Comprehensive Psychiatric Evaluation for Anxiety Disorders
Anxiety disorders are a spectrum of mental health illnesses affecting all population groups. These illnesses comprise selective mutism disorder, separation and generalized anxiety disorders, and specific phobias. The hallmark feature of these disorders is an excessive fear of actual or perceived threats that cause significant impairment in individuals’ social functioning (Szuhany & Simon, 2022). Anxiety disorders are a health concern. These disorders have been implicated in increased missed work and school days, increased consumption of mental and physical health resources, and significant functional disability. This paper analyzes anxiety disorders through the lens of an interview with a client seeking psychiatric consultation.
Purpose Statement: The purpose of this paper is to detail the comprehensive psychiatric evaluation of a client seeking psychiatric consultation. It will formulate a diagnosis based on the subjective and objective findings from the case.
Subjective
The interview is with a 19-year-old White male, RN. He lives in Columbus, OH.
CC (chief complaint): “I am having a feeling of fear and sadness.”
HPI:
RN is a 19-year-old male who reported to the clinic with complaints of feelings of sadness and fear. The feelings started two months ago when he learned he was being activated into the Navy. He fears that people in his military unit will feel uncomfortable when he opens up about his sexuality to them. He also reports having difficulties opening up about his sexuality. He also fears being rejected once he opens up about his sexuality.
Past Psychiatric History:
- General Statement: The client has never had any psychiatric illness.
- Hospitalizations: The client has never been hospitalized for any illnesses before.
- Medication trials: The client has a negative history of psychiatric illnesses.
- Psychotherapy or Previous Psychiatric Diagnosis: Negative history of psychotherapy or previous psychiatric diagnosis.
Substance Current Use and History: No reports of alcohol or substance use, smoking, or use of illicit substances.
Family Psychiatric and Medical History: Negative family history of chronic illnesses or any mental health disorders.
Family Substance Use/Alcohol: No reports of substance use or alcohol consumption in the client’s family.
Psychosocial History: The client is a 19-year-old male. RN is gay. He is single and works in the reserve unit of the military. He is also a part-time as a construction worker. He lives alone with his dog, Chance.
Medical History:
- Current Medications: The client is not on any medication. There were no reports of past medication use.
- Allergies: The client has no known allergies.
- Reproductive Hx: There are no reports of any anomalies in the reproductive system.
ROS
- GENERAL: No reports of recent weight loss, fever, and chills.
- HEENT: No reports of any head injuries, visual and hearing loss, or nasal congestion and discharge. There are also no reports of sore throat or difficulty in swallowing.
- SKIN: No reports of any skin lesions, skin color inconsistencies, discoloration, or excessive skin dryness.
- CARDIOVASCULAR: No reports of chest pain, chest discomfort, or palpitation
- RESPIRATORY: No reports of wheezing, labored breathing, coughing, excessive mucus production, or wheezing.
- GASTROINTESTINAL: No reports of bowel movement inconsistencies, abdominal pain, or distension.
- GENITOURINARY: No reports of dysuria, urinary frequency, urgency, and hesitancy.
- NEUROLOGICAL: No reports of fainting, dizziness, headaches, tremors, confusion, ataxia, or loss of bowel and bladder control.
- MUSCULOSKELETAL: No reports of muscle stiffness and pain or joint movement restrictions.
- HEMATOLOGIC: No reports of ease of bruising, anemia, or excessive bleeding.
- LYMPHATICS: No reports of lymph gland swelling or splenomegaly.
- ENDOCRINOLOGIC: No reports of heat or cold intolerance, diabetes, or sudden weight changes.
Objective
Physical Exam:
- Vital signs:T- 97.0 P- 70 R 18 116/68 Ht 5’9 Wt 175lbs
- Lab results/ labs order. Not needed.
Assessment
The client presented with complaints of sadness and fear. Subjective and objective data highlighted fear as the main issue in the case. The client, in this case, presented fear of revealing his sexual identity to his peers. He is also scared of being rejected because of his sexual identity. The fear seems to be affecting his social functioning considerably as he is having mixed thoughts about being activated into the Navy despite being a military reserve.
Mental Status Examination:
The client is alert and responsive to the assessment questions asked. He is oriented to the place and event. His speech is coherent, goal-directed, and logical. The client’s voice is normative in volume and intonation. There is no sign of speech defects or stuttering and stammering. The client is cooperative. His judgment is also intact. His mood is sad and affect blunt. His thought process is logical, insightful, and goal-directed. The client has a history of suicidal thoughts, as he had considered suicide at one point in his life, but denies having experienced any suicidal ideation recently.
Differential Diagnoses:
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Social Anxiety Disorder:
Social anxiety disorder is an anxiety disorder characterized by excessive fear of being humiliated, embarrassed, or rejected upon exposure to negative evaluations from others during social interactions. Persons with social anxiety disorder will have concerns about being judged negatively and will more likely report fearing rejection. According to the fifth edition of the Diagnostic and Statistical Manual for Mental Health Disorders (DSM-V), a positive diagnosis of social anxiety disorders is made in the presence of fear that appears when one is in a situation that may fetch scrutiny. The fear must be causing significant impairment in the social functioning of the individual and must be present for at least six months (Alomari et al., 2022). In the case presented, the client had a fear that was attributed to his fear of revealing his sexual identity and the apparent negative judgment that revealing his sexual identity would elicit. These presentations are aligned with those of social anxiety disorder.
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Generalized Anxiety Disorder (GAD):
GAD is another anxiety disorder characterized by a feeling of fear and persistent worry about things. The hallmark features of GAD are excessive worry or fear that causes social impairment and difficulties controlling the worry (Mishra & Varma, 2023). This differential was included because of the presence of fear in the client’s case presented. It was, however, ruled out due to the absence of other features supportive of GAD, such as the absence of at least one somatic symptom, usually accompanying GAD.
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Agoraphobia:
Agoraphobia is an anxiety that occurs when one is in crowded spaces, for which the possibility of escaping is narrow. According to the DSM-V, agoraphobia is characterized by marked fear about an actual or anticipated exposure to a public space (Shin et al., 2020). In this case, a person with the disorder may manifest anxiety symptoms even with the thought of being in a public space. This differential was included because of the presence of fear about an anticipated event. It was, however, ruled out because of limited proof of the fear of being in public spaces or multiple situations.
Diagnostic Impression: Social anxiety disorder. The client’s manifestations meet the criteria for social anxiety disorder as outlined in the DSM-V.
Reflections
The interview gave me insight into how anxiety disorders manifest. During psychiatric evaluation, I would be keener on other subjective features pointing to the etiological factors interplaying in the client’s presentation. I would also be keen on legal considerations. Accordingly, the legal consideration that may play in this case is competence. Per the competency provisions, caregivers should not allow their judgment to be influenced by their client’s emotions. Incompetent psychiatric care, caregivers should maintain objectivity when addressing their client’s concerns. Further, an ethical consideration is beneficence. Beneficence requires caregivers to act in the best interest of their clients. Discerning an appropriate therapeutic modality is a demonstration of beneficence.
Moreover, access to quality mental healthcare remains a social determinant of health across communities. In this case, the caregiver maintains the responsibility of providing the best psychiatric care to the client. As a health promotion and disease prevention intervention, the client should be educated on the disease process and a coping strategy that will help him overcome his fears and prevent such occurrences.
Conclusively, anxiety disorders are a health concern. These illness causes social impairments and may cause functional disability in affected persons. As evident in the interview, the effects of anxiety disorders are far-reaching. This warrants their address.
References
Alomari, N. A., Bedaiwi, S. K., Ghasib, A. M., Kabbarah, A. J., Alnefaie, S. A., Hariri, N., Altammar, M. A., Fadhel, A. M., & Altowairqi, F. M. (2022). Social anxiety disorder: Associated conditions and therapeutic approaches. Cureus. https://doi.org/10.7759/cureus.32687
Mishra, A. K., & Varma, A. R. (2023). A comprehensive review of the Generalized Anxiety Disorder. Cureus. https://doi.org/10.7759/cureus.46115
Shin, J., Park, D.-H., Ryu, S.-H., Ha, J. H., Kim, S. M., & Jeon, H. J. (2020). Clinical implications of agoraphobia in patients with panic disorder. Medicine, 99(30). https://doi.org/10.1097/md.0000000000021414
Szuhany, K. L., & Simon, N. M. (2022). Anxiety disorders. JAMA, 328(24), 2431. https://doi.org/10.1001/
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Question
Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a 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.).