Clinical Intake Assessment

Assignment 1: Intake Assessment Your Name Subject and Section Professor’s Name Date Intake Assessment Assessment date: July 24, 2024 Client legal name: Maha H. Client preferred name: Maha Client pronouns: She/Her Client date of birth: 14/1/1990 Client’s Presenting Problem: Maha is a new mother who complains of severe exhaustion and lack of sleep secondary to taking care of her newborn child. Moreover, Maha also has a five-year-old son, who has several needs to cater to, increasing her feelings of exhaustion and inadequacy. Maha talks of her guilt due to the perceived lack of attention she can afford for her older son once he is a newborn. In turn, this is now becoming a source of anxiety and could be a sign of Postpartum issues that warrant evaluation and management. Clinical Impressions: The diagnosis suspected at this point is postpartum depression, which is categorized under the DSM-5 under Major Depressive Disorder (MDD) (Tebeka et al., 2023). Maha is frequently tired at work, sleeps at night, and feels guilty, which highlights several of the postpartum depression symptoms. In the DSM-5 criteria for diagnosing MDD with peripartum onset, it was noted that five or more symptoms must be present and manifest over two weeks. The symptoms must be present and cause significant impairment in functioning compared to the patient's previous level of functioning. These symptoms must be present, and one of them must be either depressed mood or loss of interest or pleasure. Other signs are substantial weight loss or weight gain, sleeping too much or being unable to sleep, agitation or slowness of movement, inability to be energized, hopelessness or excessive guilt, difficulty in focusing or making decisions, and persistent thoughts of death or active thoughts of dying (Marx et al., 2023). Maha's reported symptoms of fatigue, sleeplessness, and guilt are likely to incapacitate her from working or performing other vital functions, as well as severely affecting her psychological status, which meets the criteria for MDD with peripartum onset. During the consultation, Maha seemed rather exhausted, although she did not show any signs of agitation in her behavior; she was neatly groomed, made eye contact, and smiled sometimes. The findings of this presentation indicate that, although the woman suffers from considerable emotional issues, she remains functional to some extent. The severity assessment of Maha's condition also requires information about suicidal or homicidal ideation, and although Maha exhibited some signs of hopelessness, she denied any suicidal or homicidal thoughts when directly asked. Although she said that she does not have any suicidal thoughts, the fact that she described her fatigue as a chronic condition, her sleep-wake cycle disturbance, and her guilty feelings about her parenting skills showed that she has had these symptoms for quite some time now. Based on these symptoms' length and severity, it is possible to diagnose Maha with Major Depressive Disorder with peripartum onset as defined by the DSM-5 criteria; therefore, her condition requires further assessment and effective treatment to ensure her mental health is managed correctly. Mental Status Appearance/Behavior Maha was well-groomed to the extent that she dressed correctly for her age and situation. In her behavior, she appeared fatigued, for example, with a tired expression on her face. However, she showed no signs of tiredness and willingly complied with the assessment tests. Speech Maha's speaking was intelligible, well-connected, and at the right time. There was no indication that she attempted to speak faster than usual or in any way slowed down her language processing, and she conversed. Emotion (Mo...