Psychiatry Initial Consultation

Main Complaint

34 y/o female (Thandiwe Nkosi, DOB: 12/05/1990, ID: 9005120084082) presents with a 3-month hx of persistent low mood, anhedonia, and overwhelming anxiety. Reports significant impairment in daily functioning, including frequent absenteeism from work and social withdrawal.

Symptoms

• Depressed mood: Present daily for 3 months, worse in the mornings (7/10 severity).
• Anhedonia: Complete loss of interest in running and socialising since onset.
• Anxiety: Constant excessive worry regarding work performance and finances; experiences episodic palpitations and restlessness 3–4 times/week.

Other Symptoms

• Fatigue: Chronic low energy throughout the day despite rest.
• Psychomotor retardation: Subjective feeling of "moving through mud" and slowed thinking.
• Irritability: Easily frustrated by minor domestic tasks, leading to interpersonal friction.

Stressors

Corporate restructuring at her firm 4 months ago resulted in retrenchment of half her team and a doubled workload. Concurrent financial strain supporting extended family in KwaZulu-Natal.

Past Psychiatric Hx

Diagnosed with Adjustment Disorder in 2018 following a bereavement; treated with 6 sessions of CBT with full resolution. No prior psychiatric admissions. Trialled escitalopram (Cipralex®) 10 mg PO OD via GP 2 weeks ago, discontinued after 4 days due to nausea.

Past Medical Hx

• Hypothyroidism (diagnosed 2021), stable on levothyroxine (Eltroxin®) 50 mcg PO OD.
• Laparoscopic appendicectomy (2015).

Trauma Hx

Involved in a hijacking in Johannesburg in 2019. Experienced transient hypervigilance for 2 months post-event; denies ongoing flashbacks or PTSD symptoms.

Habits

• Substance use: EtOH 1–2 glasses of wine on weekends; denies illicit substances or tobacco. High caffeine intake (4–5 cups of coffee/day) to combat fatigue.
• Diet: Irregular meals, relies on convenience foods.
• Exercise: Previously ran 5 km 3x/week; completely sedentary for the past 2 months.
• Sleep: Initial and middle insomnia.

Childhood

Raised in Durban by both parents; eldest of three siblings. Normal developmental milestones. Describes household as warm but academically demanding.

Education

Matriculated with distinction (2008). Completed BCom Accounting at the University of the Witwatersrand (2011). No learning difficulties reported.

Work Hx

Employed as a Senior Financial Analyst in Sandton for the past 5 years. Previously high job satisfaction, now reports severe burnout, dread prior to shifts, and fear of making errors.

Personal Hx

Married for 4 years to a supportive husband (36 y/o engineer); no children. Good social support network in Gauteng, though currently isolating herself from friends.

MSE

Appearance

Neatly groomed, dressed in casual attire appropriate for weather. Appears stated age; mild dark circles under eyes.

Behaviour

Cooperative and polite. Psychomotor retardation noted with slumped posture and minimal hand gestures.

Speech

Soft volume, slightly reduced rate and tone. Normal prosody, no pressure of speech.

Eye Contact

Intermittently avoidant, looking down when discussing occupational stressors.

Concentration

Mildly impaired; needed two multi-part questions repeated during the interview.

Attention

Maintained focus throughout the 50-minute session without distractibility.

Mood

"Exhausted and hopeless."

Affect

Dysphoric, restricted range, congruent with stated mood. Tearful when discussing work expectations.

Thought Form

Linear, logical, and goal-directed. No loosening of associations or flight of ideas.

Thought Content

Preoccupied with occupational failure and financial ruin. Denies delusions, obsessions, or phobias.

Perceptual Disturbances

Denies auditory, visual, or tactile hallucinations.

Suicidal Ideation

Passive thoughts of "wishing to go to sleep and not wake up" 2x/week. Denies active suicidal ideation, intent, plan, or history of self-harm.

Insight

Good; recognises symptoms as a depressive episode triggered by occupational burnout and actively seeks psychological intervention.

Judgement

Intact; capable of making safe decisions regarding medical care and daily responsibilities.

Intelligence

Estimated above average based on vocabulary, abstraction, and educational attainment.

Mode of Thinking

Negative cognitive triad evident; frequent catastrophising and all-or-nothing thinking regarding career trajectory.

Sleep

Initial insomnia (takes > 90 mins to fall asleep) and middle insomnia (waking at 03:00 with racing thoughts). Averaging 4–5 hours of fragmented sleep/night.

Appetite

Decreased over the past 6 weeks; reports unintentional weight loss of 3 kg.

Libido

Markedly decreased over the past 3 months.

Physical Complaints

Frequent tension-type headaches (bilateral, frontal) occurring late afternoons, managed with paracetamol (Panado®) 1,000 mg PO PRN.

Assessment

• Major Depressive Disorder, single episode, moderate, with anxious distress (DSM-5).
• Differential diagnosis: Burnout syndrome; hypothyroidism-related mood disorder (requires biochemical exclusion).
• Contributing factors: Acute occupational overload, high internalised perfectionism, financial pressure.

Plan

• Commence weekly individual psychotherapy (CBT and stress management focus); next session scheduled for 24/10/2024 at 10:00 SAST.
• Refer back to GP/Psychiatrist to check TSH and Free T4 levels, and to review SSRI re-initiation (e.g., sertraline (Zoloft®) 50 mg PO OD with food to minimise GI side effects).
• Psychoeducation provided regarding sleep hygiene, caffeine reduction, and behavioural activation.
• Safety plan established: Patient agreed to contact spouse or SADAG crisis line (0800 567 567) if passive ideation progresses.