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Patient Name: Thomas Darden Date of Birth: August 26, 1971 Occupation: Help Desk, SII Original Complaint (physical): None Original Complaint (psychological): Fear of social situations Brief Summary: Mr. Thomas Darden is a bright, sarcastic man who is completely unable to interact with others socially. His social isolation and substance abuse have left him bitter, lonely, and sexually frustrated--often seemingly hovering on the brink of suicide. He feels an almost unbearable emotional pain the source of which I've been working to discover. Total number of sessions: 36. Brief Impression: Tom sports a shy, polite exterior while harboring a large store of pain and resentment built up from a source currently unknown. Tentative Diagnosis: Possible unspecified atypical delusional disorder. Social phobias, perhaps avoidant personality disorder Current Medications: Zoloft, currently 30 mg. q.d., was 20 mg. q.d. upon rising, six week trial begun 9/4/98, then raised to 30 mg on 11/02/98. Previously prescribed 20 mg. Fluoxetine q.d., six week trial begun 06/29/98, discontinued 08/17/98; Librium, three times daily, begun 5/09/97 ended approximately 7/05/97 when patient discontinued and did not wish to consider somatic treatment. Patient has a history of alcohol abuse |
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