Date: Thu, 11 Jul 2002 12:21:16
Subject: CLIENT ASSESSMENT REPORT #46892
From: debarthelme@rush.edu
To: mentalhealth.autofiler@rush.edu, tabitha_moran@rush.edu

DATE: 7/11/02

NAME: Berto Tazar

SSN: 327-90-0666

REPRESENTATIVE PAYEE: Self

ADDRESS: 4097 N. Lakeshore Drive, Suite 7082

DOB: 4/18/65

AGE: 37

SEX: M

RACE/ETHNICITY: Cauc

MARITAL STATUS: Single

PRESENTING PROBLEMS
Chief Complaint: Delusions
Symptom Inventory: Anhedonia, Anxiety, Behavior Problems (see notes), Compulsions, Delusions, Depressed Mood, Grief, Low Self-Esteem, Memory Problems, Paranoia, Poor Judgement, Ruminations, Sleep Problems, Other (Extreme paranoia leads patient to refusal to communicate directly with therapists, will communicate only "through" patient Pedro Vasquez, whom he calls "Sancho.")

HISTORY OF PRESENT ILLNESS
Multiple stress factors including loss of employment & unrequited love preceded patient's descent into a delusional state. Patient, a copywriter by trade, began writing fantastical email messages to friends and casual acquaintances describing a journey in the past, to 14th Century medieval Italy. What may have started as a healthy distraction from stress factors soon became obsessive behavior. As they become more and more violent, his medieval fantasies also became the sole focus of his existence. Patient remained indoors for several weeks, drawing and writing these email messages, became increasingly withdrawn from his social contacts, and ceased his search for new employment. His delusions culminated in a violent attack on one of his friends, Skip Valent, who later admitted the patient. At the time of his admittance, patient was exhibiting signs of autism, slack jaw, glazed eyes, and a total lack of communication with admitting staff. He soon thereafter however exhibited a violent mood swing, challenging staff to a "joust" after grabbing hold of an orderly's broom. After this episode, patient was put in restraints, and resumed his feigned catatonia. Patient was released from restraints 72 hours later. Patient refuses to communicate with staff, but is reading email messages sent to him by friends and loved ones. Patient does speak (conspiratorially) with fellow patient Pedro Vasquez, who will be transferred early next week to a long-term facility.

HISTORY OF PAST PSYCHIATRIC TREATMENT
None.

SUBSTANCE ABUSE
Current drug or past alcohol use: Patient's brother, Ernesto Tazar, reports that Patient is a light drinker and occasional marijuana smoker.

SAFETY
History of suicidal ideation or attempt: no (though patient exhibits signs of self-neglect).
Current suicide risk: Not at this time
History of homicidal ideation or attempt: yes (Patient attacked his best friend with a bicycle lock).
Current homicide risk: No? Patient has been generally complacent in the treatment environment, but his delusions vary in intensity.
Risk of other violence (arson, fire, etc.?): none while medicated.

PSYCHOSOCIAL HISTORY
Living Arrangement: Private home/apartment, sole occupant.
Living environment adequate and safe: yes (though patient has been served eviction notice, so new living arrangements may be necessary).
Significant events in childhood/adolescence/adulthood: Patient was physically and verbally abused as a child by father. Said abuse was not of a sexual nature. Patient's father was institutionalized during patient's teenage years. Patient's mother deceased in 1995.
Family History
Substance Abuse: Father (alcoholism, drugs), Brother (alcoholism)
Mental Illness: Father (diagnosed schizophrenic), Brother (clinically depressed)
Medical Illness: Mother died of breast cancer, both grandmothers died of cancer (breast, ovarian), grandfathers both died of heart disease.
Past/Present Relationship with Parents: Mother dead, father institutionalized (Woodlawn Mental Health Center, Palo Alto, CA). No discernable present relationship with father.
Past/Present Relationship with Siblings: Strong relationship with brother, Ernesto (residing near Los Angeles, CA). Distant relationship with sister, Olivia (residing near Chattanooga, TN). Both siblings have attempted contact via email. Brother Ernesto has consulted with attending physicians. Brother Ernesto plans to visit at start of August, may help with living arrangements.
Significant Relationship History: Patient had strong relationship with deceased mother. Patient in monthly phone contact with brother, annual contact with sister. Patient alienated from father. Patient never married, but did have string of significant monogamous heterosexual relationships.
Children: None.
Family Support: Moderate
Family Members to Involve in Treatment: Brother -- Ernesto Tazar
Friendships: yes
# close friends: 3-4
# casual friends: 10-12
Support From Friends: Moderate (admitted with assistance of friend Skip Valent, three other friends have visited).
Other Social Supports: no
Relationship Problems: Conflict (fallout with best friend preceded hospitalization), Social Isolation (in two months preceding hospitalization, Patient had dropped off contact with most of his friends).
Deaths/Losses: Death of mother had significant effect, and patient has suffered from recurring incidents of unrequited love.
Trauma History: yes (childhood verbal/emotional abuse, physical abuse, adulthood verbal/emotional abuse in workplace).
Education: highest grade: BA in English, Italian minor, UCLA
Learning disabled: no
Academic Achievement Problems: no
Literate: yes
Work History: Journalist, LA Times (2 years), Barker, Barnum and Bailey Circus (2 Years), copywriter, OGVB Marketing (11 years), currently unemployed
Military Service: no
History of Legal Problems: no
Guardianship: self
Religion/Spiritual Beliefs: Buddhist (light practicing)
Primary Language: English
Primary Culture: American
Speaks and Understands English: yes
Leisure and Recreational Activities: tai chi, creative writing (fiction), videogames, drawing
Sexually Active: yes
Sexual Orientation: heterosexual
Sexual Dysfunction: unable to determine

MENTAL STATUS
Appropriately Dressed and Groomed: yes (poor grooming upon admittance, acceptable since admittance).
Oriented X 3: Person-yes. Place-no. Time-no.
Speech Activity: soft (when speaking to fellow patient, does not speak to physicians)
Motor Activity: appropriate
Affect: blunted
Mood: sad
Thinking: tangential
Concentration: preoccupied
Hallucinations: unable to determine
Delusions: yes
Describe: Patient believes that he is imprisoned in 14th Century Italy, and that medical staff are his captors.
Cognitive Functioning/Intelligence: above average
Reasoning Ability: confabulatory
Insight: limited
Motivation: resistive

Clinician: D. BARTHELME, MD