Case Study Consult

Submitted by Therapist: Myles Tonnacliff

Client Patient Information

Patient age:   21
Gender: Male
Demographic status: Single

Reason for referral
Patient referred due to multiple symptoms of depression to include inability to get out of bed, eat properly, very limited socialization, excessive sleep and thoughts of death. Risk assessment indicates thoughts of suicide but no plan, method or time-frame. He recently dropped out of college due to inability to attend classes / homework. Unemployed and unmotivated to find work. Family Practice MD prescribed an initial dose of Citalopram, which he shared has helped some w/ depressive thoughts.

History of issue

Patient reports early developmental experiences were okay in Mexico, but difficulties with repatriation back to the states when he entered high school. He noted he was a shy adolescent who had limited socialization skills but was able to have a couple of friendships with girls he met in his freshman year, which eventually terminated within months.

Past psychological/Mental health history or treatment

Upon graduation from High School, patient enrolled in college for Bible based / religion studies, where he considered going into the missionary field as his parents did years ago. First semester was difficult with socially limited interactions and grades were average. Second semester attendance decreased dramatically and eventually withdrew from college and returned home due to depression.

Current stressors

Currently living with mother and step father; he has stayed in contact with his father and indicated a very good relationship with him and his wife, whom he related was instrumental in “helping me get out of my shell during high school.” He noted that interaction with his father since returning home from college has been minimal at best.

Family constellation (if applicable)

Previous counseling history when his family returned to the states from Mexico for 6 or so sessions – family does not know diagnosis but Adjustment Disorder suspected. Only positive history for mental illness was maternal uncle who had depression and odd thinking – one suicide attempt when uncle was in early adolescence. Family does not have much contact with uncle.


Denies thoughts of self-harm or harm to others. Administered a Suicide Screening form where his score was in the Moderate range, but negative to plan, lethality or timeframe. He contracted for safety and a Safety Plan was established. Risk factors include separation from college, limited friend / social contacts / negative symptoms of depression which impair his ability to function in the community / COVID-19 apathy and unwillingness to acknowledge medical implications of the virus / Axis II

Risk assessment

Ongoing symptoms of depression, meeting criteria for Major Depressive episode; he denies any thoughts of self-harm at the present time; he does acknowledge some odd thinking / thoughts about friendships which merits further exploration. He does complain of variety of physical symptoms from gastrointestinal distress, along with other physical maladies.

Brief background history

PREVIOUS PSYCHOLOGICAL TESTING – PART I No previous psychological testing appears to have been completed on this patient, but present testing that has been administered to date included: Beck Depression Inventory-2 where his scores suggested he was in the Moderate to Severe range for Depression. Additional testing for Suicidal Thinking with the ASIQ indicated a high moderate risk. The other clinical measure that he was administered was the Millon Multiaxial Clinical inventory – III;

Previous psychological testing

PART II – On this measure, which matches symptom responses to the DSM criteria, he was noted to have elevations in the areas of a Depressive Personality, along with Schizoidal thinking, and Borderline Personality traits. Additionally, his Clinical Syndrome scores were noted to be significantly elevated in the areas of Anxiety, Somatoform and Dysthymia. Of note is the prominence of his score in the area of Severe Clinical Syndromes, where his highest scores indicated Major Depression.

Spiritual Issues

Notably, he denied having spiritual concerns other than he was unable to be successful in his attempt to become a missionary as his parents were. He acknowledges going to church with his parents and feels connected to God. He does acknowledge some guilt and shame that he has not lived up to his own expectations. He reports prayer life ok, but individual devotions are very sporadic.

Treatment objectives

-To address and monitor Safety Concerns and any thoughts of self-harm in an on-going and proactive manner, -To address his Clinical issues of Major Depression, Anxiety and Somatoform concerns through regular psychotherapy and the monitoring of his medication compliance, -To address his low self-esteem / low self-worth through ongoing psychotherapy and psychological testing, -To address his past acculturation trauma and his perceived inability to fit back in the current culture, Plus other

DSM clinical impressions/Differential diagnosis

Major Depressive Episode Recurrent- Moderate / Dysthymia / Somatoform Disorder / Generalized Anxiety Disorder. Rule Out: Depressive Personality and Borderline Personality traits and patterns / Schizoaffective Disorder.

Clinical strategies

Negative symptoms of Depression and other psychological issues have hampered this patient’s attendance in therapy or further psychological testing. The goal will be to monitor his negative self-thoughts and be mindful of any thoughts of self-harm, while also increasing his ability to be successful at enhancing his social circle of interactions.