A case and treatment plan for a fictional or real client encountered in clinical practice.

Full Answer Section

  Presenting Concerns Jane is a 25-year-old female graduate student who presents with symptoms of depression, anxiety, and low self-esteem. She reports feeling sad, hopeless, and worthless. She has difficulty concentrating and making decisions. She has lost interest in activities that she used to enjoy. She has also been experiencing increased anxiety, including panic attacks. She feels like she is not good enough and that everyone else is better than her. She has thoughts of self-harm and suicide. History of the Present Illness Jane's symptoms began about 6 months ago, after she started graduate school. She is in her first year of a PhD program in psychology. She reports feeling overwhelmed by the workload and the pressure to succeed. She also feels isolated and lonely. She doesn't have many friends in the program and she doesn't feel like she fits in. Past Psychiatric History Jane has no prior history of mental health treatment. She has never been diagnosed with a mental illness. Past Medical History Jane is physically healthy. She has no chronic medical conditions. Social History Jane is single and lives alone. She has a good relationship with her parents and siblings. She is close to her family and they are very supportive of her. She has a few close friends from college, but she doesn't see them very often since she started graduate school. Mental Status Exam Jane is a well-dressed, well-groomed female in her early 20s. She is cooperative and polite. She is oriented to time, place, and person. Her mood is sad and her affect is congruent. She denies suicidal or homicidal ideation. She has no perceptual disturbances. Her thought process is linear and goal-directed. Her attention and concentration are intact. Her memory is intact. Her judgment is impaired. Diagnosis

• Major depressive disorder, single episode, moderate
• Generalized anxiety disorder
• Low self-esteem

Treatment Plan

• Individual therapy: Jane will meet with a therapist once a week for 50 minutes. The therapist will use a cognitive-behavioral approach to help Jane identify and challenge her negative thoughts and beliefs. The therapist will also help Jane develop coping skills to manage her anxiety and depression.
• Medication: Jane will start taking an antidepressant medication. The medication will help to improve her mood and reduce her anxiety.
• Support groups: Jane will attend a support group for people with depression and anxiety. The support group will provide her with a safe place to connect with others who understand what she is going through.

Prognosis Jane is a bright and motivated young woman. She is eager to get better and she is willing to work hard in therapy. With treatment, she has a good prognosis for recovery.

Sample Answer

    Client Demographics

• Name: Jane Doe
• Age: 25
• Gender: Female
• Race/ethnicity: White
• Marital status: Single
• Occupation: Graduate student
• Insurance: Blue Cross Blue Shield