chapter six

Chapter Six
January 12 Grael 17
Adrienne Venet Vanessa McClain, MA, LAPC
DOB:7-1-1982
Psychotherapy Note
Client identified a pattern of apprehension and nervousness in response to her severe persistant mental illness symptoms. Client reports history of Bipolar Disorder, Obsessive Compulsive Disorder, Post Traumatic Stress Disorder, Panic Disorder. Records indicate that client has a history of medication noncompliance. Referral indicates that client often adjusts medication on a whim and adds her own concoction of herbal remedies. Client has new diagnosis of Bipolar I with psychotic features, per recent discussion with psychiatrist. Client identified specific symptoms, such as frightening hallucinations, manic/racing thoughts, which have led to increased anxity. Client reports “hearing voices.” Client described anxiety in regards to stress and demands of masters level coursework and teaching assistant position at local university. Client reports interpersonal relationship difficulties due to increased ansity with worry that something dire is about to happen. Client began to describe “the retrograde of mercury lasting for a three week period.” Client’s records indicate religious preference to be pagan. Client was preoccupied with references to Tarot cards and the phrase “five of wands crosses the devil.” Client described a history of restlessness, tiredness, muscle tension, and shaking. Client appeared to have bruise on left hand side of face. Client denies memory of how the injury occurred. Client moved about in her chair frequently and sat stiffly. Client described a pattern of recurrent persistant fear due to the persecutory delusions and bizarre beliefs. Client described her delusions and bizarre beliefs as well as anxiety that she experiences due to those beliefs. Client related that she is constantly feeling on edge, sleep is interrupted, and concedntration is difficult. Other symptoms of hypervigilance include client report of being irritable in interaction with others as her pathience is thing and she “worries about everyting”. Client’s family members report that she is difficult to get along with, as her irritability is high. Client ‘s records indicated two half siblings: one brother, one sister, two step siblings, and a deceased fraternal twin who died at birth. The client reported an inability to concentrate or maintain her train of thought due to anxious preoccupation. Client’s lack of ability to concentrate has resulted in poor functioning in her social and educational needs. Today’s clinical contact focused on building the level of trust wit hthe client though constant eye contact, active listening, unconditional positive regard, and warm acceptance. Empanthy and support were provide for the client’s expression of thoughts and feelings during today’s contact. The client was provided with support and feedback as she described her maladaptive pattern of anxiety. The client verbally recognized that she has difficulty establishing trust because she often felt let down by others in the past and was accepted for this insight. The client was asked about the frequency, intensity,duration, and history of her anxiety symptoms. The Anxiety Disorder’s Interview Schedule for DSM-IV (Dinardo, Brown, and Barlow) was used to assess the client’s anxiety symptoms. The assessment of the client’s anxiety symptoms indicated that her symptoms are extreme and severely interfere with her life. Follow up scheduled for the end of this week.