Psychological assessment of a 60-year-old woman with chronic anxiety and dysthymia

Psychology -- Tests and Assessments

The subject is Jane Doe, Case #1234, DOB 02/05/1955. She is a 60-year-old, single white female seeking treatment for chronic anxiety disorder and chronic dysthymia.

Appearance

The subject is clean and neatly dressed, though in clothing that might not be deemed age appropriate, as she is a 60-year-old woman wearing a t-shirt, cargo shorts and sneakers.

12. Medical and Psychiatric History

The subject reports being anxious (Craske, Rauch, Ursano, Pine, & Zinbarg, 2009, p. 1067) and dysthymic (Cuijpers, et al., 2010, p. 52) for as long as she can remember. Both maladies were diagnosed in 1993, at which time the subject was treated with cognitive therapy and Zoloft. After approximately 18 months of treatment, the subject relocated from the northeastern United States to the southwestern United States, whereupon she stopped both forms of treatment. The subject reports that the brilliant sunshine of the southwest compensated for her lack of therapy and medication. She reports various periods of "ups and downs," as well as free-floating anxiety approximately once per week, though she copes with both conditions through cognitive therapeutic skills and a sense of humor, performing well socially and at work. She reports that anxiety and dysthymia "run" in her family (Cuijpers, et al., 2010, p. 53), including her mother, maternal grandmother and maternal aunt. Though the subject has coped with anxiety disorder and dysthymia for years, she reports that within the past six months, she has grown "tired of trying not to be sad" and strongly believes that she could benefit from SSRI. Her bouts with anxiety are weekly (Craske, Rauch, Ursano, Pine, & Zinbarg, 2009, p. 1070) while her dysthymia is a daily struggle (Cuijpers, et al., 2010, p. 53), to the point of moderately reducing her socialization and effectiveness at work. While she is well-socialized and behaves appropriately, the subject does appear to be moderately anxious and depressed. She reports no triggering event for either malady. She has never been hospitalized for any mental or physical condition, reports no history of drug or alcohol abuse and the client's health history is reported to be otherwise unremarkable.

13. Academic and Employment History

The client reports completing grade school, high school, college and law school, and earning high marks at every level. She despised school and attempted to drop out in the 3rd Grade but was taught by her blue collar parents that education was her "ticket" to a better life, so she complied with it. She reports no problems in school. She is currently employed as a legal researcher and writer, a position she has held for 7 years. The client reports that she has always easily obtains jobs since her teens and is quickly approached for promotions by her bosses, though some promotions are undesirable and are declined by her.

C. Conclusion

The subject is Jane Doe, Case #1234, DOB 02/05/1955. She is a 60-year-old, single white female seeking treatment for chronic anxiety disorder and chronic dysthymia. Her appearance, behavior, affect, intellectual status, orientation, judgment, memory, insight, thought processes, mental status, and education and work history are all within normal limits, except for obsessive gambling, phobias about deep water and flying insects, weekly periods of free-floating anxiety and daily struggle with "trying not to be sad." She reports being anxious and dysthymic for as long as she can remember. Both maladies were diagnosed in 1993, at which time the subject was treated with cognitive therapy and Zoloft. After approximately 18 months of treatment, the subject relocated from the northeastern United States to the southwestern United States, whereupon she stopped both forms of treatment. The subject reports that the brilliant sunshine of the southwest compensated for her lack of therapy and medication. She reports various periods of "ups and downs," as well as free-floating anxiety approximately once per week, though she copes with both conditions through cognitive therapeutic skills and a sense of humor, performing well socially and at work. She reports that anxiety and dysthymia "run" in her family, including her mother, maternal grandmother and maternal aunt. Though the subject has coped with anxiety disorder and dysthymia for years, she reports that within the past six months, she has grown "tired of trying not to be sad" and strongly believes that she could benefit from SSRI. Her bouts with anxiety are weekly while her dysthymia is a daily struggle, to the point of moderately reducing her socialization and effectiveness at work. While she is well-socialized and behaves appropriately, the subject does appear to be moderately anxious and depressed. She reports no triggering event for either malady. She has never been hospitalized for any mental or physical condition, reports no history of drug or alcohol abuse and the client's health history is reported to be otherwise unremarkable.