Purpose for Evaluation:
The patient is a 16 year old, single, white, male. He is currently a junior in high school and was recently expelled from his boarding school Pencey Prep in Agerstown Pennsylvania, where he was the manager of the fencing team. Family admitted this patient after suffering a nervous breakdown. The purpose for the current evaluation is to determine whether or not the patient suffers from any mental illnesses.
· Clinical Interview · Mental Status Examination · Physical Examination · Beck Depression Inventory (BDI) · Blood Test · Medical History Review
· Physical tests as well as lab test are conducted to rule out the possibilities of the patient having a serious health issue, which could lead to signs of a mental illness.
Based on the clinical interview of the patient I was able to determine that the patient has a difficult time communicating with his peers. He appears to be very discontent with society and tends to isolate himself from those around him. The patient has a very hard time connecting with his peers and is unable to properly socialize with others. The patient talks about not liking humanity but then will usually ask past friends to join him for a drink. He can usually only hold a conversation with an adult figure or a person of authority such as his former English teacher, Mr Antolini and his former history teacher Mr. Spencer. The patient was also able to communicate with Ms. Morrow. The patient voluntarily isolates himself from society and believes that all those around him are “phony”. He mentions that he wishes to become the catcher in the rye and save children from growing up. The patient is convinced that growing up automatically makes you a person who is very phony. The patient’s use of the term phony is superficial; it gives the indication that his use of the term phony makes the patients own perception of people other than himself superficial. The patient strongly criticizes people who are what he would refer to as “boring, insecure, and phony “. Holden feels victimized by the world around him and he feels as if he does not belong. He believes that nobody is able to relate to him, because of this the patient is a very lonely individual and chooses to not interact with his peers or those around him and frequently alienates himself from society.
This patient does not meet the academic standard and does not actively participate in school. Although he manages the fencing team his academic grades are quite low. He previously attended four different boarding schools. Three of which are Elkton Hills, Whooton School, and Pencey Prep. The patient was expelled from all of the schools he previously attended because of his poor grades. He refers to the previous learning institutions that he attended as phony. He believes that these institutions were filled with thieves. This patient have a minimal amount of friends at the schools he previously attended, he did not try to interact with others. This patient has no real ambitions or goals he wishes to achieve in his lifetime. He appears to be very intelligent but does not have the motivation to put forth effort in his studies. This patient is very capable of academic
success if the effort was put forth. The parents of the patient were unaware that the patient had been expelled from his most recent school.
The patient is the child of a wealthy corporate lawyer and a society woman mother. His family is very conservative and appears to be wealthy. He is the second of four children. The patient’s oldest sibling D.B Caulfield is employed as a writer for Hollywood films. The patient considers his brother very phony and does not respect the fact that he chose to write films for Hollywood and transition out of writing short stories, which the patient used to enjoy. The patients younger brother Allie Caulfield passed away of leukemia three years prior to the patients admittance. The patient was very close to his brother and was distressed by his death. This caused many emotional problems for the patient. The patient is very close to his younger sister Phoebe Caulfield who is ten years old. He thinks she is the only one who is able to understand and relate to him. The patient indicates that his sister is very intelligent and is able to comprehend how the patient feels and is able to listen to him. The innocence of the patient’s sister is one of his only sources of happiness. The patient mentions that his family background is a burden on him. He is saddened by the events that have taken place in his life. He feels that he is not very close to his family because they are still suffering from the death of his younger brother Allie. The patient is unable to hold a proper relationship. He has a hard time initiating a conversation especially with a person of the opposite sex. This patient lacks proper communication skills and seems to be immature when it comes to holding a conversation, which leads to him not having many close friends. It is apparent that many of the patient’s peers would like to befriend him but because of his inappropriate behaviour they quickly grow distant from the patient. The patients roommate Ackley tries to befriend the patient and the patient treats his with disrespect and only chooses to associate with Ackley if he is suffering from boredom or is in need of some attention. He has not tried to contact Ackley since the patient was expelled from Pencey. The patient recently reunited with a previous girlfriend Sally Hayes, after going out one evening the patient began to argue with Sally causing him to publicly yell at her, forcing her to leave. Another female friend of the patients Jane Gallagher
seems to be very important to the patient. He frequently talks about her but throughout him recent time in New York the patient never contacted her. The patient explained that he tried to contact her but was too frightened to call her and would always put off the act. Although the patient never actually contacts Jane, she is one of the only females the patient truly respects and finds attractive. The patient overall does not have many friends and tends to spend most of his time alone.
The patient seems to resort to alcohol and tobacco as a source of comfort. Throughout his visit to New York the patient spent many nights at local bars and clubs drinking alcohol. Although the patient is under age it appears to be very easy for him to be able to have access to alcohol. He patient spent many nights drinking and smoking cigarettes. The patient frivolously spends money, most of it being spent on alcohol. The patient seems to react to arguments with excessive anger. He instigated a fight with a former roommate at Pencey Prep named Stradlater. The patient proceeded to attempt to fight his roommate because he assumed Stradlater mistreated Jane Gallagher when they went out one evening. The patient did not have any substantial evidence that Jane was mistreated. Another dorm mate of Holden who’s name is James Castle committed suicide after being bullied by other students. The patient witnessed his suicide and this greatly affected Holden. The patient was sold a prostitute one night while in New York. He decided he did not want to become intimate with her and when she left the patient did not pay her the proper amount resulting in the patient being hit by the man who sold him the prostitute. The patient stated that the hit made him feel as if he were shot and the patient thought that there was a possibility that he would indeed pass away. The patient’s mother became very unstable after the death of Allie and constantly worries; this has become a burden on the patient.
Mental Status Examination:
After conducting many tests on Holden Caulfield and reviewing his symptoms ,
it is apparent that he suffers from depression. Common symptoms of depression are; sadness, trouble making decisions , possible thoughts of death of suicide , fatigue , and trouble sleeping. In my opinion the trigger for the patients depression is the death of his younger brother Allie. It is apparent that the patient has not been able to properly cope with his brothers death and this could be because he was unable to attend his brother’s funeral. Because of the death of Allie, Holden wants to preserve the innocence of youth because his brother lost his so young due to his battle with cancer. Holden’s inability to keep children from growing up troubles him. The patient also is saddened by the fact that he is very lonely and lacks a female companion. The patient displays other common symptoms of depression such as trouble making decisions. Holden is unable to decided what he wants to do in life. The patients displays signs of being unable to decided whether or not he is capable to take on the role of an adult. He is unable to make simple decisions and often changes his mind as the last minute such as when he wanted to become intimate with the prostitute at the Edmont Hotel in New York, but then quickly decides he no longer wants to. The patient is unable to decided whether or not he wants to contact Jane Gallagher and spends countless hours contemplating this act and never does goes through with it. The patient also displays thoughts of death or suicide. After the prostitute left his hotel room Holden contemplated jumping out the window. Holden also stated that he is happy that the atomic bomb was invented and that if there was another war he would volunteer himself to sit directly on top of the bomb. The patient mentions trouble sleeping and immense fatigue. He explains that while in New York he was unable to sleep. Holden also mentions that the movies make him depressed and while in New York anything he witnessed that would remind him of a film would make him feel upset and “depressed”. Judging by the patients symptoms and clinical evaluation it is very clear that he suffers from severe depression clearly caused by his unhappiness which the world around him. It is apparent that he is saddened by the world around him and his impression on society provokes his feelings.
Anxiety Disorder :
Based on the information obtained from the Clinical Interview is it apparent that Holden Caulfield suffers from anxiety. Common symptoms of anxiety are, worrying , belief that bad things will happen , trouble concentrating and being easily overwhelmed. Holden displays all of the symptoms listed. The patient has mentioned to me several times that he does not particularly like society. He believes that all human who have reached adulthood and as Holden words it “lost innocence” , are phonies. Holden believes that by children associating with adults they will loose their innocence and also become a “phony”. It is also apparent that Holden has trouble concentrating and can become very irritable. While conducting the interview Holden had trouble answering simple questions and was unable to concentrate on a specific subject that we were talking about. Holden also mentioned that when he speaks he can never stick to one subject or finish a story. The patient seems to be easily overwhelmed. He mentions that while in New York he was walking down Fifth Avenue and witnessed some children playing. Holden said that this made him very overwhelmed thinking about children loosing their innocence. Holden easily become overwhelmed at the thought of children. The patient easily becomes worried and this was triggered especially when his roommate Stradlater when out one evening with Jane Gallagher. Holden constantly worried about the possibilities of Stradlater not treating her right. There are also physical symptoms displayed by Holden that lead me to believe he suffers from anxiety. Someone with anxiety will experience nausea caused by the constant worrying. Holden mentions that he often feels nauseous and gets sick. After his day at the zoo with his sister Phoebe he mentions going home and getting sick. Holden also mentions dizziness and fainting while visiting the Museum of Natural History which are also physical symptoms of anxiety. It is my professional opinion that Holden suffers from a minor case of anxiety disorder. It is apparent that daily life is overwhelming for Holden and he is constantly worrying about society.
Bipolar Disorder :
The patient displays many symptoms associated with bipolar disorder. Common symptoms of bipolar disorder are outbursts, isolating yourself from society , delusions and hallucinations , trouble sleeping as well as physical
symptoms such as weakening of the body and loss of appetite. Holden appears to be suffering from all of the listed symptoms. Holden seems to easily become overwhelmed resulting in outbursts. After the death of his brother Allie , Holden mentions that he became so enraged that he proceeded to punch in a glass window from his garage resulting in a broken hand. Because of this Holden was hospitalized and was unable to attend his brother’s funeral which devastated his. As mentioned before the patient attempted to fight his former roommate Stradlater after he returned from his date with Jane Gallagher. Holden assumed Stradlater mistreated Jane and attempted to hit Stradlater. Holden also mentions that he yelled at Sally Hayes in public after skating at Radio City resulting in her leaving. Holden tends to completely isolate himself from society because of his opinions. Holden’s judgements about society are very harsh therefore he struggles to form relationships with his peers. Holden mentions that if he is feeling very lonely he would ask him former dorm mate Ackley to go out but otherwise he treated Ackley with disrespect and was not very nice to him. He also mentioned that one night in New York he called up an old friends named Carl Luce and asked him to go out for a drink. Usually Holden chooses to be alone and isolate himself from everyone including his family because he considers them all phonies. Nearing the end of Holden’s trip to New York he mentioned he began to experience hallucinations. While walking down Fifth Avenue, Holden mentions that every time he came to the end of the block he felt as if he would not be able to cross the street, he thought he would disappear if he stepped out into the street. In order to cross the street Holden began to talk to Allie and would ask him to make sure he did not disappear. Holden appears to be delusional. He believes everyone is phony and that the loss of innocence is terrible and children should no experience it. Holden is convinced that growing up makes you a phony person. Holden also believed while in New York that he had Pneumonia and he was accepting the fact that he was going to die. He also mentioned reading an article on how if you develop sores in your mouth there is a chance you have cancer, and Holden thought he had cancer. Holden begins to believe whatever he hears. Throughout Holden’s evaluation he mentions many times that after leaving school to visit New York he had many sleepless nights. He would be up to all hours of the night and day because he was unable to sleep. Accompanied by
many sleepless nights Holden mentions his loss of appetite. He states that if he did eat it would usually only be a cup of coffee and a swish cheese sandwich. The lack of food in Holden’s system makes his body become very week , Holden mentions that his final day in New York he felt very sick. This is the result of lack of food and proper nutrition as well as lack of sleep. Depression definitely plays a factor in the way Holden acts and feels.
Post Traumatic Stress Disorder :
Post Traumatic Stress disorder otherwise known as PTSD is apparent in Holden Caulfield. Post Traumatic Stress Disorder is usually caused by a painful memory or event that happened in someone’s life time that greatly affected them. Common symptoms of PTSD are , constantly reliving the traumatic experience in your head , avoiding activities and social interaction and lack of sleep. Holden clearly shows all of these symptoms. As mentioned previously Holden lost his brother Allie to leukemia three years prior to his evaluation. Holden was unable to attend the funeral because of a broken hand. Although Holden’s brother was much younger they were very close and Holden considered him very intelligent. Holden was devastated by the death of his brother and has been isolating himself and withdrawing himself from society since his death. Holden also witnessed the suicide of a former dorm mate James Castle who committed suicide after being bullied. Holden witness James fall out of the window and saw his body lying on the ground. This greatly affected Holden and changed his thoughts on society and how people treat one another. Because of these events Holden avoids day to day activities and does not participate in social events. He mentioned that before leaving Pencey there was a football game but he decided he wanted to visit his old history teacher Mr. Spencer instead. Holden refrains from going out with his peers unless he feels very depressed or lonely. Usually Holden is very judgemental towards those around him , therefore he does not have many friends. Holden mentions that at times he will ask his former roommate Ackley to go out to eat. As mentioned in the previous paragraphs Holden also does not get much sleep. It is apparent that the patient is unable to move past these two traumatic events in his life. He seems to
incorporate them into his everyday life causing him to withdrawal from society and be very harsh and judgemental towards others. Holden does not want other children to loose there innocence so early like his brother Allie did to cancer. He feels that he can preserve innocence and by not being able to do that Holden feels a sense of helplessness. Holden mentions that he feels very yellow and it shows when communicating with him. It is evident that Holden is suffering from PTSD.
After over looking the patients mental illnesses and symptoms I have come up with a assortment of medications that should help manage the symptoms of the illnesses. The patient will be placed on Abilify for bipolar disorder , Symbyaz which is a combination of Prozac and Zyprexa. This will be used as an anti depressant. Cipralex will be given to the patient to manage his anxiety and Trileptal will be given as a mood stabilizer to help the patient with his outbursts. I recommend the patient receive weekly counselling or therapy to help relieve his stress and anxiety. This will also help the patient learn to manage his symptoms and it will teach him the fundamentals to be able to work through his problems. Additionally this will help Holden learn to control his emotions and help him think more positively. In addition to medication and counselling I would like the patient to spend more time with his family. The presence of his family will help him realize that he has a strong support system that will be there for him in his time of need. A combination of these medication and therapy will help Holden live a happier and more well balanced life.