Case History – Training Record

Chief complaints:

persistent feeling of overwhelm and dread drained energy level loss of interest

Presenting concerns:

the client have severe anxiety issues with intense negative thoughts showing reflection in her physical self like tiredness, sleep distractions, shortness of breath and tightening in the chest specially while dealing with professional pressure, also unable to concentrate on the things she earlier enjoyed like hobbies or friends, due to fear and anxiety

Client verbatim statement:

energy levels are drained no interest in hobbies waking up at 3 am loss of appetite anxiety specially before professional meetings increased isolation from peers

A – Affect / Emotion

overwhelm and dread drained energy levels

B – Behaviour

withdrawal, fear, anxiousness

C – Cognition

worries about future, professional life, and being left alone, losing interest in hobbies and daily stuff

D – Daily functioning

disruption in sleep loss of appetite

Onset details

insidious along six months timeline

Course details

continuing for past six months

Predisposing factors

-

Precipitating factors

professional meetings, hypothetical future failures

Perpetuating factors

negative thoughts

Protective factors

trying to cope up through professional help

Present maintaining factors

overthinking and anxiety

Family history

-

Personal history

-

Educational history

-

Vocational / occupational history

professionally sucessful

Sexual and marital history

-

Forensic history

-

Suicidal / self-harm / substance use history

-

Living conditions

alone and self established

Premorbid personality

good mood, friends, hobbies, professional achiever