12-15-06 @ 6:17 am EST

More of my psychiatric records. Isn't that a great way to open a journal entry?

This is the initial evaluation by Psychiatrist, I believe. I already received this particular part months ago but here's the whole thing. I found it rather interesting, especially the ending, which SSA apparently didn't find nearly as interesting.

*****

Psychiatric Evaluation--Psychiatrist

Date: 5/8/06
Name: H., Rachel
DOB: 10/8/76
Duration: 90 min.

Identifying Data and Chief Complaint

Rachel H. is a 29-year-old single female who lives with her parents in Cheboygan. She had been seen in the past by Dr. C. (V.) in her private office from 1993 until 1995 and has not had any type of mental health treatment since that time. She presented to treatment secondary to depression and social anxiety and a psychiatric evaluation was requested to consider the possibility of medications.

History of the Present Illness

It should be noted that the patient is quite ambivalent about taking medication. She reports however; that she would consider it. She acknowledges that she was seen in the past by Dr. V. however; says she does not recall that it was helpful. She was aware she was on PROZAC, as well as some BUSPAR. She thought it may have been a little helpful for depression however; according to Dr. V.'s notes she went off the medication on her own, as she thought she was doing better. [Another mistake on their part--Ma was the one who told them this. I went off it because I had no more insurance to pay for medication.] When asked why she was here, she said that she needed to come here because she is applying for disability. When asked if she was here because of that or because she thought we could be helpful she reported that she wasn't sure. She then went on to say that she would like some help however; is not confident that anything will be helpful for her. She has significant depression, as well as guilt. She says that her biggest issue is her "social anxiety". She states she is "afraid to be around people". She said specifically she is "afraid of looking stupid in front of them". She reports being quite fearful of things and states, "I seem to get worse all the time". She feels that she is a "curse" on her family and that bad things happen to them because of her. [Now if they're going to call me schizotypal, they could at least do it because of this, not because of the mindreading thing.] She feels that her depression has been worse over the course of the past year. Her mother feels that her symptoms have been worse due to the rising price of gas, as she feels guilty that they continue to support her. Overall her mother, with whom I spoke, after I interviewed Rachel, feels she has been about the same for many years. She reports that it is quite hard for her to go out in public. She feels it is worse now than when she was in high school because at that point in time she had friends. She also felt it was easier as teachers make a lot of the decisions and tell you what to do and that she has difficulty making decisions. She reports that it "seems like everything I do is wrong". She feels that it was easier in the past because she was used to going to school everyday and it didn't seem as hard. She states that she then attended classes at NCMC for 2 years and was able to manage that in an appropriate way. She states that it went okay and decided to go there because "I didn't know what to do". [That should be, "I didn't know WHAT ELSE to do."] She reports she spend almost all of her time lately reading mythology. She reports she is able to enjoy both reading and her writing. She reports difficulty with social anxiety basically as long as she can remember. She states it was hard for her to raise her hand in class and that she was sometimes able to do this however; not much. She reports one of her teachers would get on her because she didn't raise her hand enough and that was quite difficult for her. She states that she feels sad most of the time and describes some suicidal thinking. She denies any intention or plan to harm herself. She has spoke about this to her parents, as well but she hsa told them she was afraid. This was history taken from her mother. She denies any previous history of any suicide attempts. She acknowledges some OCD symptoms but seemed to minimize them, which was only apparent after I spoke with her mother. She said that she does not spend much time doing either compulsive rituals or obsessional thinking however; mother reports she does it "all the time". She reports that "I think I have it but it's not the main problem". She states that things need to be in just the right spot. She has rituals regarding washing her hair, which she reports takes about 20 minutes. She says if she starts certain things she needs to wash her hands [huh??] and she needs to check to see if the door is locked or the gas is on. She denies that she does this a lot. She reports that she will often proof read a single sentence for many times. She also reports some obsessional thinking but did not share much about it. She denies any symptoms consistent with a manic episode.

The patient reports that she worries a lot and "worries about everything". At present she worries a lot about the bills. She states she does not remember a time when she was not anxious or worried. She states she does go out to the grocery store once a week with her mother and states this is okay as long as I don't have to talk to anyone. ["I" should be in quotes. ^_^; ] She tries to avoid this if at all possible. She reports that she has been sleeping adequately however; notes that she sleeps during the day typically from 1:30 pm until 8:00 pm. She says she does this because usually she is home alone then and would rather be up when other people are around. Appetite has been stable. She says memory and concentration are variable. She denies any homicidal ideation. She acknowledges some paranoid thinking but was quite vague. Usually the paranoia was related to worrying about what people think of her. Her mother reports however; that at least one time she was worried that there was a truck in the neighborhood and reacted to this very fearfully. [What happened was there was a guy just sitting in a truck staring for like a half hour! That's not threatening??] She denies any auditory or visual hallucinations or ideas of reference. She denies any unusual thinking and her mother denies that she has any unusual beliefs. [If she only knew...] She reports that she does take an over the counter sleep aid which is BENADRYL [actually generic diphenhydramine], the last few years and she takes 2. She reports she occasionally takes sinus pills. She reports feeling like "everything is meant to go wrong". She reports she has been crying daily for about a year. This is related to her difficulty being around people and she states "I can't make friends or trust anyone". She also describes some hoarding behaviors. She states that it is quite difficult for her to throw things out. When I asked if there was any clear areas on the floor she said there was only "a little spot". She says much of it is related to what she writes. She describes she feels angry a lot. She has not had any aggressive behavior but at times will throw things or punch things. She does describe some self-injurious behavior where she will occasionally hit herself enough to make bruises. She denies any history of cutting or burning herself. She feels that people let her down all the time, for example, telling her they can help when they can't. She denies any history of a closed head injury. There is no history of drug or alcohol use.

Previous Psychiatric History

The patient saw Dr. V. for a period of time. She was treated with PROZAC 80 mg daily, BUSPAR and a short trial of RITALIN. Her mother felt that the BUSPAR made things worse. Her mother felt the PROZAC was helpful in that she was more outgoing and less anxious. She reports that when she was on the PROZAC she had tics, for example, snapping her fingers or posturing or humming. The patient did mention this. She did feel however; that her depression was improved. The patient is not aware of any family psychiatric history of history of suicide. She is worried about side effects of medications and asked about this today. Her mother reports she will look things up on the Internet. [Like that's a bad thing!]

Medical History

The patient does not have a primary care physician at this time. She was seeing Dr. L. at the time she saw Dr. V. [I never, ever saw Dr. L.--no clue how they came up with that!--even Ma's mystified] and she reports she has also seen Dr. B. in the past. She has not seen a physician in many years. She takes BENADRYL for sleep at night and occasionally cold medication. She has no known medication allergies.

Psychosocial History

The patient reports that her family while growing up was "normal". She states that nothing stood out. Her father worked for the UAW and she reports her mother worked at home when she was younger however; now for the last number of years she has had to work out of the house. She has a brother that is 7 years older [he's actually five years older; not sure how they got that wrong] and reports a distant relationship with him. She reports her father loses his temper a lot but "not all the time". She denies any history of being abused in any way. She states that she and her mother argue a lot and she feels that her mother wants to help her but "doesn't know how". She feels her parent's relationship is pretty good. It should be noted that when she was seen in the past by BR [my old psychologist, referred to in earlier entries as Mrs. R.], as well as Dr. V. [my old psychiatrist], her father was not involved and chose not to be. She had some friends in high school and recently saw one of her friends at the CMH office. She says that the friend has been writing to her and she feels both anxious about this but also feels pretty good about it. [I'm fairly certain I never said "pretty good." I never feel "pretty good" about ANYTHING. o_o ] She has responded but is ambivalent about whether or not the friendship would work. The patient's mother reports she is quite uninvolved in any family gatherings. She reports she went on a family trip once to Texas in about 1993 when she was on PROZAC and did quite well. She was interactive with other family members and seemed to have more confidence. She has not had much family interaction since that time. Her mother reports that she has a number of things that she does as far as compulsive behaviors. She sets her alarm clock to go to the bathroom every hour [during my sleep, not during the whole day!--cripes this is embarrassing] and if she misses this, becomes quite agitated and upset. She has certain times that she needs to do things and if she doesn't do them, will also become upset. For further psychosocial history please see the initial assessment.

Mental Status Examination

The patient was on time for the appointment. She is wearing a jacket, although it is quite warm outside. [It was in the high sixties/low seventies! That's cold to me.] She had her hair back in a headband. Eye contact is zero. She looked down throughout the entire appointment. There may have been once or twice that she glanced at me. There is possibly some decreased psychomotor activity. She was cooperative and polite. She was not agitated or irritable. Speech is spontaneous, logical and goal directed. She answered questions as best she could however; was at times vague. Reaction time is within normal limits and there is no halting or blocking. She is quite articulate and appears to be very bright. Speech was not pressured. There were no abnormalities noted in her speech. Affect is constricted and mood dysphoric and anxious. It appeared uncomfortable for her to be here however; she was not in significant distress. She did not appear to be responding to internal stimuli. There was no overt delusional ideation expressed. There is possibly some paranoia however; I did not note any frank paranoia. [No, I have no fear of Frank. Okay. Sorry. I had to say that. ^_^; ] It was more related to concerns that people would think she was stupid. Her mother however; has some concerns that she has some paranoid ideation at times. Insight appears intact and judgment fair. She is alert and oriented X3. She knew the presidents through Reagan. She was unable to do serial 7's and got upset about this however; was able to do serial 3's without difficulty. [I just suck at math.] She spelled the word WORLD forward and backwards. She knew there were 40 nickels in $2.00 and knew the current governor. She remembered 3 out of 3 objects in five minutes and was able to abstract without any difficulty.

Formulation

Rachel H. is a 29-year-old single female who currently lives with her parents. She has never been able to live independently. Since she finished a two year degree NCMC she has spent most of her time at home. She will go out to the grocery store with her mother but avoids contact with people as much as she can. She acknowledges this discomfort. She describes depression for some time, which has worsened over the past year. She describes some suicidal thoughts however; denies any intention or plan to harm herself. There is no history of alcohol or poly-substance dependence. She denies any history of psychiatric illness in her family. She has symptoms consistent with OCD with both obsessional thinking and compulsive behaviors. Social anxiety is extremely significant.

Diagnosis

Axis I: Generalized Anxiety Disorder, Social Phobia, severe. Obsessive-Compulsive Disorder. Major Depressive Disorder, moderate to severe w/o frank psychotic symptoms. I would consider the possibility of some underlying psychotic symptoms related to some paranoia, which she is not sharing, as she seemed to minimize at least the symptoms of OCD.

Axis II: Personality Disorder NOS w/avoidant traits. [Why they don't diagnose me with Avoidant Personality Disorder, I have no clue.] Dr. V. felt she may have Schizotypal Personality Disorder [she never told ME that!] however; I do not feel at present her symptoms are consistent with this diagnosis. [Then why is it still on there...? :/ ]

Axis III: Obesity.

Axis IV: Severe.

Axis V: GAF: 45

Treatment Plan:

The treatment plan was discussed with the patient at length. It should be noted that I also spoke with the patient's mother for some historical information. The patient did not want to be in the room when I spoke with her mother, as she "did not want to hear what she had to say". At present, I would like to begin a trial of an SSRI to address the anxiety and OCD symptoms as well as depressive symptoms. We agreed on a trial of LEXAPRO, as we have samples available for the LEXAPRO and at present she has no insurance or income. It was noted that the PROZAC in the past was somewhat helpful however; she did have tics, as reported by her mother and we should watch for this. [I think Ma is mistaken. I didn't have "tics" so much as I felt a little more hyper and so would engage in kind of odd behaviors...like clucking like a chicken. I was fully conscious of doing this and it wasn't tic-ish behavior; none of it was involuntary. I think the combo of the Prozac and BuSpar just made me a bit more hyper than usual, so I was more willing to engage in weird behaviors. o_o ] We discussed the expected benefits, as well as the potential risks and side effects of LEXAPRO and consent was signed. She was given a medication-teaching sheet. We had a very long discussion about side effects, as clearly the patient is concerned about side effects. I let her know that the side effects that are listed do not necessary occur and that any symptom that has ever been reported needs to be written in the PDR and information sheet. She continues to be ambivalent about the medication and acknowledges this however; hopefully she will take the LEXAPRO. We will begin LEXAPRO 10 mg daily for one week and then if she has no side effects we will increase this up to 20 mg daily. My belief is that we will likely need to add some type of anti-psychotic medication, as this can help with the OCD symptoms, as well as her difficulties with anger [ha!] and if there is some underlying psychosis for example, more paranoid thinking reported, this will also be helpful. I would consider either the possibility of a low dose of RISPERDAL or possibly GEODON. The patient was strongly encouraged to keep all appointments with CMH. Hopefully she will come in for therapy and will share her concerns. I feel if she is willing to take medication that we can improve her level of functioning and level of distress. [Insert another "ha" here.] I feel that if she does not follow through, her prognosis is poor. She was also given a lab slip to have laboratories drawn. Her mom said that they would be willing to pay for this. At present, I do not feel that she is able to function occupationally. She has never worked nor has she ever lived independently. Unless she shows dramatic improvement, I do not feel optimistic regarding her ability to work in the future.

Psychiatrist, MD
Diplomate, American Board of Psychiatry and Neurology

Date: 5/15/06

*****

This is of course not proofed as I haven't nearly the patience. Most of the errors however were in the original text.