NCMHCE Practice Test 2

Presenting Problem

You are a licensed mental health counselor working in a community mental health agency. Terrence, a 41-year-old warehouse shift supervisor, was referred by an emergency department (ED) physician after his third ED visit in seven months for chest pain that cardiac testing found to be noncardiac. Terrence says, "Every time, I was sure it was a heart attack. They ran the EKG and blood work and sent me home with a pamphlet about anxiety." He has not followed up with a primary care provider because he "didn't want to waste anybody's time."

Terrence describes his first episode, seven months ago, while driving on the interstate: his heart pounded, his chest tightened, his hands went numb and tingly, he felt dizzy and short of breath, and he was certain he was dying. He pulled onto the shoulder and called 911. The episodes peak "within a few minutes" and now occur two to three times a week. Some come "out of nowhere," including twice when they woke him from sleep. Since the first episode he has worried "almost constantly" about having another one, carries aspirin in every jacket, and checks his pulse many times a day.

Over the past six months Terrence has stopped driving on highways, stopped taking the bus to work, and avoided crowded stores and his children's school assemblies. His wife now does all of the grocery shopping. He explains, "If it hits me in the middle of a packed store, I can't get out, and nobody there would know what to do." He has missed nine shifts in three months and was moved off the overnight schedule, which cut his pay.

He drinks four or five large coffees a day "to keep up," and for the past two months he has had three or four beers most evenings: "It takes the edge off so I can sleep." Terrence denies suicidal ideation, intent, or plan, stating, "I'm scared of dying, not wanting to." He denies homicidal ideation and has no history of violence. He adds that he feels ashamed: "I've always been the one who holds everybody together."

Mental Status Exam

Terrence arrived ten minutes early, well groomed and dressed in his work uniform. He was oriented to person, place, time, and situation. He described his mood as "on edge," and his affect was anxious and congruent with his mood. Recent and remote memory were intact. He chose the chair nearest the door, jiggled his leg throughout the interview, and twice pressed two fingers to his wrist to check his pulse; gait was normal. Eye contact was intermittent. His thought process was logical and goal directed, and his thought content centered on fears about his heart and about losing control in public. He denied hallucinations and denied suicidal and homicidal ideation. He reported no history of manic or hypomanic episodes. Substance use includes heavy daily caffeine and three to four beers most evenings for the past two months.

Psychosocial and Family History

Terrence has been married to Renee for 14 years; they have two children, ages 9 and 13. He is the oldest of four siblings. His father died of a heart attack at age 52, when Terrence was 19, and Terrence helped his mother support the family afterward. He has worked at the same distribution center for 16 years and was promoted to shift supervisor three years ago. His reduced shifts have strained the family budget. He and Renee attend a Baptist church, and he describes his faith as "something that keeps me grounded." His trauma screen was negative apart from his father's sudden death. As the intake ends, Terrence mentions that his supervisor has asked for "a note from my counselor" explaining his missed shifts, and he asks whether you will have to tell his job what is wrong with him.