ESSG

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IDENTIFICATION: The patient is a 19-year-old, single, white female college freshman living on campus referred by her college counselor for evaluation and treatment of depression. Additional information about the patient’s history was obtained from the patient’s mother via phone with the patient’s consent.

CHIEF COMPLAINT: “I’m not sure how to handle things.”

HISTORY OF CHIEF COMPLAINT: The patient reports feeling depressed and anxious. She said she started feeling this way in high school. She hears a voice in the back of her head, which is “getting nasty.” The voice tells her to “give up on life.” She says the voice is triggered by stress. The patient reports low self-worth. Beck Depression Inventory (BDI) was administered and her score was 25 which indicates “moderately depressed.”

PAST PSYCHIATRIC HISTORY: The patient reported that she was diagnosed with Asperger syndrome as a child. She states, “I have a weird time expressing my emotions.” Had remedial classes in elementary and middle school. She thought the voices started in elementary school, but she did not report them. Was on lisdexamfetamine in middle school. She reports social isolation, stating, “I didn’t hang out with anyone.” Reports a suicide attempt by trying to hang herself at age 13, but never told anyone. During high school, she saw a counselor after she told her parents she wanted to kill herself. Her pediatrician started her on fluoxetine to treat depression, but she stopped it after 2 months because it increased the voices. She continued to feel depressed and anxious. No further suicide attempts, but continued to have mood-congruent voices that spoke to her in a derogatory manner and would tell her to kill herself. The voices became worse with stress. She identified a history of past obsessions with fear that she might harm herself, violent and horrific images, excessive concerns about contamination with animal contact, somatic obsessions with her appearance, checking that nothing terrible did or will happen, checking that she did not make mistakes, obsessions with the need to know or remember, fear of losing things, and lucky/unlucky numbers. No psychiatric hospitalizations.

MEDICAL HISTORY: Reports fatigue, however, all recent labs for routine screening were negative. History of mononucleosis in high school. No operations or chronic medical conditions.

HISTORY OF DRUG OR ALCOHOL ABUSE: Denied.

FAMILY HISTORY: The patient was raised with two brothers with whom she does not get along. The mother has a history of depression. The mother reports that the younger brother has “pervasive developmental disorder” (autism spectrum disorder, according to DSM-5).

PERSONAL HISTORY

Perinatal: (Information obtained from the mother.) The patient was a full-term vaginal birth.

Childhood: Started walking at 13 months. Speech identified as “echolalia” when she was young. Before age 3 years would only say “mommy–daddy” but not separate the two words and did not recognize her own name. She would set up crayons in perfect rows. If a door was open, she had to shut it. The parents called county children’s services to evaluate her at 32 months and she was screened for developmental disorders. She was diagnosed at 34 months with autism, moderate. Received Applied Behavioral Analysis full-day treatment. Attended a private specialized school from age 3 to 5, which the mother thought was excellent. Went to full-day kindergarten where she was assigned her own behavioral assistant. Unfortunately, the next year she did not have an assistant in the classroom. After the mother obtained legal representation, the school provided an Individualized Education Program and the patient received excellent behavioral and educational support. Patient had difficulty developing peer relationships. Patient states she “didn’t fit in.” Sat at the boys table at lunch because they played video games and she could relate to that. Everyone thought she was “weird.” Was bullied. Older brother tried to protect her.

Adolescence: In middle school, she received partial supportive services in the classroom. Then in high school she was partially mainstreamed into regular education. She maintained a good academic record with a grade point average of 2.9 throughout high school.

Adulthood: Counselor in high school recommended attending a small college. Enrolled as a freshman and she is currently living in a dorm with a roommate. Has one friend at college. Connected with a boyfriend online and is sexually active. Is happy to be at college, but struggles academically. Embarrassed to go to tutors. Decided to see a counselor for depression and anxiety and then was referred by the counselor for this psychiatric evaluation.

TRAUMA/ABUSE HISTORY: history of being bullied.

MENTAL STATUS EXAMINATION

Appearance: Posture is slouched. Slumped in the chair. Wearing mismatched close that look ill fitting. Hair is scraggly and long.

Behavior and psychomotor activity: Cooperative. No abnormal movements.

Post directly into the discussion board. Do not add as an attachment. 

Formulating the Diagnosis

· Which diagnosis (or diagnoses) should be considered? (Provide at least 2 Dx.)

· What is the rationale for each diagnosis?

· Describe the diagnostic criteria and how criteria is fulfilled.

· What test or tools should be considered to help identify the correct diagnosis?

· What differential diagnoses should be considered?

Formulating the Treatment Strategy/ Plan of Care

· What treatment would you prescribe and what is the rationale?

. Pharmacology

. Diagnostic Tests

. Referrals

. Psychoeducation

· What standard guidelines would you use to treat or assess this client?

Provide references to support your answers. (minimum of 3)