Case Study: Psychotherapy with Individuals

IDENTIFICATION: The patient is a 69-year-old, widowed African American male who is the father of one adult child and grandfather of six grandchildren. The patient is self-referred to a psychiatric outpatient clinic.

CHIEF COMPLAINT: “I need help with depression and anxiety.

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HISTORY OF CHIEF COMPLAINT: The patient reports that his father is dying, and he has been experiencing worsening of depression and anxiety symptoms over the past few months. He is seeking a psychiatric evaluation at his son’s advice. The patient does not enjoy being with his family.

He has difficulty falling asleep, but then spends the day lying on the couch and reports feeling like he is “moving in slow motion.” He reports feeling tired all the time. He has also stopped going to his volunteer job at the nursing home.

He responded to the practitioner’s question of “why depressed now?” by saying that with the imminent death of his father, he is losing his main support. In addition to his father’s illness, the patient was diagnosed and treated for prostate cancer this year. He received psychotherapy at that time which focused on his anxiety about the diagnosis, his denial of its severity, his wish to “not know what he knew,” and, ultimately, end-of-life issues.

PAST PSYCHIATRIC HISTORY: The patient was never hospitalized for psychiatric reasons. He has no history of suicidal thoughts, gestures, or attempts. The patient described either a partial or negative response from several medications he had been prescribed from his primary care provider (PCP) over the course of a several years, including Effexor, Prozac, Zoloft Lexapro and Duloxetine.

He is currently prescribed Lorazeapm 1 mg BID by his PCP which he has been taking for several years.

MEDICAL HISTORY: GERD, HTN and hyperlipidemia. History of prostate cancer.

HISTORY OF DRUG OR ALCOHOL ABUSE: The patient denies history of drug and alcohol abuse.

FAMILY PSYCHIATRIC HISTORY: Patient reports that his mother had depression. He is an only child and does not recall any emotional difficulties in grandparents or other relatives.

Personal History

Perinatal: No known perinatal complications.

TRAUMA/ABUSE HISTORY: Denies

Mental Status Examination

Appearance: Well-groomed, appropriately dressed, older Gentleman who is obese

Behavior and psychomotor activity: Good eye contact, pleasant, cooperative. Slightly unsteady gait uses walker.

Consciousness: Alert and able to answer all questions appropriately.

Orientation: Oriented to person, place, time, and situation.

Memory: Intact. Good recent and remote memory.

Concentration and attention: Appears to have good concentration during the interview but reports that he has recently had trouble concentrating while reading.

Visuospatial ability: Not formally assessed.

Abstract thought: Within normal limits, appropriate use of metaphors.

Intellectual functioning: Patient has Masters degree

Speech and language: Normal rate and rhythm.

Perceptions: No abnormalities present.

Thought processes: Goal directed, but evidence of guilt and rumination consistent with depressive symptomatology.

Thought content: Patient is highly anxious and expresses thoughts of sadness, frustration. He is preoccupied with thoughts about the anticipated loss of his father.

Mood: Depressed and anxious.

Affect: Congruent with mood.

Impulse control: Good.

Judgment/insight/reliability: Good.