Comprehensive Biopsychosocial Intake

1. Presenting Problem

Pt is a 34 y/o F presenting for initial psychiatric evaluation and therapy due to worsening depressive sxs and anxiety over the past 6 mos. Pt states, "I feel completely overwhelmed and just can't get out of bed some days." She reports seeking care to "get my energy back and stop snapping at my husband."

2. DSM-V-TR based Signs and Symptoms resulting in impairments

• Social: Withdrawing from friends, declining weekend social invitations.
• Occupational: Missed 4 days of work in the past month; difficulty concentrating on tasks and meeting deadlines.
• Affective: Depressed mood most of the day, anhedonia, increased irritability, and feelings of worthlessness.
• Cognitive: Impaired concentration, indecisiveness, and passive suicidal ideation without plan or intent ("Sometimes I wish I could just go to sleep and not wake up").
• Physical: Terminal insomnia (waking at 03:00 and unable to return to sleep), fatigue, low energy, and 5 kg unintentional weight loss over 3 mos due to decreased appetite.

3. History of Presenting Problem

• Sxs precipitated by corporate restructuring at her job in 10/2023, which doubled her workload, alongside a miscarriage at 8 weeks gestation in 11/2023.
• Sxs occur daily, lasting most of the day, rated 8/10 in severity. No manic or hypomanic cycling noted.
• Worsening explicitly identified in 01/2024 following the original due date calculations and post-holiday return to work.
• Family Hx: Mother with MDD and GAD; maternal uncle completed suicide at age 45; father with AUD.

4. Current Family and Significant Relationships

• Married for 5 yrs to a supportive husband; close relationship with her younger sister who lives locally.
• High stress related to fertility struggles and decreased libido causing tension in the marriage.
• Husband recently started traveling 2 days/wk for his job as of 02/2024.
• Desires improved communication with her husband regarding grief from the miscarriage.
• Lives in a single-family home with her husband and one dog; no children.

5. Childhood/Adolescent History

• Born and raised in Chicago, IL. Raised by biological parents; lived with parents and one younger sister. Strongly influenced by maternal grandmother who lived nearby.
• Middle-class suburban home and community. Financial stability reported; parents emphasized high academic achievement.
• Met all developmental milestones on time. No childhood behavioral issues. Denies Hx of physical, sexual, or emotional abuse. Experienced trauma when maternal uncle died by suicide when pt was 14 y/o.
• Regular school attendance, A/B student. No learning disabilities. Experienced subclinical anxiety in high school around exams, untreated.
• Maintained a small, stable group of 3-4 close friends throughout childhood and adolescence; participated in school orchestra.

6. Current Social Relationships

• Has two long-term college friends living in the area who check in via text regularly.
• Feels guilty for canceling plans; triggered by friends announcing pregnancies or bringing infants to gatherings.
• Stopped attending her monthly book club 3 mos ago.
• Wants to re-engage with her two closest friends without feeling overwhelmed or triggered.

7. Cultural/Ethnic

• Identifies as second-generation Polish-American; finds comfort in traditional family gatherings and foods.
• Reports cultural stigma within her extended family regarding mental health care and "airing dirty laundry" outside the family.
• Requests that therapy respect her close ties to her parents despite their traditional views on mental illness.

8. Spiritual/Religious

• Raised Roman Catholic; views her personal faith and prayer as a historical source of comfort.
• Experiencing anger at God and questioning her faith following the miscarriage.
• Requests avoidance of religious platitudes in therapy, focusing instead on secular grief processing.
• Stopped attending Sunday Mass in 11/2023.
• Wishes to eventually reconcile her spiritual beliefs, though not an immediate priority.

9. Legal History

• No past or current legal involvement; no history of arrests, DUIs, or litigation.
• None; no legal stressors reported.

10. Education

• Completed Bachelor of Science in Accounting at age 22; passed CPA exam on the first attempt.
• Reports perfectionistic tendencies during schooling that caused severe test anxiety; no unmet educational goals.

11. Employment/Vocational"

• Employed full-time as a Senior Accountant for 6 yrs; strong analytical skills; supportive immediate supervisor.
• Understaffed department since 10/2023; working 50-55 hrs/wk; fear of making a major financial error due to poor concentration.

12. Military

• No personal military service. Maternal grandfather served in WWII (deceased); no current impact from military involvement.

13. Leisure/Recreational

• Enjoys reading fiction, gardening, and walking her dog.
• Ceased gardening and reading over the past 4 mos due to anhedonia and fatigue.
• Wants to resume daily 30-minute walks and read one book per month.

14. Physical Health

• Hx of hypothyroidism (dx 2019) and mild intermittent asthma. D&C performed in 11/2023 following miscarriage. Current meds: levothyroxine (Synthroid®) 75 mcg PO daily, salbutamol (albuterol, ProAir® HFA) 90 mcg/actuation 2 puffs INH q4h PRN SOB.
• Reports chronic fatigue, though recent TSH in 02/2024 was within normal limits (1.8 mIU/L).

15. Chemical Use History

• Denies illicit drug use or tobacco use. Alcohol use: drinks 1-2 glasses of wine PO 4 nights/wk for the past 4 mos to help initiate sleep (increased from 1-2 drinks/mo previously). Cannabis: tried 2x in college, none since.
• Pt recognizes using alcohol as a sleep aid is "unhealthy" and wants to cut back, though denies feeling dependent.

16. Counseling/Prior Treatment History

• Outpatient individual therapy (CBT) for 6 mos in 2016 (age 26) for work-related GAD. Prescribed sertraline (Zoloft®) 50 mg PO daily by PCP from 2016 to 2018.
• Learned basic grounding techniques; sertraline effectively reduced baseline anxiety.
• Discontinued sertraline in 2018 due to sexual side effects (anorgasmia) and weight gain (4 kg); felt former therapist was "too directive."