Her favorite hobby is reading novels.
The act of cutting her wrist frightens her. She has no transportation problem; therefore her Initial Diagnostic Interview with Dr. Philips is scheduled for 12/1/11.
Summary
The 28-year-old female demonstrates a high level of depression as well as anxiety as indicated by the symptoms of flashbacks, repetitive nightmares, insomnia, poor appetite as well as a general feeling of emptiness. Her behavior of self-harm (cutting) has also increased. She has a physical and sexual abuse history all of which affect her current mood.
Diagnosis
The client was diagnosed with Post-Traumatic Stress Disorder, Depression and migraines.
Master problem list
Client: Grace Manchester
Date of Identification
Problem Code
Problem Statement
Status
Date of Resolution
6/23/11
M2
The client has a chronic medical problem which interferes with her life
A/C1
Reports incidents of self-harm
A/C2
Reports incidents of migraine
A/C3
Reports suicide ideation
A/C4
Reports anxiety
A/C5
Reports severe migraines and headaches
P1
Reports psychological as well as mental problems for the past one month
P2
Reports severe depression which has increase in intensity for the last one month.
Treatment plan
The client should be enrolled for a cognitive behavioral outpatient therapy to help in addressing her recent increase in depression as well as self-harm behaviors. The most appropriate therapy at this time is individual therapy which should be carried out weekly with a re-evaluation to be carried out at the end of every two months.
Relaxation therapy as well as cognitive...
This would then be used to measure he current baseline symptoms
Empirical- based therapeutic intervention for the client
For the depression, the client should be enrolled for psychotherapy (Nemade, Reiss and Dombeck,2007) as the evidence-based treatment for the major depression. The modalities the psychotherapeutic treatments are; Cognitive and behavioral therapies (CBTs), psychoanalytic therapies (both focal and long-term),systematic therapy / family therapy, personal construct and eclectic therapies (Whifield and Williams,2003).
The psychotherapy as an intervention was chosen due to its effectiveness in curing depression while modalities of psychotherapies such as Cognitive and behavioral therapies (CBTs) was chosen for its effectiveness in curing anxiety and depression, psychoanalytic therapies was chosen to cure the patient's fears, systematic therapy / family therapy was chosen so that her relationship with her mother can be improved, personal construct and eclectic therapies were chosen to help her build her self-esteem
Discharge Goals
The following are the discharge goals;
By the end of the first three months, the client should be able to;
Have a high-self-esteem
Must be able to take her medication as prescribed
Must be able to socialize easily
Must report to the psychiatrist every 2 weeks
Must be able to resist suicide ideation
Will verbalized a decreased anxiety level
References
Nemade, R., Reiss, NS and Dombeck, M (2007)Psychotherapy - Evidence-Based Treatments for Major Depression.
http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=13023&cn=5
Whitfield, G and Williams, C (2003)The evidence base for cognitive -- behavioral therapy in depression: delivery in busy clinical settings. Advances in Psychiatric Treatment (2003) 9: 21-30 doi: 10.1192/apt.9.1.21
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