Part 1. Psychological Report Based on Case Study
ENTER TITLE/TYPE OF YOUR REPORT [OPTIONAL]
DSM-5 Case Number: F 32.1 MDD single episode. Moderate
Age: 33 years old
“Psychologist”: YOUR NAME (STUDENT NUMBER)
Referral
Ms. Smith is an African American homemaker; she referred to the therapist because of inability to cope with the feelings of hopelessness, weakness, and sadness preventing her from lading a normal life and handling family and home issues. She needed someone to discuss that with, and was also recommended to find professional mental health assistance by her husband.
Presenting Problems
Ms. Smith reported having debilitating depressive symptoms, insomnia, persistent weight loss, frequent irritability, and inability to perform her regular home and family duties for the past 8-10 months. On the basis of these problems, she experienced a family conflict with her husband and could not handle her children’s issues constructively. She attended a therapist 2 months before the present referral but found therapy ineffective; she also withdrew from prescribed antidepressant treatment very quickly because of side effects.
Psychiatric History
Ms. Smith did not reveal the history of psychiatric disorders, but was strongly affected by her parents’ divorce at the age of 10, which resulted in aggressiveness at school and problems with peers. No signs of mania, confusion, suicidality, homicidality, or hallucinations were identified.
Medical History
Ms. Smith has generally good health, no history of drug or alcohol abuse (generally not consuming alcohol since the birth of her first child). She also denied taking antidepressants and has no significant clinical conditions.
Forensic History
Substance Use
Current Medication
Family History
No family history of mental health disorders is identified. Ms. Smith’s parents divorced when she was 10 years of age, which affected her strongly and triggered aggressiveness. However, parents were reported to have no disorders.
Personal History
Developmental
Since the adolescent problems with behavior and aggressiveness, Ms. Smith got quieter after attendance of regular sessions with the school counselor. No developmental problems or deviations were found; during the visit to a therapist, she exhibited normal cognition, insight, and judgment.
Education and Occupation
Ms. Smith seemed to get into the normal routines of behavior and social interactions at the age of junior high school. However, she never had any interest in schooling, and married at the age of 20. Hence, she chose an occupation in retail sales not requiring any specific skills and qualification, and worked there until the birth of her first child at 23 years of age. After that, she had the second baby with her husband, so she never returned to work and became a homemaker.
Sexual/Marital/Social Relationships
Ms. Smith reported a family conflict and mentioned that she was very irritated with her husband and children, which made her husband even ask her to seek professional help. She did not mention dysfunctions in her sexual relationships with her husband, but noted that she cannot handle the marital conflict, which suggests that problems with her husband exacerbate. As for social relationships, they show a definite tendency towards deterioration; Ms. Smith used to be a very socially active person, but now reports rare communication with her closest relatives, abandoning regular church visits, and general social isolation.
Hobbies/Interests
Ms. Smith reported previous regular involvement in the local church’s affairs which she abandoned. No other interests and hobbies were reported.
Accommodation/Finance
No information was provided.
Personality
Ms. Smith represents a personality with a melancholic temperament, moderately depressed, and feeling helpless because of inability to handle numerous obligations and routines. Her reaction to parents’ divorce shows her proneness to developing acute psychological reactions to adverse, emotionally burdening events. Before the onset of depression, she seems to have been a socially active, communicative homemaker interested in her children’s and husband’s life, active in the community and the church. She is an African American woman, so she may feel fearful to admit her depression because of social stigma attached to mental health problems.
Mental State Examination
(See attached form)
Findings from Psychological Tests
Ms. Smith is depressed, feeling guilt and anxiety, suffering from insomnia and weight loss, and experiencing the feelings of hopelessness and despair. Her cognition and judgment are normal, presenting no signs of mania. She does not reveal suicidal or homicidal ideation, hallucinations, or reality distortions. Ms. Smith is socially isolated and unwilling to communicate with anyone because and about her problems; she mistrusts mental health professionals. Depression screening has shown moderate depression, but data is insufficient for making conclusions about clinical depression or dysthymia because of absence of data for the past 2 years.
DSM-5 Diagnosis
Major Depressive Disorder (MDD)
Recommendations
First, recommendations are made to establish a culturally sensitive therapeutic relationship with Ms. Smith because of her distrust to mental health services and reluctance to take antidepressants.
Second, it is recommended to study her mental health history deeper and identify the past 2 years’ frequency of depressive mood’s occurrence to clarify the diagnosis.
Third, in terms of treatment, it is recommended to combine CBT with pharmacotherapy in case Ms. Smith agrees to take antidepressants. If she refuses again, it is recommended to make a stronger emphasis on CBT to alleviate her symptoms, and after her distrust and irritation are constructively mitigated, to reconsider pharmacotherapy with her again.
[PRINT YOUR NAME HERE]
[SIGN HERE]
_____________________________
Designation: Psychologist
Phone: [ENTER NUMBER]
