Case Study – Assessing And Diagnosing Patients With Anxiety Disorders

Case Study – Assessing And Diagnosing Patients With Anxiety Disorders

Patient Information:

Mr. Ralph Newsome is a 19-year-old male residing in Columbus, Ohio. He currently works part-time in construction and has recently been activated for military duty with the Navy Reserves, where his Military Occupational Specialty (MOS) is CM3 Construction Mechanic.

Subjective:

CC (chief complaint):

Mr. Newsome presents with continued sadness, fear, and confusion about his future. His emotional discomfort compounded due to military reactivation, along with an internal struggle regarding his sexual identity. He expresses apprehension about coming out as gay within a military context.

HPI:

The patient described symptoms that began approximately two months ago after being notified of his activation with the Navy Reserves for another tour in Iraq. Mr. Newsome shows increased anxiety and ambivalence with regard to the disclosure of his sexual orientation to fellow military personnel. He also received some homophobic remarks from one of the soldiers, which heightened his level of fear regarding being shunned and alienated. His most dominant sources of concern are the setting of the military, judgment, and the battle to maintain his sexual identity. Mr. Newsome has never experienced psychiatric illness in the past. He has not shared with anyone about his sexual orientation before this session. He denies ideation of suicide currently but admits having had such creativity in the past. He states emotional stress impairs daily functioning; he is still working and eating and sleeping usually.

Past Psychiatric History:

• No prior history of hospital stays, therapy, or mental disorders. There have been no psychiatric drugs taken by Mr. Newsome.

Substance Current Use and History: Mr. Newsome denies any substance use, including alcohol and recreational drugs.

Family Psychiatric/Substance Use History: No known history of psychiatric illness in the family.

Psychosocial History:

The patient works part-time as a construction worker and lives alone in Columbus, Ohio. Despite having a close bond with his military unit, he fears being rejected because of his sexual orientation. He is single at the moment and does not have any children. Although Mr. Newsome’s parents are local and supportive, he has not revealed his sexual orientation to them.

Medical History:

• Current Medications: None reported
• Allergies: No known drug allergies (NKDA)
• Reproductive Hx:

• Newsome self-identifies as gay and engages in sexual activity. Although he has occasionally had sex, he has never been in a committed relationship. He denies having ever had a history of STDs and has not recently experienced any problems with his sexual health. He has never discussed his sexual health with medical professionals and does not presently use any contraception.

ROS:

• GENERAL: No weight changes, fatigue, or fevers reported.
• HEENT: No visual disturbances, ear pain, or sore throat.
• SKIN: No rashes, itching, or skin lesions
• CARDIOVASCULAR: No chest pain, palpitations, or history of heart issues
• RESPIRATORY: No shortness of breath, cough, or history of respiratory illness.
• GASTROINTESTINAL: Appetite remains good; no nausea, vomiting, or abdominal pain reported.
• GENITOURINARY: No burning sensation during urination, changes in urinary habits, or genitourinary issues.
• NEUROLOGICAL: No headaches, dizziness, or changes in coordination or mental status.
• MUSCULOSKELETAL: No joint pain, muscle stiffness, or history of musculoskeletal issues.
• HEMATOLOGIC: No history of bleeding disorders, easy bruising, or anemia.
• LYMPHATICS: No swelling or tenderness of lymph nodes.
• ENDOCRINOLOGIC: No symptoms of heat or cold intolerance, no excessive thirst or urination.

Objective:

Physical exam:

In appearance, Mr. Newsome does not seem scruffy or dirty, and he is decently dressed. He is helpful but gets angry whenever he discusses matters related to his nature, such as his gay nature and his time with the military. He has a normal rhythm and pitch of speaking and speaks fluently and in sentences. He maintains appropriate eye contact, yet he turns away at times as he discusses some matters. There are no manifestations of psychomotor agitation.

Vital Signs:

• Temperature: 97.0°F
• Pulse: 70 bpm
• Respiratory Rate: 18 bpm
• Blood Pressure: 116/68 mmHg
• Height: 5’9”
• Weight: 175 lbs

Diagnostic results: Not done

Assessment:

Mental Status Examination:

• Appearance: Well-groomed and dressed suitably for the situation.
• Behavior: Supportive yet reluctant to talk about his sexual orientation.
• Mood: Tense and depressed.
• Affect: Restricted, displaying sporadic indications of mental discomfort.
• Speech: Transparent, logical, regular in pace and volume.
• Thought Process: Reasonable, focused, yet overcome with rejection worries
• Thought Content: Centered on his worries about telling his fellow service members about his sexual orientation. Although he acknowledges having had suicidal thoughts in the past, he denies having suicidal ideas presently. There are no delusions or hallucinations.
• Cognition: Conscious and focused on the person, place, and time.
• Insight: Little understanding of how his worries affect him emotionally
• Judgment: Just but deeply impacted by his inner turmoil about his sexual orientation.

Differential Diagnoses

1. Adjustment Disorder with Anxiety (Primary Diagnosis):

Rationale: Mr. Newsome’s anxiety began after learning about his military reactivation, which aligns with the DSM-5-TR criteria for Adjustment Disorder with Anxiety. In detail, he has a fear of rejection, anxiety about his disclosure of sexual orientation, and emotional distress, all of which relate to specific stressors of sexual minorities. These stressors include the future military reactivation and his burden of accepting and/or revealing his sexual orientation. O’Donnell et al. (2020) have expounded on the fact that Adjustment Disorder with Anxiety is precipitated by a specific event, making it possible for Mr. Newsome to be given this diagnosis.

1. • Pertinent Positives: Stressors from the past (military reactivation), rejection anxiety, and situational anxiety.
   • Pertinent Negatives: No evidence of persistent fear or anxiety in other aspects of his life, nor any history of chronic worry prior to the stressor.

1. Generalized Anxiety Disorder (GAD):

Rationale: The DSM-5-TR specifies a six-month period for symptoms, although Mr. Newsome’s anxiety may only last for two months, which may indicate GAD initially. Furthermore, his anxiety is more situation-specific than it is all-encompassing in various areas of his life (Munir & Takov, 2022).

1. • Pertinent Positives: Anxiety related to sexual identity and military service.
   • Pertinent Negatives: Short duration of symptoms, no evidence of chronic, generalized anxiety across multiple domains.

1. Social Anxiety Disorder:

Rationale: Mr. Newsome possibly has social anxiety disorder based on his fear of rejection and being evaluated by his military colleagues (Rose & Tadi, 2022). However, rather than being a broad fear of social circumstances, his anxiety is mostly centered on his sexual identity in the context of a particular social setting, which makes the diagnosis of adjustment disorder more accurate.

1. • Pertinent Positives: Fear of judgment, concerns about rejection.
   • Pertinent Negatives: Anxiety is limited to his concerns regarding sexual orientation disclosure and is not generalized across all social interactions.

Reflections:

If I could interview Mr. Newsome, I would explore his support system outside the military, such as friends, family, and LGBTQ+ networks. I would also provide resources for LGBTQ+ in military contexts and ways of coping with anxiety around disclosure. Psychoeducation on managing stress, communication capabilities, and self-acceptance will be indicated.

Legal/Ethical Considerations

Primary ethical considerations about Mr. Newsome are confidentiality in general and his sexual identity in particular in the context of serving in the military. Even though Don’t Ask, Don’t Tell was lifted, being LGBTQ+ may still be problematic in the context of serving in the military. It is necessary to ensure his privacy is protected and to discuss with him the possible consequences of such disclosure in his particular environment, as stressed by Tariq and Hackert (2023). Another factor could be his fellow persons’ cultural and religious convictions, which may affect their reactions concerning his disclosure.

Health Promotion and Disease Prevention

Where mental health promotion and prevention are concerned, Mr. Newsome is armed with regulating means for his emotional responses, coping with stress, and the availability of identity-supportive resources, as indicated by Singh et al. (2022). Encourage the client to support groups or therapy as ways to negotiate the emotional ups and downs of his sexual identity working within the military. The education of self-care, resiliency, and many other factors will protect him from potential stressors and prevent further emotional turmoil.

References

Munir, S., & Takov, V. (2022). Generalized anxiety disorder. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2020). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

Rose, G. M., & Tadi, P. (2022). Social anxiety disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/32310350/

Singh, V., Kumar, A., & Gupta, S. (2022). Mental health prevention and promotion—A narrative review. Frontiers in Psychiatry, 13(13). https://doi.org/10.3389/fpsyt.2022.898009

Tariq, R. A., & Hackert, P. B. (2023). Patient confidentiality. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519540/

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“Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease.

For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE:
Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
BY DAY 7 OF WEEK 4
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.

Incorporate the following into your responses in the template:

Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
Objective: What observations did you make during the psychiatric assessment?
Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).