HISTORY: Mr. Jones is a married African American 38-year-old man.

His chief complaint is,

"symptoms of depression and anxiety, that are causing mood swings and interfering with
marriage.
Mr. Jones often loses control of his anger. Marital difficulties have been caused by his
anger and irritability. His anger also interferes with his occupational and social functioning.
Severity:
Based on the description of interference with function and the risk of morbidity without
treatment, Mr. Jones's severity is estimated to be moderate.
History:
Mr. Jones describes symptoms of bipolar disorder, but most often has struggled with
depressive symptoms.
Current Symptoms:
*He reports anger and angry outbursts.
*Mr. Jones reports concentration difficulty.
*Mr. Jones reports feelings of guilt.
*He describes irritability.
*He describes irritability.
*He has difficulty sleeping.
*Mr. Jones reports that his sociability has decreased.
*Increased worrying is described by Mr. Jones
Mr. Jones describes the following anxiety symptoms:
*Difficulty concentrating occurs.
*Irritability
*Fears of losing control
*Feelings of restlessness
*Difficulty staying asleep.
*Excessive worrying
PAST PSYCHIATRIC HISTORY:
Out Patient Treatment:
Mr. Jones received outpatient mental health treatment for depression and anxiety.
Psychotropic Medication History: *Prozac: This medication was previously taken but is
not currently taken. It was stopped months ago because it caused side effects. The main side
effect was sexual dysfunction.
SOCIAL/DEVELOPMENTAL HISTORY:
Mr. Jones is a married 38 year old man. He is Caucasian. He is a Baptist.
Childhood History:
Quality of childhood was reported as normal but strict.

*Corporeal punishments such as spankings or beating were used.

*Limited expression of emotion in the household.
*Lack of love and compassion shown by parents.
*Very religious
Relationship/Marriage:
The current relationship is described as:
*Turbulent because of mental illness, yet supportive.
Support System:
Mr. Jones has the social support of the following:
Spouse:
*Highly supportive
*Lives with his spouse
Mr. Jones passed the various developmental milestones at age appropriate times.
MEDICAL HISTORY:
Medical history is negative and Mr. Jones has no history of serious illness, injury,
operation, or hospitalization. He does not have a history of asthma, seizure disorder, head injury,
concussion or heart problems. No medications are currently taken.
EXAM: Mr. Jones appears friendly, attentive, communicative, well groomed, normal weight,
but appears anxious. He exhibits speech that is normal in rate, volume, and articulation and is
coherent and spontaneous. Language skills are intact. He exhibits speech that is normal in rate,
volume, and articulation and is coherent and spontaneous. Affect is appropriate, full range, and
congruent with mood. Associations are intact and logical. There are no apparent signs of
hallucinations, delusions, bizarre behaviors, or other indicators of psychotic process.
Associations are intact, thinking is logical, and thought content appears appropriate. There are no
apparent signs of hallucinations, delusions, bizarre behaviors, or other indicators of psychotic
process. Associations are intact, thinking is logical, and thought content appears appropriate.
Suicidal ideas or intentions are denied. Cognitive functioning and fund of knowledge are intact
and age appropriate. Short- and long-term memory are intact, as is ability to abstract and do
arithmetic calculations. This patient is fully oriented. Insight into problems appears normal.
Insight into problems appears normal. There are signs of anxiety. Mr. Jones is fidgety. Mr.
Jones's behavior in the session was cooperative and attentive with no gross behavioral
abnormalities. Mr. Bennet's behavior in the session was cooperative and attentive with no gross
behavioral abnormalities. No signs of withdrawal or intoxication are in evidence.
DIAGNOSES: The following Diagnoses are based on currently available information and may
change as additional information becomes available.
(F31.32) Bipolar disorder, current episode depressed, moderate (Active)
THERAPY CONTENT/CLINICAL SUMMARY:

Guilty feelings predominated this session. Feelings of frustration were also expressed in regards
to mood regulation. Feelings of sadness were expressed due to marriage problems. The clients
low frustration tolerance was discussed in today's therapy session.
The focus of today's session was on assessing the type and severity of the problem and providing
support. The client was encouraged to ventilate feelings. The session also focused on identifying
triggers and sources of feelings, challenging irrational thoughts and behaviors, and identifying
healthier alternatives.
Time spent face to face with patient and/or family and coordination of care: 60 plus minutes