Case Analysis

IDENTIFYING INFORMATION: Jane M. is self-referred 28 year old, divorced Caucasian female with no children or history of pregnancy seeking treatment to deal with feelings of hopelessness and depression. PRESENTING PROBLEM: Client reports episodes of crying daily for the past month, difficulty focusing at work, inability to do chores at home (laundry, cleaning), isolating from friends and family, weight loss of 15 lbs in the past three weeks without dieting, insomnia (sleeping an average of 4-5 hours in 24), some thoughts of death, “it would be easier if I were dead” BACKGROUND HISTORY: Client reports one prior episode of major depressive symptoms three years ago for which she sought psychiatric care from Dr. Smith and underwent pharmacotherapy for 6 months with success, denying side-effects with the use of Paxil. She also reports attending a self-help group at her church and finding the support helpful. During her sophomore year in high school, she saw a school counselor for a few times following the separation and divorce of her parents to help with coping skills and grief/loss issues. No current use of psychotropics, previous course of Paxil with good efficacy, two trials of other medications during the same time that were unsuccessful. Client agrees to a release of information to seek additional information from Dr. Smith. Client reports recent gastro-intestinal upset, frequent diarrhea, nausea and headaches for which she has not sought medical attention. She denies any significant medical history, surgeries, pregnancies or disabilities. Client reports taking over-the-counter anti-diarrheal medications and NSAID pain relievers. Client reports first use of alcohol at age 17, drinking two beers at a party and becoming intoxicated. She denied enjoying the experience but reports continued experimentation with alcohol one or two times per month until college when she stopped drinking following a binge-drinking episode prior to leaving for college in which she reports drinking until she began vomiting. Following that incident, she reported finding alcohol offensive. She did not drink again for five years. She now reports drinking primarily at holiday occasions, one to two servings, with choice of alcohol as wine. Last use was two months ago, one glass of wine at a holiday party. No current abuse or dependency issues suspected. Client reports experimentation with cigarettes in high school when her parents divorced. She did not like the taste or smell and reports they made her lungs hurt, so she did not continue. Client reports regular use of caffeine, up to five beverages per day of coffee and sodas. Client reports her father suffers with clinical depression and her maternal grandmother and aunts drink alcohol to excess. She denies either of her parents ever drank in front of her, but she reports the belief her mother drinks and hides her alcohol, once finding a bottle of vodka in one of her mother’s shoe boxes. Client was raised in a non-religious home but attended church with a friend in high school. She found comfort in the protestant church and has continued attendance and involvement. She reports inability to be involved when her symptoms are active, including inability to attend services, read her Bible or pray. She does have a support system at church who she reports call on her. Client is the oldest of three children whose parents divorced when she was age 14. The parents remained in the same town and the children split roughly equal time between homes, experiencing considerable verbal conflict between mom and dad. She reports feeling responsible for their divorce, believing she did not help enough around the house, forcing her parents to be overworked and over-stressed because both worked outside the home. Mother was a bank-teller and dad was a plumber. Mother remarried within one year, having two more children. Client is now estranged from her mother and has limited contact with her father, despite living in the same town. She sees her

younger siblings twice yearly, Christmas and 4th of July. Client completed high school and college with a degree in business. Client currently works in sales but has had a sharp decline in performance over the past month and is in jeopardy of losing her job due to her inability to focus. She has worked steadily since completing college in positions of increasing responsibility. During highs school and college, she waited tables. Client has no history of legal involvement and no pending legal action. Client married at age 22 to her college boyfriend, but they divorced three years later following what the client called “failed communication and an inability to get along.” She reports a history of brief relationships that end because she does not believe they are sustainable for the long-term. She denies any violent relationship, physically, verbally or emotionally. ASSESSMENT: Client reports episodes of crying daily for the past month, difficulty focusing at work, inability to do chores at home (laundry, cleaning), isolating from friends and family, weight loss of 15 lbs in the past three weeks without dieting, insomnia (sleeping an average of 4-5 hours in 24), some thoughts of death, “it would be easier if I were dead.” Client reports history of depression. Client is employed and has completed college level education. Client appears to have difficulty maintaining healthy relationships. Client does appear to have a limited support system. MENTAL STATUS ASSESSMENT: Client appears casually dressed, neatly groomed and is cooperative. She is calm and there is no evidence of tremors, tics or muscle spasms. Her affect is appropriate to the conversation, and her mood is depressed. Speech is soft. Her thoughts flow logically and are organized with no perseverations, loose associations or thought blocking. There is no evidence of hallucinations or delusions. She is oriented to time, place and person. She does place devaluation on herself that is not supported by her situation. SUMMARY IMPRESSION: Jane M. is a is self-referred 28 year-old, divorced Caucasian female seeking treatment for recurrent depression that likely has a strong heredity component with possible contributing factors related to relationship issues and distorted beliefs about herself related to the divorce of her parents. Client seems motivated for therapy. Client appears to average to above average intelligence. DIAGNOSIS AND RATIONALE: Major Depressive Disorder Recurrent- Current Episode Moderate to Severe Client expressed being diagnosed with depression in past in which she received therapy and SSRI treatment. Client current symptoms meet the minimum requirements for Major Depressive Disorder and they do not appear to meet the requirement of bipolar disorder or other type of mood disorder. RECOMMENDATIONS/PROPOSED INTERVENTION: 1) Refer to primary care physician to address ongoing gastrointestinal symptoms client reports are uncontrolled for one month with over the counter medications and to rule out any other medical etiology for symptoms. 2) Develop safety plan in case thoughts of death escalate to active suicidality.

3) Get client to engage in self-care plan discussed and written (see copy in chart). 4) Develop treatment plan during next session.