Psychotherapy Progress Session Note

Presenting problem(s)

• Follow-up for Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD).
• Persistent workplace stress and performance anxiety.
• Ongoing middle insomnia and daytime fatigue.

Current functioning

• Mood: Depressed and anxious; rates mood 4/10 over the past two weeks.
• Sleep: Averaging 5 hours per night; initial insomnia improved, middle awakening at 03:00 persists.
• Employment/Education: Working full-time as a financial analyst; struggling with concentration and deadlines.
• Family: Supportive partner (Sarah); occasional tension regarding household chores due to patient's low energy.
• Social: Withdrawn; declined two invitations from friends this week, though maintaining weekly phone call with brother.
• Exercise/Physical Activity: Walking dog 15 mins daily; stopped gym attendance 2 months ago.
• Eating Regime/Appetite: Decreased appetite; skipping breakfast, eating two small meals per day, no weight loss.
• Energy Levels: Low throughout the day, prominent afternoon slump around 14:00.
• Recreational/Interests: Anhedonia present; no longer playing guitar, passively watches television in the evenings.

Mental State Exam

• Appearance: Casually dressed, well-groomed, appears stated age of 34.
• Behaviour: Cooperative, mild psychomotor retardation, good eye contact.
• Speech: Normal rate and rhythm, slightly reduced volume.
• Mood: "Tired and overwhelmed."
• Affect: Dysthymic, anxious, constricted range, congruent with mood.
• Perception: No auditory or visual hallucinations; no derealisation or depersonalisation.
• Thought Process: Linear, logical, goal-directed.
• Thought Form: Normal, no formal thought disorder or flight of ideas.
• Orientation: Oriented to person, place, and time (x3).
• Memory: Immediate, recent, and remote memory intact on clinical interview.
• Concentration: Mildly impaired per subjective report; intact during 50-minute session.
• Attention: Attentive throughout interview.
• Judgement: Intact.
• Insight: Good; recognises connection between perfectionistic beliefs and anxiety flares.

Session Content

• Reviewed CBT thought records from the past two weeks, focusing on cognitive distortions (catastrophising and all-or-nothing thinking) related to upcoming quarterly presentations.
• Explored behavioural activation strategies to reintroduce pleasurable activities without triggering overwhelm.
• Discussed medication adherence and tolerability: tolerating escitalopram (Cipralex®) 15 mg PO daily well, mild transient nausea resolved.

Obstacles, Setbacks and Progress

• Progress: Successfully completed 4/7 thought records; identified "mind reading" during meetings with manager. Adherent to pharmacotherapy.
• Setbacks: Increased workload this week led to skipping scheduled evening walks and reverting to working late in bed, worsening sleep hygiene.

Risk Assessment

• Suicidal Ideation: Denies active or passive SI, intent, or plan. No past attempts.
• Homicidal Ideation: Denies HI.
• Self-harm: No history of NSSI; denies current urges.
• Violence & Aggression: No history of violence or aggression.
• Addictive Behaviours: Drinks 2–3 units of alcohol on weekends; denies illicit substance use or gambling.
• Risk-taking/Impulsivity: None reported.

Clinical Formulation

• Predisposing Factors: Family history of MDD (mother); perfectionistic temperament.
• Precipitating Factors: Corporate restructuring and increased managerial responsibilities 4 months ago.
• Perpetuating Factors: Maladaptive coping (overworking, social withdrawal), poor sleep hygiene, cognitive distortions.
• Protecting Factors: Strong marriage, stable housing/income, good insight, engagement in treatment.

Session Summary

34-year-old male presenting for session 6 of CBT alongside pharmacotherapy for MDD and GAD. Symptoms remain moderate, exacerbated by occupational stressors and poor sleep maintenance. Risk remains low with no SI/HI or self-harm. Engaged well in cognitive restructuring exercises today, challenging catastrophic thoughts regarding work performance. Reinforced sleep hygiene protocols (removing laptop from bedroom) and agreed on graded behavioural activation goals for the coming fortnight.

Treatment Plan

1. Major Depressive Disorder, single episode, moderate (DSM-V-TR):

• Goals for Treatment: Achieve symptom remission, restore baseline occupational and social functioning, re-engage in mindestens two weekly recreational activities.
• Outcome Measures: PHQ-9 score < 5 (today: 13, baseline: 18); self-reported activity logs.

2. Generalized Anxiety Disorder (DSM-V-TR):

• Goals for Treatment: Reduce frequency of worry episodes, improve sleep maintenance, develop adaptive cognitive coping skills for workplace stressors.
• Outcome Measures: GAD-7 score < 5 (today: 11, baseline: 16); review of weekly CBT thought records.

Next Steps

• Next Appointment: 24/05/2025 at 14:00 (America/Toronto).
• Assigned Homework: Complete 3 CBT thought records focusing on alternative balanced thoughts; remove all work electronics from bedroom by 21:00 nightly; practice guitar for 10 minutes twice this week.

Additional Notes: Continue escitalopram (Cipralex®) 15 mg PO daily. Will reassess for potential titration to 20 mg at next visit if depressive symptoms and middle insomnia do not show further improvement. Patient provided with crisis line numbers and advised to return to clinic or ED if acute safety concerns arise.