Johnny Begood: An Evidence-Based Case
Presentation
PATRICK WARING
CPSY 646
JANUARY 2013
Identifying Information

39-year-old Caucasian male

Referred by his wife for help with explosive outbursts

Lives with his wife and son age 5 and daughter age 2

Also has daughter age 10 from previous marriage
Mental Status

Appearance - The client is average in height and
weight. His appearance was consistent with
chronological age with some signs of fatigue. He is well
groomed.

Mood – He appears mildly unhappy or dysthymic

Affect: The client’s self-report of feeling at fault and
being upset over current circumstances is consistent
with affective experience and also appeared consistent
with observations.
on initial interview.
Mental Status

Thought processes: The client’s thought process were very logical
and sequential with good reality testing. His thought
processes are generally logical but laden with selfblame, self-doubt, and some other maladaptive
thought patterns.

Thought content: The client’s thought content was appropriate to
the situation.

Dangerousness to self or others: Denies self-harm ideation,
domestic violence or homicidal ideation. In later sessions would
admit to using threat of self-harm as a method of gaining attention
and/or making sure he was heard.

Sensorium: The client was alert and oriented to person, place, and
time and purpose of the meetings
Chief Complaints

client’s chief complaints were:

that he had a “quick trigger”

that people saw him as a person easy to anger.

concerned about anger and outburst in front of his children.

Nobody listens to him

he is angry with God for the death of his father prior to his birth.

client states he had to discontinue Fluoxetine, which was prescribed for
his


anger and to stabilize his mood

Discontinued due to financial concerns and moving to Muncie.
he is concerned that his recent vasectomy

has somehow impacted his sexual ability and functioning

affects his general manliness.

been experiencing different expectations than wife regarding the
intimate components of their marriage.
Additional Information

Mother in law is very involved in family as social support

Client lacks any social support outside of marriage

Client shows tremendous resistance to discussions of
primary family

Father died before client was born

Mother remarried for 9 months to man with son but
ended marriage after feeling like man was unfair to her
son.

Mother was a strong willed and very dominant person
and is still a valuable source of support when things go
bad at home. Mother will allow client to stay with her.
Additional information

Attends Local Comm College for eventual photography
business

Wife also attends same community college

Has part time job as computer tech support through temp
agency

Often in trouble as home blow ups interfere with work
schedule.

Hobbies are time-lapse photography, making snowflakes

Considers his half-brother his only male social connection but
not close connection

Shows insight into anger outbursts being undesirable

10 year old daughter is a frequent weekend visitor.

After first major outburst during x-mas, pt got and is taking his
Prozac.
Assessment
Specific Definitions of Presenting Problem
1 Anger with outbursts accompanied by destruction of property,
self-defeating actions, and occasional minor physical aggression
toward primary partner.
2. Feelings of shame, guilt, and frustration over outbursts that seem
to feed into more outbursts
Problem
Anger, Anxiety, Impulse control, relational conflict and possibly risky and
3. Presenting
Feelings
of repeating
his relationship with his mother with his
aggressive behaviors.
wife, especially in response to feelings of not being heard or
understood.
4. Rigid beliefs about self-concepts of masculinity, the impact of
his vasectomy, and his relational ability with both women and men
causing moderate anxiety about primary relationship.
Diagnosis


AXIS I: Clinical Syndromes or Other Conditions
That May be a Focus of Clinical Attention:

312.30-Impulse-Control Disorder NOS

V61.20-Parent-Child Relational problems

V61.10-Partner Relational Problems

300.02-Generalized Anxiety Disorder (Provisional)
AXIS II: Personality Disorders/Mental Retardation:


799.9-Diagnosis Deferred
AXIS III: General Medical Conditions

None reported
DSM Axis IV
X
Problems with primary support
group (Specify)
Communication problems in primary
family, overreliance on primary family
for social support. Outbursts of anger
that may become physical interfere with
primary relationships.
X
Problems related to the social
environment (Specify)
Small primary support group, relies
primarily on spouse for social support,
the clients states he has trouble making
friends
X
X
X
X
Educational problem (Specify)
Occupational problem
Quit one job for another then quit the
(Specify)
new job.
Housing problem (Specify)
Economic problem (Specify)
Living on student loan money, part time
job and borrowing from parents,
Problems with access to health No health insurance, no money for
care services (Specify)
psychiatric medication.
Problems related to interaction
with the legal system/crime
(Specify)
Other psychosocial and
Clients managing strong emotions of
any kind.
environmental problems
(Specify)
DSM AXIS 5
Global Assessment of Functioning Scale (Score)
65
Global Assessment of Relational Functioning (Score)
45
A
Treatment Goals-Long
Term
Long Term Goals
1 Eliminate inappropriate displays of anger and self-harming
behaviors or simulation of self-harming behaviors.
2. The client will gain sufficient insight into his own interpersonal
process, including guilt, shame and anger, to be able to benefit
and enter couples counseling.
3. Identify patterns of thoughts and behaviors which may have
been adaptive as a child that are no longer adaptive in the
client’s relationships. Replace maladaptive patterns of thoughts
and behavior with more adaptive patterns.
4. Explore and help the client examine and come to determine
his own definition of masculinity.
Treatment Goals Short
Term
1. Eliminate physicality during periods of 1. Check in each week with client
anger and/or outbursts
whether any physicality took place in
anger; Monitor any possible issues of
mandatory reporting. Work on solution
focused coping methods to end
physicality in anger by the client.
2. Explore early childhood and
relationship with mother.
2. Interpersonal exploration of childhood
memories and attempt to access
repressed memories, as client denies
clear memories of mother prior to age
10.
3. Identify patterns of thoughts and
behaviors which carry over to present
day
3. Examine the adaptive nature of the
thought and behavioral patterns for a
child versus the patterns of behavior as
an adult.
4. Help the client to define for himself
what it means to be a man.
4. Explore the meaning of masculinity.
What the literature says about
mixed anxiety and impulse
control and intermittent
explosive disorder

http://www.psychologicaltreatments.org/

http://article.psychiatrist.com/dao_1login.asp?ID=10006061&RSID=55996345638836

http://journals.psychiatryonline.org/article.aspx?ar
ticleid=175139
Case Formulation

A lack of ability to identify emotions, lack of anger
coping methods, lack of success in attempts to
initiate self-change, and repetition of perceived
failures of attempts to change have led to socialisolation (especially with other males),
overdependence on the primary relationship, low
self-esteem and self-worth, inappropriate
management of interpersonal relationship building.
available may have been. He also is repeating the
relationship with his pre-deceased father with other
males as he imagines friendships but claims not to
know how to relate to males. The need to feel heard
tied to unawareness of primary emotions as a child is
now being repeated as episodes of anger as a
means of drawing attention to the client.
Not quite fish nor foul

Client does not meet criteria for anxiety disorder
yet he has features of anxiety like catashrophizing,
solely blaming self for both his and partner’s
problems, worry about how everything effects
partner, how he is perceived by children. His is
the only bad example for the children, he sees his
poor outburst strategies being repeated by 5 year
old son.

Does not meet any of the impulse control
disorders clearly either hence the NOS.

Best this counselor can manage is some impulse
control issues with some anxiety like features.
How to treat?

Perhaps, best thought of from a CBT perspective
that forgets the DSM and instead works on specific
problems like

Assertiveness of communication skills to combat
feelings of not being heard

Cognitive restructuring of self-blame into
understanding in any disagreement both parties are
likely to have a role to play

Behavioral treatment of communicating before feels
like a “soda bottle that is going to pop”

Reinforcement of safety plan and concrete behavioral
methods of preventing episodes of loss of control

Someday in the future, after behavioral strategies are
mastered, explore the interpersonal process stuff of
mother parallels with wife.
So far with this patient it has been
crisis management and anger
management skills

Evidence support for medication treatment with
either anti-depressants or mood stabilizers is good
so continue to reinforce Prozac use

Explore primary relationships vis-à-vis original
primary relationship

Expand social supports beyond family

Use Linehan’s communication exercises for
increased communication skills

Use CBT approaches to combat maladaptive
thought patterns regarding self-blame, self-doubt,
anxiety producing changes, surprises, and
unexpected events.
Rationale

There is no clear evidence base to work from on
impulse control NOS so must draw from lit on
typical impulse disorders (gambling, shopping,
etc) and explosive disorders. Evidence for antidepressent usage in explosive disorders.
Moderate research support for CBT/ACT/DBT in
mixed anxiety disorders, anxiety disorders, and for
people with communication difficulties and,
hopefully, with someone like this client who seems
to feel unheard often will respond to assertiveness
training in communication and he already had to
some extent.
Case Summary

Prognosis is good.

Patient has made great strides in self-control and behavioral
strategies for anger control but needs continued support of
these new behaviors

Patient has insight that some of his issues are “deeper” than
what we have been able to cover in 10 weeks but will
continue to work on that with new counselor

Next counselor could use Linehan’s program of
communication skills or similar.

After that and coupled with couples counseling, patient may
need to spend some time digging deeper into interpersonal
process material, mother issues, and similar material

Estimated time of continuing treatment, 10 weeks of CBT skills
and 10-15 weeks of deeper meaning issues-psychodynamic
approach. Couples Counseling length unknown.