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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.

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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

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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