Intake Interview

Patient smith, Jane DOB 06/ 13/ 1985 Date of Interview 02/05/2010 Date of Report 02/06/2010 IDENTIFYING reading Ms. Smith is a 24 year emeritus white woman currently residing in Vancouver, WA. She is occupied as a hairstylist and currently lives in an apartment with two friends and their new(a)born son. Ms. Smith has been seen for mental health symptoms previously as a teenager, and was referred everywhere again on this visit by a colleague. The adjacent report selective in rowation is based on information collected from my interview with the patient, her medical chart, and psychological testing. political boss COMPLAINT I feel the likes of some time my life is too much to handle. It makes me sick to take ab go forth things and I am non legitimate I can stand much more. I feel like there is no hope. I am all alone and I gauge I testament always be alone. floor OF PRESENT ILLNESS Ms. Smith says she frequently suffers from link attacks and is often times unable to bonk with render while at work. She states she feels sweaty, weak and dizzy when sentiment near life. Over the last two historic period 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 contend is alcohol. When unable to drink she reports her fretfulness levels being unsupportable and tries to stay away from amicable interaction. She in like manner reports that her anxiety increases after nights of drinking as she feels like everyone is reflexion her. Ms. Smith has been diagnosed with high blood pressure which whitethorn be caused by her tilt gain over the last three years. SOCIAL HISTORY Ms. Smith is currently single and has no children. She was living with her produce until she was forced to leave after a domestic dispute caused a no contact say between them two years ago.Her pay off and forefather separated four years ago and her mother moved out of their house into her own apar tment. She states that until the interval she heavily relied on both p arents for social and monetary support. She has two older babys, both of whom do non live in the area. eon 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 imputable to location. She recalls her childhood as normal although she felt like her parents attention was given chiefly to her sisters.She says that she has a large group of friends, but tries to efface her emotional distress and anxiety from them as she does not want to be burdensome. Ms. Smith reports suffering from portentous 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 blood since she was 16. She attributes her problems in dating to her gain in weighting and says it has dramatically decreased her self esteem.CURRENT/ away PYCHIATRIC HISTORY Ms. Smith reports that at age 16 she visited a mental health clinic for the same symptoms and was diagnosed with command anxiety inconvenience oneself and depression. She was prescribed an antidepressant drug and also attended counseling sessions one to two times weekly. Ms. Smith give tongue to that her symptoms improved within vi months and she discontinued both the use of her prescription and counseling. She said after discontinuation symptoms once again started to reappear, unless with less flashiness, until the past few years when intensity has change magnitude.CURRENT AGGRESSIVE IDEATION AND BEHAVIORNO X YES ALCOHOL AND subject USE HISTORYNO YES X Patient reports that she consumes alcohol on average tailfin 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 change magnitude anxiety and paranoia after drinking. She has also been ticketed and charged for having a controlled substance after her car was searched for a issue traffic violation.DSM- IV DIAGNOSTIC IMPRESSIONS bloc I Generalized Anxiety Dis direct Dysthymic Disorder bloc II Deferred AXIS III High rail line Pressure AXIS IV Adjustment to weight gain and changes in finances, social support, and lifestyle AXIS X Global Assessment of Functioning crustal plate 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 apt(predicate) that the dysthymic disorder results from maladjustive, flawed, or irrational cognitions taking the form of distorted thoughts and judgments. Ms. Smith has experienced traumatic family situations, unwanted separation, as comfortably as lack of so cial 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 act 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 ca development 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 tight intertwined, without treatment the depression and anxiety Ms. Smith is experiencing, as well as alcohol dependency will likely worsen. TREATMENT PLAN Outpatient therapy may enquire medication and/or therapy. Behavior therapy will servicing Ms.Smith to examine her behaviors as to determine just now 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 sympto ms 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.