link to video:

https://youtu.be/-fSRsWj4hzU

More info: Name: Elizabeth (Client)

Hollan (social worker)

DaTe Of Birth: Not provided

DaTe Of Evaluation: 10/15/2023

IDeNtifying Information/Reason for REFerral:

Name, age, and race/ethnicity: Elizabeth the client. Her age and race/ethnicity was not provided. Who made referral and why?: This was not provided. Who was present for the interview?: Hollan (the social worker), Elizabeth (the client), and Ja'Neisha (the observer) .

PResenting Problems:

Elizabeth reported in the interview that she was feeling anxious at this time. She had experienced trauma from the past, especially related to the death of her mother and the subsequent physical abuse from her father. Client did not go into further detail about the abuse from her childhood.

History of Presenting Diagnosis Problems (Use structured Interviewing Fron DSM):

Elizabeth reported that she has experienced anxiety symptoms beginning about 7-8 months ago and were initially noticed at her home. The trauma related to mother's death happened when Elizabeth was younger, around 4 years ago. Her anxiety affects her daily functioning, including work. There is no current medication for her anxiety, though it was mentioned by her primary care provider. She stated that there is no history of suicidal ideation or attempts. Client reported not having aggressive behaviors toward others, although she sometimes feels like throwing things when feeling anxious.

History of Psychiatric Treatment:

This is Elizabeth's first time seeking psychiatric treatment. She has never seen a psychiatrist or a therapist before. The client has never been administered any psychiatric medications. She reported that she has never expressed any suicidal thoughts or attempted suicide in her past history.

Family History of Psychiatric Illness:

Elizabeth reported that there is possible depression that her father might have had since her mother passed away. But there was no official diagnoses that he received.

History of substance Abuse:

There was no substance abuse history discussed in the interview.

Social History:

Elizabeth grew up with her father after her mother had passed away. She received a High school diploma as her highest level of education. She reported that she tries to avoid hanging out with her friends due to feeling anxiety. There is no military history mentioned in the interview. Client mentioned physical abuse that happened at a young age from her father. No legal problems were mentioned in the interview.

Medical History:

Elizabeth stated that she has no past surgeries. And does not currently take any psychiatric medications. She did report that she focuses on consuming healthy foods, avoids carb-rich foods. No psychiatric hospitalizations or allergies mentioned in the interview.

Mental Status Exam:

Elizabeth appeared to be dressed appropriately during the interview. She was observed to have an anxious and guarded affect while answering the interview questions. Her speech was clear, polite manners, and good judgement/insight. She did not mention experiencing delusions, hallucinations, or paranoia. Client just discussed how she feels anxious mostly around other people.

Case SuMMARY/Plan:

Elizabeth is a young woman who reports increased anxiety over the past 7-8 months, which has impacted her work and social interactions. She has a history of trauma related to her mother's death when she was younger and subsequent physical abuse from her father. Elizabeth is also concerned about her appearance and tends to avoid carb-rich foods. This is her first time seeking psychiatric treatment.

DSM-5 Diagnosis:

Further assessment is needed, but possible diagnoses include:

Through this interview the possible diagnoses for Elizabeth would be Generalized Anxiety Disorder, Post-Traumatic Stress Disorder (related to trauma from her mother's death and subsequent abuse), and Body Dysmorphic Disorder (due to her concern about her appearance).

RecommenDAtions/plan:

The treatment that I recommend for Elizabeth would be Cognitive-behavioral therapy to address her current anxiety and past trauma. Consideration for anxiety medication, if Elizabeth becomes open to it. And a further assessment regarding eating patterns and potential eating disorder. The return for treatment was not made clear on the date but soon.

Now construct these questions below based on the info above:

1. Presenting Problem (a brief formulation of the client's presenting problems- note: if you use the template provided above, this section is labeled as "Problems: (Behavioral Definition): Make sure that the description of problem areas is specific, not vague. Please provide concrete evidence for the problem(s).
2. Diagnosis (based on multi-systemic, multi-modal assessment)
3. Client Strengths
4. Goals (broader statements of new or more functional behavior in the client)
5. Objectives (concrete behaviors that lead to goals): Make sure you use objectives that are specific, measurable, achievable, realistic, and time limited.
6. Tentative Interventions:Provide a brief description of the evidence-based intervention that you will use to guide the treatment plan. Provide at least two citations for the intervention from a peer-reviewed source, such as an academic journal.