NCMHCE Practice Test 7

Presenting Problem

You are a licensed mental health counselor working in a university counseling center. Talia, a 20-year-old junior majoring in graphic design, was referred by her academic advisor after she failed two midterms and stopped attending her morning studio class. She says, "I'm not lazy. I just can't make myself care about anything."

For the past five weeks, Talia reports feeling sad "most of the day, almost every day," losing interest in drawing and in her friends, sleeping 10 to 11 hours a night and still waking up exhausted, and having trouble concentrating on readings. She has been skipping meals, has stopped answering her friends' group chat, and has turned in two design assignments late; her advisor warned her that she is at risk of academic probation. She feels guilty about "wasting my parents' money." She had a similar low period at 17 that lasted about two months and resolved without treatment.

When you asked about times she felt the opposite of depressed, Talia described last April: "It was the best week of my life." For about six days she slept three hours a night without feeling tired, talked so fast that her roommate told her to slow down, started three new design projects, and spent about $700 on art supplies she has not used. She kept attending classes and her campus job and says she "honestly got more done than ever." She was not hospitalized and denies hearing or seeing things during that time. She was not taking any medication then and drinks two coffees a day, "same as always." She pulls "a few all-nighters every semester" to meet design deadlines.

Talia reports passive thoughts of death over the past two weeks: "Sometimes I think it'd be easier if I just didn't exist." When you ask directly, she says these thoughts come a few times a week and pass quickly; she denies any plan, intent, or preparatory steps, has never attempted suicide, and has no access to firearms or stored medication. She denies homicidal ideation. Her PHQ-9 total at intake was 17.

Mental Status Exam

Talia arrived five minutes late in an oversized hoodie, with adequate hygiene and unwashed hair. She was oriented to person, place, time, and situation. She described her mood as "flat"; her affect was constricted and at times tearful, congruent with content. Eye contact was limited. Memory was intact, although she asked for some questions to be repeated. Psychomotor activity was slowed, and gait was normal. Thought process was linear but slow; thought content included guilt and hopelessness about school. She denied hallucinations, and none were observed. She reported passive death wishes, as noted, and denied homicidal ideation. She reported a six-day period of elevated energy last April. She drinks alcohol "maybe twice a month" at parties and denies other drug use.

Psychosocial and Family History

Talia is the oldest of three children. Her parents, who pay her tuition, live two hours away and call her every weekend; she describes them as loving and has not told them about her midterms. Her maternal aunt has bipolar disorder and has been hospitalized several times, and Talia says the family "doesn't really talk about it." Talia works 12 hours a week at the campus library. She has a close group of friends from her design program but has been avoiding them. She is not currently dating. She attends Mass with her family when she is home. She denies any history of abuse, and a trauma screen was negative. Before leaving, Talia says she found your personal Instagram account and asks, "Can I follow you and message you there on nights when it gets bad?"