My client UF is a 31 years old, university graduate, and married Asian woman, has one newborn child who is 3 months old and apparently seems healthy. Her chief complaints as stated are:
- “I do feel anxious “and sad” for the last 2 months.”
- “I do not get interest in any activity and feel weak.”
- “Nobody loves me.”
History of present illness:
Emotional problem: 3 months ago after the first child was born, UF has been suffering from mood swings, loss of energy and interest. Her mood was unhappy with anxious and pale face. Subjectively she is not suicidal and Columbia suicidal scale also reveals that she is not suicidal. But she wishes to be in a place where happiness is awaiting for her.
Present Life situation: She lives with her husband in a rented house. She is religious, heterosexual and currently unemployed. She does not do any kind of physical exercise.
Past Psychiatric and psychological:
She had been suffering from anxiety disorder before one year.
Social and family history:
She does not have any relevant childhood trauma. One piece of information she released about herself is how she divorced her now ex-husband after they immigrated to Canada. After staying in Canada for a while, she married another man, older than her but from her culture and religion, who is now her husband. Her family members, especially parents and her siblings, avoid her due to UF not following her cultural and social. As a result, after her child was born, she’s not getting any help from her intimate circle and eventually, she has become socially isolated.
Due to her transition into becoming a mother, she has to fulfill a lot of family and social demands. At the same time, hormonal change has a very significant impact on her mental health. She is a non-smoker and has no relevant history of drug/substance abuse.
Brief mental status examination:
Appearance: She appears stable and soft-spoken. Her motor behavior are unremarkable.
Mood: sad and anxious.
Affect process: Labile.
She is not suicidal or homicidal revealed by Columbia suicidal severity rating scale.
No perceptual disturbance like hallucination, illusion, depersonalization and derealization.
Stream of though: Circumstantial.
Thought content: Flight of ideas
Abstract thinking: She can think abstractly.
Education and intelligence: Unremarkable.
Concentration: She cannot concentrate fully which is 3 out of 5 in rating scale.
Orientation: Normal regarding place, time and person.
Memory: Immediate memory seems normal but recent memory is forgetful. Her past memory also seems normal.
Impulse control: She cannot control her anger which is 3 out of 5 in rating scale.
Judgment: 3 out of 5.
Insight: 3 out of 5 but she blames others for her illness.
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