Psychological Case File Notes

February 24, 2013 — Leave a comment

Case File # 121774-3249

 

 

Subject Name: Jesse James Anders (Jesse James Sanborn)

D.O.B.: 17-November, 1987

Address: 1816 Burnsville Parkway, Burnsville, MN  55337

Contact: 953-443-4309 (last known working phone, no longer in service)

Single Caucasian Male

0 children/dependents

No religion specified

 

 

Chief Complaint from patient: “I’m having troubles with time. I can’t remember when I’m scheduled to work. I don’t know what to do anymore. I feel numb. And, I’m drunk.” – Message taken by staff member Shelly Gleason over the phone on September 6, 2012.

Notes: Patient first seen in by Dr. Jackson on August 4, 2003 after complaints of previous doctor not using effective treatment methods. After refusal of psychotherapy, patient has been seen regularly by Dr. Jackson to update his prescriptions.

Initial Diagnosis: ADHD, victim of severe physical abuse by biological parents and two foster fathers before the age of 15. Other Detachment disorders noted, but not specified as patient is reluctant to discuss childhood.

Date of Diagnosis: March 1997 by Dr. Ralph Carlson, MD. before referred to our offices in 2003. (see attached notes from Dr. Carlson)

Current Diagnosis: Bipolar I (initial diagnosis retracted after prescribed medication failures to ease symptoms).

Date of Current Diagnosis: December 2003

History: Born in St. Paul, MN to John and Melinda Sanborn. No known complications with childbirth or mental health history before ten years of age. Father, John worked for a manufacturing plant, and mother, Melinda, a domestic engineer. Mother had a bipolar diagnosis but remained un-medicated throughout patient’s childhood. Have not been able to reach patient’s biological parents for confirmation.

Patient describes his social life before ten as “normal.” Received good grades, had many friends, adjusted well to new situations, etc. Patient refuses to discuss the death of his sister, Mandy, and when asked general questions about his family life through childhood, he chooses not to respond. (see attached interview with father and Dr. Carlson, discussing initial diagnosis and circumstances surrounding “Mandy’s” death.)

Marriage, Education and Occupational History: Patient is single, but dating. One significant relationship to date. Patient is heterosexual with a history of promiscuity with multiple partners.
High school diploma and one year complete of Community College. Social situations through school presented challenges for patient in communication and focus.

Occupational history includes: restaurant industry, warehouse, USA Cycling National Championships cross-country and other competitions, and briefly, The US Marines.

High risk behaviors include: Alcohol abuse, marijuana abuse, aggression, and a history of police confrontation.

Current living/social situation: Lives with friend, Jake, and Jake’s father, Dennis, in a single-family home in suburb of Minneapolis, MN. He rents out a single room in the home. Patient describes social situations as solitary or few friends of note. Patient is highly intelligent (see attached MMPI and Weschler results), but prefers an environment of low risk and low challenge.

Summation and Notes:

Initial visit in 2003: Patient was brought by foster mother, Lily Lamoureaux, to our offices at fourteen years of age. Patient’s overall appearance was clean and appropriate. Eye contact minimal and very few words spoken. Ms. Lamoureaux described patient as “sad, confused and broken.” Patient evasive and bouncing knee with arms folded in front of chest. Posture was slouched and showed ambivalence. Patient was alert, but hostile when asked specific questions of state-of-mind, depression and previous foster care. Ms. Lamoureaux described his past situation as “unfortunate and unloving” and “abusive, neglectful and punishable.” (see enclosed audio recording of initial visit – #A3328)

Anxiety visibly increased in patient as Ms. Lamoureaux described previous foster living arrangements and previous biological parental abuse, along with the death of patient’s sister, “Mandy.”

Initial diagnosis of ADHD by Dr. Carlson in question.

Hospitalizations and Interventions: Patient suffered head trauma as a result of a social altercation in 2012. Previous hospitalizations before in my care are noted in Dr. Carlson’s file (see attached).

Medications: (see full history and side effects attached)

Lithium; 2004-2008.

Seroquel 2008-present.

Lorazepam 2008-present.

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