rashad

Client reports significant sleep issues, anxiety, and an overall 'depressive feel'.

The client reports an onset of symptoms approximately two months ago. He describes significant anxiety and depressive features, including hopelessness, a lack of interest in living, intermittent avolition (e.g., reluctance to bathe), and poor appetite. He endorses a cyclical pattern to his mood, with periods of being 'very bright' and active followed by withdrawal. He also notes intermittent, though not frequent, episodes of irritability or 'behaving out of control' with others. No specific triggers were identified.

(None elicited)

(Not elicited)

Client's name is Shamil. He was born via Cesarean section and had asthma during childhood. He describes his developmental growth as normal. He was an 'average' student who reported a lack of interest in his studies despite making progress. Other details regarding current living situation, work, relationships, and substance use were not elicited.

The client, Shamil, presented as cooperative via a telehealth session. His speech was of a normal rate and tone. He reported a mood characterized by anxiety and depression, with a congruent and constricted affect. Thought process was logical and goal-directed. Thought content was significant for hopelessness and a stated 'no interest in living at all.' No perceptual disturbances were elicited, and cognition appeared grossly intact. Insight is rated as fair.

Client's presentation is consistent with a Major Depressive Episode, given the reports of depressed mood, anhedonia, sleep disturbance, and hopelessness. The endorsement of mood cycles (periods of being 'very bright' followed by withdrawal) and intermittent irritability warrants further assessment to rule out a Bipolar Spectrum Disorder (e.g., Bipolar II Disorder). A comorbid Anxiety Disorder is also possible given the client's self-report.

The Pass 3 initial-assessment brief expands this into a differential with citations.

(Not elicited)