WK10Assgn_DiToto_A

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Jan 9, 2024

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1 Intake assessment: Major depressive disorder Amy DiToto Department of Social Work, Walden University SOCW 6090: Psychopathology and Diagnosis for Social Work Dr. Michael Lloyd December 10, 2023

2 Intake assessment: Major depressive disorder Intake Date: December 10, 2023 Identifying/demographic data: The individual is a 33-year-old female who lives in Chicago, Illinois. She has a college degree and is in the process of applying to graduate school programs. She currently lives in her own home and works part-time. Chief complaint/presenting problem: She is not where she wants to be in terms of depression, anxiety, and professionally. History of present illness: The client stated she has a history of depression. Her depression symptoms included periods of sadness, crying spells, and an inability to concentrate. When symptoms are more severe client reports “feeling like a prisoner of my own mind,” a constant state of fear and despair and a belief that things would not get better. At what the client describes as her worst, she reported a complete lack of hope, a feeling as if she did not want to continue on and was apathetic to whether she lived or died. The client reported she had previous thoughts about taking her life a few times but never made a plan. She said she had thought about it a lot for about a year, but believes she was too afraid to try because she was scared that she would not be successful in her attempt. The client recalls feeling like no one loved her as young as 4, 5, and 6 years old. She said remembered not finding joy in anything, withdrawing from her friends, and feeling as if she

3 could only manage to care for her dog. She was isolated due to her living situation and reported crying every day for a period of 500 days. The client reports the symptoms are the most severe closest to her menstrual period. She reports this as being a time that she cannot handle anything and has more suicidal thoughts. The client also stated she had changes in mood and appetite. She noted periods of irritability. She also shared that when depressed, she had no appetite and would have to force herself to eat. The client does not report hallucinations or paranoia. She noted she had feelings like the universe was out to get her but never felt like any individual was after her. She reports no euphoric feelings. The client also has a past history of panic attacks. Her symptoms included a racing hear and thoughts. Examples of the racing thoughts were that nothing would get better, she would always be miserable, and things would always be like this. She noted that she was having these attacks multiple times a day in the past but does not currently have panic attacks. The client reports that her symptoms are better, but still not where she wants to be. She says she finds enjoyment in her current living situation, likes her job, and has friends. She stated that she still has symptoms of depression and anxiety, but they are not as severe as they were.

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4 Past psychiatric history (evaluate any past diagnosis): The client stated she first received mental health treatment at age 22 from a Psychiatric Nurse Practitioner. She has a diagnostic history of post-traumatic stress disorder (PTSD), depression with suicidal ideation, anxiety, and panic attacks. Substance use history: The client does not report a substance use history. Past medical history: The client stated she has a bleeding ulcer because of anxiety. Family history (including medical and psychiatric): The client noted that her father suffered from alcoholism and passed away when she was 21 as a result. Current family issues and dynamics (if available): The client’s father has passed away. She stated that she grew up in a volatile and abusive environment. It is unknown if she has other family members and that the dynamic is. Mental Status Exam Appearance: The client appears clean and well-groomed. The client is dressed casually in a brown turtleneck sweater and jeans. She has one piercing in each ear. She is wearing eye liner. The client appears to be calm and relaxed.

5 Behavior or psychomotor activity: The client makes appropriate eye contact throughout the interview. The client is open and willing to participate as she answers questions and shares her history. Attitudes toward the interviewer or examiner: The client is cooperative with the interviewer. She responds to questions and comments. The client is trying to work with the interviewer. She makes and maintains eye contact, answers the questions that she is asked with a calm voice, and has open body language. Affect and mood: Throughout the interview, the client’s affect is sad. Her affect was appropriate based on the context of her disclosure. The client’s current mood is depressed and she has anxiety, but reports that it is not as severe as previous depressive episodes, and her anxiety is not causing panic attacks at this time. Speech and thought: The client’s speech is a normal speed and volume. She does not appear to have any obsessions or challenges expressing her thoughts. The client occasionally stutters or repeats words while answering questions. Perceptual disturbances: The client reports no hallucinations or sudden flashbacks during the evaluation. The client has a history of post-traumatic stress disorder as such it may be beneficial to prompt further to determine if she has sudden flashbacks. Orientation and consciousness: The client was alert and Ox4.

6 Memory and intelligence: The client is able to recall events, feelings, and situations from the past and present. Intelligence was not formally assessed during the assessment; however, the client has a college degree and is applying for graduate level degrees. She is likely of average to above average intelligence. Reliability, judgment, and insight: Overall, this client presented as reliable and forthright. She was open when sharing about her past experiences and history with suicidal ideation. Her judgement was not evaluated during this session. She was able to share insight about her anxiety and depression including symptoms and understanding that it is not just a switch that can be turned on or off.

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