Chapter Text
Date: 28.5.2002, 11:00a.m.
Pt: Holmes, Sherlock
Psych Note:
Sherlock Holmes, a 25yo White man with a history of polysubstance abuse (cocaine and heroin) and a differential diagnosis of a mood disorder, was seen for 45min to continue the intake interview begun on 27.5.2002. The previous intake with Dr Northrup was discontinued due to the pt’s intoxicated state and uncooperativeness.
Mental status: Mr Holmes was taciturn and did not engage easily with the examiner. He was argumentative and stated that he did not wish to be at Blakely House. Speech was pressured. Pt described his mood as “morose.” In contrast to his behaviour with Dr Northrup, pt displayed little motor activity and spent the entirety of the session slumped in his chair with his eyes inappropriately fixated on the examiner. Pt appeared internally preoccupied but denied hallucinations. Thought content was focused on the pt’s developmental history. Pt’s thought processes were somewhat tangential. Pt persisted in his delusion that he is responsible for preventing a murder. No SI/HI. No AH/VH.
Session Notes: Mr Holmes arrived on time for his first appointment with Dr Carola Rivas, his psychologist. A developmental and psychiatric history was taken. See attached form for details. Pt appeared guarded and initially refused to supply information about himself. Five minutes were spent in silence before the pt demanded that the psychologist “deduce” his past. She provided some minor observations on his appearance and attitude, noting, for example, that his clothing and his accent denoted a privileged upbringing, which information he corroborated. He made some similar observations about the psychologist, at which point she explained that the purpose of the intake was not to gather information about the psychologist but rather about the patient. Pt responded poorly to her redirection, and requested to fill out the intake form himself “because I [he] could do a better job than the lot of you idiots.” This idiot responded that she would be the note-taker because she needed him to direct his full attention to the task. Appearing somewhat mollified, he assented to answer her questions. Pt spoke in a grandiloquent manner; e.g., when describing his Caesarean birth, stated that he had been “from his mother’s womb untimely ripped”. Pt frequently needed to be reminded to stay on task.
Progress towards goals: Mr Holmes appeared to make some progress in establishing a relationship with this examiner. He displayed less agitation at the end of the session. Pt reluctantly agreed to return to begin psychotherapy in two days, saying, “not much else to do around here and you still need to get your report.” The pt displayed evidence of a sense of humour, joking that he would present the psychologist with her own intake report at the next session.
Recommendations: Differential diagnosis: R/O autism spectrum disorder, R/O bipolar disorder; R/O obsessive-compulsive disorder. Treatment plan to be determined; minimum of three sessions of individual psychotherapy per week. Continuation of methadone maintenance is recommended. Pt to be referred for the following groups: Social Skills Building; Men’s Support Group; Drama and Music; Risk Reduction. Pt also eligible for career counselling and housing placement services.
Signed,
Carola Rivas, Ph.D.
Attending Psychologist
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Page 2: Developmental History
Name: Holmes, Sherlock
DOB: 7/19/1976
Age: 25
Father: Holmes, Sigur Frederic (died when patient was 22, colon cancer). Served in Foreign and Commonwealth Office.
Mother: Holmes, Violeta Portnoy (died when patient was 12, car accident). Concert pianist.
Siblings: Holmes, Mycroft (31yo). Special Assistant to the Home Secretary.
Pregnancy and birth: Pt was born via Caesarean section after a full-term pregnancy. There were no complications during pregnancy or delivery. Mother did not consume alcohol, nicotine, or other substances during pregnancy. No significant illnesses in first year of life.
Developmental milestones: Pt met developmental milestones early. First words, 9mos. Sitting, 6mos. Crawling, 8mos. Walking, 9mos. Using sentences: 14 mos. Reading: 4yo. Toilet training (day and night) by 3yo.
Family environment: SH grew up with his mother, his father, and his brother (7 years older). Pt reported having had a “satisfactory” relationship with his mother. He refused to comment on his relationships with his father and brother despite prompting from the psychologist. Pt became agitated when talking about his family and threatened to discontinue the interview.
Education: Pt left home for public school at age 12. Pt reported receiving excellent grades in every level of school. Entered Cambridge at age 17 to read chemistry. Took a dual degree in biochemistry and music performance (violin). Pt displayed evidence of grandiosity when discussing his academic history; additional information is needed to corroborate his report of receiving a doctorate at age 22. Vocabulary and comprehension appeared to be in the superior range. Pt spontaneously demonstrated his skill in mental arithmetic by correctly multiplying five-digit numbers without the use of a calculator or paper/pen.
Employment: Pt is not currently employed. Pt is financially supported by his older brother. Pt was previously employed as a chemistry tutor at Cambridge, until 2001. Pt earned small sums of cash as a violinist until several months ago, when he withdrew from his position in a regional orchestra. When asked what his ideal job would be, SH responded “consulting detective”. May need help with reality testing, as he struggled to accept that stable employment was a desirable future outcome for him.
Substance Use: Pt reported that he began smoking cigarettes at age 12. He denied that there was an association between his early drug use and his mother’s accidental death around the same time. Beginning at age 16 and until he was 21yo, SH experimented infrequently (1-2 times for each substance) with cannabis, ecstasy, heroin, cocaine, and LSD. Pt began to use cocaine and heroin with greater frequency around age 21. Pt denied that there was an association between his increased drug use and his father’s hospitalization for cancer around that time. Insight was lacking into the association between major personal losses and his drug use.
Psychiatric History: There is a family history of mental illness. Paternal grandfather was reported to have “some kind of madness,” but pt could not specify. Mother was reported to have bouts of depression. Pt said that his father was an “alcoholic and philanderer”. He diagnosed his brother with several fictitious disorders (e.g., called him a “bastardus rex” with “pervasive scopophilia”). Pt reported having had psychotherapy from age 12-15 for “problems with peers.” When asked to describe these problems, SH showed the psychologist a cigarette burn on his arm made by a classmate. He described various other incidents where he was bullied or victimized in school. When asked why he was the target, he said, “People always hate what they do not understand.” Pt reported that he had been diagnosed with conduct disorder at age 12 but refuted the diagnosis, now and at the time. He denied having tortured or killed animals for pleasure as a child. He denied violence towards others as a child or adolescent, “except in self-defence.” Mr Holmes has memorized the criteria for various psychiatric disorders and stated that he did not currently meet enough of the criteria to qualify for bipolar disorder disorder, PTSD, or a personality disorder. When this examiner asked him what he thought would be the closest diagnosis, he said, “Mood Disorder NOS, perhaps Eating Disorder NOS.” He acknowledged feeling sometimes “as if life were worthless, it’s so boring” and he admitted to “going for days on end without eating.” He had somewhat delusional beliefs around food, stating that he “could not think while he was digesting.” Patient is 6 feet tall, weighs 10 stone, and has a BMI of 19.0, putting him close to “underweight” (<18.5).
Interaction with the legal system: Prior to his arrest for intoxication on 5/26/2002, Mr Holmes had one prior arrest for consumption of cocaine in 2000. He was held overnight and issued an ASBO.
Progress towards goals: No stated goals; treatment plan to be completed. Mr Holmes appeared to make some progress in establishing a relationship with this examiner. He displayed less agitation at the end of the session. Pt reluctantly agreed to return to begin psychotherapy in two days, saying, “not much else to do around here and you still need to get your report.” The pt displayed a sense of humour, joking that he would present the psychologist with her own intake report at the next session.
Recommendations: Differential diagnosis: R/O autism spectrum disorder, R/O bipolar disorder; R/O obsessive-compulsive disorder. Treatment plan to be determined; minimum of three sessions of individual psychotherapy per week. Continuation of methadone maintenance is recommended. Pt will be referred for nutritional counselling. Pt to be referred for the following groups: Social Skills Practice; Men’s Support Group; Drama and Music; Risk Reduction. Pt also eligible for career counselling and housing placement services.
Signed,
Carola Rivas, Ph.D.
Attending Psychologist