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Case, MSE

● Appearance
● Behavior
● Speech
● Mood
● Affect
● Thought Process
● Thought Content
● Perception
● Cognition
● Insight
● Judgment

Case History: Emma

Identifying Information:

● Name: Emma Thompson

● Age: 32
● Gender: Female
● Occupation: Marketing Specialist
● Marital Status: Single, no children
● Presenting Problem: Difficulty managing work stress, feelings of inadequacy, and
social withdrawal.

History of Presenting Problem:

Emma is a 32-year-old woman who presents with symptoms of anxiety and low mood. Over
the past six months, she has experienced increasing difficulty in managing the demands of
her high-pressure job as a marketing specialist. She reports feeling overwhelmed with her
responsibilities and a persistent fear of failure. Emma also experiences frequent episodes of
irritability, sleep disturbance, and difficulty concentrating at work.

She notes a significant decline in her social interactions and has been avoiding social
gatherings with friends. She expresses feeling disconnected and "disinterested" in things
she used to enjoy, such as reading and exercising. Emma describes a pervasive sense of
inadequacy and often feels like she is "not good enough" in both her personal and
professional life.

Emma initially sought counseling after an argument with her supervisor at work, which left
her feeling "terrified" and "embarrassed." She reports that she has been feeling increasingly
isolated and is afraid of letting people down, including her family and colleagues.
Past Psychiatric History:

Emma has no known history of psychiatric disorders. She has not had any previous
hospitalizations or significant mental health treatment. She reports mild anxiety during her
college years, but this was managed with self-care techniques and did not require
professional intervention.

Family History:

Emma's maternal grandmother had a history of depression, and her mother has experienced
periods of depression in the past but has not sought treatment. Her father struggles with
alcohol use but has not received treatment.

Social History:

Emma grew up in a stable, middle-class family environment. She has a good relationship
with her family, although she feels that her parents have high expectations of her. Emma has
a small but close-knit group of friends. However, over the past few months, she has become
increasingly isolated, not responding to invitations or making time for social interactions. She
denies any significant history of abuse or trauma.

Medical History:

No significant medical issues. She reports a history of mild headaches and occasional
gastrointestinal discomfort, particularly during stressful periods.

Substance Use:

Emma drinks alcohol socially, about 2-3 times a week, but reports no issues with binge
drinking. She denies the use of illicit drugs and smoking.

Current Medications:

None.

Mental Status Examination (MSE):

Appearance:

● Emma appears well-groomed but somewhat fatigued. Her clothing is neat but not
particularly fashionable. She is sitting with her hands folded on her lap and avoids
eye contact at times.

Behavior:

● She is cooperative during the session but displays signs of restlessness, occasionally
tapping her foot. She does not engage in excessive movements or gestures.

Speech:

● Her speech is clear and coherent, though it is somewhat slow in pace. The volume is
within normal limits, but her tone is flat and lacking in enthusiasm.

Mood:

● Emma reports feeling "anxious" and "overwhelmed." She describes her mood as
"down" and "empty," saying that she struggles to find joy in things she used to enjoy.
She also states that she is often "irritable" and quick to anger.

Affect:

● Her affect is congruent with her mood, appearing sad and somewhat withdrawn.
There is a noticeable lack of expression in her face, and she exhibits restricted affect.

Thought Process:

● Emma’s thought process is logical, but somewhat ruminative. She often speaks
about her worries regarding work and her social life in a circular manner, returning to
the same concerns about failure and inadequacy.

Thought Content:

● She reports frequent negative thoughts about her abilities and her self-worth,
including feelings of being a "failure." There are no delusions or hallucinations, but
she expresses significant self-doubt and concern about disappointing others.

Perception:

● Emma denies experiencing any hallucinations or perceptual disturbances.

Cognition:

● She is alert and oriented to time, place, and person. Her attention span appears
intact, though she reports difficulty concentrating, especially when under stress.
Short-term memory is intact, but she notes that she forgets small details of daily
tasks due to her overwhelming thoughts.

Insight:
 ● Emma demonstrates some insight into her emotional state, acknowledging that her
feelings of inadequacy and anxiety have been affecting her life. However, she
minimizes the extent to which these issues are affecting her performance at work and
her relationships.

Judgment:

● Her judgment appears somewhat impaired due to her anxiety. She reports difficulties
in decision-making at work, often second-guessing her choices and fearing that
others will criticize her. There is no evidence of risky behavior or self-destructive
tendencies.

Impression and Recommendations:

● Impression: Emma’s symptoms are consistent with an adjustment disorder, primarily

characterized by anxiety and low mood in response to work stress and perceived
social pressures. Her lack of interest in previously enjoyable activities, combined with
feelings of inadequacy, suggest a possible depressive component, though the
symptoms do not fully meet criteria for major depressive disorder.
● Recommendations:
1. Cognitive-Behavioral Therapy (CBT): To address the negative thought
patterns of self-doubt, work-related stress, and rumination.
2. Stress Management: Techniques such as mindfulness, relaxation exercises,
and time management strategies to help her cope with work-related pressure.
3. Behavioral Activation: Encourage engagement in enjoyable activities to
reduce feelings of isolation and apathy.
4. Support for Work-Life Balance: Discuss ways to improve her work-life
balance and reduce the pressure she feels from high expectations.
5. Follow-up Sessions: To monitor progress and adjust therapeutic
interventions as needed.

Case 1: Generalized Anxiety Disorder (GAD)

Identifying Information:

● Name: John Harris

● Age: 45
● Gender: Male
● Occupation: Accountant
● Marital Status: Divorced, one teenage child
● Presenting Problem: Chronic worry, restlessness, physical tension

History of Presenting Problem:

John is a 45-year-old accountant who reports a long history of excessive worry about work,
family, and health. Over the past year, his anxiety has worsened, with constant rumination
about potential negative outcomes in both his professional and personal life. He is unable to
control his thoughts, feeling an overwhelming sense of dread even when there is no
immediate threat.

John has trouble relaxing, experiencing frequent muscle tension, headaches, and trouble
sleeping (insomnia). He avoids social situations due to a fear of judgment or making
mistakes. He is particularly worried about his ability to meet deadlines at work and the
well-being of his elderly mother, who lives in a different city.

Past Psychiatric History:

John has had anxiety for most of his adult life but has never sought treatment before. He
occasionally used alcohol to "calm his nerves," but denies alcohol dependency. He has had
no psychiatric hospitalizations or suicide attempts.

Family History:

John's mother has a history of anxiety and depression. His father was diagnosed with
hypertension and died at a young age from a heart attack.

Social History:

John is divorced and maintains a limited social circle. He has a good relationship with his
teenage daughter but often feels inadequate as a parent due to his anxiety. He is a
perfectionist at work, which has caused strain in his professional life. He enjoys solitary
activities like reading and watching TV but tends to avoid group socializing due to his fears
of being judged.

Medical History:

No significant medical history except for tension headaches and occasional digestive issues
related to stress.

Substance Use:

Occasional alcohol use (1-2 drinks per week). Denies illicit drug use or smoking.
Case 2: Obsessive-Compulsive Disorder (OCD)

Identifying Information:

● Name: Sarah Miller

● Age: 29
● Gender: Female
● Occupation: Teacher
● Marital Status: Single
● Presenting Problem: Persistent intrusive thoughts and compulsive behaviors

History of Presenting Problem:

Sarah, a 29-year-old elementary school teacher, has been experiencing intrusive thoughts
and compulsive behaviors for the past two years. She reports that she is constantly plagued
by thoughts of harming others accidentally, particularly her students. As a result, she
engages in rituals like checking the door locks repeatedly and washing her hands multiple
times to alleviate the anxiety caused by these thoughts.

The compulsions interfere with her daily life, including her work as she often feels compelled
to double-check everything in her classroom, delaying her lessons. She feels embarrassed
by her behavior but is unable to stop. The intrusive thoughts have caused significant
distress, leading her to avoid certain tasks and situations that might trigger her fears.

Past Psychiatric History:

Sarah has no history of psychiatric hospitalization but began experiencing mild symptoms of
anxiety in her late teens. She was never formally diagnosed but sought therapy for some
time during her college years for stress-related issues. She has not received treatment for
her current symptoms.

Family History:

Her mother has a history of anxiety, and her paternal uncle was diagnosed with OCD.

Social History:
Sarah is single and lives alone. She has a few close friends but finds it difficult to maintain
relationships due to her compulsive behaviors. She enjoys reading and cooking but
sometimes avoids socializing because she fears others will notice her rituals.

Medical History:

No significant medical conditions, though she occasionally experiences gastrointestinal

discomfort, which she attributes to stress.

Substance Use:

Sarah reports no substance use, including alcohol, smoking, or illicit drugs.

Case 3: Major Depressive Disorder (MDD)

Identifying Information:

● Name: Sarah Williams

● Age: 40
● Gender: Female
● Occupation: School Teacher
● Marital Status: Divorced
● Presenting Problem: Persistent low mood, loss of interest, and difficulty functioning.

History of Presenting Problem:

Sarah is a 40-year-old schoolteacher who reports feeling "sad and empty" most days for the
past six months. She describes a persistent lack of energy, anhedonia (inability to enjoy
activities), and difficulty concentrating at work. She feels disconnected from her colleagues
and has withdrawn from social activities. Her appetite has decreased, and she has lost
significant weight over the past few months.

She reports trouble sleeping, often waking up at 3 a.m. and unable to fall back asleep. Sarah
has lost interest in hobbies she used to enjoy, including gardening and reading. She feels
guilty about not being a better mother to her teenage daughter, as she often feels "too tired"
to engage with her.

Past Psychiatric History:

Sarah has a previous history of mild depression during her 20s, but it was short-lived and did
not require medication or therapy. She has not had any psychiatric hospitalizations or major
interventions.

Family History:

Her maternal aunt had depression and was treated with antidepressants for many years. Her
mother struggles with anxiety.

Social History:

Sarah has a strained relationship with her ex-husband, who is co-parenting their teenage
daughter. She has a small group of friends but has become increasingly isolated. She
previously enjoyed hiking and painting but has lost motivation for these activities.

Medical History:

No significant medical issues. She has occasional headaches and low energy, which she
attributes to her mood.

Substance Use:

Sarah occasionally drinks alcohol but denies any dependence or excessive use. She does
not smoke or use illicit drugs.

Case 4: Post-Traumatic Stress Disorder (PTSD)

Identifying Information:

● Name: Michael Cooper

● Age: 28
● Gender: Male
● Occupation: Firefighter
● Marital Status: Single
● Presenting Problem: Flashbacks, nightmares, and hypervigilance following
traumatic events.
History of Presenting Problem:

Michael is a 28-year-old firefighter who has experienced recurrent flashbacks and

nightmares about a traumatic event that occurred during a rescue operation three months
ago. During the rescue, he was unable to save a child from a burning building, which has
haunted him ever since.

He has trouble sleeping, frequently waking up from nightmares. He experiences intrusive

memories of the event during the day, which cause intense distress and panic. He has
become hypervigilant, always feeling "on edge" and constantly checking for potential
dangers. Michael has also withdrawn from friends and family and avoids places that remind
him of the trauma.

Past Psychiatric History:

Michael has no prior psychiatric history. He has not sought mental health treatment before,
but his symptoms have worsened since the traumatic incident.

Family History:

No family history of mental illness.

Social History:

Michael is single and lives alone. He has close friends in the fire service but has distanced
himself from them since the trauma. He previously enjoyed outdoor activities, but now feels
unsafe and has stopped participating in these hobbies.

Medical History:

No significant medical issues. He reports occasional headaches and difficulty concentrating.

Substance Use:

Occasional alcohol use. Denies drug use or smoking.

Case 5: Social Anxiety Disorder (SAD)

Identifying Information:

● Name: Emily Davis

● Age: 26
● Gender: Female
● Occupation: Graphic Designer
● Marital Status: Single
● Presenting Problem: Intense fear of social situations and avoidance.

History of Presenting Problem:

Emily is a 26-year-old graphic designer who reports experiencing severe anxiety in social
situations. She fears being judged or making mistakes in front of others, which has led to her
avoiding social interactions, both at work and in her personal life. She feels physically ill at
the thought of attending social events, experiencing symptoms such as sweating, dizziness,
and a racing heart.

Her anxiety has interfered with her ability to attend meetings at work and participate in
casual conversations with colleagues. She has avoided dating for several years due to a fear
of being scrutinized.

Past Psychiatric History:

Emily has had social anxiety for as long as she can remember, but it has become more
pronounced in her mid-20s. She has not sought therapy before and has self-isolated in
response to her fears.

Family History:

Emily’s mother has anxiety and is highly protective of her. There is no known history of
mental health disorders in the father’s side.

Social History:

Emily lives alone and has few close friends, all of whom she has known since high school.
She enjoys solitary hobbies, such as reading and video gaming, but has difficulty forming
new connections.
Medical History:

No significant medical issues.

Substance Use:

Emily denies alcohol use, smoking, or any illicit drug use.