My client is a 25-year-old South Asian woman. She appears thin with long black hair and brown eyes. She is wearing dark pants, a long sleeved blue shirt with a multicoloured scarf. Her clothing is neat and appropriate to her environment. She is wearing makeup, appears clean and is well put together. The client answers direct questions but does not provide a lot of information. Patient is willing to provide more information when asked directly or prompted by the writer. The client’s rate of speech was slow at first but as the interview continued, became a normal rate. Her speech was clear; however spoke in a soft volume with a monotone voice. Her rhythm was smooth and her speech was not pressured. The client’s energy level appeared low, and sat with rigid posture and was very still during the interview. The client maintained focused eye contact with the writer throughout the interview. Her body language showed no sign of emotion and her facial expression appeared sorrowful and times and bored at others.
The client described her mood as “very sad and unhappy.” She rated her mood on a scale of one to ten, one as being described as the worst you have ever felt and 10 being the best, as a three. When asked to rate her was mood when she entered the hospital on the same scale she rated her previous mood to be a one to a two. She acknowledged she has started to feel a little bit better but her mood was still low. She felt that her mood has improved due to the medication she has been on as well as being around more people. The client also had a flat affect. When the client told the writer about her break up with her ex-boyfriend, there was very little indication of feelings or emotions. The client’s responses were blunted as she showed a significant decrease in facial animation and no appropriate emotional responses. The client seemed down and had low energy, which is affecting all aspects of her life including her eating habits.
The client expressed she has been hearing the voice of her ex-boyfriend, which is unusual for her. She felt the voice was coming inside of her head. She expressed that she hears the fights they used to have and that he speaks to her in a self-depreciating way, for example “you’re not good enough for me.” The patient denies any auditory command hallucinations. The patient stated that she has not told to anyone else that she hears him because she does not want to be labeled as weird, but acknowledged she understands that she is the only person that is able to hear him. She expressed that the voice she hears “won’t go away,” and hears him approximately three to four times a week. The patient also states she has not felt like herself lately, but wants to feel like her old self again.
The client’s thought formation is appropriate, however her thought content is solely focused around her ex-boyfriend. She worries that she is unable to...