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Mary is a 46 years old divorced Caucasian female with 2 children (23 year old son and 16 year old daughter) who resides in London in her own apartment. She supports herself on ODSP.

She was raised in the Kitchener area and is the fourth of five children. She has four brothers (one mechanical engineer, one social worker and two teachers). Her father who was a teacher suffered anxiety attacks and was an alcoholic. He died in 1992 secondary to complications of cancer (secondaries in the liver) at the age of 64. Her mother is now ill with terminal carcinoma and is scheduled for surgery soon. Mary?s mother was quite hostile, angry, anxious, manipulative and domineering during Mary?s formative years. The mother also suffered from alcoholism. Mary was an average student in school and attended Waterloo University, for a year of theology courses. Later she attempted RN training but dropped out after 1.5 years. In the past she has worked as a payroll clerk, gym coach, health care aide, and superintendent of an apartment.

There is a very prominent history of psychotic, mood and anxiety disorders along with alcoholism in many of Mary?s maternal and paternal grandparents, aunts and uncles. Two of her brothers are also alcoholics. Mary has indicated that her childhood was quite traumatic. She was forced to be a parent to her siblings due to emotional non-availability of her parents. She was sexually abused by her brother between the ages of 5 and 7 years and on one occasion by her uncle.

Mary was briefly married to an Iraqi gentleman and has a has a 23-year-old son from this relationship. Mary?s mother raised this child but there was significant conflict between the patient and her mother over this issue. Mary later married a psychiatric patient and the couple had a daughter. This marriage dissolved after seven years. Mary had to go to court on various occasions over custody battles for this child. Her brother-in-law and his wife raised this child. Mary has regular phone contact with her daughter. In this marriage, Mary was subjected to extensive physical and emotional abuse. Mary has also common-law with another psychiatric patient who was also abusive towards her.

Mary?s psychiatric difficulties date back to her childhood when she would often have episodes of screaming and uncontrollable crying associated with marked hyperventilation. She was described as an anxious child. She was treated for this but is unsure of the prescribed medication or the diagnosis. She required her first hospitalization at the age of 20 with a diagnosis of bipolar disorder. She was involved with a "weight control cult" possibly related to the Church of Scientology. Both Mary and her brother were members of this cult and were subjected to extremely harsh physical, verbal, emotional and possible sexual abuse. After an involvement of over three years she eventually left the group.

Mary has had multiple hospitalizations (10) in London and in Kitchener for psychotic episodes where she presented with manic, depressive and mixed states of her bipolar disorder. She was quite aggressive and assaultive. She has made several suicide attempts. Her anxiety symptoms have waxed and waned over the years and have contributed to her significant psychopathology. Whenever she became anxious, she would often take off in her car and head towards Northern Ontario.

Mary has been involved with the London PACT Team since 1997. Although she has lived in the community with PACT support, she continues to have intermittent symptoms of anxiety that manifest predominantly in the form of panic attacks. During the past Christmas holidays, Mary returned to Kitchener to assist in the care of her ailing mother. After spending two weeks with her mother, she felt extremely exhausted, emotionally drained and overwhelmed. Upon her return to London on the weekend, she felt relatively calmer and was looking forward to returning to her volunteer work in a children?s day care centre. However, she received a phone call from her brother who ordered her to return to Kitchener to look after her dying mother. This triggered a panic attack that presented with palpitations, sweating, tightness in the chest, nausea, vomiting, dizziness, feeling of passing out, paresthesias and racing thoughts. She contacted the PACT worker the following day and was able to relax once she discussed her issues. She was able to look at the role that demands of a caregiver placed on her played in triggering the feelings of helplessness and anxiety. Her cognitive distortions were challenged and she was able to correctly label her emotions. Since then she feels more relieved and calm. At the present time she does not exhibit any psychotic symptoms and her mood is stable. She has been adherent to her treatment.

Mary also suffers from several medical conditions including asthma, sleep apnea, obesity and hyperlipidemia. She underwent exploratory laparotomy for a ruptured appendix and developed and incisional hernia which was repaired in 2003. She has no known allergies and there is no known history of alcohol or substance abuse.

Mary?s current medications are:

  1. Clozaril 150 mg qhs
  2. Topamax 150 mg qhs
  3. Epival 250 mg qhs
  4. Sertraline 175 mg qhs
  5. Nozinan 2 mg qhs prn

Independent Learning Issues for January 12 Pick and choose

   * Stigma of mental illness and ramifications
   * Physician assessment of patient capacity, both in regard to treatment and finances
   * Physician responsibility and assessement patient safety for driving
   * Sexual and physical abuse and the role of the physician
   * 'Community Treatment Orders'
   * Susceptibility of mentally ill patients to abuse, violence, exploitation (cults?)
   * Genetic and environmental background to mental illness