DSM Diagnosis: Include behaviors & symptoms consistent with diagnosis. Axis I: 296.21 Major Depressive Disorder; Axis II: none; Axis III: obesity and low back pain; Axis IV: primary relationships and social; Axis V: 30 Background information: John Smith is in his mid-twenties Caucasian male living alone. Recently, he separated from his wife and their 3 children lives with their mother. The patient went to the emergency room for having hallucinations and having suicidal ideation. The patient has an ongoing struggle with depression and suicidal ideation for a couple of years and received outpatient/inpatient treatment during that time. The patient’s strengths include being employed and verbal; however, his weaknesses consist of anxiety, impulsive, mood disturbances, and …show more content…
I explained that I am the intern student and would be sitting in one session. Student started with small talk and asked him about his thoughts and feelings. Student precedes by asking him questions that pertain to the assessment; however, the patient avoided eye contact throughout the session. Client was looking at the floor and appeared guarded when answering the questions. Therapist and patient had not met in previous sessions. Client appeared to have preoccupied thoughts during the interview. Student asked, “did you have any growth or developmental delay when growing up? The patient said, “I had ADHD, but I was never diagnosed with it.” Student asked, “did you complete high school?” Patient replied, “yes, I went to several schools?” Intern asked, “have you ever been arrested?” He verbalized, “yes, I have been arrested for not attempt court, DWI, and 2 drunk disorderly.” John Smith said, “I need to contact my probation officer tomorrow to check in with him. Who do I ask if I can make that phone call?” Intern said, “you need to ask the nurses if you can make a phone call.” He said,