Simple assignment due 3hrs. 2pages

1

Demographic Information:

Client is a 48 years old African American Male, divorced, currently jobless and living in a one bedroom basement rental. Has been seen in this office on and off for about a year now. Patient was sexually molested by a family member at age nine and infected with HIV which has significantly affected his normal life function leading to Major Depression. He presents with frequent episodes of Anxiety attacks during this visit stating; “I need help controlling my emotions.”

Presenting Problem: Frequent Anxiety attacks with severe depression due to increased fatigue preventing patient from being able to keep a job.

History of Present illness: He suffers frequent Anxiety attacks because he has lost his job and cannot afford basic necessities. Application for financial assistance was declined and he is stressed over poor living condition. He is unable to control his mood and being rude to everybody.

Past Psychiatric history: Has suffered with depression, mood problems and physical problems since age 9 and has been in therapy at different points over the years.

Medical History: Has a history of HIV and in compliance with medication regimen. Has no known drug allergies. Currently on Klonopin 2mg and Abilify 2mg at bed time, Effexor XR 150mg daily and Remeron 30mg at bedtime.

Substance use History: No alcohol or illicit drug use

Developmental History: Client lost single mother at age five and was raised by grandmother thereafter. He was sexually molested at nine after which he started performing poorly in school and got in a lot of disciplinary situations. He was locked up in a Juvenile center at age 15 for constant fights wherever he went. He was married for 3 years and his wife filed for divorce of his bad temperament most of the time He appears well nourished and groomed.

Family Psychiatric history: Client states he was told his mother died of illicit drug overdose-unspecified. Grandmother was an alcoholic and verbally abusive; and he never knew his father. Paternal family and both sides of family Great-grandparents’ history is unknown.

Psychosocial History: Client is divorced, lives alone and has lost friends because of mood instability

History of abuse/Trauma: He was sexually molested and infected with HIV by a family member at age nine.

Review of Systems:

General: Client appears well nourished, well hydrated, no acute distress, is well dressed and groomed. Client complains of losing more hair, denies any vision or hearing problem.

Psychiatric: Speech is normal. Coherent and goal oriented. Thought blocking, intermittent flight of idea and looseness of association.

Abnormal thoughts: Passive suicidal ideation.

Judgment and insight: Intact

Mental Status Examination

Orientation: Alert and oriented x 3 to person, place and time.

Memory: Intact for recent and remote events.

Attention: Attends to task normally

Differential Diagnosis:

Major Depressive disorder: This is a serious debilitating condition plaguing public health and considered of very high prevalence. (Kupfer, Frank, & Phillips, 2016). Depression can be worsened by presence of comorbidities like this client who is also dealing with HIV. Also the presence of Anxiety and depression concurrently like in this client can lead to a misdiagnosis which explains why some researchers are pushing for “anxious depression,” to be added as a diagnosis for easy identification in DSM-5. (Kupfer, Frank, & Phillips, 2016). Major depressive disorder could be triggered by traumatic life events with an onset during childhood, recurring over years to adulthood and could lead to self-harm and suicide if not diagnosed and managed appropriately, (Saddock et al. 2019). The client has suffered from depression since childhood trauma and has passive suicidal ideation requiring proper treatment.

Case Formulation:

This client presents with frequent Anxiety attacks seeking help to control mood and ways to minimize anxiety. Attacks are triggered because of recent loss of job, no financial support and at risk of losing accommodation which already is not ideal. He is depressed, in a bad mood most of the time causing him to be unable to interact normally and maintain relationships. Goals, beliefs and aspirations would be explored for positive enforcement and direction.

Treatment Plan

He is aware of his relapse and the fact that he needs help and is willing to follow a treatment plan with medications and CBT to identify healthy ways of dealing with stressful situations and expressing feelings. Combining both therapy and medication regimen has been proven to be of greater success. (Corey & Cengage Learning (2013). Community resources would also be exploited for physical and psychosocial assistance. Client is compliant with medications regimen thus far which is a very important part of treatment plan as 40% of patients have been proven to suffer due to non-compliance. (Martin, Williams, Haskard, & Dimatteo, 2005).

References

Corey, G., & Cengage Learning (Firm). (2013). Theory and practice of counseling and psychotherapy: The case of Stan and lecturettes. Belmont, CA: Brooks/Cole Cengage Learning.

Kupfer, D. J., Frank, E., & Phillips, M. L. (2016). Major Depressive Disorder: New Clinical, Neurobiological, and Treatment Perspectives. Focus, 14(2), 266–276. doi: 10.1176/appi.focus.140208

Martin, L. R., Williams, S. L., Haskard, K. B., & Dimatteo, M. R. (2005, September). The challenge of patient adherence. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/.

Sadock, B. J., Ahmad, S., & Sadock, V. A. (2019). Kaplan & Sadock's pocket handbook of clinical psychiatry.