SOCW 6090
CASE PRESENTATION – KATIE
Intake Date: August 2020
IDENTIFYING/DEMOGRAPHIC DATA: Katie is a 21yr old single woman from Greece. Katie moved to the United States 3 years ago with her parents and two siblings, a brother and sister, both older.
CHIEF COMPLAINT/PRESENTING PROBLEM: Katie was referred to the outpatient department of a community hospital after a medical examination revealed that most of her physical symptoms did not have a physical cause.
HISTORY OF PRESENT ILLNESS: Katie complained about weight loss, headaches, menstrual irregularity, low energy, and high anxiety. The physician referred her to a clinical social worker in the hospital. Katie told the social worker that she felt confused and sad; she did not know what to do with her life. She has felt down much of her life, but now it is interfering with her ability to function in daily life. About a month ago, she says she experienced a strange period of anxiety in the middle of the night. She awoke suddenly at 3 am feeling absolute terror. Her heart was beating so hard, she was afraid she would have a heart attack. Her surroundings felt odd and unfamiliar. She felt like running away and would only feel safe if she could get back to her parents. She could not stand to stay in the apartment, so she drove around town until she calmed down. Since then, she has developed a fear of being alone in the apartment and is thinking of getting another job so that she can work a late shift and does not have to come home so early. It frightened her that she had another episode last night with the same chilly sensation.
PAST PSYCHIATRIC HISTORY: Katie denies any past therapy. She has never been an overly excited person. Katie has always felt there was a big burden on her shoulder. Her mood has always been rather down.
SUBSTANCE USE HISTORY: Katie reports drinking socially and denies any drug use.
PAST MEDICAL HISTORY: Katie went to her family doctor due to her weight loss and other physical symptoms that she has been experiencing. She is convinced that there is something going on, but the doctors cannot find any physical symptoms.
FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC:
When asked further about her family of origin, she said that she was an “abused child.” She said that her father used to “kick me around while my mother stood and watched.” She said that her brother and sister were also abused, but she was the only one who used to fight back with her father, even though she was small. She said that her brother and sister have managed to forgive her parents, but she cannot. Nevertheless, it still bothers her that they ignore her outside of work.
CURRENT FAMILY ISSUES AND DYNAMICS (OPTIONAL): Katie lives with Max, who works as a long-haul truck driver. Max is 10 years older than she and has a 7-year-old son from a previous marriage who lives with his mother. Katie met Max at her family’s diner where she works as a waitress. Since moving in with Max 2 years ago, Katie’s physical symptoms have become more and more evident. When asked to talk further about the circumstances surrounding her moving in with Max, Katie said that “In moving in with Max, I lost my parents.” When asked to explain, she said that her parents consider her “loose” and have cut off a lot of communication with her. Their only discussions are in the diner about work. Katie does, however, keep in close contact with her brother and sister, who live together in an apartment in town. Katie said that even though she and Max have two incomes, they are struggling financially. Max has to pay child support. She does not earn very much.
Katie said that she loves Max, moving in with him has not been as wonderful as she had anticipated. For one thing, he is out of town a great deal, so she is alone in their apartment much of the time. Because she is living with him, she does not feel comfortable running around with her old crowd. She thinks all she does is go to work, while he comes home and watches TV. Last month, however, Katie did go out with one of the waiters at the diner. It started out as a casual invitation on Rick’s part that they go out for a drink, but she ended up sleeping with him. Even though Max was out of town, she did not spend the whole night with Rick. The next morning she felt terrible qualms of guilt. She sees Rick every day at work and they continue to be friends, but it disturbs her greatly to be around him.
MENTAL STATUS EXAM: Katie presents with a depressed mood. She becomes teary eyed periodically when describing how bad she feels. There are no reported delusions or hallucinations. She denies suicidal and homicidal ideation. When asked what her goals for herself were, she said that she always wanted to make something of her life, but she feels trapped. She said that a “high school diploma doesn’t get you very far;” but she can’t afford to go to college. She would like to get married someday but she does not feel mature enough to do so in the near future. She has thoughts about getting into work involving animals, which she loves, but does not know how to start. Her immediate goal she said was to feel “unconfused” and not so afraid.