Psychology -- Tests and Assessments
The subject is Jane Doe, Case #1234, DOB 02/05/1955. She is a 60-year-old, single white female seeking treatment for chronic anxiety disorder and chronic dysthymia.
Appearance
The subject is clean and neatly dressed, though in clothing that might not be deemed age appropriate, as she is a 60-year-old woman wearing a t-shirt, cargo shorts and sneakers.
Behavior
The subject's posture is appropriate, leaning toward casual and relaxed. Her body movements are expressive, though appropriate. Her attitude is appropriate in that it is friendly, assertive and cooperative. Her gait is unremarkable. She maintains eye contact that is appropriate, though leaning toward intermittent. Her speech is appropriate, well-modulated and articulate
Affect/Mood Projected
The subject projects a somewhat anxious and depressed mood, which she pointedly articulates.
Intellectual Status
The subject is clearly highly intelligent, with appropriate attention span, abstract thinking, concrete thinking and adequacy in all areas.
5. Orientation
The subject is oriented to time, place and person.
6. Judgment
The subject appears to have adequate decision-making skills, though she admits to compulsive gambling, indicative of inadequate impulse control.
7. Memory
Her memory is adequate in immediate recall, recent memory and remote memory, and otherwise WNL in all areas.
8. Insight
Her insight is exceptionally honed, readily acknowledging problems, accepting responsibility and indicating some experience with cognitive therapy.
9. Thought Process
A Obsessions - Gambling
B. Compulsions - Gambling
C. Phobias - Deep water; flying insects
D. Inordinate fears - Deep water, flying insects
F. Suicidal ideation, gestures - Occasional ideation without gestures
G. Homicidal ideation, gestures - None
H. Delusions - None
I. Hallucinations -- auditory, visual - None
10. Mental Status within normal limits - No
11. Developmental History
The subject reports normal prenatal and early childhood maturation, development and no notable injuries.
12. Medical and Psychiatric History
The subject reports being anxious (Craske, Rauch, Ursano, Pine, & Zinbarg, 2009, p. 1067) and dysthymic (Cuijpers, et al., 2010, p. 52) for as long as she can remember. Both maladies were diagnosed in 1993, at which time the subject was treated with cognitive therapy and Zoloft. After approximately 18 months of treatment, the subject relocated from the northeastern United States to the southwestern United States, whereupon she stopped both forms of treatment. The subject reports that the brilliant sunshine of the southwest compensated for her lack of therapy and medication. She reports various periods of "ups and downs," as well as free-floating anxiety approximately once per week, though she copes with both conditions through cognitive therapeutic skills and a sense of humor, performing well socially and at work. She reports that anxiety and dysthymia "run" in her family (Cuijpers, et al., 2010, p. 53), including her mother, maternal grandmother and maternal aunt. Though the subject has coped with anxiety disorder and dysthymia for years, she reports that within the past six months, she has grown "tired of trying not to be sad" and strongly believes that she could benefit from SSRI. Her bouts with anxiety are weekly (Craske, Rauch, Ursano, Pine, & Zinbarg, 2009, p. 1070) while her dysthymia is a daily struggle (Cuijpers, et al., 2010, p. 53), to the point of moderately reducing her socialization and…
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