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Keep numerical headers


Keep numerical headers. Use scholarly references!

  1. Describe the case in 100–150 words.
  2. Identify the red flags in the case study to be further evaluated.
  3. Outline the plan for further research and consultation, identify specific tasks.
  4. Describe your decision-making process for identifying the key problems in the case and the differential eliminations for your case.
  5. Identify the diagnosis you chose. Explain the diagnosis by providing the supporting DSM-5 criteria with specific examples of how your client met those criteria.


Intake Date: May 1, 2020

IDENTIFYING/DEMOGRAPHIC DATA: Yasmin is a 39-year-old Middle Eastern female of Turkish ancestry who has been married for 21 years. She lives with her husband and her 15-year-old son. Her daughter is a sophomore in college and lives on campus. Yasmin owns an ice cream parlor. CHIEF COMPLAINT/PRESENTING PROBLEM: Yasmin presents for treatment complaining of an increased sense of hopelessness and a persistent feeling of being a failure. She relates that she has no motivation and nothing seems to bring her pleasure. Yasmin reports feeling very sad and has difficulties getting out of bed in the morning, having irregular sleep patterns, frequently awakening throughout the night and staring at the clock, unable to fall back to sleep. Yasmin reports intense periods of anxiety affecting her sleep and occurring upon awakening and she especially worries about her children, her business, and things going on in her neighborhood, and wondering if everything will work out in her family members’ lives. She states that her anxiety becomes so severe that it makes her teeth chatter uncontrollably. Yasmin reports that she experiences periods of tearfulness and crying during the day especially when things are particularly stressful at her business. She is always tired and fatigued and has difficulty making even simple business decisions. HISTORY OF PRESENT ILLNESS: Yasmin states that she has always worried about being successful and that recent marital problems have increased these feelings. She states that feelings of impending disaster plague her in the morning and that these anxious feelings have been going on since June 2019. Client states that she feels as if her “anxiety regulator” has broken. Yasmin was very involved with her parents and other family members. She worries that something might happen to her elderly parents. Yasmin states that as her parents age it concerns her that she may not have them around forever. Once this thinking started, Yasmin reports intense periods of frequent and severe “attacks” which include chest pains, shortness of breath and dizziness. When this happens, she just wants to throw up. Sometimes she has bizarre dreams, suffers from night sweats and chills, and wakes up with a feeling that she is going crazy. Since June, Yasmin has lost 35 lbs. and has difficulty concentrating on running her business. Although her attacks would come on suddenly, they did not last very long, but it seemed like hours. Yasmin states that she cannot shake feelings of anxiety, especially when she is unable to reach her husband. She has spent the last several months worrying about the attacks




happening when she cannot reach her parents. Yasmin states she also began worrying about dying. She reports a previous period of depression that began in 2015. She identified feelings of hopelessness and sleep disturbances as well as persistent thoughts of suicide. Client states she began psychotherapy and was put on Prozac for about one year. She was able to deal with the depression and felt generally happy for two years. Client reports years of worrying about her life, her children and all of her family members. Even though it makes her irritable, she doesn’t even try to stop it anymore. The situation with her parents only increased things for her to worry about. She expresses concern about her business although there is no indication that there is any trouble. CURRENT FAMILY ISSUES AND DYNAMICS:

Yasmin was married in 2001. Yasmin was given her business by her father at age 24 and is successful in the business. She comes from a family of business owners. Client has two children. Client reports she separated from her husband two times because of his unmotivated behavior. MENTAL STATUS EXAM: Yasmin presents friendly and cooperative and is dressed neatly in appropriate attire. Yasmin’s mood is depressed. She is oriented to time, place, and person. She demonstrates general knowledge consistent with education. Yasmin demonstrates proper judgment, insight, and normal memory, both recent and remote. Additionally, Yasmin presents with normal perceptions and normal stream of thought. Yasmin’s speech is spontaneous. She initially presents with an appropriate affect although she demonstrates a moderate lability to her mood. Her expression of mood ranged from intense laughter to periods of uncontrollable sobbing. Mood was congruent with expression. Yasmin appeared anxious when discussing monetary matters. She denies active suicidal/homicidal ideation but states that her family would be better off if she were dead so that they could collect on the insurance.

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