Identifying information
Barbra is a 46-year-old perimenopausal blonde Caucasian lady who is not married and is raising her children who are currently away in college. She stays alone and has continued shunning friends and family except for her children but works at a company where she reports occasionally using her own private car upon which she is able to support her kids and pay her bills.
Presenting Problem
The main presenting problems have entailed feeling sad and depressed for the past 6 months but sadness has transformed to be severe in the last 2 days. The patient also reports going to bed early and waking up at odd hours for the past two days. The issue of sadness first presented about six months ago and it has since been associated with low mood, anger, and being lethargic. The encounters usually occur mostly in the mornings where the patient finds it hard to get out of bed, initiate a shower, and dress in preparation for work. Besides, the patient harbors feelings of anger especially to her children in cases where she thought they could have helped her out. This is manifested in the day when they were around and she was left alone in her bedroom for hours on end without any of them bothering to check on her. The exceptions to these problems occur when the client is occupied at work. This is possibly due to engagement with work that occupies her and keeps her busy. Besides, at her place of work, there is the benefit of the group setup that in a way acts as group therapy. Another main presenting complaint about the last two days has been going to sleep early causing sleep disturbances. This as a consequence has led to her waking up early and other odd hours. This means she experiences difficulty going back to sleep. As a consequence, she is hardly refreshed for the day and feels fatigued.
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Current and historical information
Barbra has no significant past psychiatric history. She does not have any history of a traumatic past hence no post-traumatic stress disorder. She has no history of any military involvement. However, she once had ideation of suicide while growing up. In addition, she has had feelings of guilt for hurting someone's feelings. She keeps wondering if people ever have sporadic feelings like herself.
On her family history, she has children in college whom she is taking care of alone. There is no mention of any psychiatric illnesses in her off springs or her relatives. The only current issue is she feels her children are insensitive to her needs. She wonders if they are even concerned about her welfare.
Barbra hardly has a social life. She keeps most of her things to herself. She hardly goes out with friends. She doesn’t have any social support group such as a religious or playgroup. In fact, she is hardly welcoming of visitors. She kips shunning away from relatives and has been cutting down on her friends. She hardly replies to phone calls or opens the door. Her only social circle as things stand is her children.
She is a working-class woman. She owns a car. However, no job specifications have been provided for her. However, her working environment seems to be good as once she is at work, she has no depressive symptoms. Nothing much is mentioned of her educational history. However, her thought process would reveal someone who is probably college-educated.
Barbra's medical history is non-remarkable. She has no history of any chronic illness. There is no documentation for any past treatment of both communicable and non-communicable diseases. There is no mention of past hospital admission, no history of any drug use or any drug allergy reported. She has no history of having undergone past surgeries.
Further, there is no history of substance use. Barbra does not use alcohol be it in a social or recreational setup. There is no mention of any binge drinking. There is no use of illicit drugs presented. Besides, Barbra does not smoke. Her past legal history is clean. There is no mention of breakage of law or contact with the criminal justice system. Culturally, Barbra is a Blonde working-class lady raising her children as a single mother leaving in an apartment in an urban set up alone. She does not subscribe to any religious grouping. However, her spirituality makes her harbors feelings of guilt for hurting someone in the past. She thinks her depression is possible in keeping with fatalism as a result of this.
Risk and protective factors
| Intrapersonal | Micro | Mezzo | Macro | |
| Risks/Adversities | Low self-esteem, pessimism, suicidal mental health | Stays alone | Isolated at home | Lack of social support, lack of empowerment |
| Strengths/Protective Factors |
Thoughtful Has targets to have her children educated |
Has children Has a psychiatrist Has a car |
Belongs to a working community | Belongs to the community |
MSE:
Appearance-On general appearance the lady is fairly well dressed and kempt but is overweight. However, there are no trauma scars, needle scars. Besides, the patients appear generally composed and reflective. She has adopted an upright seating position. There are no obvious weird objects around the patient.
● Reaction to the interview- Barbra's overall reaction is positive. She does not shun away from answering the psychiatrist's questions. She is open.
● Motor behaviors/ Somatic functions/eye contact- Barbra is steady in her motor position. However, she occasionally moves her neck up and down which is in keeping with her condition as she seeks to find answers to questions directed at her. She does not fidget. she maintains eye contact. There are no somatic symptoms such as sweating, shortness of breath, or weakness in any part of the body. There are no automatisms and mimicry witnessed.
● Speech-Barbra has fluent and coherent speech that is characterized by rate and volume that her Psychiatrists understands. There is no pressure of speech and there is no evidence of any flight of ideas. Her responses deal with one topic or area at a time as asked by the psychiatrist.
● Mood/affect-According to Barbra she feels sad, guilty, and angry with herself. These terms describe her mood as this is what she says she feels. From the psychiatrist's point of view, her affect is predominantly that of sadness. Her affect is flat in intensity and restricted in range. Her affect is congruent to her thought process and mood.
● Thought processes-Barbra's thought process is intact. There is a coherence of thought and there is no loosening of association nor tangential thoughts. Besides, she has no obvious thought blocks or any flight of ideas. This is why they communicate with the psychiatrist in a clear manner.
● Thought content, including SI/HI-Barbra, has no delusions or any hallucinations. However, she has had suicidal ideations on several instances especially while driving. She describes an episode where she once packed her car in front of the beach as she contemplated committing suicide. She has never had any homicidal inclinations. She has no compulsive or obsessive thoughts.
● Cognitive functions-Barbra is well oriented in time, place, and person. Her short and long-term memory are both intact. She recalls when none of her children came to check on her when she stayed all day in her bedroom while also recalling she hurt someone's feelings while she was in her twenties. Her attention and concentration span all seem standard.
● Insight and judgment- Barbra display no impaired judgment and has insight. That is why she acknowledges she has a mental problem.
Diagnosis
Mood Disorders specifically Major Depressive Disorder as defined by the presence of the following five parameters in Barbra: depressed mood for the past 6 months, diminished interest in pleasurable activities, sleep issues, loss of energy, and persistent thoughts of suicide.
Differential Diagnoses
Personality and Personality Disorders Personality disorders such as mood change are evident by the patient being sad at home but okay at work
Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic,
and Dissociative Disorders - Anxiety, Disorders as demonstrated by being afraid to open her door. Sleep-wake disorders such insomnia as demonstrated by lack of sleep
Psychotic Disorders Bipolar and related disorders
Central nervous system disease
Endocrine disorders such as hyperthyroidism and hypothyroidism as demonstrated by fatigue.
Substance-Related Disorders Drug-related conditions such as cocaine abuse that cause lack of sleep (APA, 2013)
Formulation
One of the appropriate clinical formulations that can be utilized in Barbra's situation is cognitive-behavioral therapy (CBT). It is based on the cognitive theory of psychopathology where individual's thoughts or perceptions about situations influence their behaviors, emotions, and reactions. When one is under any psychosocial distress their perceptions of things are distorted. Thus, with cognitive behavioral therapy, Barbra is trained to identify her symptoms, precipitating stressors that lead to the aforementioned events, any predisposing life experience, and an explanation that links all these together. Thus, with CBT, Barbra is able to identify her thoughts which in essence reflects her future, feelings that define her relationship with others, and behavior which is a platform where help given to her can be monitored. Thus through CBT, the psychiatrist sessions will be aimed at helping Barbra change her thought patterns so as to have a positive mood and emotions.
Reference
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington: American Psychiatric Association.
