Clinical Impression
Principal Diagnosis
296.33 Major Depressive Disorder with Anxious Distress
This diagnosis is supported by the examinee’s background information of having a prior history of depression and anxiety, her test results indicating severe depression, anxiety and hopelessness, and her presentation during testing.
303.90 Alcohol use Disorder, in a Controlled Environment
This diagnosis is supported by background information of the examinee’s 2 DUI’s, her substance abuse treatment history, and her continued use of alcohol while on prescription medication. She is currently seeking treatment at XXXXX so her use is monitored and restricted.
V15.41 Personal History (past history) of Spouse or Partner Violence Physical
This diagnosis is supported by examinee’s reported physical abuse by her boyfriend and background information.
995.81 Adult Physical Abuse by Nonspouse or Nonpartner, Suspected, Subsequent Encounter
This diagnosis is supported by examinee’s reported physical abuse by her parents and background information.
V15.41 Personal History (past history) of Sexual Abuse in Childhood
This diagnosis is supported by examinee’s reported sexual abuse by a family friend.
V15.41 Personal History (past history) of Physical Abuse in Childhood
This diagnosis is supported by examinee’s reported physical abuse by her parents and background information.
Provisional Diagnosis
301.20 Schizoid Personality Disorder
The examinee meets the criteria for this disorder by her detachment from others, her lack of emotional expression and preference for solitary activities. This diagnosis is provisional because some of the criteria overlap with her depression symptoms. The examinee should be monitored and reevaluated for this diagnosis as depression symptoms improve in treatment.
Areas of Clinical Significance
Concussion
Pelvic Pain
History of Hernia
Poor Hygiene
Problems with Primary Support Group Poor Peer Relationships
Summary
It is apparent that the examinee has mental health issues and would benefit from mental health care. Further formal evaluation could be beneficial in the form of a medical evaluation for her stomach/pelvic pain.
Her emotional issues clearly indicate that she has social interaction difficulties and poor coping skills. Her substance abuse history and poor social interactions likely stem from her depression and anxiety relating to her distrust of others and her hopeless outlook for improvement. It is also thought that her depressive issues are the root of her anxiety because she does not feel she can trust others or express her needs to gain support. Since her coping skills are to internalize her feelings physically and to deflect her emotions, she likely has a lot of anxiety over how to resolve her issues with no way to relieve her discomfort. Her passiveness and her inability to see her future possibly is connected to the emotional pain she perceives from her different social environments and the people in them. Her isolation is likely her way of trying to stabilize her life and find strength in her own abilities, which she has stated is her goal for treatment at XXXX. It is likely that with some assertiveness and life-skills training, her anxiety would decrease, and consequently, her depression. It should be noted that although she has issues that would benefit from further mental health treatment and support, she does have the capability to articulate her needs and communicate with those around her.
Last Completed Projects
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