CASE STUDY: A CASE OF ANXIETY AND INSOMNIA
Identification: The patient is a 22-year-old single white male seen in a private outpatient mental health office. Patient was referred by his mother.
Chief Complaint: “I feel really anxious and angry and I have trouble breathing.”
History of Present Illness: Besides feeling anxious, the patient also reports feeling depressed and angry. He has not been sleeping and does not have an appetite. He reports episodes of shaking, shortness of breath, nausea and sweating which occur suddenly. The symptoms started a month ago after a breakup with his girlfriend. She said she did not want to see him anymore and then she started dating his best friend. He started thinking about her all the time and couldn’t focus on his studies. He is worried he will fail his exams. He has been avoiding his friends because he does not want to be around people. He sought help at the urging of his family.
Past Psychiatric History: No prior psychiatric treatment.
Medical History: No acute or chronic medical conditions; Average height and weight; Poor appetite.
History of Drug or Alcohol Abuse: Denied
Family History: The patient was raised by his mother and father with his older brother. His father and older brother have a history of panic attacks. Father was very encouraging about the benefits of medication for his panic attacks.
Perinatal: Full-term vaginal birth. No complications.
Childhood: Normal development and achievements.
Adolescence: Did well academically in high school; Played hockey.
Adulthood: Currently enrolled as a junior in college; Unemployed. No military or legal history.
Trauma/Abuse History: Denies bullying or other trauma.
MENTAL STATUS EXAM
Appearance: Casual dress.
Behavior and psychomotor activity: Good eye contact. Initially tapping foot rapidly.
Orientation: Oriented to person, place, and time.
Concentration and attention: Attentive during interview. He describes poor concentration with school work. He is worried about failing an exam.
Visuospatial ability: Not assessed.
Abstract thought: Not assessed.
Intellectual functioning: Average or above.
Speech and language: Normal rate and volume.
Perception: No abnormality.
Thought process: He has been obsessing about his ex-girlfriend.
Thought content: His thoughts center on his ex-girlfriend and these thoughts were confused and angry. He fears that he will fail his exams because he cannot concentrate enough to study.
Suicidality or homicidality: Denied.
Mood: Anxious, depressed.
Affect: Congruent to mood.
Impulse control: Good.
FORMULATING THE DIAGNOSIS (Please answer all questions)
- Which diagnosis (or diagnoses) should be considered?
- Please provide support of diagnostic criteria from DSM-5.
- Please provide diagnostic code with diagnosis.
- What is the rationale for the diagnosis?
- What diagnostic tests or tools should be considered to help identify the correct diagnosis?
- What differential diagnosis (or diagnoses) should be considered?
FORMULATING THE TREATMENT STRATEGY
- What treatment would you prescribe and what is the rationale?
- Psychotherapy? If so, which therapy?
- Psychoeducation indicated? If so, what education and to whom?
- What standard guidelines would you use to assess and treat this disorder?
Please add clinical impressions, nursing diagnoses, outcomes, goals, interventions for this patient.
Please add citations to support your treatment modalities