Initial Psychological Evaluation — Whitfield, James R.

Psychological Evaluation Signed Risk: Low-Moderate

Summary

Mr. Whitfield is a 38-year-old married male presenting with a 3-month history of insomnia, irritability, and occupational dissatisfaction following being passed over for a workplace promotion. He reports increased alcohol consumption (from 2-3 to 10-12 drinks/week) as a coping mechanism. No suicidal or homicidal ideation. Cognitive functions intact. Insight and judgment are good.

Identifying Information

James R. Whitfield, 38-year-old Caucasian male. Married, two children (ages 6 and 9). Employed as senior analyst at a financial services firm for 12 years. Referred by spouse.

Presenting Complaint

Insomnia (3 months), irritability, occupational dissatisfaction, increased alcohol consumption. Onset coincides with being passed over for promotion.

History of Present Illness

Client reports early morning awakening (2-3 AM) with inability to return to sleep. Daytime irritability affecting family relationships. Two uncharacteristic sick days in the past month. Increased alcohol from 2-3 drinks/weekend to 10-12/week. Denies SI/HI. Appetite slightly increased. Concentration impaired.

Mental Status Examination

Appearance: Well-groomed, age-appropriate attire. Behavior: Cooperative, good eye contact, mild psychomotor restlessness. Speech: Normal rate and volume. Mood: "Stuck." Affect: Congruent, mildly constricted range. Thought Process: Linear, goal-directed. Thought Content: No delusions, no SI/HI. Cognition: Alert and oriented x4. Insight: Good. Judgment: Fair.

Psychometric Results

PHQ-9: 14 (Moderate Depression). GAD-7: 8 (Mild Anxiety). AUDIT: 9 (Hazardous drinking). ISI: 18 (Moderate Clinical Insomnia).

Diagnostic Formulation

Primary: Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23). Rule out: Major Depressive Disorder, single episode. Monitor: Alcohol Use — currently hazardous but sub-threshold for AUD.

Clinical Impressions

Based on the clinical interview, psychometric screening, and behavioral observations, Mr. Whitfield meets criteria for Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23). The onset is clearly linked to the occupational stressor in November 2025. His increased alcohol use is notable but does not yet meet criteria for Alcohol Use Disorder — however, it represents a maladaptive coping pattern that warrants monitoring. Strengths include strong family motivation, good insight into his behavioral changes, willingness to seek help, and no prior psychiatric history. Risk factors include escalating substance use, sleep deprivation affecting occupational functioning, and potential for chronic adjustment if not addressed.

Recommendations

1. Weekly individual therapy (CBT) focusing on cognitive restructuring around workplace identity and value 2. CBT-I protocol for insomnia — sleep hygiene education and stimulus control 3. Alcohol use monitoring — psychoeducation on the relationship between alcohol and sleep disruption 4. PHQ-9 and AUDIT screening at 4-week follow-up 5. Consider referral to psychiatry if depressive symptoms escalate or do not respond to therapy within 6-8 weeks 6. Encourage couples session to address communication patterns around his mood changes

Report Details

Report Type: Psychological Evaluation
Status: Signed
Generated: Feb 17, 2026 at 6:29 AM
Signed By: Dr. Sarah Mitchell, Psy.D.
Signed At: Feb 11, 2026 at 2:30 PM

Diagnoses (DSM-5)

F43.23 PRIMARY

Adjustment Disorder with Mixed Anxiety and Depressed Mood

Z56.9

Unspecified Problems Related to Employment

Risk Assessment

2/5

Low-Moderate

Risk Level

Risk Factors

Increasing alcohol use, sleep deprivation, occupational stress

Source Session

James R. Whitfield

Feb 10, 2026 — 90 min

JRW-2026-0041

AI Analysis Confidence

Diagnostic Accuracy 92%

Treatment Relevance 88%

Risk Assessment 85%

Documentation Quality 95%