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Gender	Gender Male Female
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Summary	Psychiatric Report: Patient Name: Tasnim Ali Age: 32 years Gender: Female Marital Status: Single Date of Report: [15/11/2024] Clinical Assessment: Tasnim Ali is a 32-year-old single female presenting with chronic anxiety and depressive symptoms, alongside persistent migraines unresponsive to various treatment modalities. During the clinical interview, she arrived wearing sunglasses indoors, explaining that the light sensitivity caused by her chronic migraines exacerbates her discomfort. She showed visible signs of distress, including rubbing her temples, grimacing intermittently, and expressing frustration with her condition. She reported persistent worry about daily activities, excessive fear of negative outcomes, and difficulty concentrating. Additionally, she described a pervasive low mood, anhedonia, insomnia, fatigue, and feelings of worthlessness. Tasnim denies suicidal ideation or intent but reports ongoing emotional distress that significantly affects her quality of life. Her symptoms align with criteria for both Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD), confirmed by clinical observations and assessment tools. Assessment Tools: 1. Beck Depression Inventory (BDI): Severe Depression 2. Beck Anxiety Inventory (BAI): Moderate Anxiety Current Mental State Examination (MSE): - Appearance: Arrived wearing sunglasses indoors due to light sensitivity from migraines. She was otherwise well-groomed and appropriately dressed for the setting. - Behavior: Cooperative, maintained eye contact when able, though occasionally appeared distracted by her discomfort. - Speech: Clear, coherent, with normal rate and tone. - Mood: Subjectively reported as “low”; objectively congruent with affect, which is depressed. - Affect: Restricted but appropriate to the discussion. - Thought Process: Logical and goal-directed with no evidence of thought disorder. - Thought Content: Preoccupied with worry, sadness, and frustration over her migraines; no delusions or obsessions identified. - Perception: No hallucinations or perceptual disturbances reported or observed. 2 - Cognition: Fully alert and oriented to time, place, and person; memory and concentration are mildly impaired by anxiety and migraines during assessment. - Insight and Judgment: Insight is fair; she acknowledges her condition but feels helpless. Judgment is intact. - Suicidal Ideation: The patient denies any suicidal or self-harm thoughts or behaviors. Summary: Tasnim Ali presents with significant anxiety and depressive symptoms, compounded by chronic migraines that intensify her functional impairment and emotional distress. Her symptoms fulfill the criteria for Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD), with severe depressive symptoms noted on the Beck Depression Inventory and moderate anxiety on the Beck Anxiety Inventory. Recommendations: 1. Medication: Review her current treatment regimen for migraines and psychiatric symptoms. 2. Psychotherapy: Initiate Somatic Experience Therapy along with Cognitive Behavioral Therapy (CBT) focusing on anxiety management, mood regulation, and coping with chronic pain. 3. Neurological Evaluation: Reassess migraine triggers and consider adjunctive treatments, such as Transmagnetic stimulation 4. Lifestyle Adjustments: Incorporate relaxation techniques, mindfulness, and stress-reduction strategies tailored to her condition, as well as optimizing sleep hygiene. 5. Follow-Up: Schedule regular psychiatric and neurological follow-ups to monitor her progress and treatment efficacy.
Diagnosis/Notes
Social
Allergy
Family History	Family History No Yes
Follow Up	هي تحويل دكتور الشربيني، هي كانت جاية ليا عشان نشتغل شغل سومتيك، كانت بتعملة مع حد بره المركز ، اشتغلنا مع بعض اكتر من 5 جلسات او اربعة علي شغل سوماتيك، وجت النهاردة وخلصنا الي انه الصداع النصفي اللي بتعاني منه هو انها لما حد بيسال انتي عاملة ايه بتبقي مش عايزة تقول انها متحسنه ، بقيت تقول هو انا معقولة اكون بعمل كدة بشكل غير واعي ، فبدأنا نشوف ايه وراء ده فأشتغلنا شوية علي انها تحكي موقف كدة حصل لها 2018 ، شركة كانت هتأسسها مع اصحابها فالموضوع مكملش ، كان فيه مشاكل كتيرة وبدأت تحس احساس كبير بالعجز ، بدات تنكر كل المشاعر اللي موجودة لحد ما بدأ يحصلها اتاك في 2020 واتشخصت بشكل واضح وقتها ، هي بتقول انها كان عندها في 2015 الصداع النصفي بس كانت الامور عادية بيجي نوبات بسيطة برضوا وكل فترات، وبدأنا نشتغل علي ده ونحط تصور علي الالم بتاع الصداع النفسي ونقسمة درجات زي المسطرة كدة لما بيجي ، عشان لو جاي شديد قوي نبتدي ناخد اجراءات، بس ممكن في وقت تاني يبقي الحياة ماشية عادي لأنه مش قوي، بحيث بالتدريج نوصل لدرجة نتعامل معاه الخفيف كانه مش موجود، حتي لو هنبتدي بدقائق معدودة، عشان ميوصلهاش احساس انه لازم يبقي مش موجود تماما عشان احس اني كويسة ، واتفقنا نغير اسم صداع نصفي نشوف مسمي تاني

Depressive symptoms	Depressive symptoms Depressed mood Anhedonia Decrease concentration Easy fatigability Death wishes Suicidal ideations/plans/attempts Hopelessness / helplessness Sense of suffocation Significant weight loss Insomnia Psychomotor retardation Psychomotor agitation Excessive guilt
Manic symptoms	Manic symptoms Irritable/elated mood Volubility Flight of ideas Decrease need for sleep Easy distractibility Inflated self-esteem Increase goal directed activities Hyperactivity Involvement in risk activities

Delusions	Delusions General delusions Bizzare Delusion Acting out No acting out Others
Hallucinations	Hallucinations Auditory Non auditory Acting out No acting out Perception illusion Others

Sleep	Sleep Insomnia Interrupted sleep sleepiness Cataplexy Night mares Obstructive apnea/ hypopnea Sleep walking
Appetite	Appetite Decrease appetite Increase appetite Eating non-food substance Repeated regurgitation of food Restriction of eating Recurrent binge eating Recurrent compensatory behavior
Sexual symptoms	Sexual symptoms Decrease desire Increase desire Erectile dysfunction Premature ejaculation Anorgasmia Dyspareunia Paraphilia Gender incongruence

Agitation	Agitation Yes No
Aggression	Aggression Verbal Physical sexual Destruction Homicide
Obsessions/ compulsions	Obsessions/ compulsions Obsessions Compulsions Hoarding Body dysmorphia Skin picking Hair bulling
Suicide	Suicide Death wishes Ideations Plans Attempts current Prior attempts
Anxiety symptoms	Anxiety symptoms Mental symptoms Physical symptoms Ill-defined fear Specific phobias Panic attacks
PTSD Symptoms	PTSD Symptoms Intrusive memories (thoughts- feelings- images- nighmares) Hyperarousal Avoiding dissociation Negative thinking Mood changes
Somatic symptoms	Somatic symptoms Hypochondriasis Conversion Induction of disease or physical symptoms Falsification of physical/psychological symptoms
Dissociative symptoms	Dissociative symptoms Depersonalization/ derealization Others
Neurocognitive symptoms	Neurocognitive symptoms Learning / Memory Attention Language Social cognition Self care House keeping Daily activities Ambutaion?????

Speech	Speech Delay Stuttering Vocal tics Others
Intellectual functions	Intellectual functions Daily activity Social functions Cognitive ?????? Others
Restricted/repetitive behavior Angry/irritable mood	Restricted/repetitive behavior Angry/irritable mood loses temper touchy resentful Others
Argumentative/defiant behavior: Vindictiveness (Aggression)	Argumentative/defiant behavior: Vindictiveness (Aggression) aggressive impulses verbal bullying threatening physical animal People Propities Sixual Stealing Setting fire Others
Enuresis	Enuresis Primary Secondary Others
Encorporesis	Encorporesis Primary Secondary Others
Attention	Attention Attention deficit Forgetfulness Easily distracted Others
Activity	Activity Hyperactivity Hypoactivity Others
Motor	Motor Ticks Delayed motor development Soft motor skills Sleep development Gender identity Others
Personality-ClusterA	Personality-ClusterA Pervasive distrust Detachment from social relationships Odd beliefs / thinking
Personality-ClusterB	Personality-ClusterB violations of rights Impulsivity Unstable relationships Unstable sense of self DSH Dramatization Ego inflation
Personality-ClusterC	Personality-ClusterC Social inhibition Difficulty in everyday decisions without help Details oriented Perfectionism Rigidity
Anxiety & Cluster C
Substance abuse/dependence	Substance abuse/dependence Harmfull use Craving Withdrwal symptoms Unable to control use Others
Impairement of functioning	Impairement of functioning Understanding and communication Getting around Self care Getting along with people Life activities (House hold) Life activities (school /work) Participation in society Others
Severity	Severity 1 2 3 4 5 6 7 8 9 10

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