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Posted: Apr 5 2015, 09:03 PM
April 2nd, 2015
PYSCH EVALUATION: CECILIA M. REYES
NAME: CECILIA M. REYES
RACE: BLACK/HISPANIC (MIXED)
ADDRESS: 1407 GRAYMALKIN LANE, NORTH SALEM
TELEPHONE: (914) 867-5309 ext. 98
Cecilia Reyes was born in San Juan, Puerto Rico. When she was three years old the family relocated to the Bronx, New York where she spent the remainder of her childhood with a few brief stints living with various relatives or guardians in the surrounding area. She is the second child in her sibling group (with an older brother close in age) and the only female child in her immediate family. Also notable is the fact that she is the product of an interracial relationship (Afro-Caribbean and Hispanic) which holds a great deal of significance to her and others in her community.
For someone of her ethnic and cultural background she has little contact with her extended family members due to disapproval on her father's side over her parent's relationship. Despite this though she does have mostly good relationships with the few family members that have moved to the tri-state area from the island. She has also enjoyed a number of friendships over the years in her neighbourhood of origin but admits that most of these have fallen to the wayside since she entered college.
Since her birth, the patient has lived in extreme poverty and is at this time the first person in her entire family to pursue a post-secondary education. During childhood, her home life was very supportive - although by her own admission not always the most stable - due to financial difficulties and the various issues that come along with that as well as the inherent problems low-income, high crime area such as the neighbourhood she grew up in has even though most of these problems did not affect her directly.
Among the more clinically significant events in her childhood (of which there are many) is the murder of her father when she was eleven years old. Despite enduring significant trauma as a result of being a witness and also a victim to this event, the patient indicates that she received no counselling or professional support afterwards and was left to “deal with things on her own” for the most part which might have set her up for (or even pre-dated) her current issues.
During the last weeks of December 2014, the patient was the victim of a coordinated attack at her university campus which resulted in her and several other student's kidnapping by a mutant extremist group. She was taken to a still undetermined location where she was psychologically/physically tortured and subjected to human experimentation until March 2015, when she was released for reasons unknown.
Since returning to the school she has been suffering from a series of mental health issues and has made a serious suicide attempt for which she was hospitalized for. Before this meeting she was assessed and prescribed medication by a physician in Boulder, Colorado.
BRIEF PSYCHOTIC DISORDER WITH MARKED STRESSORS (PRIOR TRAUMATIC EVENT)
A. Presence of one (or more) of the following symptoms:
• disorganized speech
• grossly disorganized or catatonic behaviour
B. Duration of an episode of the disturbance is at least 24 hours but less than a month with eventual full return to premorbid level of functioning.
C. The disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder or schizophrenia and is not due to the direct physiological effects of a controlled substance or other medical condition.
MAJOR DEPRESSIVE DISORDER (CLINICAL DEPRESSION)
A. Presence of five (or more) of the following symptoms have been present during the same two week period and represent a change from previous functioning, at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
• depressed mood most of the day and nearly every day, as indicated by either subjective report or observation made by others.
• markedly diminished interest or pleasure in all (or almost all) activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
• significant weight loss when not dieting, weight gain or decrease/increase in appetite nearly every day.
• insomnia or hypersomnia nearly every day.
• psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
• fatigue or loss of energy nearly every day.
• feelings of worthlessness or excessive/inappropriate guilt (which may be delusional) nearly every day.
• diminished ability to think/concentrate or indecisiveness nearly every day (either by subjective account or as observed by others).
• recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt or a specific plan for committing suicide.
B. Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
C. Symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
POST TRAUMATIC STRESS DISORDER (PTSD) WITH DISSOCIATIVE SYMPTOMS (DEREALIZATION), NO DELAYED EXPRESSION
A. Patient was exposed to actual/threatened death, actual/threatened serious injury or actual/threatened sexual violence as follows (at least one required):
• direct exposure
• witnessing (in person)
• indirectly by learning that a close relative/friend was exposed to trauma
• repeated or extreme indirect exposure to adverse details of the event(s)
B. Traumatic event is persistently re-experienced as follows (at least one required):
• recurrent, involuntary and intrusive memories
• traumatic nightmares
• dissociative reactions (flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness
• intense or prolonged distress after exposure to traumatic reminders
• marked physiologic reactions after exposure to traumatic stimuli
C. Avoidance of distressing stimuli after the event as follows (at least one required):
• thoughts or feelings related to the trauma
• external reminders related to the trauma
D. Negative changes in perception and mood that began or worsened after the traumatic event as follows (at least two required):
• inability to recall key features of the traumatic event for reasons unrelated to controlled substances or physical injuries
• persistent negative beliefs and expectations about themselves or the world at large
• distorted blame of themselves or others for causing the traumatic event or the resulting consequences
• persistent negative trauma related emotions
• markedly diminished interest in significant activities
• feeling of alienation from others
• persistent inability to experience positive emotions
E. Alterations in arousal and reactivity that began or worsened after the traumatic event as follows (at least two required):
• irritable or aggressive behaviour
• self-destructive or reckless behaviour
• exaggerated startle response
• problems in concentration
• sleep disturbance
F. Persistence of symptoms for more than one month.
G. Significant symptom related distress or functional impairment.
H. Disturbance is not due to controlled substances or other medical condition.
SWITCHING FROM 20 MG SEROQUEL TO 10 MG CLOZAPINE DAILY DUE TO INEFFECTIVENESS OF THE PREVIOUS MEDICATION AND UNCOMFORTABLE SIDE EFFECTS.
WEEKLY BLOOD TESTS REQUIRED FOR THE DURATION OF MEDICATION USE TO ENSURE AGRANULOCYTOSIS DOES NOT OCCUR IN PATIENT.
BIWEEKLY TALK THERAPY SESSIONS SCHEDULED.
DR. LEONARD SAMSON
685 EAST 12th STREET, MANHATTAN