been working w/ psychiatry and has extensive review experience.
189 Has reviewed the KP informed consent protocols for Estrogen or Androgen therapy for mtf or ftm transitions and agrees and understands risks/benefits/required labs, etc.
190 Patient also understands some side effects are not reversible/might affect fertility.
191 Patient agrees to my recommended requriements for follow-up exams and lab work in order for my continued prescribing of hormone therapy as well.
193 Zach is very clearly that he does not want a blocker, and wants to only do a low dose of estrogen at this time (as referrenced in the GNC/non-binary recommendations by UCSF)
196 KATHERINE LOUISE WALKER PHD at 2/17/2017 9:42 AM
197 Called Zack, after hearing from reception that His mother had called the clinic wanting to speak to me about Zack. I was unable to get her at the listed number (got message saying the number was unreachable). I left a message on Zack's voicemail with my return number, asking him to call me.
199 LUKE STEPHEN POTH MD at 2/17/2017 10:29 AM
201 HPI: Zachary Davis is a 29 Y male who presents to the ED requesting a psych eval. He states he hurt people with his words and wants to make amends. His mother states his co worker brought him to her house and yesterday and he was released from his job on a mental health leave. His mother gave him clonopin last night. He does not take any anti-depressants. He denies SI/HI. He denies using any drugs.
205 29 y/o with high functioning autisms/aspergers. He is not sleeping and appears in emotional distress though denies SI/HI. Mother plans to care for him.
208 MARY ELIZABETH SAGE MD at 2/17/2017 12:19 PM
209 * * *CONFIDENTIAL RECORD* * *
210 DO NOT REPRODUCE THIS DOCUMENT WITHOUT SPECIFIC RELEASE OF PSYCHIATRIC &, IF APPLICABLE, CHEMICAL DEPENDENCY (DRUG & ALCOHOL) RECORDS.
212 Inpatient Medical Center Psychiatry Consultation
214 SOURCES: Rick LaBelle PsyD, Poth, Luke Stephen (M.D.), Health Connect electronic medical record (including Kaiser outpatient Psychiatry records), Patient, mom Maxine here in Emergency Department with Patient.
216 IDENTIFYING INFORMATION
217 Zachary Davis is an 29 Year old single,Caucasian male who had been living independently in Berkeley but since yesterday will be staying with his mom. Maxine, in Walnut Creek , who was admitted to Kaiser - Walnut Creek Medical Center on 2/17/2017 for not thinking straight & insomnia. The Patient is currently in Emergency Department. The patient is referred for psychiatric consultation by Poth, Luke Stephen (M.D.) for Rx. See also note by Rick LaBelle PsyD of today, who found that Patient does not meet criteria for California Welfare & Institutions Code 5150 (LPS) for involuntary detainment for inpatient psychiatric monitoring, as Patient wants to be cared for by mother currently, and mother wants to care for him & doesn't want him psychiatrically hospitalized.
219 HISTORY OF PRESENT ILLNESS AND CURRENT COMPLAINT(S):
220 Patient has a very strong family history of psychiatric disorders, including schizophrenia, mood & anxiety disorders, and suicide. Mom reports that Patient "has always been Asberger-y, since he was a small child". Diagnosed with possible Pervasive Developmental Disorder in childhood. Patient performed very highly on intelligence, including language/verbal assessments. Patient treated for anxiety with Rx around 4th grade. Patient went to college at UCSC though dropped out, later attended DVC & SFSU. As an adult, Patient has been diagnosed with Schizotypal Personality disorder, Psychosis, Anxiety. He was hospitalized psychiatrically while at UCSC then again 2013 for psychosis. He was last in regular mental health care in 2013.
221 He did ok, off Rx, living independently, working as programmer, for last few years.
222 In late 2016, he started seeing counselors on transgender issues, identifying with autogynephilia, then starting E2 therapy in late December.
223 Patient not able to provide concrete account of events & symptoms over last month or so. He denies any new stressor or trauma. Patient states he "thought the world was made of words" and he "hurt people with words". He denies any violence to self or others. Mom had not been seeing him regularly, so is not sure, but notes that he was posting on Facebook repeatedly in the wee hours of the night, so she knows he's not been sleeping. Yesterday, Patient was released from his job as a programmer for "mental health leave". A coworker brought him to mom's, and mom reports he is not thinking as lucidly as normal, seems to have blocking of thoughts, gets caught up on "being wrong" or talking about transgender community "being wrong", and feeling depressed. He seems to be obsessing. He writes repetitively in journal, she showed me this. He did not sleep well, often pacing, maybe 4 hours total, last night. Mom gave him a Klonopin.
224 States he's down, then that he's fine. Appetite & wt stable. Denies any suicidal ideation or homicidal ideation or violent thinking of any sort. Initially states that he doesn't want any mental health treatment, just wants to be cared for by his mom & work out his issues with his friends' help. Mom believes that he needs mental health treatment, and asserts this as a condition of him staying with her, then Patient is agreeable to take Rx & return to Psychiatry Intensive Outpatient Program.
225 Denies drug or alcohol use. Prev high level of caffeine.
226 He stopped the E2 patch yesterday.
229 Outpatient Mental Health Provider(s): Katherine Walker, PhD long-term, also seeing a gender transition therapist in Oakland.
230 Previously saw out-patient psychiatrist Dr John Hawkins, who retired.
231 Diagnosis/Diagnoses: Schizotypal Personality disorder, Psychosis, Anxiety disorder, Gender Dysphoria
233 History of Psychiatric Hospitalization: total number of admission(s) 2
234 date of first hospitalization: college
235 date of last hospitalization: 2013 for similar though slightly worse presentation
236 History of suicidal ideation: Yes
237 History of suicide attempts: No
238 History of violence toward others: No
239 History of violence to property: No
240 History of trauma (note that this is sensitive information in the visible hospital chart): denied
241 History of depression: yes
242 History of hypomania or mania: no, though some O-C symptoms & insomnia could be interpreted as manic symptoms
243 History of psychosis: yes
244 History of anxiety: yes
245 History of eating disorder: not explored
246 Psychiatric medication trials:
247 Paxil, Zoloft in childhood
248 Seroquel "was overdosed", "made his tongue hang out"
250 Abilify for longest period
251 Psychotherapy trials: yes
253 SUBSTANCE USE HISTORY:
259 Benzodiazepines: denied
262 FAMILY PSYCHIATRIC AND ADDICTIVE DISORDER HISTORY:
263 Suicide--Maternal great uncle, maternal uncle, paternal uncle
264 Schizophrenia--Maternal uncle
265 Bipolar affective disorder--M uncle
267 Depression & anxiety--mom. Mom reports that she is taking Zoloft 25 mg with great benefit, sees Dr Vaughan & Ken Gregg LCSW.
268 Per mom, family counted all the relatives, and about 20% have major mental illness, "it is our family's curse".
271 Parents divorced. Siblings 1 sister, Patient reports she's supportive. Marital Status: single. Children: no. Educational History: College. Military History: no Occupational History: working as programmer for "Swift Stack" as a programmer, released on "mental health leave". Current Living Situation: was living independently in Berkeley, now will be staying with mom in Walnut Creek.
273 CYNTHIA M NEEL RN at 2/18/2017 2:42 AM
274 Document created by: Turner, K. (RN) on 2/17/2017 at 7:14:10 PM
277 ZACHARY DAVIS IS A 29 YEAR OLD MALE WHO WAS SELF PRESENTED TO CCRMC PES VOLUNTARILY DUE TO SUICIDAL THOUGHTS. PT HAS HX OF MAJOR DEPRESSION. CURRENTLY HAVING SUICIDAL THOUGHTS AND OVERT DISORGANIZATION. PT HAVING THOUGHT BLOCKING AS WELL AS PERSEVERATING ON REUNITING HIS FAMILY. PT DENIED PSYCHOTIC SYMPTOMS ABUT APPEARED TO BE RESPONDING TO INTERNAL SIMULI. PT HAS NOT SLEPT FOR THE PAST TWO DAYS, AGREES TO TAKE SLEEP MEDS. FATHER REPORTS THE PT HAS A SIMILAR EPISODE IN 2013. DID WELL WHILE HE REMAINED ON HIS MEDS BUT OPTED TO STOP THEM RECENTLY. PT SEEN EARLIER TODAY IN THE KAISER OAKLAND ED BUT WAS RELEASED WITH THE CONTRACT MOTHER WOULD TAKE HIM HOME AND MONITOR HIM. AFTER THEY GOT HOME PT LEFT WITHOUT TELLING ANYONE. MOTHER REPORTED HIM A DTS AND POLICE EVENTUALLY FOUND HIM AT THE BART STATION.
279 PLEASE NOTE U-TOX WAS DONE AT K-OAK BUT WILL NOT COME BACK FOR 24 HOURS.
281 Patient was accepted by KUMAR, D., MD/ UNIT A at Fremont Hospital on 2/18/2017 at 2:41:39 AM
283 LISETTE ROSE LAHANA LCSW at 2/18/2017 9:32 PM
286 CARRIE ABNEY RN at 2/27/2017 3:49 PM
288 Level of Care: Inpatient Hospital
290 Discharge Note By: CARRIE ABNEY RN
291 Facility: Fremont Hospital
294 Discharge date: 2-20-17
296 Date and time of follow up appointment with Kaiser Outpatient services or non-Kaiser providers: Kaiser WCR with Janice Alley PsyD 2-21-17 @ 0900
298 How many days in treatment: 2 days
300 Symptoms & presentation at discharge: Pt states that he is much better but that he seems to have some vague paranoid delusions that he's guarded about. He denies any A/V hallucinations and denies any SI/HI.
302 Discharge planning: [If living situation not listed in demographics include phone number & address, name and phone number to provider(s) (Kaiser and non-Kaiser); additional information as appropriate--APS, CPS, group home, special day school or residential treatment center, board and care operators, private case managers, DPOA, etc]: Home
304 Discharge diagnosis: R/O Unspecified Schizophrenia Spectrum R/O Schizophrenia per Dr Kumar
306 Discharge medications: Zyprexa 5 mg bid, Trazadone 50 mg qhs
309 JANICE LYNN ALLEY PSYD at 2/21/2017 10:25 AM
311 ADULT IOP THERAPIST INTAKE EVALUATION
313 ID/REFERRING INFORMATION
314 Zachary Davis is a 29 Y single, Caucasian male, referred by Dr. Sage to the Intensive Outpatient Program.
316 Patient's Rights, confidentiality and exceptions to confidentiality, use of automated medical record, Primary Care Provider and Behavioral Health Services staff access to medical record, and consent to treatment were reviewed
320 Pt reported to this writer that he believes he has no mental health problems whatsoever. He does not want help, noting that the only reason he is here is to satisfy his parents, who are "over reacting" about his recent psychotic episode of 2/16-2/17. Pt did later make reference to feelings of "femaleness" that he cannot properly classify, and that these feelings have recently created intense stress for him.
322 HISTORY OF PRESENT ILLNESS:
323 Pt has a long history of mental health tx and has been diagnosed with anixety, depression, psychosis, schizotypal personality disorder and gender dysphoria. Patient also possesses "traits" of Asperger's Syndrome per patient's father "Peter" (ROI signed/submitted for scanning), but has never been formally diagnosed with a PDD. Patient was brought to the ED by his mother on Friday 2/17 after experiencing a breakdown at work during which pt lost contact with reality (e.g., could not remember where his mother lived, could not remember how to do his work), then became highly agitated. A co-worker drove patient home at which point pt called his father, who then called his mother, for help. Please see Dr. Sage's hospital consultation of 2/17 for background/history leading to this IOP intake evaluation. Pt was d/c'd to the care of his mother after this evaluation with a plan to reconnect with WCR MH via a referral to IOP, but pt later disappeared from the home which led his mother to call 911. (Per patient's father Peter, with whom writer met both together with Zach and privately with Zach's permission, a friend texted pt inviting him to come over without knowing of his fragile mental state. Pt accepted the invitation and then proceeded to BART looking for a train where police found him and placed him on a 5150. Of note, ptt had also reportedly made statements at his workplace that he was suicidal the previous day. Pt was transferred to Fremont Hospital where he remained on an involuntary hold for 72 hours 2/17-2/20.
325 Today patient reports that he has no need for MH treatment, noting that people misunderstand him and as a result unfairly pathologize him. Pt discussed at some length his deeply held belief that people are hospitalized routinely against their will due to "authoritarian attempts to control society." He is nevertheless begrudgingly taking his medication as prescribed (Zyrexa 5 mg), but would like to stop taking it immediately but won't act on this because he promised his mother he will continue taking it. Pt did acknowledge symptoms of anxiety, but understands this as a "perfectly healthy response to society's attempt to control me." Pt acknowledged that he sometimes feels that the world is comprised only of words and philosophical principles, but again attributes this experience to others' inability to properly understand him.
327 Pt last attended IOP in 2013 and curiously stated that he would "very much like to attend" IOP toward the end of the interview. He noted that he would like some help in learning how to socialize properly. (Writer noted that patient has A limited hx of attending the Social Skills Group in WCR.) His father would like him to attend IOP as well, but acknowledged in open discussion between writer, Zachary and himself that pt may need to be pulled out of group if he cannot control his anger outbursts and demonstrated tendency during this very interview to interrupt others regularly. Writer expressed grave concern that IOP may actually agitate patient given his stated belief that he does not need MH treatment, and noted with patient that he currently appears unable to converse appropriately with others, but patient and father strongly requested that pt be allowed to "try it first" on the condition that he will agree to leave if he becomes disruptive. Peter also explained that Zach becomes "quite compliant" once situated in a group therapy format, and again asked that he be given a chance, which writer agrees to do. (Writer also noted that although pt denied ever attending IOP, he did attend WCR IOP briefly in 2013.)
330 Reports of: life problems including performance problems at work and interpersonal problems at work.
331 psychosis including delusions, disorganized speech, disorganized behavior, inappropriate affect and social/occupational impairment.
332 sleep issues including difficulty falling asleep and difficulty staying asleep.
334 Psychosocial History: Patient's parents divorced 8 years ago. Father "Peter" is remarried in Danville to "an optimist" per Peter. Pt has one younger sister who is reportedly supportive. Pt is single and has no children. He attended college briefly but opted to drop out. He has been working successfully for the past 3 years as a programmer for "Swift Stack"; a job he enjoys but very recently decided to take a LOA. Pt has been living independently in an apt with a roommate in Berkeley for the past 9 months but will be staying with his mother in WCR until further notice. Pt notes that he has "a lot of friends" in Berkeley. Per patient's father, these friends are nearly non-functional but provide pt with some sense of community/bond.
336 Housing status: Rents a room in Berkeley but currently staying with his mother in WCR
337 Financial status: Currently dependent on family
338 Employment status: Employed, currently on LOA
339 Education level: some college
341 Past Psychiatric History:
342 Outpatient therapy: individual therapy, outpatient treatment, medication management and inpatient hospitalization
343 Psychiatric hospitalization:total number of admission(s) 2, one in 2013, most recently 2/17-2/20 @ Fremont Hospital
345 Abuse History: denies
346 Legal status: There has been no history of involvement with legal system.
348 Family Psychiatric History: positive for depression/anxiety (mother - on Zoloft, maternal grandmother had ECT), positive for schizophrenia (maternal uncle), positive for bipolar disorder (maternal uncle) and positive for suicide (maternal great uncle, maternal uncle, paternal uncle)
352 MENTAL STATUS EXAMINATION
354 Appearance: healthy, appropriately dressed in khakis and black sweatshirt hoodie, disheveled (unshaven, long, curly brown hair in tangles)
355 Behavior: hyperkinetic and fidgety
356 Demeanor/Manner: guarded, aloof initially; hostile and aggressive when questioned about his MH symptoms/willingness to engage in tx
357 Speech : loud, pressured, rambling and hyperverbal, although this improved significantly toward end of interview
358 Mood: irritable and angry
359 Affect: appropriate to mood
360 Thought Process: disorganized and tangential when discussing MH symptoms; retreats into highly intellectualized, incomprehensible philosophy as a defense against disorganization/psychotic thought process
361 Thought Content: delusions, paranoia
362 Orientation: person, place and situation
363 Attention: distractible
364 Concentration: impaired
365 Memory: not formally assessed
366 Fund of Knowledge: normal
367 Impulse Control: marginal
377 Homicide Risk: denies
379 Other risk issues: poor judgment regarding his need for MH treatment
381 Assessment of risk: Pt. voiced no suicidal or homicidal thoughts/feelings and is therefore not at risk of harm to self or others at this time.
386 Impression: 29 y/o single male with a longstanding hx of sporadic MH treatment and two psychiatric hospitalizations presents at the behest of his parents for an IOP intake following his recent hospitalization at Telecare Heritage. Pt was initially guarded, argumentative and hostile but calmed considerably during the course of the interview. Patient presents a complex diagnostic picture and demonstrated an inability (at least during this interview) to acknowledge and accept responsibility for his symptoms and recent decompensation in particular, which suggests a characterological component. Pt may require a higher level of care and will be monitored in IOP accordingly.
389 Axis I: see encounter diagnosis
390 Axis II: see encounter diagnosis
391 Axis III: Patient Active Problem List:
393 DEPRESSION, MAJOR, RECURRENT
394 ADJUSTMENT DISORDER W ANXIOUS MOOD
396 Axis IV: problems with relationships, problems related to social environment and occupational problems
397 Axis V: 41 - 50 serious symptoms
399 Patient consents to psychotherapy treatment.
400 Risks and benefits of psychotherapy reviewed with patient.
401 Office policies reviewed.
402 Member understands responsibility to pay fees and copays associated with his/her treatment.Patient understands psychotherapy treatment.
404 PATIENT INFORMATION AND TREATMENT PLAN:
406 Patient is to remain free of self-harm while in program.
407 Decrease symptoms as reported by patient.
408 Increase in coping skills as reported by patient.
409 Refer patient to Kaiser/community resources as appropriate
411 Treatment plan: Attend IOP for 6 sessions/two weeks
412 Medication evaluation and monitoring prn by MD - NOTE: Pt needs a new MD in this clinic (former Hawkins patient)
413 Activity therapy for skill building
414 Process group for support, insight building, and management symptoms
415 Explain how to access Psychiatric Crisis Services
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