psych eval 1-response

Discussion including at least one meaningful response to at least one of your peers’ Psych Evals should occur by Wednesday at 11:59 pm EST in weeks 4, 8, and 12. A meaningful response demonstrates critical thought. Refer to the Carlat and Kaplan & Kaplan texts for assistance. Posts that are perfunctory or only minimally meet all grading criteria do not necessarily qualify as “excellent” which would yield full points (100). This is true for both the initial post and the response post. One response post is considered to meet the criteria minimally.

STUDENT’S PSYCH EVALUATION

Chief Complaint: “I think I may have ADHD. I have trouble focusing and I am easily distracted. I am having emotional distress over my custody case, I have been feeling anxious for the last three days.”

IDENTIFYING INFORMATION:

CL is a 43-year-old female presenting as a new patient for a psychiatric evaluation via telehealth who states that she thinks she has attention deficit disorder (ADHD). Patient reports that she has been extremely stressed for the last three days. She expresses doubts about whether she will be able to complete this evaluation.

  SUBJECTIVE DATA:

    Patient says that she thinks she has ADHD because she has difficulty with beginning tasks and has trouble with time management. She describes her thought process as a solar system. She says her mind holds a lot of ideas, and it is like the sun orbiting planets of thoughts. She says that she can process many thoughts and she will complete a task, but she gets off track and starts another task, before completing the first one. She says that she has to wake up one to two hours early to finish task. She says that she loses track of daydreaming time or become absorbed in her thoughts. She also describes episodes of being hyper focused. During this time, she reports that she can work for several hours at a time to complete a task. Patients say that during her hyper focused episodes she can mentally visualize spatial arrangements in a manner she compares to having a storage unit app. She says that she has situational episodes in which she interrupts people when they talk and she will have difficulty standing in lines. She says that she has restless legs when lying down or sitting still for too long. She says that when she was in jail, she learned how to trace words on surfaces with her fingers. This helped with her restless legs.  She describes this process as being peaceful and simultaneous. She denies that her thoughts are racing or intrusive. She denies memory issues and states that she can recall conversations and important dates both past and present.  Patient reports that her son was diagnosed with ADHD by her sister although she had suspected it years prior. Patient reports that for the last three days she has been having emotional distress over ongoing separation from her two youngest children, she says that her daughter is 12 and her son is 14. They have been in custody of her sister since 2021. She says that she feels irritable, sad and overwhelmed. She says that she has not heard from her children in the last year and does not know if they are doing well.

     Patient reports that during the Covid 19 pandemic she had lost her job, and she was a single mother with four children. Her husband had passed away. Patient reports that she has two older children, 20 and 22. She reports that in 2021 her rent was 2.800 monthly. She says that she was unable to obtain welfare benefits due to someone using her identity and it was reported that she obtained benefits fraudulently, Patient reports that she was arrested for committing a crime and went to jail. It was at this time that her sister took custody of her two youngest children. Patient says that she has been out of prison for two years. She says that she was unaware that she could phone her children from jail, but she did send letters. Patient says that her sister sent the letters back. She says that her sister has also prevented her two daughters aged 20 and 22 from having contact with their younger siblings. She describes her sister as being controlling, narcissist with a history of stealing money. She reports the two youngest kids father died from a stoke on his daughters’ birthday. She says that her lawyer did not advocate for her, and she had asked the lawyer not to place her children with her sister. She says that she asked the police to do a welfare check, but they refused citing they do not interfere with childcare family services disputes.

    Patients report a history of childhood trauma. She says that her parents did not raise her. She was raised by her now 91-year-old grandmother, she says that she was sexually abused as a child. Patient says she told her grandmother she was told to “let it go and forget about it”. She says that she was the oldest child and she was responsible for taking care of her sister. She says that her sister never helped her, due to the grandmother stopping her sister.  She says that her grandmother still encourages this behavior and shows favoritism towards her sister.

    She also says that she has been having nightmares as a child and has increased in frequency over the last four months. She says that she attributes this to worrying about her children. She denies paranoia but says there are times when she becomes hypervigilance in the sense of not being afraid of others. She says she does observe and read people. She says despite the nightmares she sleeps at least 10 hours a night.

    She has prior psychiatric history and was diagnosed with depression. She was treated in past with the following medications. Celexa and mirtazapine which she says didn’t help with her depression. She also was prescribed trazadone which she says helped with her sleep. She says that in her 20’s and 30’s she did have therapy but didn’t discuss her sexual abuse. She said this therapy sessions included grounding and relaxation techniques. She says she still uses these techniques.  She reports having an allergy to penicillin as a child but wasn’t told her reaction to it. Patient is now living with her two oldest daughters. The patient reports having full-time employment and says despite her issues she can work without missing days. Patient states that she is still on probation from her last incarceration.

 

HISTORY OF PRESENT ILLNESS: (SUBJECTIVE).

Onset--- Has been having attention deficit disorder since a child but no formal diagnosis. Treated for depression in 2021.

Location---Symptoms interfere with daily tasks, affect work and home tasks.

Duration—Has symptoms, daily but no constant

Character---Has difficulty concentration, staying on tasks, trouble with time management and nightmares.

Aggravating- Having to stand in line, people talking and thinking about her children

Relieving factors—Tracing words on surfaces and using grounding and relaxation techniques

Time—Can occur anytime of the day, nightmares happen when she is asleep, at least twice weekly

Severity---Patient describes worsening symptoms when she loses track of time daydreaming. interferes with completing tasks.

Pertinent Negatives

Patient denies suicidal, homicidal, violent ideations

PAST PSYCHIATRIC HISTORY:

Per patient she was diagnosed with depression in 2021 by a psychiatrist. She was prescribed trazadone celexa, zoloft and mirtazapine. She reports that celexa, zoloft and mirtazapine were not helpful but says that trazadone helped with helping her to sleep. She no longer takes any of these medications as of 2021. She denies self-harm and suicide attempts. Patients deny hospitalizations.

 

 

PREVIOUS PSYCHIATRIC MEDICATIONS:

 Trazodone ---prescribed in 2021, stop taking in 2021

 Zoloft---prescribed in 2021, stop taking in 2021

 Mirtazapine---prescribed 2021, stop taking in 2021

 Celexa---prescribed in 2021, stop taking in 2021

 

CURRENT MEDICATIONS:

None

SUBSTANCE USE/ ADDICTIVE BEHAVIORS:

Patient denies drugs, illicit and/or prescribed (marijuana, ETOH, stimulants like cocaine, meth, or Ritalin, opiates, synthetics. Patient states that she does not consume alcohol or use nicotine products.

FAMILY PSYCHIATRIC HISTORY:

Son: ADHD—Diagnosed by a psychiatrist

Sister: Controlling behavior, theft—Not diagnosed by a psychiatrist

MEDICAL HISTORY:

Patients have a history of hyperlipemia, has not taken medication since 2021. Patients report a history of sexual abuse as a child.

Medical Illnesses: hyperlipidemia

History of Med Illness: does not remember the medication name

Surgical history: None

Allergies: Penicillin—unknown reaction was told when she was a child

 

PSYCHOSOCIAL:

     Patient states that she has full-time employment and that she gets along with her co-workers. She reports that when she becomes hyper focused, she can work fast and complete her work ahead of time. She is not in a long-term relationship. Her husband passed away eight years ago

   Patient reports that she has one younger sister. Little is known about her parents, her maternal grandmother raised the patient and her sister. Patient states that the grandmother is now 91. She now has a strained relationship with her grandmother, she says she feels that her grandmother is the force that is helping her sister to keep her two youngest children from her. She has 4 children in total, the 2 oldest are currently living with her and the two youngest live with her sister. The sister has had these children since the patient was incarcerated. Patients continue to report to probation. She has no religion affiliation, and reports she finished high school. No substance abuse reported, however she reports child abuse as a child

ASSETS/STRESSORS:

Patient reports she is stressed about not being able to see or hear from her two youngest children. Her sister that has custody, had ceased all communication. Last time she spoke to her two youngest children was 1 year ago.

OBJECTIVE DATA

MENTAL STATUS EXAM: (OBJECTIVE).

    CL is dressed well and grooming appropriate; Patient has good eye contact, and she is wearing minimal make up. She looks appropriate. She is friendly, forthcoming and cooperative. Patient become emotional when discussion her two youngest children’s custody arrangements. Patient reports restless legs when trying to sleep or sitting still. She describes a soothing technique she used in prison by drawing letters on a hard surface with her fingers to help with the restless legs. Her speech is clear, regular, until she starts to discuss her two youngest children. Her volume and tone are adequate. Patient affects she appears tearful at times; she became more animated when she described her cognitive styles and strengths. Her thought process was circumstantial at times but elaborated when she discussed her family and incarceration history. She was able to provide information in detail. Her thought content she was preoccupied with her two youngest children and wondered about their well-being. She was upset and felt that her lawyer did her a disservice and did not represent her well. She denies suicidal, violent and homicidal ideations. Patient’s cognition she was alert and oriented, she had excellent long term and short-term memory recall. She reports that she does daydream and lose track of time. Patient insight was fair to good she acknowledges that she has situational emotional distress and distinguishes it from her baseline functioning. She recognizes that there is a disruption in her thinking process and has sought evaluation for ADHD based on her self-evaluation. She acknowledges that she has past trauma that she needs to deal with. Her judgement is fair she voices concerns that being on probation may limit certain actions and if there is any violation she can be reincarcerated. She is seeking new legal ways to attempt to get her children back.

PHYSICAL EXAM: (VS, HT, WT, LABWORK AND OTHER DIAGNOSTICS)

This was a telehealth evaluation.

Rating Scales

PHQ-9

Score 0

Generalized Anxiety Scale

Score 0

Diagnosis

Post-traumatic stress disorder, chronic, F43.12 (ICD-10)

Major depressive disorder, recurrent, unspecified, F33.9 (ICD-10)

Anxiety disorder unspecified F41.9 (ICD-10)

Post traumatic stress syndrome:  F43.12 (ICD-10)

CL meets these criteria due to her childhood trauma as well as trauma as becoming a single mother after her husband passed away. The patient is dealing with prior incarceration and losing custody of her two younger children. These incidents are causing excessive daydreaming, loss of time and excessive worrying.

I should have inquired about the type of crime she committed.

Major depressive disorder, recurrent, unspecified, F33.9 (ICD-10)

 Patient reports acute onset over the last three days, stating she has irritability, sadness and inability to redirect thoughts due to being separated from her two youngest children. This patient loses track of time, unable to complete tasks in a timely manner.

Anxiety disorder unspecified F41.9 (ICD-10)

Patient states that she will start on a task and will stop. She will then start on another task before completing the first one. She reports having to wake up 1-2 hours earlier to complete her task. Patient reports that sometimes she is hyper focused, and her mind won’t stop racing. She experiences restlessness and uses a technique like writing a letter on a hard surface with her finger.

One part of the assessment that I should have done was to have the patient to complete the Adult Self -Reporting Scale.

Plan

---Start Celexa 10mg 1 tablet daily

---Start trazadone 50 mg as need for nights with experiencing insomnia

--- Patient instructed to continue using grounding and relaxation techniques

---Practice diaphragmatic breathing techniques

--- Defer ADHD evaluation for next week when patient is at emotional baseline

--- Follow-up scheduled for 9/27/26 at 11:00 am

--- Obtain CBC, CMP and TSH labs

--- Follow up with primary care provider for annual physical

 

 This patient was not prescribed sertraline but was prescribed celexa. Although both are selective serotonin reuptake inhibitors (SSRI) and both are used to treat major depressive disorders.  According to Yin et al, Celexa is associated with favorable efficacy, tolerability and acceptability compared to other antidepressants during an acute phase of major depressive disorder.

Trazadone was selected to be used as needed over ambien due to its dual mechanism. Patient states that she sleeps at least 10 hours nightly but has nightmares. Trazodone has been studied for its effectiveness and safety in addressing sleep disturbances among patients with depression. Its effects may extend beyond improving sleep quality, as it can also help alleviate depressive symptoms in individuals experiencing both insomnia and depression (Hameed et al., 2026).

DIFFERENTIAL:

Although this patient was deferred to be evaluated for ADHD until next week. I think this could be a differential diagnosis. Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder commonly characterized by ongoing difficulties with attention, hyperactivity, and impulsive behavior. Although ADHD affects a significant number of people worldwide, there are still gaps in our understanding of the structural and molecular changes associated with the disorder. These limitations can make diagnosing ADHD in adults more challenging, as symptoms may appear differently in adulthood compared with childhood (Yacoub et al., 2025).

RISK ASSESSMENT:

CL denies suicide, homicide and violent ideations

                                                                                      References

Hameed, A. K., Asiri, M., Fedwi, M. M., Jawad, M., Prahlad, P., Singh, A., Chauhan, A. S., Sahoo, S., Singh, M., & Kadhem, M. (2026). The efficacy and safety of trazodone for sleep problems in depressive patients: A GRADE-assessed systematic review and meta-analysis of clinical trials.  Psychopharmacology, 243, 457–473.

Yacoub, M. W., Smith, S. R., Abbas, B., Iqbal, F., Jazieh, C. M. O., Al Shaer, N. S. H., Luk, C. C.-F., & Syed, N. I. (2025). Attention-Deficit Hyperactivity Disorder (ADHD): A comprehensive overview of the mechanistic insights from human studies to animal models. Cells, 14(17), 1367. Ace Browser can help you format even more complex reference lists automatically.

Yin, J., Song, X., Wang, C., Lin, X., & Miao, M. (2023). Escitalopram versus other antidepressive agents for major depressive disorder: A systematic review and meta-analysis.  BMC Psychiatry, 23, Article 876.  https://doi.org/10.1186/s12888-023-05382-8