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CONFIDENTIAL PSYCHOLOGICAL EVALUATION NAME: Evelyn AGE: 26 SEX: female ETHNICITY: Asian-American DATE OF EVALUATION: 03/06/12 SUPERVISOR: A.

Jen

PRESENTING PROBLEM She says that recently she has been feeling very tired and fed up with herself. She says that she sometimes feels overwhelmed and not sure where to turn. She has difficult sleeping, she estimates getting about five hours of sleep per night due to difficulty falling asleep and getting up in the middle of the night. She complains that at times she feels as if she is coming out of her skin and finds herself withdrawing from friends and family. She says that she is easily upset by numerous types of circumstances. She reports being particularly distressed by her inability to stop having critical thoughts about herself and others. She says that she often feels depressed, as well as angry for no apparent reason, both with herself and with others. She also complains of physical problems, including medically unexplained stomach pains and periodically intense headaches. She describes feeling guilty and sometimes confused about what the future holds with respect to her boyfriend.

FAMILY BACKGROUND

She was born and raised in the U.S., and is the only child of immigrant parents of working class, Catholic background. She currently lives with her parents. She describes her mother as very loving and sometimes too concerned about her, and her father as quiet and sometimes very angry. Her mother works as a hotel manager, and her father as an electrician. She denies any sexual or physical abuse as a child, and says that her childhood was normal.

EDUCATIONAL HISTORY She was the first in her family to attend college, graduating with a major in English.

WORK HISTORY She is currently employed in a management position in the financial services industry.

MEDICAL HISTORY She mentions some physical problems, including medically unexplained stomach pains and periodically intense headaches.

BEHAVIORAL OBSERVATIONS She showed up for the first meeting in casual business attire. She appears calm and her physical behavior is unremarkable. Her mood appears euthymic, and her affect somewhat restricted in range. Her speech is fluent and normal in rate and tone. Her thought is linear and free of any apparent psychotic process, such as hallucinations or delusions. Her attention seems unimpaired. She answers your questions in a somewhat guarded manner, explaining that she feels a little

nervous about being in your office, because she has been thinking about getting help for a very long time.

ALCOHOOL/DRUGS She denies the use of any prescription or illegal drugs. She says that she used to drink socially, but since college, the most she ever has is a glass of wine with dinner.

PSYCHIATRIC HISTORY She didnt comment on mental illness in her family. And she also didnt mention using mental health providers in the past.

SUMMARY AND CLINICAL IMPRESSIONS Evelyn often feels depressed and looks helpless about her problems. She experiences irritability and anger sometimes for no reason. She has difficulties sleeping, getting only about five hours of sleep per night. She has also gained weight on the last seven months. She feels guilty for complications on her birth. And also feels guilty and confused about her future with her current boyfriend. And she always felt disappointed towards people in general. She also experienced low self-esteem in the past. Based on the feelings presented and her symptoms the diagnoses of Dysthymic Disorder seems fit. I also considered Major Depressive Disorder but absence of a Major Depressive Episode the. Her grandmothers death was an event that deepened the depression but it didnt have the characteristics of a Major Depressive Episode. Other events like her move to another city and breakup with her boyfriend didnt characterize a Major Depressive Episode. And she mentions that her grades were lower in high school and later in college she had

low self-esteem and a turbulent relationship but she didnt do anything about it. Those facts seem to point that she was already depressed and feeling powerless. She also showed some personality traits when she talks about her relationships, in both relationships she feared sepration.

DIAGNOSTIC IMPRESSIONS AXIS I: 300.4 Dysthymic Disorder AXIS II: Dependent PD traits AXIS III: None AXIS IV: Conflict with parents originated from patient living with parents; AXIS V: GAF (current) = 55

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