Therapy Progress Note 1

Assessment and Plan

Diagnosis
CONVERSION DISORDER (primary encounter diagnosis) as evidenced by tremors, dissociation, trigger response, unstable gait which is not explained by neurological findings.

Patrick seems to be slightly improved since last visit. He states he is feeling much more energetic and optimistic, however, he continues to experience an increase in tremors in recent weeks. He reports his arms and hands have started spasming and flapping, even without his awareness, though sometimes he is aware and is shaking his hand to release tension.

He has been keeping copious notes on his diet, is trying to eat more often, but has only gained a few lbs.

We discuss long term goals for therapy (walk without a walker and return to driving) and developing skills for his PTSD and tolerating distressing emotions without withdrawing or suppressing.

Therapist encourages him to continue with check in of his body, to decrease numbness. Patient states that “I used to have severe pain for twenty years, but now I have been completely numb for the last year since I got sick and needed the canes. Now, every once in a while I feel something like pain for a few seconds, and am actually glad because I feel something again.”

He believes he needs to decrease some of his myopic focus on others, and focus on improving his relationship with his body to decrease dissociation.

He does not remember if he has eaten today (it is 7pm) but states he went out to dinner with his wife last night, and will be going out again tonight to eat.

Follow up in three weeks. Plan will involve intensive individual treatment.