COMPREHENSIVE PSYCHOLOGICAL EVALUATION

Patient: Elena Vasquez Date of Birth: July 22, 1989 (Age 36) Evaluation Date: February 10, 2026 Examiner: Dr. Sarah Mitchell, Psy.D. Licensed Psychologist — TX License #38291

PRESENTING CONCERNS

Ms. Vasquez is a 36-year-old bilingual (English/Spanish) woman who self-referred for comprehensive psychological evaluation. She reports persistent depressive symptoms, chronic anxiety, insomnia, and progressive social withdrawal over the past 18 months, precipitated by an involuntary job loss from her position as Marketing Director at Apex Solutions. She describes her current state as feeling "underwater" with everything requiring excessive effort. She reports waking at 3 AM with chest tightness and racing thoughts about worst-case scenarios.

BACKGROUND INFORMATION

Ms. Vasquez holds a Master's degree in Marketing and had a successful 12-year career trajectory, culminating in her Marketing Director role which she held for 4 years before the layoff. She describes the job loss as unexpected and tied to company restructuring rather than performance. Despite this understanding, she reports a profound loss of identity and purpose tied to the event.

She was raised in a close-knit bilingual household. She reports no history of childhood abuse or trauma. She describes her family as supportive but notes she has withdrawn from them significantly. She has a history of brief counseling (6 sessions in 2024) that was interrupted by an insurance change.

Medical history includes hypothyroidism (managed) and chronic tension-type migraines.

BEHAVIORAL OBSERVATIONS

Ms. Vasquez presented as a well-groomed, articulate woman who appeared mildly anxious at the start of the session. She made good eye contact and was openly cooperative. She became tearful when discussing her career loss but recovered quickly, demonstrating a pattern of emotional suppression that may be contributing to somatic symptoms. Her speech was normal in rate and rhythm. She demonstrated good insight into her difficulties but expressed hopelessness about change.

TEST RESULTS

Personality Assessment Inventory (PAI)

Self-Report Measures

• Beck Depression Inventory-II (BDI-II): Score of 28 — Moderate Depression
• Beck Anxiety Inventory (BAI): Score of 31 — Severe Anxiety
• PCL-5: Score of 18 — Below clinical threshold for PTSD

CLINICAL IMPRESSIONS

Ms. Vasquez presents with a complex but diagnostically clear picture. Evaluation results, clinical interview, and behavioral observations support the following diagnoses:

Primary: Major Depressive Disorder, Single Episode, Moderate (F32.1) Secondary: Generalized Anxiety Disorder (F41.1)

The depressive episode appears to have been triggered by the job loss but is maintained by avoidance behaviors, social withdrawal, and cognitive distortions related to self-worth and competence. The anxiety predates the depressive episode and may represent a longstanding vulnerability factor.

RECOMMENDATIONS

1. Cognitive Behavioral Therapy (CBT) — weekly, focusing on behavioral activation, cognitive restructuring of beliefs about self-worth tied to employment, and graduated social re-engagement.

2. Psychiatric consultation for medication evaluation — given severity of anxiety symptoms (BAI = 31), an SSRI or SNRI may provide symptom relief that facilitates therapeutic engagement.

3. Sleep hygiene protocol with possible short-term sleep medication consultation, given the 3 AM waking pattern and its role in maintaining the anxiety-depression cycle.

4. Structured daily routine including physical exercise, social contact (even minimal), and purposeful activity to counteract avoidance patterns.

5. Career counseling when mood symptoms are sufficiently stabilized — reframing the job loss and rebuilding professional identity will be important for sustained recovery.

6. Follow-up evaluation in 6 months to assess treatment response.

DRAFT — Pending Examiner Review

Dr. Sarah Mitchell, Psy.D. Licensed Psychologist — TX #38291 Lampasas Psychological Services