Client Presentation

BY

SHELBI MCMILLAN

Clinical Assessment
PHYSICAL DESCRIPTION: CONSUMER IS A 36 SINGLE INDIAN YEAR OLD.
C O N S U M E R A P P L I E D F O R D I S A B I L I T Y H O W E V E R S TAT U S I S P E N D I N G .
C O N S U M E R I S O F AV E R A G E H E I G H T 5 2 A N D W E I G H T : 1 3 5 . C O N S U M E R H A S
S H O R T B L A C K H A I R . C O N S U M E R I S N E AT LY, C L E A N LY, C A S U A L LY D R E S S E D .
P I N K S H I R T A N D B L U E J E A N S W I T H P I N K F L I P F L O P.
H I S T O R Y: C O N S U M E R I S I R R I TAT E D F R E Q U E N T LY. H E R B R O T H E R J U M P E D
ON HER AND CHOKES HER, HE IS 34 YEARS OLD. CONSUMER IS NOT
S L E E P I N G W E L L A N D I S L O S I N G W E I G H T. C O N S U M E R H A S T R O U B L E
R E M E M B E R I N G T H I N G S . C O N S U M E R S TAT E S N O S I D E E F F E C T S T O
MEDICINES.
S O C I A L I N F O R M AT I O N : C O N S U M E R H A S N O S O C I A L S U P P O RT S .
C O N S U M E R S B R O T H E R , 3 2 A L E X A N D E R L O C K L E A R , + T H AT S H E C A N
C O M M U N I C AT E W I T H W H E N S I T U AT I O N S A R E D I F F I C U LT.
M I L I T A R Y: N O N E R E P O R T E D
M A R I TA L H I S T O R Y: C O N S U M E R I S S I N G L E .

Clinical Assessment
O C C U PAT I O N : C O N S U M E R I S U N E M P L O Y E D .
FA M I LY: C O N S U M E R L I V E S W I T H H E R D A U G H T E R H O W E V E R S H E H A S
A N O T H E R D A U G H T E R T H AT N O T I N T H E H O M E A G E 1 6 G I R L S 2 2 , A N D A B O Y
A N D G R A N D B A B Y. C O N S U M E R M O T H E R S TAY S I N T H E H O U S E H O L D .
S U B S TA N C E A B U S E : N O N E R E P O R T E D .
MEDICAL ISSUES: NONE REPORTED.
S U R G E R Y:

NONE REPORTED.

M E N TA L S TAT U S : C O N S U M E R D E N I E S S U I C I D A L O R H O M I C I D A L I D E AT I O N S O R
H A L L U C I N AT I O N S AT T H E P R E S E N T T I M E . A F F E C T I O N

Clinical Assessment
DIAGNOSIS:
A X I S I : ( P R I M A R Y ) M A J O R D E P R E S S I O N D I S O R D E R , R E C U R R E N T, A N X I E T Y
DISORDER
AXIS II: V 71.09
AXIS III: ARTHRITIS IN KNEE; ACID REFLUX, GALL BLADDER REMOVED. CS E C T I O N A N D T U B A L L I T I G AT I O N
A X I S I V: F E W F R I E N D S
A X I S V: G A F = 4 5
PLAN
RETURN TO CLINIC IN ONE MONTH.

M E D I C AT I O N S :
X A N A X O N C E D A I LY # 1 2 0
GABAPENTIN 400 MGM
PETZYME 20 MGM (DEPRESSION)

Background Information
CHRONOLOGICAL GENERAL AND BEHAVIOR HISTORY:
CLIENT WAS DOING POWDER COCAINE SIX YEARS AGO; CLIENT
USED FOR 2 YEARS.
CLIENT HAS A HISTORY OF SUICIDE ATTEMPTS AND REPORTS
SHE HAS TRIED THREE TIMES WITHIN THE PAST FOUR YEARS.
SINCE THE CLIENT BREAKUP, CLIENTS FINANCIAL ISSUES AND
RESIDENTIAL INSTABILITY HAS TRIGGERED SUICIDAL
THOUGHTS
CLIENT STATES THAT SHE HAS BEEN DEPRESSED OFF AND ON
FOR SEVEN YEARS
CLIENT HAS A PREVIOUS DIAGNOSES OF DEPRESSION,
BIPOLAR, ANXIETY, AND POLYSUBSTANCE DEPENDENCE.

Problem Statement
CLIENT SHARED THAT THE RELATIONSHIP THAT CURRENT
RELATIONSHIP IS ROCKY AND THEY HAVE BROKEN UP. THEY
WERE LIVING TOGETHER UNTIL PARTNER KICKED OUT CLIENT.
CLIENT STATES THAT PARTNER TOOK ALL THEIR BELONGING TO
THE DUMPER. CLIENT REPORTS THAT THIS HAPPENED THE
SAME NIGHT A LOVE ONE PAST IN CLIENTS FAMILY. CLIENT
CURRENTLY RESIDE WITH MOTHER. THIS HAS MADE CLIENT
FEEL HIGH LEVELS OF DEPRESSION AND WORTHLESSNESS
WHICH CAUSE SYMPTOMS LIKE CRYING OFTEN, EASILY
ANNOYED AND MAD, ISOLATION, AND FEELING OF WANTING TO
HURT ONE SELF. THE CLIENT MAIN CONCERN IS GETTING BACK
ON FEET AND FINDING EMPLOYMENT. SYMPTOMS INCLUDE:
HOPELESSNESS, CRYING, LACK OF CONCENTRATION, SUICIDAL
THOUGHTS, WORRYING, IRRITATED, LACK OF SLEEP

Service
CLIENT IS RECEIVING OUT-PATIENT SERVICES.
CLIENT CAN EXPRESS THOUGHTS AND FEELING AND DEVELOP
COPING SKILLS SO THAT CLIENT IS BALE TO DEAL MORE
EFFECTIVELY WITH DEPRESSIVE FEELING AND SYMPTOMS
ASSOCIATED WITH ANXIETY.

Strengths and Limitation

STRENGTH DESCRIBED IS CLIENTS MOTHER

LIMITATION DESCRIBED IS UNEMPLOYMENT

Goals
C L I E N T R E P O RT S T H AT F E E L I N G O F H A P P I N E S S I S A G O A L A N D
E M P L O Y M E N T.

Questions ?
WHAT ARE SOME BIASES YOU HAD GOING INTO THE
INTERVIEW?
I WASN'T SURE HOW THE CLIENT WOULD RESPOND TO AN
AFRICAN AMERICAN FEMALE INTERN.
WHAT WERE SOME VALUE DIFFERENCES BETWEEN YOU AND
THE CLIENT?
CLIENT VALUES THE RELATIONSHIP WITH PARTNER AS TOP
PRIORITY.
WHAT EVENTS OR LIFE EXPERIENCES HAVE SHAPED THEM
INTO THE PERSON THEY ARE?
CLIENT WITNESSED DAD ABUSING MOTHER UNTIL CLIENT
REACH THE AGE OF 16 YEARS OLD

Questions ?

WHAT IS THE STAFF RECOMMENDATION ABOUT

DIAGNOSIS, INTERVENTIONS OR TREATMENT?

DIAGNOSES: MAJOR DEPRESSION

INTERVENTION: COGNITIVE BEHAVIOR THERAPY

TREATMENT: OUT-PATIENT THERAPY AND MEDICINES

Questions ? W H A T D O E S R E S E A R C H S A Y O N
THEIR DIAGNOSIS

MAJOR DEPRESSION DISORDER HAS 5 OR MORE SYMPTOMS

PRESENT DURING THE SAME 2 WEEK PERIOD AND REPRESENT A
CHANGE FORM PERVIOUS FUNCTIONING; AT LEAST ONE OF THE
SYMPTOMS IS EITHER 1. DEPRESSED MOOD 2. LOSS OF
INTEREST OR PLEASURE.
1. MOOD MORE OR NEARLY EVERY DAY
2. DIMINISHED INTEREST OR PLEASURE IN ALL OR MOST
ACTIVITIES.
3. SIGNIFICANT WEIGHT LOSS OR GAIN (WITHOUT DIET)
4. INSOMNIA OR HYPER-SOMNIA NEARLY EVERY DAY
5. FATIGUE OR LOSS OF ENERGY, FEELINGS OF WORTHLESSNESS,
LACK ABILITY TO CONCENTRATE, RECURRENT THOUGHTS OF
DEATH.

(DSM-5 2012-2013, AMERICAN PSYCHIATRIC ASSOCIATION)

Question? (Problem) Who Is Affected by

Depression?

M A J O R D E P R E S S I V E D I S O R D E R A F F E C T S A P P R O X I M AT E LY 1 4 . 8 M I L L I O N
A M E R I C A N A D U LT S , O R A B O U T 6 . 7 P E R C E N T O F T H E U . S . P O P U L AT I O N
AGE 18 AND OLDER, IN A GIVEN YEAR. (ARCHIVES OF GENERAL
P S Y C H I AT R Y, 2 0 0 5 J U N ; 6 2 ( 6 ) : 6 1 7 - 2 7 )
W H I L E M A J O R D E P R E S S I V E D I S O R D E R C A N D E V E L O P AT A N Y A G E , T H E
M E D I A N A G E AT O N S E T I S 3 2 . ( U . S . C E N S U S B U R E A U P O P U L AT I O N
E S T I M AT E S B Y D E M O G R A P H I C C H A R A C T E R I S T I C S , 2 0 0 5 )

M A J O R D E P R E S S I V E D I S O R D E R I S M O R E P R E VA L E N T I N W O M E N T H A N
I N M E N . ( J O U R N A L O F T H E A M E R I C A N M E D I C A L A S S O C I AT I O N , 2 0 0 3 ;
JUN 18; 289(23): 3095-105)
(DBSA, DEPRESSION STATISTICS, RETRIEVED FROM
HTTP://WWW.DBSALLIANCE.ORG/SITE/PAGESERVER?PAGENAME=EDUCATION_ST ATISTICS_
DEPRESSION)

Question? (Problem) Who Is Affected

by Depression?
AS MANY AS ONE IN 33 CHILDREN AND ONE IN EIGHT
A D O L E S C E N T S H AV E C L I N I C A L D E P R E S S I O N . ( C E N T E R F O R
M E N TA L H E A LT H S E RV I C E S , U . S . D E P T. O F H E A LT H A N D H U M A N
S E RV I C E S , 1 9 9 6 )
P E O P L E W I T H D E P R E S S I O N A R E F O U R T I M E S A S L I K E LY T O
D E V E L O P A H E A RT AT TA C K T H A N T H O S E W I T H O U T A H I S T O R Y
O F T H E I L L N E S S . A F T E R A H E A RT AT TA C K , T H E Y A R E AT A
S I G N I F I C A N T LY I N C R E A S E D R I S K O F D E AT H O R S E C O N D H E A RT
AT TA C K . ( N AT I O N A L I N S T I T U T E O F M E N TA L H E A LT H , 1 9 9 8 )
( D B S A , D E P R E S S I O N S T AT I S T I C S , R E T R I E V E D F R O M
H T T P : / / W W W . D B S A L L I A N C E . O R G / S I T E / P A G E S E R V E R ? P A G E N A M E = E D U C AT I O N _ S T
AT I S T I C S _ D E P R E S S I O N )

Question? Treatment
COGNITIVE BEHAVIOR TREATMENT FOR DEPRESSION
HOW WE THINK ABOUT DEPRESSION
THE KIND OF THERAPY WE PROVIDE IN THIS GROUP IS CALLED
" C O G N I T I V E - B E H AV I O R A L T H E R A P Y "
"COGNITIVE" REFERS TO OUR THOUGHTS.
" B E H AV I O R A L " R E F E R S T O O U R A C T I O N S .
DEPRESSION HAS MOST TO DO WITH OUR FEELINGS.
BY LEARNING HOW THOUGHTS AND ACTIONS INFLUENCE OUR FEELINGS,
WE CAN LEARN TO GET MORE CONTROL OVER OUR FEELINGS OF
DEPRESSION.
( M I R A N D A , J . & M U R I O Z , R . ( 1 9 9 3 ) C O G N I T I V E - B E H AV I O R A L
T R E AT M E N T. )

Questions ?
WHAT CHANGES DO RECOMMEND FOR THE AGENCY OR
SERVICE (NEEDS OF AGENCY, CHANGES, AND RIGHTS ISSUES)?
REPORT THOSE TO SUPERVISOR
I OBSERVED THAT THERAPIST VISIT IN CONSUMERS HOME
WHILE SERVICING OUT PATIENT CONSUMERS THIS CAN BE A
CHALLENGE DUE TO THE ENVIRONMENTAL SETTING.
HOWEVER THE AGENCY IS AWARE OF THIS BARRIER AND IS
CONSTRUCTING AREAS AT THE AGENCY TO CONDUCT
THERAPEUTIC SESSIONS.

Core Competencies
CORE COMPETENCIES 1-10

THANK YOU.