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Dr. Bonnie
Dr. Bonnie, Psychologist and RN
Category: Mental Health
Satisfied Customers: 2189
Experience:  35 years experience counseling children and families
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I'm working with someone (as a Behavior Specialist) who does

Resolved Question:

I'm working with someone (as a Behavior Specialist) who does not have a psychiatric diagnosis, but I believe that he may have an underlying psych condition. However, I can't quite pull the symptoms/ behavioral characteristics apart to come up with any real hypothesis. I just have a lot of possibilities. I want to be able to better understand what he has going on so that I can better work with him. Do you know if there's anyone who can wade through this with me so that I have somewhere to begin?
Submitted: 5 years ago.
Category: Mental Health
Expert:  Dr. Bonnie replied 5 years ago.
Hello and thank you for consulting with JA,

I would be happy to help. I prefer the Q&A format rather than chatting because I find it more efficient. Hope that is okay with you. Tell me more about the person....
Customer: replied 5 years ago.
Background: This is a male "Burt", 75 years old. Born premature,
insufficient pre-natal care. Was not expected to live long because of
low birth weight, so a nurse fed him whiskey in a dropper the night he
was born in an effort to save his life. Little medical care and poor
hygiene growing up. Poor performance in school especially reading and
spelling, held back a year. Only real success in school was in
basketball (6'3" tall). Youngest of 3 children. Father significantly
older than his mother. Father was an alcoholic and described as
controlling, angry, and belittling to his children. History of
psychosis in the family. Mother had unknown psychiatric condition
developed in her later years. She died in a mental health
institution. "Burt has 2 bio daughters and 2 bio sons. 1 daughter
has bipolar disorder, 1 son has depression. Children of average
intelligence. Burt has a diet with poor nutrition and high fat and
sodium (and is thin build). Only current diagnosis in heart disease
and colon cancer, both of which are not acute. Falls asleep easily
throughout the day (and has done this his whole adult life). Snores.
Only medication he is currently on is for the heart condition. He
also takes many vitamins and home remedies and does not go to the
doctor unless absolutely necessary. Has explosive anger, sometimes
after provocation and sometimes with no obvious antecedant. Claims to
be an alcoholic, though he typically drinks 1-3 beers a day. Refers
to alcohol as "medicine". Has poor long term and short term memory
(forgetting birthdays and other important dates, and forgetting a
movie that he saw a week before). Trouble with language (turns up the
television because he cannot hear it, but he has done this his whole
adult life). Says that he has poor hearing in one ear. "Sniffs"
through his nose frequently though he has never been diagnosed with a
sinus problem. Very religious. Biggotted against those of a
different religion, race, ethnicity, sexual preference, etc. Cannot
reproduce a word that he has heard either in writing or verbally.
Does not know simple words that he should know. Attended anger
management counseling 1x at the urging of family, then did not return
because he said he did not need it. Prefers watching children's
movies/television and is very offended by even mild adult content. Is
overly friendly with strangers, especially children. Hugs children he
does not know, tells them "I love you", or "God loves you", or telling
them that they can refer to his as their Dad. He does this even when
the child appears uncomfortable. Over feeds children and pets in an
effort to perhaps gain affection. During conversation, does not
converse with others, but talks in a monologue fashion, changes the
topic of conversation to himself without transitioning to this topic.
Feels that he is being "ignored" if others are getting attention from
other people in his presence, Exerts controll over those that appear
weak to him (children, women, those with disabilities, etc). Has
explosive episodes of anger when one of these individuals appears
superior in some way. Has kicked 3 of his teenage children out of the
house while still in high school (1 for teen pregnancy, 2 were of high
intelligence and strong personality). Appears to strangers to have
dimentia, although he has displayed these behaviors his whole adult
life. A hard worker who will do a task for years even if it's not
going well. Believes that God cured his cancer, although he had also
been receiving treatment. Does not trust doctors and says that they
are only out to get your money. No known IQ test exists.

What do you think?
Expert:  Dr. Bonnie replied 5 years ago.
Hello again,
What about......

delusions? paranoia (besides MD's)?

obsessions? compulsions? (I notice a few...any more)

explain more about "can't reproduce word"

trouble with change in routine or transitions?

Any sensory issues? light, sound, touch aversions?

Trouble with empathy? Trouble reading non-verbal communication?

What are the tasks he does for years?
Customer: replied 5 years ago.

:includes believing people are doing things "behind his back", like smoking in his house in private although he forbids it

Delusions: He believes he could have been a Gym Teacher or Minister, although he has been told that these positions require more schooling than he received and he knows it was very hard to get through school

Obsessions & Compulsions: He is a collector. He collects things that he does not use and are relatively worthless except that they remind him of positive things in his life (motorcycles because he used to ride, accordians because he used to play, etc)

Word production: If a word is said to him verbally (example: "eplilepsy", he will repeat "espity", and may be corrected multiple times before getting it right). If he hears a name (example: "Megan", he will write is in such a way that it cannot even be read, like "Elmin")

Change in routine/ Transitions: He can deal with change in his routine, but after he has been told he will be doing something, he becomes very agitated and will either refuse to change his plans or will remain agitated and angry. No known problems with transitions

No known sensory issues

Observable trouble with empathy, and trouble reading non-verbal communication (very self-centered)

He worked for a difficult boss for many years, stayed in a destructive marriage, takes lessons playing an instrument although he sees little progress, etc

Expert:  Dr. Bonnie replied 5 years ago.
Here's a differential diagnostic formulation based on given information and not seeing him face-to-face: Using a DSM IV axial format

  • Axis I: possible Asperger Syndrome (social skill delay; intrusive with children, lacks empathy; rigid by-the-rules thinking) or traits
  • Intermittent Explosive Disorder
  • possible Alcohol Dependence

  • Axis II: possible Borderline or lower Intellectual Functioning - need IQ to validate;
  • possible Personality Disorder (paranoid, narcissistic, mixed)

Axis III: Colon cancer; Heart Disease; Sleep Disorder (possible narcolepsy)

Axis IV: Affects social functioning

Axis V: Global Assessment of Functioning: Moderately affects functioning;

A complete neuropsychological evaluation or geropsychological assessment would help to define the possibles. I am leaning towards the Asperger Diagnosis rather than Personality Disorder. In considering AS, your interventions would need to be based on making changes in the environment because expecting behavioral change in him will be fruitless. In fact, that is probably also true for PD's.

I hope this is somewhat helpful...Now, what were you thinking?
Customer: replied 5 years ago.
I had thought about a possible sleep disorder as well, and possibly narcissistic personality disorder. Intermittent Explosive Disorder definately fits. I hadn't considered Asperger's, because of his lower intelligence and his speech is normal in terms of volume, cadence, facial expressions are appropriate, etc. But I'll look more into that. Do you think any brain damaged may have been caused in infancy do to alcohol consumption as an infant? I think maybe I'll start with reccommending a sleep study, a psychological eval, any other follow-up I could suggest?
Expert:  Dr. Bonnie replied 5 years ago.
I definitely think insults from infancy are involved. You plan is good...most adult psychologists do not look at Asperger Syndrome because it is a diagnosis made in childhood so do mention it as a possibility so that psychologist gets some consultation on this. That would be all I can think of.
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