Setting/Modality

Telehealth session, conducted via secure video platform.

Consent and Confidentiality

The clinician reviewed informed consent for the evaluation and obtained verbal consent for telehealth services. No release of information was discussed in this session.

Demographics

Emma Brown is a 29-year-old woman who identifies as heterosexual and uses she/her pronouns. She identifies as White, and English is her preferred language. No specific cultural considerations were raised as relevant to care.

Presenting Problem / Chief Complaint

Ms. Brown presented for an initial evaluation reporting, “I’ve been anxious all the time and I can’t shut my brain off.” She described symptom onset approximately four months ago, coinciding with a promotion at work that increased her responsibilities. She reported near-daily worry, difficulty concentrating, and low mood most days, with symptoms gradually worsening over the past six weeks. She identified her new workload and a recent breakup as primary stressors. She reported that her anxiety has interfered with her ability to focus on work tasks, has led her to cancel plans with friends on multiple occasions, and has disrupted her sleep, leaving her fatigued most days.

Mental Status Examination

• Appearance: Casually dressed, adequate grooming and hygiene.
• Behavior: Fidgeted with her hands throughout the session; maintained a cooperative and engaged demeanor.
• Mood: “Anxious and kind of down.”
• Affect: Constricted, congruent with stated mood; became tearful briefly when discussing the recent breakup.
• Thoughts: Thought process logical and linear. Thought content notable for recurrent worry about work performance; no delusions, obsessions, or phobias reported. Passive suicidal ideation present (see Safety and Risk Assessment).
• Perceptions: No hallucinations or perceptual disturbances reported.
• Cognition: Alert and oriented to person, place, time, and situation. Attention and concentration grossly intact during session; no memory concerns reported.
• Insight: Good; client recognizes her symptoms as excessive and is motivated to seek treatment.
• Judgment: Intact; no evidence of impaired decision-making.

Safety and Risk Assessment

• Suicidal ideation: Client reported passive current suicidal ideation, stating “sometimes I think it would be easier if I just wasn’t here,” without intent, plan, or preparatory behavior. She denied prior suicide attempts. No specific instrument was administered.
• Homicidal ideation and risk to others: Client denied any current or past homicidal ideation, intent, or identified targets.
• Self-harm: Client reported a history of cutting on her forearms between ages 15 and 17, with no episodes since. She denied any current self-harm urges or behavior.
• Access to lethal means: Client denied firearm access. No medication stockpiling reported. No specific means-reduction steps were discussed in this session.
• Violence and aggression history: Client denied any history of violent or aggressive behavior, toward herself or others.

Risk formulation and management

The clinician noted that Ms. Brown’s passive ideation appears related to her current depressive and anxiety symptoms rather than an acute crisis, given the absence of intent, plan, or means. Protective factors identified include stable housing, supportive friendships, engagement in seeking treatment, and stated reasons for living, including her relationship with her sister. The clinician reviewed crisis resources, including the 988 Suicide & Crisis Lifeline, and asked the client to contact the clinician or go to the nearest emergency department if her ideation intensifies. Follow-up was scheduled for one week.

Clinical History

Psychiatric/Therapy History:

Ms. Brown reported one prior course of therapy approximately three years ago for adjustment-related stress, lasting about four months, which she described as “somewhat helpful.” She denied any prior psychiatric hospitalizations and reported no formal psychiatric diagnosis prior to this evaluation.

Medical History:

Client reported no current chronic medical conditions. She did not name a primary care provider.

Current Medications:

Client reported taking no psychotropic or other prescribed medications at this time.

Substance Use History:

Client reported drinking alcohol socially, approximately two to three drinks per week, and denied any negative impact on functioning. She denied any cannabis use, illicit drug use, or tobacco/nicotine use.

Family Psychiatric History

Ms. Brown reported that her mother has a history of depression and was prescribed antidepressant medication for several years. She was not aware of any other mental health conditions, substance use, or suicide history among first- or second-degree relatives.

Trauma History

Client denied any history of abuse, interpersonal violence, or significant childhood adversity. She described her adolescent self-harm as related to social stress and difficulty coping with peer relationships at the time, without an identified precipitating traumatic event.

Social History

Ms. Brown lives alone in an apartment and works full-time in a marketing role. She holds a bachelor’s degree and reported generally stable employment history. She described a small but supportive friend group and regular contact with her sister, who lives in the same city. She does not identify with a specific religious or spiritual practice. She denied any legal involvement or immigration-related stressors.

Clinical Assessments

Ms. Brown’s self-reported symptoms are consistent with moderate anxiety and moderate depressive symptoms. Her PHQ-9 score reflects moderate depressive symptomatology, including low mood, fatigue, and concentration difficulties consistent with her reported history. Her GAD-7 score reflects moderate anxiety symptoms, consistent with her described worry and difficulty relaxing.

Summary of Scores

Clinical Assessment Summary

Ms. Brown presents with a four-month history of anxious and depressed mood following a work promotion and a recent relationship breakup, with associated sleep disruption, concentration difficulty, and social withdrawal. Her presentation, MSE findings, and PHQ-9/GAD-7 scores are consistent with Generalized Anxiety Disorder, DSM-5-TR 300.02 (ICD-10-CM F41.1), with co-occurring Major Depressive Disorder, Single Episode, Moderate, DSM-5-TR 296.22 (ICD-10-CM F32.1). Functional impairment across work performance and social engagement, along with moderate symptom severity on standardized measures, supports medical necessity for outpatient individual therapy. Adjustment Disorder was considered but ruled out given the duration and severity of symptoms exceeding what would be expected from the identified stressors alone.

Treatment Plan and Recommendations

Individual therapy is indicated. No referral for a higher level of care or additional specialty provider is indicated at this time.

Recommended Modality: Individual Therapy

• Frequency: Weekly
• Initial Treatment Goals:
  
  1. Client’s words: “I want to stop feeling anxious all the time and get back to feeling like myself.” Reduce generalized anxiety symptoms to a mild severity range.
     Objective: Client will identify and challenge anxious thought patterns between sessions.
     Intervention: Clinician will use cognitive restructuring and worry-time scheduling drawn from Cognitive Behavioral Therapy (CBT).

• 1. Client’s words: “I want to feel less down and start seeing my friends again.” Improve depressive symptoms and increase behavioral engagement.
     Objective: Client will re-engage in one previously enjoyable social activity per week.
     Intervention: Clinician will use behavioral activation techniques drawn from CBT.
• Referrals Provided: None