Training Title 118
Name: Mr. Connor Walsh
Gender: male
Age: 57 years old
T- 97.2 P- 94 R 20 156/88 Ht 5’8 Wt 163lbs
Background: Born and raised in Peru Indiana Is staying at a shelter after being homeless in
MacArthur Park for 1 year in Los Angeles. He lost his apartment and his job working part-time
at Home Depot. Enjoys playing music. He has long hx of mental health treatment since age 19.
Previous medication trials include lithium (was effective), Depakote (gastric upset), aripiprazole
(akathisia), risperidone (hyperprolactinemia), haloperidol (dystonia), quetiapine (didn’t give a
fair trial), Poor historian. divorced once, reports being gay, no children; estranged from only
living sister, parents deceased. He is not sure of his family mental health or substance use history
but feels like he is most like his aunt, she has history of mental health treatment “but
I’m not sure for what.” States that he got a master’s degree in music theory at Stanford. Admits
to 3-6 drinks of alcohol when “playing music in the clubs”, denied illicit drugs, has history of
intentional drug overdose at age 22, history of 8 inpatient psychiatric hospitalization, most recent
was 8 months ago. hx of one detox admission 15 years ago Allergies: bee stings
Symptom Media. (Producer). (2018). Training title 118 [Video].
https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/wa
tch/training-title-118

1. Introduction
Patient: Mr. Connor Walsh, 57‑year‑old male.

Context: Case study from Symptom Media video (2018).

Clinical Focus: Mood disorders in older adults with chronic psychiatric history, substance use, and social instability.

Importance: Highlights the intersection of long‑term mental illness, homelessness, substance use, and treatment adherence.

2. Demographics and Background
Age: 57 years old.

Gender: Male.

Vitals: T 97.2, P 94, R 20, BP 156/88 (hypertensive).

Height/Weight: 5’8”, 163 lbs (BMI ~24.8 → normal).

Family: Estranged from sister, parents deceased.

Education: Master’s degree in music theory from Stanford.

Occupation: Former part‑time worker at Home Depot; currently unemployed.

Housing: Homeless for 1 year in Los Angeles, now in shelter.

Social: Divorced, gay, no children.

Medical History: Hypertension noted; allergy to bee stings.

Psychiatric History:

Long history of treatment since age 19.

Multiple medication trials: lithium (effective), Depakote (gastric upset), aripiprazole (akathisia), risperidone (hyperprolactinemia), haloperidol (dystonia), quetiapine (not fully trialed).

Poor historian.

8 inpatient psychiatric hospitalizations, most recent 8 months ago.

Intentional drug overdose at age 22.

Detox admission 15 years ago.

Substance Use: Alcohol use (3–6 drinks when playing music in clubs); denies illicit drugs.

Family Psychiatric History: Unclear, but aunt had mental health treatment.

3. Psychosocial Stressors
Homelessness: Loss of apartment and job, living in shelter.

Family Estrangement: No contact with sister, parents deceased.

Occupational Loss: Unemployment, financial instability.

Substance Use: Alcohol consumption, history of overdose and detox.

Chronic Mental Illness: Long history of psychiatric treatment, poor adherence.

Social Isolation: Divorced, no children, limited support system.

4. Clinical Presentation (Mood Disorder Features)
Reported Symptoms:

Chronic mood instability.

Poor adherence to medications.

Alcohol use contributing to instability.

History of overdose and repeated hospitalizations.

Behavioral Indicators:

Poor historian, difficulty recalling treatment details.

Social withdrawal, estrangement from family.

Homelessness and unstable living conditions.

Risk Factors:

Long psychiatric history.

Substance use.

Poor adherence to treatment.

Social isolation.

History of suicide attempt (overdose).

5. Mental Status Examination (MSE)
Appearance: Disheveled, appropriate weight.

Behavior: Cooperative but vague historian.

Speech: Normal rate/volume, may be tangential.

Mood: Depressed, irritable.

Affect: Constricted, flat.

Thought Process: Logical but limited detail.

Thought Content: Denies psychosis, but history of impulsivity.

Cognition: Alert, oriented ×3, poor memory for treatment history.

Insight/Judgment: Limited, poor adherence, risky behaviors.

6. Differential Diagnosis
Bipolar I Disorder: History of lithium response, multiple hospitalizations, mood instability.

Major Depressive Disorder (MDD): Chronic depression, social withdrawal, suicide attempt.

Alcohol Use Disorder: Regular alcohol intake, history of detox.

Schizoaffective Disorder: Must rule out psychotic features independent of mood episodes.

Persistent Depressive Disorder: Chronic low mood.

7. Diagnostic Considerations (DSM‑5)
Bipolar I Disorder: At least one manic episode with impaired functioning.

MDD: ≥5 symptoms for ≥2 weeks, including depressed mood or anhedonia.

Alcohol Use Disorder: Problematic alcohol use with impairment.

Connor’s Case:

Likely bipolar disorder given lithium response and repeated hospitalizations.

Comorbid alcohol use disorder complicates presentation.

8. Assessment Tools
Mood Disorder Questionnaire (MDQ): Screens for bipolar disorder.

Young Mania Rating Scale (YMRS): Assesses severity of manic symptoms.

PHQ‑9: Screens for depressive symptoms.

AUDIT‑C: Screens for alcohol use disorder.

C‑SSRS: Suicide risk assessment.

9. Treatment Plan
Pharmacological:

Mood stabilizers: Lithium (effective previously), valproate (monitor GI side effects), carbamazepine.

Atypical antipsychotics: Aripiprazole, risperidone, quetiapine (monitor side effects).

Address side effects with careful monitoring.

Antihypertensives for BP control.

Psychotherapy:

Cognitive Behavioral Therapy (CBT).

Motivational interviewing for alcohol use.

Supportive therapy for social isolation.

Lifestyle Interventions:

Structured daily routine.

Sleep hygiene.

Alcohol reduction strategies.

Supportive Measures:

Housing support and social services.

Vocational rehabilitation.

Crisis planning for suicide risk.

10. Monitoring and Follow‑Up
Frequent psychiatric visits during stabilization.

Medication monitoring (serum lithium levels, renal/thyroid function).

Suicide risk reassessment.

Coordination with shelter services and community resources.

Alcohol use monitoring.

11. Challenges
Medication Adherence: Poor historian, history of discontinuation due to side effects.

Substance Use: Alcohol complicates mood stability.

Social Isolation: Estranged from family, divorced, homeless.

Chronic Illness: Long psychiatric history with multiple hospitalizations.

Stigma: Mental health stigma in older adults.

12. Ethical and Cultural Considerations
Confidentiality: Respect patient privacy.

Consent: Informed consent for treatment.

Safety: Suicide risk management.

Cultural Sensitivity: Address stigma and identity (gay, divorced, homeless).

13. Case Summary
Mr. Connor Walsh: 57‑year‑old male with chronic psychiatric illness, homelessness, alcohol use, and poor adherence.

Likely Diagnosis: Bipolar I Disorder with comorbid Alcohol Use Disorder.

Treatment: Mood stabilizers, psychotherapy, social support, housing assistance.

Outcome Goal: Stabilization of mood, improved functioning, adherence to treatment, reduction of relapse risk, improved quality of life.

📝 Quiz (15 Questions)
Multiple Choice – Select the best answer.

What is Connor’s age? a) 55 b) 57 c) 60 d) 62

Where was Connor homeless for 1 year? a) New York b) Los Angeles c) Chicago d) Miami

Which medication was effective for Connor? a) Lithium b) Depakote c) Risperidone d) Haloperidol

Which medication caused gastric upset? a) Lithium b) Depakote c) Aripiprazole d) Quetiapine

Which medication caused akathisia? a) Risperidone b) Aripiprazole c) Haloperidol d) Lithium

Which medication caused hyperprolactinemia? a) Risperidone b) Quetiapine c) Lithium d) Depakote

Which medication caused dystonia? a) Haloperidol b) Lithium c) Depakote d) Aripiprazole

How many inpatient psychiatric hospitalizations has Connor had? a) 5 b) 6 c) 8 d) 10

When was his most recent hospitalization? a) 6 months ago b) 8 months ago c) 1 year ago d) 2 years ago