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Apply Erik Erikson's 8 stages of psychosocial development to the attached case study. Throughout the case study,

students should gather information related to examples of struggles between the opposing tendencies within each developmental stage the adult experienced. In order to gather information that is of importance to each stage, students will need to be familiar with Erikson's sequence of stages, conflicts that may occur within each stage, and healthy or maladaptive outcomes at each stage:

           

Basic trust versus mistrust (Birth-1 year)

           Autonomy versus shame and doubt (1-3 years)

           Initiative versus guilt (3-6 years)

           Industry versus inferiority (6-11 years)

           Identity versus role confusion (Adolescence)

           Intimacy versus isolation (Early adulthood)

           Generativity versus stagnation (Middle adulthood)

           Integrity versus despair (Late adulthood)

 

Address each stage in Erikson's theory as it applies to the case study. Define each stage and discuss how the individual resolves or does not resolve the issue(s) that form and contribute to the struggles within each stage. Integrate additional theorists and theories within their paper, however Erikson's stages of psychosocial development should be the primary reference in the paper.


CONFIDENTIAL PSYCHOLOGICAL REPORT

 

Name: TK

Age: 73

Race: Caucasian

Dates of Evaluation: July 19, 20XX; July 20, 20XX; and July 27, 20XX

Date of Report: July 30, 20XX

Examiner: Dr. X

 

REASON FOR REFERRAL:

According to security staff, TK has been displaying impairments in his memory since his arrival to the institution last week. He has difficulty walking around the institution, has become lost several times, and requires an officer escort for appointments outside of his housing unit. He was referred to assess his cognitive and memory abilities and for treatment recommendations, given that he will release to the community later this year.

 

BACKGROUND INFORMATION:

The following information was obtained through a clinical interview with TK and through a Psychological Services Unit File Review. As TK was admitted to Smith Memorial Hospital for chest pains on 7/29/11, a full comprehensive assessment was not completed.

 

Family History

TK was born and reared in Milwaukee, Wisconsin. He stated that he has spent his entire life in the Milwaukee area except during the winter months growing up, when his family spent the season in their vacation home in Florida. He reported that he is 100 percent Greek and spoke the Greek language until he reached kindergarten, when he began to learn and speak English. He stated that once he learned English he slowly began losing how to speak the Greek language.

 

TK stated that his parents were born in Greece. He said his mother moved to the United States when she was 20-years-old and settled in Milwaukee. He stated he was unsure when his father came to the United States but thought his father arrived before his mother. TK said he was unsure if his parents were married prior to or after their immigration. He stated that his father owned and operated a family restaurant and tavern that served American food. He stated that his mother did not work, as he stated that among Greeks "your husband will take care of you." When asked about his relationship with his parents, he stated that it was "good." TK reported that he could not remember anything about his early experience with his parents, but that he did recall that his oldest brother and sister had told him that he had been an insatiable, greedy baby who seemed to spend more time at his mother's breast than away from it and whose mere hint of a whimper of discomfort or neediness brought his mother to him. In this connection, he also recalled that his sister, who called him the "little prince," complained that he had been a tyrannical toddler who did what he wanted, eschewed toilet training in favor of his mother's ministrations with diaper changes and related hygiene, and seemed to bask in the doting care of his mother who protected him from any rivalry behaviors of his older siblings. He recalled his parents "hollering" at each other but stated these incidents never escalated beyond arguments. He stated that his father never hit him but his mother did. When asked to elaborate, he stated, "You're asking me to me to go back years" and he stated that he could not remember any details. He did remember, however, that his sister had once told him that his memory was faulty and that it was not his mother who hit him but his father. She told him that the parents argued about him, with his father paying more attention to him as TK moved beyond being a toddler and the father increasingly objecting to the mother's "spoiling" of him. Although he could not recall what year his father passed away, TK said that his father died at the age of 75. He stated his mother died in 1994 but he was unsure of her age at the time of her death. He said that prior to his mother's death he took care of her, including washing her, bathing her, and clothing her.

 

TK stated that he is the youngest of four children. He said he has two older brothers, George and James, who are six and five years older than him, respectively. He stated his sister, Helen, died in 1983 of Lou Gehrig's Disease. However, according to records, he reported his sister died in the summer of 2009. When asked about his relationship with his siblings growing up, he stated that he was always picked on and told things were always his fault. He said that his oldest brother was jealous of his high grade point average and whipped him with a cartridge belt because of it, indicating "He tried to whip intelligence out of my mind." TK stated, "The oldest Greek boy governed everybody" but that he "wasn't that sharp." He said that his other brother was nicer but did not elaborate on this. TK stated that prior to his mother's death, his brothers did not help to take care of her, and they referred to him as his mother's "pet."

 

TK stated that he was married twice. He said he married his first wife at the age of 20 and that the marriage lasted about 10 years, which he noted was his longest relationship. He stated that he cheated on his wife, commenting, "Why make one happy when I can make many happy?" He stated that there were several years between his marriages and that his second marriage lasted "not long at all." Records indicate his second marriage lasted three years. He said that he was 10 years older than his second wife and because of this his mother-in-law did not approve of him. TK reported that prior to their marriage, his second wife lived with her mother and a priest and that she performed oral sex on the priest. He stated because of this his second wife was "turned off" by sex, resulting in the marriage failing. TK stated that he has been in several relationships since that time but has not been in a serious relationship. He said that he is currently dating his cousin's daughter whom is 50-years-old but is "very young looking and petite...like a teenager...like 15 or 16."

 

TK did not report having children during the clinical interview but according to records, he has four adult children with whom he has contact with. His oldest two children, ages 49 and 48, are from his first marriage. He has two 30-year-old children from two women that were born during his second marriage. 

 

Social History

TK stated that he had many friends growing up but could not remember who they were. He said that he and his friends would "hang out." When asked about current friendships, he stated he has friends but that none visit him. He stated that in high school and college that he was an athlete and claimed the Amateur Athletic Union (AAU) college state title for his weight division for three years. He stated, "I was the best there was."

 

TK stated that he first engaged in sexual intercourse at the age of 15 with a female partner estimated to be 25-years-old. He reported that he had "many" partners and that he "can't put a number on it." He stated that a number of his sexual partners were the result of one-night stands.

 

Educational History

TK stated that as a child he was a good student and skipped the sixth grade. He said that at the age of 13 he was placed in military school because "my mother and father were busy and wanted others to care of us." He reported feeling homesick during this time. He returned home within the year and was placed in the seventh grade of a local school that he could not remember. He stated that he graduated from Riverside High School in 1956. When asked about his high school years, he stated, "I did alright. I wasn't a brainiac or a moron." TK stated that he attended the University of Wisconsin - Madison for one semester but did not like it. When asked why, he said that he travelled home to Milwaukee twice per week to visit his girlfriend at the time. TK said that he transferred to the University of Wisconsin - Milwaukee and graduated in 1961 with a degree in political science.

 

Occupational History

TK stated that he worked in the restaurant and tavern business his entire life and learned the business by watching his father growing up. He stated that he operated a restaurant and tavern with his brothers for several years but indicated, "My brothers aren't good for business." He said he felt his brothers treated him like a slave and that the three engaged in many arguments during this time. At the age of 21 or 22, TK said he sold cars to get out of the business. About one year later, he stated he opened his first restaurant and tavern independently. He stated he ran a good business because "I'm a people person. I had the best cocktail hour in the city, the state, and the Midwest." He said that over the years he owned and operated several restaurants and taverns, with each establishment being "bigger and better" than the next.

 

Substance Use History

TK stated that he did consume alcohol while in the community. When asked what he drank and how much, he responded, "My brothers drank a hell of a lot more. They drank as if the country would dry up tomorrow." He did not indicate how much or what he drank. According to records, TK first consumed alcohol at the age of 21. At his peak, he drank to the point of intoxication once per week for a period of four to five years. He indicated that it took about five to six drinks for him to become intoxicated. He denied a history of blackouts. He stated that he quit drinking alcohol "a long time ago." He stated that at the age of 50 he began smoking cocaine for a six-month period. At his peak, he reported using three-and-one-half grams per day intermittently. His last use was estimated to be more than eight years ago. He did not report the circumstances preceding his cocaine use but indicated, "I smoked pot to come off the high of cocaine so I could sleep." When asked about other substance use, he acknowledged a history of experimenting with hash about 20 years ago. He reported no perceived need for treatment.

 

Legal History

TK has no known juvenile criminal history. His adult criminal history began in 1973 when he convicted of lewd and lascivious behavior and sentenced to two years of probation. This offense involved him engaging in sexual intercourse with a prostitute while in a parked automobile. While in Florida in 1984, he was placed on one year of probation for shoplifting. In 1987, he was placed on one year of probation for contributing to the delinquency of a minor. In 1989, he was convicted of two counts of delivery of a controlled substance (cocaine) and was sentenced to 15 months of adult incarceration. In 1990, he was convicted of retail theft and was placed on probation for two years.  

 

On November 25, 1992, TK approached a 16-year-old non-relative female at a Milwaukee County transit bus stop. According to the victim's statement, TK stated, "I'm looking for a nice Polish girl to marry and settle down with...You know Polish girls have sex better...I want to sleep with you." The victim stated that TK then showed her, using his hands, "how long his you know what was" and then asked her if "her you know what smelled good." He began taking pictures of her with a camera and then grabbed her inappropriately. She informed him to leave her alone and she walked away. He followed her down the street and grabbed and pinched her inappropriately. She walked into a McDonald's restaurant in an attempt to get away from him. He followed her into the restaurant, pulled out money, and asked her if she wanted something to eat or drink. The victim walked out of the restaurant, he followed her outside, and he touched her inappropriately with his hand, stating, "Does your you know what stink? I don't think so. It really smells nice to me." An unknown citizen walked up and told TK to leave the victim alone. TK has maintained his innocence, stating the victim "had emotional problems" and was coached into making the accusations. TK was convicted of two counts of second degree sexual assault, one count of fourth degree sexual assault, and one count of false imprisonment. For the first count of second degree sexual assault, he was sentenced to 96 months of adult incarceration. For the false imprisonment conviction, he was sentenced to 24 consecutive months of adult incarceration. The second count of second degree sexual assault resulted in a 90-month consecutive adult stayed incarceration term and he was placed on 48 months of consecutive probation in lieu of his prison term. He was sentenced to nine months concurrent for the fourth degree sexual assault conviction.

 

In 2002, while TK was on parole, he was revoked for engaging in the same behavior to four adult women. He returned to the community in January 2003 and was revoked again in May 2004 for violations of his parole which included having unsupervised contact with minors, possession of sexually explicit material, lying to his agent, being involved in an unapproved intimate relationship, and touching his girlfriend without her consent. He returned to parole supervision in September 2004 and discharged from parole in July 2005, at that time beginning his consecutive probation term of 48 months. In the final months of 2010, TK was revoked for having unapproved contact with minors, violating a no-contact order, and failing to provide true and correct information to his agent.

 

Medical History

TK stated that he had his appendix removed at the age of 13. He reported that at the age of 29 he was involved in an automobile accident. He stated that while driving on a slippery road and a bridge constructed of steel he lost control of his vehicle. He said that he was in the hospital for two months with a skull fracture. He stated that a blood clot developed in the left side of his head and that surgery occurred to drain the blood clot. He reported that following the surgery he experienced double vision for some time but since then has reported no complications related to his head injury. TK reported that he was diagnosed with non-insulin dependent diabetes 10 years ago. He stated that he is managing his diabetes effectively and stated, "I can eat anything I want...like candy."

 

Mental Health History

TK reported that his sister was diagnosed with Schizophrenia. When asked to elaborate, he said that his cousin had sex with her when she was 15. He stated, "Because we were Greek, the family didn't want a scandal." TK said that his sister was in and out of hospitals and underwent "shock treatments." When asked about the efficacy of the treatments, he stated, "She would come out all stupid." He reported no other family mental health history.

 

TK stated that in his 20s he was admitted to a psychiatric hospital in Milwaukee. When asked about the placement he stated, "I would go to the lavatory and strain all the time. I had a polyp removed." He stated that despite this he still had difficulty straining and that medical staff indicated the cause was due to emotional problems. TK stated, however, that he did not have any emotional problems.

 

TK attended sex offender treatment at Jones Enterprises from December 2010 to May 2011. He was terminated for being argumentative, disruptive, falling asleep in group, making sexual comments in group, and failing to come out of denial for his sexual offense. He returned to Jones Enterprises for sex offender treatment from February 2003 to March 2003 at which time he was terminated for failing to make any progress and failing to come out of denial about his offense. As a result, he was given an alternative to revocation, allowing him five more sessions of sex offender treatment at Jones Enterprises to come out of denial. He was also required to complete a polygraph examination. He failed to complete the polygraph examination and was terminated from sex offender treatment in May 2003. He has yet to complete sex offender treatment.

 

TK indicated that he saw a psychiatrist in the community "but it was a waste of time." He has been treated by psychiatry within the Department of Corrections for anxiety and insomnia. While incarcerated at the Milwaukee Secure Detention Facility (MSDF) between May 2007 and January 2008, TK reported to psychiatric staff that he had been experiencing problems with anxiety since 1969. He informed staff that his problems with anxiety were most often related to his incarcerations and worries about the future. He also reported experiencing insomnia. While at MSDF, he was prescribed several psychotropic medications including Remeron, Trazodone, Hydroxyzine, and Imipramine. He was diagnosed by psychiatry with Anxiety Disorder Not Otherwise Specified, Bipolar Disorder Not Otherwise Specified, and Polysubstance Dependence in Remission. While at Oshkosh Correctional Facility between April 2008 and October 2008, TK was prescribed Buspirone but it was discontinued as his compliance was sporadic. From October 2008 until April 2011, he was prescribed Amitriptyline. He was diagnosed primarily with Generalized Anxiety Disorder and Antisocial Traits.

 

There is no familial history of dementia noted in TK' records. However, TK reported taking care of his mother whose memory became progressively worse prior to her death. During his most recent period of adult incarceration, TK' records indicate that impairments in his memory have been a concern by clinical and security staff. In July 2007, he was evaluated for competency to stand trial due to questions regarding his memory and was found to be competent. In September 2007, results from a Mini Mental Status Examination (MMSE) indicated problems with recall. In January 2008, he was evaluated again with the MMSE and demonstrated improvement in recall but reported that he thought his memory was worsening. In February 2008, he was administered the Shipley Institute of Living Scale and his estimated level of intellectual functioning was found to be in the average range. In May 2008, TK was noted as forgetful of days and times. In September 2008, he appeared to be confused with the time of the day and attempted to go to the Health Services Unit for an appointment at 12AM. However, he was noted as having no problems with daily functioning during daytime hours. In October 2008, TK had difficulty recalling times to take his medication. In February and April 2010, he submitted request slips to staff with the incorrect date written, with each request slip dated one month off. In March 2010, security staff indicated that TK presented occasionally as disoriented to time of day on his housing unit.

 

In March 2010, TK was administered the Montreal Cognitive Assessment (MOCA), a brief screening for cognitive impairment. Results of testing indicated mild cognitive impairment, but it was noted that TK' attention was not sustained while directions were given, he was quite talkative throughout the testing, and he rushed through the drawings. He was noted as doing well in recalling events from his life in detail, as well as naming political figures and names of officers working on his housing unit.

 

In November 2010, TK walked to the breakfast line twice during the night shift looking for breakfast when no one was in the dayroom, appearing confused. He was noted by security staff as having difficulty keeping on a schedule without being prompted or having information written down in front of him, which resulted in him receiving numerous conduct reports. He was administered the Wechsler Memory Scale - Third Edition (WMS-III), the Brief Test of Attention (BTA), the North American Reading Test (NART), the Rey-Osterrieth Complex Figure Test - Taylor Version (REY), and the Mini Mental Status Examination (MMSE). Results indicated average intellectual ability and that his overall memory functioning had not deteriorated since he was administered the MMSE in 2007. He was noted as having adequate visual recognition and planning ability to organize and copy what he saw. He displayed intact attentional abilities that could possibly wane when the amount of information or stimuli increased. He exhibited adequate working memory. However, TK displayed deficits in immediate recall, delayed recall, and discrimination of presented information from that which was not presented.

 

In January 2011, TK described episodes of confusion to psychiatry, including being convinced that his mother was waiting for him outside. He requested security to allow his mother to meet with him. It was felt by some staff members that he was experiencing symptoms of a mild delirium. Psychiatry indicated the possibility of hyperglycemia and/or anticholinergic medication causing episodes of confusion, dry mouth, and blurry vision, and his Amitriptyline dosage was decreased. In addition, psychiatry indicated his episodes of delirium were likely related to a urinary tract infection, which was treated. His cognitive functioning appeared intact and he did not display any symptoms of depression. However, he displayed poor motivation to maintain his hygiene. His hair was often uncombed and greasy, explaining that he used coco butter for grooming cream. He was often unshaven and had food stains on his pants and shirt. In April 2011, Amitriptyline was formally discontinued and he was placed back on Trazodone.

 

MENTAL STATUS:

TK was seen over the course of several days and arrived to each appointment about 10 minutes late. His hair was disheveled and he appeared unshaven. He wore his pants well above his waist. He reported his mood as "okay" and his affect was congruent with his reported mood. He smiled and laughed appropriately. He was cooperative throughout the assessment process. However, at times throughout the clinical interview, TK had difficulty remaining on task when asked questions, particularly about his occupation history, and would need to be redirected. His volume and articulation of speech were normal. However, he did display a concrete and slow thought process. At times when asked questions, he took several seconds before responding. His thought content focused primarily on his occupational history and his aspiration of reopening a tavern upon his release to the community. He reported no perceptual disturbances. Although he did not appear to have significant impairments in long-term recall, he did appear to have difficulties with his short-term memory. However, he reported having a good memory. He did not appear to have insight into his difficulties, based on his occupational goals and his short-term memory impairments. He denied any intentions of harming himself or others.

 

BEHAVIORAL OBSERVATIONS:

At the onset of the clinical interview, TK stated, "My life is an open book." However, at times when asked to describe details regarding relationships growing up, he stated, "You're asking me to go back far" or "I can't remember." He would occasionally speak in tangents or in excessive irrelevant detail, particularly when discussing his occupational history. TK had difficulty remaining on task to the questions asked of him and would tell jokes of an ethnic manner directed at the examiner, based on the spelling of the examiner's last name, which is Polish. Based on the examiner's ethnic heritage, TK stated, "I'll talk slow so you can understand." At the conclusion of the clinical interview, TK requested a break for a drink of water. TK was escorted by the examiner to the waiting area and TK walked past the water fountain. The examiner called TK' name and pointed toward the water fountain, and TK turned around and walked back to the water fountain. While being escorted back to the examiner's office after the break, TK could not remember the way and initially walked past the examiner's open office door. When he sat back down, he asked, "Why am I here again?"

 

While at Smith Memorial Hospital on 7/29/11, TK continuously yelled for a nurse and pressed his nurse call button for concerns that were not medical emergencies. This behavior continued despite numerous direct orders from security officers and nursing staff. While at the hospital on 7/31/11, he was found on the floor and informed staff that he had fallen. However, video of his room showed that he intentionally went to the floor. While on the floor, he yelled loudly for a nurse to "wipe his back side." Throughout the remainder of his hospitalization, he continued to yell and was disruptive to staff and other patients.

 

Personality Functioning

As TK was admitted to Smith Memorial Hospital for chest pains on 7/29/11, a full comprehensive assessment was not completed.

 

Cognitively, TK appears to have deficits in abstract thinking abilities. When presented with ambiguous stimuli, he becomes overwhelmed and negativistic. Throughout most of his recall of life events, he focused on concrete details and he had difficulty with putting events into a contextual framework.

 

TK had a limited ability to recognize how he feels and difficulty describing his feelings to others, which leads him to avoid emotional situations altogether. For example, when asked questions related to feelings during the clinical interview, he would tell jokes rather than discuss how he feels. He provided limited emotional detail when describing relationships with family and past romantic partners, and his own feelings related to his past and current emotional states. His responses on the sentence completions indicate concrete, simplistic thinking with little emotional investment. He does not appear to grasp the psychological processes that connect events, feelings, and actions of those around him.

 

DIAGNOSTIC IMPRESSIONS:

TK's level of general cognitive functioning was low. He displayed significant difficulties recalling orally presented information, it appears that TK may be experiencing memory impairments and disturbances in executive functioning related to Possible Alzheimer's Disease, however his memory deficits could also be related to the traumatic brain injury from the automobile accident, skull fracture, and subsequent blood clot and surgery that occurred at the age of 29, or organic damage due to his longstanding dependence on alcohol.  

 

Although TK did not complete any self-report measures, he does have a lengthy history of sexual misconduct and legal troubles, which appears to be an enduring pattern for many years prior to the onset of his memory impairments. His acting out behavior does not appear to meet the full criteria for Antisocial Personality Disorder, however, as there does not appear to be evidence of Conduct Disorder before the age of 15. Based on his perceptions regarding his high school athletic abilities, his tavern business history, and his view of himself with regards to sexuality and women, he does appear to have features of Narcissistic Personality Disorder, as noted by his grandiose sense of self-importance, his lack of empathy, and his preoccupation with unlimited success.

 

RECOMMENDATIONS:

As TK was admitted to Smith Memorial Hospital for chest pains on 7/29/11, a full psychological assessment was not completed. Further psychological testing is recommended for a full comprehensive conceptualization of TK's functioning. Based on observations and mental status examination, neurological testing is recommended to better determine what factors specifically have contributed to TK's memory impairments and what interventions should be put into place to best support functional improvement and basic living needs. Given his impairments in memory and daily living skills, TK will need to be monitored in a highly structured living environment, within the remainder of his incarceration and upon his release to the community. Given his history of sexual acting out behavior, it is recommended that he be placed in a structured facility with minimal female contact.

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