January 23, 1991

The patient was seen for 50 minutes by himself and with his mother for approximately 10 minutes. He was more discouraged today and his affect was noticeably depressed. He indicated that he felt more down although he tended to minimize the seriousness of it and discussed the external factors occurring which leads to depression. The initial one related to discovering that the play he wanted to try out for was not very interesting and he did not really think he would enjoy it so he decided not to try out. He also is discouraged because he has two finals tomorrow that he does not feel he is prepared for and that his headaches get worse every time he tries to study. We talked about some specific interventions for the headaches. He does not have many relaxation skills now and it was not possible to go over this very extensively with him. It was recommend he try a hot shower or bath fairly early in the evening. Further relaxation skills need to be discussed on the next visit. It was also recommended that he go ahead and use ibuprofen 200 to 600 mg for his headache tonight if it starts getting worse and he was encouraged to take at least 200 mg before he starts studying. Finally, he discussed his disappointment about social exclusion and the tendency for people to not talk to him or avoid him. He gave an example of the disc jockey business that he does with a friend. The friend usually is the person people come to talk about scheduling and at one point one of the people asked him to leave while he talked to the friend and then it turned out that they were discussing business. The patient asked about this and the friend said he did not realize that was what was going to be discussed. The patient also said he wrote his friend a letter expressing his disappointment but did not get a response. He is sleeping adequately. He is not having an increase in suicidal thinking. I recommended that we continue discussing specific issues but also gave him the option of increasing his nortriptyline from 75 to 100 mg starting tomorrow night. I will see him again in one week.

The Cheese Doctor, M.D.