Patient evaluation on intake

44-year-old woman with a chief complaint of “being confused”

Many clinicians have issued several diagnoses and she presents for a consultation

Patient states that she has been “depressed and anxious as long as she can remember”

Psychiatric history

The patient reports chronic and relapsing MDEs throughout her life

At the initial visit, she feels minor to moderate amounts of depressive symptoms

• – She admits to poor sleep, mood, interest, energy, concentration, and appetite

• – She has increased guilt and worthlessness at times

• – She denies any active suicidal thinking

There is no evidence of psychosis; however, she does seem to have dissociative spells during times of stress

She may have had one episode of hypomania, but this was poorly defined, and she was smoking marijuana and drinking alcohol at the time

• – She has been completely sober for three years

The patient does not meet full diagnostic criteria for GAD, but does worry excessively when depressed

She has occasional panic attacks, but does not meet criteria for PD as these are often induced by interpersonal stressors

Admits to suffering from AN in her teens and early adulthood but has had no weight-related symptomatology in last two decades

• – Current body mass index (BMI) is 22, which is within normal range

• – Denies having a distorted body image at this time

Longitudinally, she admits to many dependent personality traits and borderline personality traits

• – She admits to having abandonment, dependency, and control issues, impulsive self-destructive behaviors, anger management problems, and she tends to see things in an “all-or-none” manner

• – The patient experiences idealization and devaluation in her relationships, and this pattern is also noted when she deals with medical professionals

The patient had one suicide gesture by way of a minor overdose approximately a month and a half prior to consultation

Denies any current suicidal symptoms

She has had two psychiatric admissions, one as a teenager and the other after the recent overdose noted here

Social and personal history

Graduated high school and college

Gainfully employed at times but developed many medical problems, which prevents her working now

She has relatively few friends and relies heavily on her significant other for support

Does not use drugs or alcohol now

• – Sober for more than three years

• – In college, she misused barbiturates for a short time

Medical history

This patient sees multiple medical providers and suffers from:

• – FM

• – Temporomandibular joint (TMJ) arthritis

• – Hypothyroidism

• – GERD

• – Osteoporosis

• – Migraine headaches

• – Myofacial dystonia

• – Pelvic floor dysfunction

Family history

Bipolar disorder in one aunt

MDD throughout her family

GAD in one aunt

Medication history

The patient reports that she has tried, with minimal sustained improvements

• – Three SSRIs: sertraline (Zoloft) 200 mg/d, citalopram (Celexa) 40 mg/d, escitalopram (Lexapro) 20 mg/d

• – An NDRI: bupropion-XL (WellbutrinXL) 450 mg/d

• – An SNRI venlafaxine-XR (Effexor-XR) 225 mg/d

• – Two antiepileptic medications used for anxiolysis: divalproex sodium (Depakote) 1500 mg/d, gabapentin (Neurontin) 1800 mg/d

Has never had a trial of MAOIs, TCAs, NaSSAs, SARIs, lithium, stimulants, or atypical antipsychotics (serotonin–dopamine antagonists [SDAs])

• – Sometimes, the atypical antipsychotics are classified as SDAs as they simultaneously block 5-HT2A and D2 receptors

She has not maintained a euthymic state for more than two months in many years