DSM Diagnosis: Include behaviors & symptoms consistent with diagnosis. 296.33 Major Depressive Disorder, severe; deferred; chronic pain; family and social Background information: John Smith is a white male in his mid-fifties residing alone in an apt complex. Pt has an ongoing struggle with depression for many years. Pt was admitted voluntary to SBBH for having hallucinations. John reported, he has received therapeutic treatment in the past for his depression and hallucinations. Pt source of income is SSI Disability. He does not have any legal matters. John strengths consist of verbal, motivated for treatment, and use health care systems. His weaknesses are depression, poor health, and sleep disturbances. His barriers to treatment are hallucinations and being …show more content…
I explained to the patient that I am an intern student. I would be sitting in on session from time to time. The patient was cooperative when speaking and engaging with the intern. The student started with small talk and asked the patient his thoughts and feelings. Intern asked, “what is your current living situation?” Pt reported, “I live alone in an apt complex. I am considering a nursing home placement. My daughter is helping me with my placement.” The intern asked, “are you seeing things that others are not?” Pt reported, “not today.” Also, the intern asked, “are you hearing things that others are not?” Pt said, “no.” The intern asked, “what do you want happen while you are at SBBH?” Pt stated, “I want to be able to figure out what is going on with me. I can’t keep living like this. Something has got to live. I was discharge yesterday and I had to come back. I don’t understand what is going on.” At the end of the interview, the student answered the patient questions. Pt presented in a euphoric mood during the interview. He appeared to be guarded and reserved when talking to the intern. Pt was cooperative when answering the