Detailed Clinical Format

Patient ID: 5367

Name: [Not Provided]

Age: 19-20

Sex: Female

Place: [Not Provided]

Date: 17-05-2024

Presenting Concerns:

- Social Isolation: Prefers solitude and avoids social interactions. Expresses no interest in forming or

maintaining relationships, including with family members, and feels most comfortable when alone.

- Emotional Detachment: Shows indifference to both positive and negative life events. Does not

react emotionally to significant occurrences, such as the deaths of close relatives, and her affect is

consistently flat.

- Imaginary World: Spends extensive amounts of time in an imaginary world, which she describes as

more satisfying and vivid than real life. Uses music to facilitate her escape into this inner world.

- Lack of Motivation: Despite being highly intelligent, she lacks motivation for academic pursuits and

has a history of poor academic performance. Selected her current fields of study (software

engineering and physics) primarily for their solitary nature.

- Speech Difficulties: Speaks rapidly and sometimes confuses words. Has a history of stuttering,

which improved with speech therapy, but discontinued therapy due to a lack of interest and

avoidance of self-reflection.

- Repetitive Behaviors: Exhibits strict routines, such as specific bedtime rituals, and obsessive

behaviors, like eating the same food for extended periods. These behaviors are disrupted only by

external changes, such as dining out or a negative experience with the food.

- Obsessive Interests: Becomes deeply engrossed in specific topics (e.g., dogs, philosophy,
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psychology, math, physics) for months at a time, acquiring extensive knowledge in these areas.

- Sensory Sensitivities: Dislikes loud noises and crowded places, often using headphones to block

out sensory input.

- Maladaptive Daydreaming: Shows signs of maladaptive daydreaming, where she acts on her

dreams. Rehearses and practices scenarios from her dreams in real life, which can last for hours.

- Indifference to Social Norms: Does not care about societal expectations or norms, such as

attending social events or maintaining relationships. Indifferent to both praise and criticism.

History:

- Early Childhood:

- Stuttering in childhood, improved with speech therapy but discontinued due to disinterest.

- Independent and isolated from a young age, with a preference for solitary play and obsessive

interests.

- Poor academic performance due to lack of interest and concentration.

- Developed coping mechanisms such as assuming the role of 'class clown' to mask her true

feelings.

- Mother physically abusive during stressful situations, contributing to trauma.

- Neglect and lack of understanding from parents regarding her social and emotional needs.

- Adolescent Years:

- Indifferent emotional responses to significant life events and familial relationships.

- Expresses emotions only in dreams; feels more alive in her inner world than in reality.

- Avoids social gatherings and shows no interest in making friends or maintaining social

connections.

- Prefers reading and studying topics of personal interest, such as philosophy and science, over

academic pursuits.
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- Exhibits repetitive routines, such as bedtime rituals, and obsessive behaviors, like eating the

same food for extended periods.

- Significant identification with literary characters expressing themes of alienation and emotional

detachment.

- Present:

- Currently studying software engineering and physics, chosen for the solitary nature of the work.

- Prefers to live alone and dreams of moving to a small Greek island.

- Spends significant time in solitary activities and avoids social interactions.

- Engages in maladaptive daydreaming, often acting out scenarios from her dreams.

Mental Status Examination:

- Appearance: The patient appears physically fit and well-groomed. Maintains good hygiene and

dresses appropriately for her age and setting.

- Behavior: Cooperative during the examination but exhibits minimal spontaneous interaction.

Behavior is consistent with someone who is emotionally detached and prefers solitude.

- Speech: Speech is rapid, and she sometimes confuses words. Has difficulty with vocalization,

often speaking in a monotone without variation in pitch or volume. Speech patterns reflect her

discomfort with social communication.

- Mood: Describes her mood as consistently neutral, neither happy nor sad. Reports that she has

always felt this way and does not experience significant mood swings.

- Affect: Restricted and flat. Shows little variation in facial expressions or emotional responses

during the interview. Expressions often appear rehearsed rather than genuine.

- Thought Process: Logical and coherent. Able to provide detailed and structured responses to

questions. Thoughts are often preoccupied with philosophical and existential themes.

- Thought Content: No evidence of delusions or hallucinations. Thought content is primarily focused

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on her internal world and her obsessive interests. Shows no signs of paranoia or other psychotic

symptoms.

- Insight and Judgment: Some insight into her emotional detachment and social difficulties.

Recognizes that her behavior and feelings are not typical but does not seem motivated to change

them. Judgment is intact; capable of making rational decisions, but prefers isolation.

Differential Diagnosis:

- Primary: Autism Spectrum Disorder (ASD), Level 1 (requiring support)

- Evidence: Social communication difficulties, repetitive behaviors, restricted interests, sensory

sensitivities, and early onset.

- Secondary: Schizoid Personality Disorder (SPD)

- Evidence: Emotional detachment, preference for solitude, indifference to relationships and social

norms, and lack of emotional expressiveness.

- Tertiary: Attention-Deficit/Hyperactivity Disorder (ADHD) (previously diagnosed)

- Evidence: Poor concentration, daydreaming, and history of academic difficulties.

- Consideration: Complex Trauma (due to history of abuse and neglect)

- Evidence: Physical abuse, emotional neglect, and coping mechanisms developed in response to

trauma.

Diagnosis:

- Primary: Autism Spectrum Disorder (ASD), Level 1 (requiring support)

- Secondary: Schizoid Personality Disorder (SPD)

- Tertiary: Attention-Deficit/Hyperactivity Disorder (ADHD) (previously diagnosed)