CONFIDENTIAL PSYCHOLOGICAL EVALUATION

NAME: B AGE: 39 SEX: male ETHNICITY: Caucasian DATE OF EVALUATION: 1/31/12 SUPERVISOR: A. Jen

PRESENTING PROBLEM B explained that he is seeking help at this time because he recently told his wife about an affair that he was having with a woman he met online. He says that with the help of couples therapy, he and his wife have decided to stay together, but he still finds himself "miserable" at home and at his job as an accountant. He also reported bouts of anxiety that reveal no specific internal or external, fear-inducing stimuli.

FAMILY BACKGROUND B has been married for 15 years and has two daughters ages 8 and 12. B. reports that he is the oldest of three children, and that he grew up in a working class family. His mother died when he was a teenager, and his father supported him and the remaining siblings by working multiple jobs. He reports infrequent contact with his family.

EDUCATIONAL HISTORY B earned good marks in high school including a college scholarship.

WORK HISTORY B. is currently working as an accountant.

MEDICAL HISTORY B. mentioned taking medication for erectile dysfunction. He says that his doctor recently gave him a clean bill of health and indicated that there is no apparent medical cause for the sexual dysfunction.

BEHAVIORAL OBSERVATIONS B. appears well-groomed and casually dressed. His mood appears dysthymic, and his affect is generally flat. He smiles defensively when talking about his problems. His speech is normal in rate and tone with a broad vocabulary appropriate to his high level of education. He is physically restless, often tapping his feet and shifting his weight as he sits across from you. His thought process is linear, with no obvious impairments in memory or attention. His insight and judgment appear to be within normal range.

PSYCHIATRIC HISTORY B. denies any history of mental illness. Except for the recent couples counseling, he has no history of prior psychotherapy or psychiatric medication. B. reports having experimented with various drugs in college, but that since then he only has an occasional glass of wine. He denies having a substance abuse problem. He also mentioned that he has been drinking too much in an attempt to deal with the stress at work. And later he also admitted using cocaine and speed to deal with work projects. There is no reported history of substance abuse in his family, but he does say that his mother used to joke about having to take "happy pills" for what he thinks was depression.

SUMMARY AND CLINICAL IMPRESSIONS B. is having a mix of anxiety (desperate) and fear because of doubts and confusion

about his sexual desires and the responsibilities as a husband and a father that he feels toward his wife and children. He also showed a dysthymic mood and a flat affect. The AXIS I diagnosis of 300.4 Dysthymic Disorder with late onset is based on the following facts: he started looking for sex outside marriage about two years ago, he has been overeating, insomnia, poor concentration at work. Based on the facts presented on this interview there no AXIS II diagnosis.

DIAGNOSTIC IMPRESSIONS AXIS I: 300.4 Dysthymic Disorder

AXIS II: V71.09 No diagnosis

AXIS III: None

AXIS IV: Possible marriage dissolution; job dissatisfaction;

AXIS V: GAF (current) = 55