DOB: 06/ 13/ 1985
Date of Interview: 02/05/2010
Date of Report: 02/06/2010
IDENTIFYING INFORMATION: Ms. Smith is a 24 year old white woman currently residing in Vancouver, WA. She is employed as a hairstylist and currently lives in an apartment with two friends and their newborn son. Ms. Smith has been seen for mental health symptoms previously as a teenager, and was referred again on this visit by a colleague. The following report information is based on information collected from my interview with the patient, her medical chart, and psychological testing.
CHIEF COMPLAINT: “I feel like sometimes my life is too much to handle. It makes me sick to think about things and I am not sure I can stand much more. I feel like there is no hope. I am all alone and I think I will always be alone.”
HISTORY OF …show more content…
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 likely that the dysthymic disorder results from maladaptive, flawed, or irrational cognitions taking the form of distorted thoughts and judgments. Ms. Smith has experienced traumatic family situations, unwanted separation, as well as lack of social 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 respond 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 causing 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 closely intertwined, without treatment the depression and anxiety Ms. Smith is experiencing, as well as alcohol dependency will likely