A Note to Patients: Symptoms are concisely summarized to inform treatment recommendations. For reasons of privacy and brevity, this note does not attempt to capture all experiences that were discussed.
[Patient] is a 83 y.o. man with a history of chronic fatigue syndrome, meningioma, BPH, osteopenia, anemia, PSA, generalized weakness, polypharmacy, long term steroid user who presents for initial intake for polypharmacy management, diagnostic clarity, referred by PCP OAB, MD.
Subjective
Patient stated goal(s) in their own words: "Dr. OAB sent me here"
History of Present Illness
#Depression
[Patient] reports a long-standing history of depression and chronic fatigue, with symptoms beginning in grade school and persisting throughout his life. He describes his childhood as marked by neglect, feeling that his parents were not invested in his life or activities. He mentions he participated in extra-curricular activities as a child, but felt unsupported by his family. He describes his home environment as "not a happy place" and felt like a "neighbor in my household." He denies any physical or sexual abuse but acknowledges emotional neglect.
#Anxiety
>Denies presence of current anxiety panic attacks, or obsessive/compulsions but reports feeling anxious about political events. He denies irritability and describes himself as "heavily drugged" but feels okay with his current medication regimen.
#Psychiatry
[Patient] has been under the care of Dr. AK, for approximately 10-15 years and is currently prescribed multiple medications, including Trintellix, Rexulti, ziprasidone, methylphenidate, and modafinil. He reports that the methylphenidate and armodafinil help manage his fatigue, which has been progressive since his late 20s. He states antidepressants have been helpful to manage depression, and has been on current regimen for years. [He] has a long history of psychiatric treatment, including psychoanalysis in the early 1960s and therapy from 1974 to 1990, which he found beneficial for improving interpersonal relationships. He denies current therapy but is open to the idea. He has no history of suicidal ideation or self-harm behaviors. Thomas has a history of psychiatric hospitalization in the early 1990s for medication management. He reports a family history of psychiatric issues, describing his father as having "problems" and his mother as "emotionally unavailable."
#Psychosocial
[Patient] has never been married and has no children, citing health reasons and chronic fatigue as barriers to pursuing relationships. He is currently involved in an online relationship through a virtual platform called Second Life, and has been inactive/active for 17 years, recently re-started activity on platform 1 year ago. He has a few close friends, including RM whom he sees every 2-3 weeks. Thomas expresses a desire for more social interaction but is limited by physical fatigue.
#Sleep/Appetite
He sleeps 7-8 hours per night, with occasional awakenings to use the bathroom. He denies nightmares, snoring, or difficulty falling asleep. He reports a consistent appetite, eating regular meals and using meal delivery services.
Reports history of no concern for mania or hypomania including no history of multiple consecutive days of elevated/irritable mood with decreased need for sleep. No periods of increased goal directedness, impulsivity, talkative, or grandiosity. Reports history of no occurrences of auditory hallucinations, visual hallucinations, delusions, or increased paranoia.
EMR review--
--03/10/25 per AK, MD: reviewed recent progress notes scanned into EMR sent by MD staff; r/o ASD. Notes difficult to read and understand.
--02/24/2014 per BT: "Had an extensive conversation with outpatient psychiatrist, Dr. AK. Patient currently doesn't have a confirmed diagnosis of depression but has elements at times resembling depression, bipolar disorder, amnesia disorder, and chronic fatigue syndrome/fibromyalgia"
[h]as a past medical history of Adrenal adenoma, Allergic state, Anemia, Blood transfusion without reported diagnosis, Cancer (CMS code), Chronic fatigue, Chronic fatigue syndrome, Complication of anesthesia, Depression, Elevated PSA, Fibromyalgia, GERD (gastroesophageal reflux disease), Glucose intolerance (impaired glucose tolerance), Hip fracture, left (CMS code), Hypercholesteremia, Osteopenia, Other mechanical complication of prosthetic joint implant (02/04/2015), Peyronie's disease, Polyp of colon, Prostate disorder, Pseudoparasitic dysesthesias (CMS code), Pure hypercholesterolemia, Renal insufficiency, and Tremor.
[f]amily history includes Bladder Cancer (age of onset: 73) in his father; Breast cancer (age of onset: 50) in his cousin; Colon cancer in his maternal aunt; Colon cancer (age of onset: 96) in his mother; Heart disease in his paternal grandmother; Leukemia in his maternal grandmother; Prostate cancer in his paternal grandfather. There is no history of Malig hyperten.
[r]eports that he has quit smoking. His smoking use included cigarettes and cigars. He has a 10 pack-year smoking history. He has never used smokeless tobacco. He reports that he does not drink alcohol and does not use drugs.
Was living in New York in the 60s, moved to San Francisco in the 70s. Worked as a computer consultant. Retired about 8-9 years ago. To fill the time he reads the paper, visits with friends, watch TV, rest, managing money. Enjoys working on computers reading articles, going on Second Life (social environment). Lives alone with no pets. Friends live nearby. Brother lives in suburban Chicago, "sort of close", talks to him once a week. Describes the relationship as "friends". Never married. He feels he would turn to his friend RM. Friendship with RM and other friends and friends on Second Life bring him joy, reading brings joy. Feels like he is leading a content life.
Social History
Stocks, Second Life, walks 1000 steps a day
He has one younger brother, three years his junior, who lives in Chicago.
[Patient] is a 83 y.o. man with a history of chronic fatigue syndrome, meningioma, BPH, osteopenia, anemia, PSA, generalized weakness, polypharmacy, long term steroid user who presents for initial intake for polypharmacy management, diagnostic clarity, referred by PCP OB, MD. [He] is a chronically depressed adult male with longstanding psychiatric treatment history, including over a decade of care with his current psychiatrist whom he sees every two months. His primary complaints are depression and chronic fatigue, symptoms he traces back to middle school. He describes a cordial relationship with his parents, though emotionally distant. Parents stayed married but seemingly without emotional attunement to patient's needs while growing up. He recalls feeling like “a neighbor” in his own home, suggesting early relational detachment. He reports further detachment during shared family experiences. Online engagement (Second Life) appears to suggest behaviors that reflect complex dynamics around identity, intimacy, and escapism. He maintains a few longstanding social relationships, indicating some social connectedness despite overall isolation. He shows a preference for solitary routines and minimal social contact, with little interest in romantic or emotionally vulnerable interpersonal relationships offline. Predisposing factors to presentation include early emotional neglect despite structurally intact family, possible underlying genetic vulnerability to mood disorders, and limited emotional expression in childhood. Precipitating factors include onset of depressive sxs in adolescence, lack of emotional support from family when first signs of depressions evolved, and fatigue and functional decline in late 20s. Perpetuating factors include long-term pharmacologic treatment with little change, avoidance of emotional closeness and introspection, current reliance on dissociative or escapist behaviors, and possible chronic anergia and low engagement in meaningful activities. His protective factors include long-standing engagement with psychiatrist, adherence to medication and medical appointments, and retained daily structure and ability to manage own finances, independence. Differentials include Avoidant Personality Disorder, with schizoid personality features though this combination appears complex. Given his hx of emotional neglect, rejection, and invalidating environments, pt may have learned fear of closeness despite desiring connection with others (avoidant trait) and numbing out emotions as adaptive strategies (schizoid trait). MDD although pt appears to show resistance or difficulty engaging in reflective emotional work may reflect both personality structure and longstanding patterns of detachment. Complications to diagnosis include collateral gathering being difficult due to the long duration of illness and reliance on patient’s recollection of decades-old experiences. Current treatment has been unchanged for decades, suggesting a need for re-evaluation of pharmacologic and psychotherapeutic approach. Given the unclear diagnosis and medication indications, I will reach out to the long-term psychiatrist to obtain additional information that may clarify the rationale for the current polypharmacy regimen.
Type “.psyvisitdiagnosis” to add a diagnosis with today's assessment and interventions.
Assessment and Plan
>Visit Diagnosis: Avoidant Personality Disorder with schizoid traits
Assessment: Tom Rubens is a 83 y.o. man who is being treated today for the mental health conditions of anxiety, depression. Pt has verbally consented for clinician to gather collateral from psychiatrist and long-time friend. Plan to evaluate feasibility of medication reassessment, especially if fatigue remains functionally impairing. Consider referral to neuropsych testing if cognitive decline is suspected or if fatigue could be masking other processes.
Interventions:
-Explore long term therapy, particularly ACT, DBT, with a focus on emotional insight, relational patterns, and re-engagement with values
-Monitor for further evidence of personality disorder traits impacting functioning and engagement in care
-Continue daily exercise, increase steps per day. Currently at 1000 steps/day which may be negligible. Encouraged increase (ideally 4k steps/day)
-Upcoming appt with PCP Bernal, MD on 09/10/25
Visit Diagnosis: Chronic Fatigue Dx
Assessment: There is unclear treatment goals for the fatigue this pt is currently experiencing. He states the stimulants have been helpful, though is unable to elaborate on what symptoms appear to be alleviated (such as daytime sleepiness or fatigue due to another cause). Pt is also on two antipsychotics to which I am unsure what the indications are. He was reportedly previously on trazodone and fluoxetine, which gave him "strength" and "energy," which I questioned if it was in relation to mood improvement, which MDD symptoms would be better managed with antidepressants rather than antipsychotics. Also expressed concern for QT prolongation and metabolic side effects or EPS with prolonged use. Gabapentin, Geodon, and Rexulti may be contributing factors to chronic fatigue.
-Recommended to decrease ziprasidone or Brexpiprazole to avoid increased risk of falls, cognitive impairment, cerebrovascular events. Difficult to discern which to discontinue due to unclear indication of both
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