seven

Chapter Seven
Freya’s Day January 14 Grael 19
Adrienne Venet
DOB: 7-1-1982
Vanessa McClain, MA, LAPC
Psychotherapy Note
The client reported that she has had a significant decrease in her appetite. Client’s change in appetite has resulted in significant weight changes associated with the depressive phase of her Bipolar diagnosis. Client reported that she felt deeply sad and had periods of tearfulness on almost a daily basis. Client’s depressed affect was clearly evidenced within the session as tears were shed on more than one occasion. Client reported a diminished interest in or enjoyment of activities that she previously found pleasurable. Client reported periods of inability to sleep and other periods of sleeping for many hours without the desire to get out of bed. Client reported that she feels a very low level of energy compared with normal times in her life. It is evident within the session that the client has low levels of energy demonstrated by slowness of walking, minimal movement, lack of animation, and slow responses. The client expressed that she is experiencing suicidal thoughts but has not taken any actions on these thoughts. An assessment was conducted on the client’s current and past mood episodes, including the features, frequency, intensity, and duration of the mood episodes. The Inventory to Diagnose Depression (Zimmerman, Coryell, Corenthal, and Wilson) was used to assess the client’s current and past mood episodes. The results of the mood episode assessment reflected severe mood concerns and this was communicated to the client. Client was provided with sleeping, eating, and activity logs in which to document the current level of functioning. Client was encouraged to identify and share her feelings of depression in order to clarify them and gain insight into the causes. Client was provided with support and empathy as she described her feelings of depression. Client was unable to clearly identify her feelings of depression, and was provided with additional feedback in this area.