NCMHCE Practice Test 8

Presenting Problem

You are a licensed mental health counselor working in a private practice. Desmond, a 41-year-old insurance claims adjuster, schedules an intake after his older sister told him he "hasn't been himself in years" and urged him to get help. He says, "I've felt like I'm walking through wet cement since I was about 32. It's not terrible every day; it's just never good." He reports that his mood has been low most of the day, more days than not, for about nine years, and he cannot recall a stretch longer than a few weeks when he felt like himself.

He eats one real meal a day because "food doesn't interest me," feels worn out by midafternoon, and says that since grade school he has felt "less capable than my brother at pretty much everything." He adds, "I don't see the future getting any better. It just is what it is." He sleeps about seven hours, concentrates adequately at work, and still coaches his 12-year-old daughter's weekend soccer practices, though he does it "on autopilot." He denies any period of two weeks or longer in which his mood dropped sharply or he stopped functioning. His fatigue worsens during the busy fourth quarter at work, when he often stays late. His divorce was finalized three years ago, and he calls it "sad but mutual." His supervisor recently remarked that he seems "flat" in team meetings, which embarrassed him.

When asked about suicidal thoughts, he says, "Sometimes I think it wouldn't matter much if I didn't wake up. But I'd never do anything. My daughter needs me." He denies a plan, intent, or past attempts, and he has never been in counseling. His PHQ-9 total is 13. Near the end of the interview he says, "Honestly, nothing has ever really lifted, so I don't see why talking would."

Mental Status Exam

Desmond is casually dressed and adequately groomed, and he is oriented to person, place, time, and situation. His affect is constricted and congruent with his stated mood of "blah." Recent and remote memory are intact. Gait is normal, and motor activity is slightly slowed. Eye contact is intermittent. Thought process is linear and goal directed; thought content centers on self-criticism and low expectations for the future. He denies hallucinations, and none are observed. He reports passive thoughts that it "wouldn't matter" if he did not wake up, without plan or intent, and denies homicidal ideation. He denies any history of elevated or irritable mood, decreased need for sleep, or racing thoughts. He drinks one or two beers on some weekends and denies other substance use.

Psychosocial and Family History

Desmond is the middle of three children. His father, who died five years ago, was "quiet and gloomy a lot," and his younger brother lives ten minutes away. He shares custody of his daughter, who stays with him on alternating weeks. He has worked for the same insurance carrier for 14 years and describes finances as stable but tight since the divorce. He attends church occasionally and says faith is "more habit than comfort right now." A trauma screen is negative. He has few close friends and spends most evenings watching television alone. As the session ends, he asks whether using his employer-sponsored health insurance means his manager will find out that he is "seeing a shrink."