Ms. Kaysen is an eighteen-year-old Caucasian female who is voluntarily admitted to Claymoore Psychiatric Hospital. Prior to her admission, Ms. Kaysen lived at home with her mother and father Mr. and Mrs. Kaysen. Ms. Kaysen recently received her high school diploma, from McLean High School.
Ms. Kaysen is interested in writing and has expressed a desire to become a professional writer. She performed above average on a test of cognitive ability. She demonstrates care in appearance and compassion for her peers at Claymoore. She also displays a compassion for animals.
Ms. Kaysen was referred for evaluation and treatment to decrease her suicide attempts, suicidal ideations, …show more content…
Based on client’s report, Ms. Kaysen frequently feels “blue” or has “been blue.” She “does not know what she is feeling.” And frequently feels “sad” wanting “to make shit stop.” She “knows what it it’s like to try and fake a smile.” Several individuals in Ms. Kaysen life report that she doesn’t not feel anything. These statements made to others and reported to the clinician indicate that Susanna frequently experiences a depressed mood and feelings of emptiness.
2. Insomnia or hypersomnia nearly every day
a. Ms. Kaysen reports that she frequently has trouble sleeping. Based on observations, she also experiences hypersomnia. During a two-month period Ms. Kaysen sleep an excess of 10 hours daily. She also displayed lethargic behavior as evident by laying in bed all day and refusing to leave. Ms. Kaysen parents reported that she fell asleep during her high school graduation. Suggesting, that Ms. Kaysen experiences both insomnia and hypersomnia at varying time periods.
3. Feelings of worthlessness or excessive inappropriate guilt nearly every day
a. Ms. Kaysen reports that she has little control over life and destiny. She also experiences excessive guilt over her friend Daisy’s …show more content…
Occupational: Ms. Kaysen does not have a job and states that she wants to “rest” before obtaining a job.
C. The episode is not attributed to the physiological effects of a substance or to another medical condition.
1. Ms. Kaysen reports that she uses nicotine and alcohol. She has tried cannabis. No other substance use is reported. Further, Ms. Kaysen has no known medical conditions.
With mood-congruent psychotic features:
Based on a clinical interview with Ms. Kaysen, she experiences visual hallucinations and somatic delusions. Ms. Kaysen uses blunt force on her wrist due to having “no bones in her wrist.” Explaining that the bones in her wrist disappear and than come back, defying the laws of physics. She also reports “seeing things” and that she has extra-sensory perception.
Ms. Kaysen does not have a history of drug abuse or medical conditions (ruling out substance/medication induced and mood disorder due to medical conditions). She also does not display impulsivity or irritability. Additionally, she does not have a history of inattention or impulsivity (ruling out attention-deficit/hyperactive