A/N: This is something that I have been toying with, and I put it together thanks to the help of Roane72, who has been my sounding board for this idea I have of writing a Sherlock-in-therapy piece, starting with the notes from his therapist.

Patient: Sherlock Holmes

DOB: 7/19/1976

Date of admission: 5/27/2002

Age: 26

Reason for referral: Pt was admitted to dual diagnosis unit for detox on 5/27/2002. BIB brother, Mycroft Holmes, following arrest for intoxication on 5/26/2002. Pt was under the influence of cocaine when he was admitted. Pt was admitted for 28 days with possible extension to two months. Requested single unit. Request granted by special permission of the Director.

History: Pt is a 26-year-old, White university graduate who is currently unemployed. He does not have a fixed residence. Pt reported having received various psychiatric diagnoses in the past, including: bipolar disorder, conduct disorder, Asperger's disorder, histrionic personality disorder, antisocial personality disorder, and obsessive compulsive personality disorder. Pt is not taking rx. Pt does not currently have a PCP or a psychiatrist. Pt last saw psychiatrist in 1992. He said that he stopped therapy because "the doctor was an idiot." Pt reported some neurological symptoms and will be referred for a neuropsychological evaluation. Pt has no other reported medical conditions. Pt is allergic to shellfish and sulfa drugs.

Pt has a hx of cocaine inhalation and injection heroin use; began using substances in 1994 during university. Pt also smokes cigarettes, approx. 1 pack/day. Denies current alcohol use. Displayed lack of insight into substance use; said that he was "not your usual addict." Pt is sexually active; pt said that his sexual orientation was "irrelevant" because he "uses protection and doesn't share needles."

Mental status: Patient was oriented to place, person, time. Pt was hostile towards the examiner and refused to answer some questions. Pt appeared poorly related and did not adhere to social norms. Eye contact was intermittent and ranging. Pt reported that his mood was "bored". He displayed a limited range of affect. Speech was pressured and loquacious. Psychomotor agitation; pt paced during session. Thought content was focused on the reasons for the patient being in rehab. Thought processes were tangential and paranoid; pt reported that his brother "had set you [the examiner] up for this". Pt also evinced delusional thought processes and grandiosity; he claimed that he needed to leave the facility "in order to prevent a murder". Attention was inconsistent; pt was easily distracted by minor aspects of the examiner's appearance and the layout of the office. Pt's intellectual abilities are superior. Pt denied substance use in the last 10 days. Pt denied auditory/visual hallucinations. Denied suicidal/homicidal ideation. No evidence of malingering. Pt will return for his first therapy session tomorrow.

Diagnosis:

Axis I:

Cocaine-Induced Psychotic Disorder, With Delusions [292.11]

R/O Bipolar disorder, most recent episode hypomanic [296.40]

Axis II:

R/O Histrionic personality disorder [301.50]

Axis III:

Peripheral autonomic neuropathy [337.1]

Allergies to shellfish, sulfa medications.

Axis IV:

Economic problems, housing problems, problems with primary support group, problems related to interaction with the legal system.

Axis V:

Global Assessment of Functioning: 30. Behavior is considerably influenced by delusions. Inability to function in almost all areas. Some danger of hurting self or others.

Note: All terms and conventions are common to American psychiatry. Sorry, folks, I'm not a Brit and I don't know how it works across the pond. ;) But I do know my way around a psych unit. And I conduct intakes. Damn good ones too, IMHO. Honestly, Sherlock would not be the hardest of the patients that I've met. But he would be challenging for most therapists, of that I'm certain.
Abbreviations: pt = patient; hx = history; BIB = brought in by; rx = prescription medication; PCP = primary care physician; R/O = rule out
dual diagnosis = substance use + psychiatric disorder/embr /
All diagnoses and diagnostic codes come from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

Would you like to read more? As in, a full-length story? Will write more if demand is there.