Psychosocial/Developmental History:

CASE of BRAYLON

 

Intake Date: February 13, 2021

 

Demographic Data:

Braylon is a 32 year old, single African-American female. She has never been married. Braylon has a 9-year-old son from a prior relationship. Braylon did not graduate from high school, but returned to school to get her G.E.D. She is presently a first year student at Brookdale Community College. She is working in the college library in conjunction with a work-study program. Braylon’s goal is to become a teacher. Religious affiliation is Baptist, though she does not practice.

 

Chief Complaint:

“I find it hard to concentrate, and have difficulty sleeping. I wonder if I’m going crazy”.

 

Presenting Problem:

The intake was precipitated by her inability to concentrate and stay focused. Braylon reports she has felt like this since she was a teenager. She also states that one year ago, she began to develop what she described as panic attacks, always worried about something and her heart beats very fast and she has sweaty palms. She reports that she does not want to go to class because she fears that, “I’ll say something stupid.”

She often has to re-read class material several times before she can absorb it, and often thinks about leaving school. She thinks that these symptoms may be due to her son’s placement in special education classes. Braylon reports that she does not go out as much anymore because she likes to stay home with her son. Braylon reports she sleeps for a few hours every night, with difficulty falling asleep, and waking up in the middle of the night with an inability to fall back a sleep. She reports no change in appetite.

 

Past Psychiatric History:

Braylon denies any past psychiatric history. She reports this is the first time she has ever seen a therapist. Braylon denies suicidal and homicidal ideation in the past or present. She denies all substance abuse. She reports she will have only one drink on a special occasion, or if she goes out, which is rare. Braylon tried marijuana once when she was a teenager, but states she never tried it again because “ I didn’t like the way it make me feel”.

 

Past Medical History:

Braylon denies any significant medical history. She states she has had normal childhood illnesses. There is no significant weight gain or loss.

 

Psychosocial/Developmental History:

Braylon states her parents never married. Her parents’ relationship was on again off again, but her father left for good when Braylon was 14 years old. Braylon was pleased when her father left for good, stating he was a “bad man.” He drank a lot and used marijuana in the house. Her parents fought frequently and her father would physically abuse her mother. Braylon believes her mother deserved the beatings because she cheated on the father.

 

Issue & Dynamics:

Braylon is the first of 3 daughters from her parents union. She is aware of two half sisters on the paternal side. Braylon is unsure if her father has more children. Her mother had another daughter 10 years ago. Braylon reports her mother kicked her out at 16 years old, because Braylon interfered with her mother’s relationship at the time. Braylon lived with friends and in group homes, but returned home when she found out she was pregnant. The child was the result of her first sexual experience. She dated the father about one year. She has no current relationship with her child’s father, although he sees his son periodically.

Braylon has no close friendships. She has a male friend and reports no intimate relationship with him. She has had one boyfriend for 6 months since the relationship with her son’s father. The relationship with the boyfriend ended 2 years ago. Braylon speaks to her mom, sister, and father at times.

 

Braylon likes to stay home with her son in her leisure time. She liked to go out to the movies in the past.

 

Mental Status Exam:

Braylon presents as a casually dressed female who appears her stated age of 32. She is tense during the interview and her affect is blunted. Motor activity is appropriate. Speech is clear. At times during the interview she lost

her train of thought and had to be redirected to the subject. There is no evidence of delusions or hallucinations. Braylon’s intelligence appears above average. She is oriented to time, place, and person.

 

Diagnostic criteria:

F41.1 Generalized Anxiety Disorder

Criteria A, B, C3,5,6 D, E, F

 

Ruled Out:

F32.1 Major Depressive Disorder, single episode, moderate

No evidence of A1, A2 yes, A3 no, A4 yes, A5 no, A6 no report of but could be since sleeping is off, A7 no, A8 yes, A9 no

 

Not enough criteria to go further

 

F34.1 Persistent Depressive Disorder

No evidence of A no need to go further