Depression Case Summary

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Identifying Information
Sara is a 25-year-old divorced Caucasian female, she is currently employed as a nurse assistant and attends school part-time majoring in Psychology. Sara currently lives alone and is a self-referral for the anxiety she is experiencing.
Presenting Problem/Symptoms/History
Sara reports, she has always felt uncomfortable or getting along with other people and has a hard time making friends or getting close to people. She admits always feeling she is being judged by other people and she is inadequate or not as intelligent. Feels specifically overwhelmed when in the presence of strong men, feeling she is sexually inadequate. Sara reported she self-medicates with marijuana to help relieve the stress, and when she is drinking …show more content…
Again, suggesting Sara is a candidate for therapy.
• Folstein Mini Mental Status Exam (MMSE): Sara scored a 28 of 30 on the MMSE, missing point in the recall and attention and calculation categories. Even while scoring extreme on the anxiety inventory and moderate for depression the MMSE does not indicate any cognitive impairment.
Summary of test findings:
When Sara completed the Burns Anxiety Inventory, Burns Depression Checklist although anxious she completed them with a positive attitude and my impression and scores indicate she answered them thoroughly and honestly. Although the Burns Anxiety Inventory is not designed to make a formal diagnosis it is a self-report questionnaire that give the counselor an idea of what is affecting their client and the severity they are reporting. Although Sara scored as moderate on the Depression Inventory she was high on the moderate end of the scale, therefore this will need to be monitored.
Individuals with test scores and profiles produced by this client are frequently described as ¬ moderate for depression and high and severe for anxiety.
Diagnostic …show more content…
Sara scored a 68 out of 99 on the Burns Anxiety Inventory which is considered Extreme Anxiety or Panic, therefore, therapy is recommended. On the Burns Depression inventory Sara scored a 29 out of 45 which is determined at a Moderate risk for depression. Sara’s score on the MMSE was 28 out of 30 which does not indicate any cognitive impairment which is good since her high scores are on the anxiety assessment.
Recommendations:
1. Assess the severity of her alcohol and marijuana use. Eliminate the use of these substances to help the treatment for her anxiety. The removal of these may also help reduce the symptoms of anxiety and depression.
2. Attend 12 weeks of group counseling to address anxiety disorder, gaining insight into the source of the anxiety and learning encounter these situations while reducing the stress by cognitive restructuring, and slowly introducing in vivo exposure therapy. All while receiving and giving peer support to and from group members experiencing the same type of anxiety.
Treatment plan:
• Modality: Attend group counseling once a week for 12 weeks with individual sessions if they are
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