Patient: Smith, Jane DOB: 06/ 13/ 1985 Date of Interview: 02/05/2010 Date of Report: 02/06/2010 IDENTIFYING INFORMATION: Ms. Smith is a 24 year old white woman currently residing in Vancouver, WA. She is employed as a hairstylist and currently lives in an apartment with two friends and their newborn son. Ms. Smith has been seen for mental health symptoms previously as a teenager, and was referred again on this visit by a colleague. The following report information is based on information collected from my interview with the patient, her medical chart, and psychological testing.
CHIEF COMPLAINT: “I feel like sometimes my life is too much to handle. It makes me sick to think about things and I am not sure I can stand much more. I feel like there is no hope. I am all alone and I think I will always be alone. ” HISTORY OF PRESENT ILLNESS: Ms. Smith says she frequently suffers from anxiety attacks and is often times unable to cope with stress while at work. She states she feels sweaty, weak and dizzy when thinking about life. Over the last two years she has been unable to relax, often has difficulty falling or staying asleep, and often feels ill and tired.
She says her primary way of coping is alcohol. When unable to drink she reports her anxiety levels being “unbearable” and tries to stay away from social interaction. She also reports that her anxiety increases after nights of drinking as she feels like everyone is watching her. Ms. Smith has been diagnosed with high blood pressure which may be caused by her weight gain over the last three years. SOCIAL HISTORY: Ms. Smith is currently single and has no children. She was living with her father until she was forced to leave after a domestic dispute caused a no contact order between them two years ago.
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Her mother and father separated four years ago and her mother moved out of their house into her own apartment. She states that until the separation she heavily relied on both parents for social and financial support. She has two older sisters, both of whom do not live in the area. While she says that one sister is caring she describes the other as “self-centered” and says she has a hard time staying close to either due to location. She recalls her childhood as “normal” although she felt like her parent’s attention was given primarily to her sisters.
She says that she has a large group of friends, but tries to hide her emotional distress and anxiety from them as she does not want to be burdensome. Ms. Smith reports suffering from significant financial distress after moving out of her parents. She also says she is unhappy with her living situation and the new addition to their household. Ms. Smith also shows great concern over being single and without a relationship since she was 16. She attributes her problems in dating to her gain in weight and says it has dramatically decreased her self esteem.
CURRENT/PAST PYCHIATRIC HISTORY: Ms. Smith reports that at age 16 she visited a mental health clinic for the same symptoms and was diagnosed with general anxiety disorder and depression. She was prescribed an antidepressant and also attended counseling sessions one to two times weekly. Ms. Smith said that her symptoms improved within six months and she discontinued both the use of her prescription and counseling. She said after discontinuation symptoms once again started to reappear, however with less intensity, until the past few years when intensity has increased.
CURRENT AGGRESSIVE IDEATION AND BEHAVIORNO X YES ALCOHOL AND SUBSTANCE USE HISTORYNO YES X Patient reports that she consumes alcohol on average five times a week. She drinks five to ten drinks per sitting. She also reports that on occasion the smokes marijuana. While Ms. Smith states that she does not think alcohol or drugs are negatively affecting her, she does report increased anxiety and paranoia after drinking. She has also been ticketed and charged for having a controlled substance after her car was searched for a routine traffic violation.
DSM- IV DIAGNOSTIC IMPRESSIONS AXIS I: Generalized Anxiety Disorder Dysthymic Disorder AXIS II: Deferred AXIS III: High Blood Pressure AXIS IV: Adjustment to weight gain and changes in finances, social support, and lifestyle AXIS X: Global Assessment of Functioning Scale Score: 80 CLINICAL FORULATION: Ms. Smith presents as very depressed and anxious. Her symptoms appear to be that of dysthymic disorder and generalized anxiety disorder. I believe that these are onset by interlinked biological, psychological and social factors.
It is likely that the dysthymic disorder results from maladaptive, flawed, or irrational cognitions taking the form of distorted thoughts and judgments. Ms. Smith has experienced traumatic family situations, unwanted separation, as well as lack of social support from family and friends. It appears that these have caused her to feel negatively about herself which has affected her feeling of self-worth and ability to successfully respond to the tasks and stressors present in daily living.
It is likely that these maladaptive behaviors were learned from friends or family. These stressors are causing increased anxiety and hopelessness. The anxiety disorder developed a result of not being able to cope with the dysthymic disorder. Due to the fact that these are so closely intertwined, without treatment the depression and anxiety Ms. Smith is experiencing, as well as alcohol dependency will likely worsen. TREATMENT PLAN: Outpatient therapy may involve medication and/or therapy. Behavior therapy will help Ms.
Smith to examine her behaviors as to determine exactly what is decreasing her mood or keeping her from achieving goals. This therapy should be conducted in individual therapy sessions, one or more times a week until symptoms improve. As well as therapy Ms. Smith should be prescribed an antidepressant to deal with the contributing biological factors. Ms. Smith should seek evaluation for alcohol and drug dependency, as it appears she is using these substances for self medication. It is important that she discontinues use in order to learn new coping mechanisms.
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