Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
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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.).
Subjective:
CC (chief complaint): “I can’t even begin to describe what I am feeling.” H
HPI : Mr. Newsome is a 19-year-old male who reported to the clinic with his chief complaints of having mixed feelings. He described it as having feelings of sadness and fear following his re-activation with the Navy Reserves. Mr. Newsome feared being called for deploved back to Iraq for another mission. He reported having mixed feelings about whether to reveal his sexuality to his fellow soldiers and also fears how they would judge him after learning that he was gay. He admitted to being worried that people in his unit would treat him differently and not be comfortable when around him after learning about his sexuality.
Past Psychiatric History :
G eneral Statement: No prior psychiatric treatment. Admitted to previously being worried about rejection to the extent of wanting to commit suicide.
C aregivers (if applicable): N/A
H ospitalizations: None reported
M edication trials: Currently not on any medications
P sychotherapy or P revious Psychiatric Diagnosis: None reported
Substance Current Use and History: No reported current substance use or history
Family Psychiatric/Substance Use History: None reported
Psychosocial History:
Lives independently in Columbus, OH, with his dog Chance
He is the only child, his parents live locally
Works part-time in construction
He is single, not currently partnered
Is with the Navy Reserves as a CM3 Construction Mechanic
No legal history
Medical History:
Current Medications : None
Allergies : No known allergies
Reproductive Hx : Not available
ROS :
GENERAL: Mr. Newsome denies having unintended weight change. No fever, no reported chills.
HEENT: Denies visual loss and double or blurred vision. Denied having hearing loss or ear discharge. Denied having a runny nose or sore throat.
SKIN: Denied having rashes or lesions.
CARDIOVASCULAR: No reported chest pain, chest pressure, or palpitations.
RESPIRATORY: Denied experiencing shortness of breath.
GASTROINTESTINAL: Denied having any abdominal pain. They reported having a good appetite.
GENITOURINARY: Denied experiencing pain while urinating or change in urination frequency.
NEUROLOGICAL: Denied having tingling or numbness.
MUSCULOSKELETAL: Denied having swollen or painful joints
HEMATOLOGIC: Denied experiencing excessive bleeding.
LYMPHATICS: Denied having swollen lymph nodes
ENDOCRINOLOGIC: Denied experiencing excessive sweating and heat and cold intolerance.
Objective:
Physical exam:
Vital Signs
Height: 5’9″
Weight: 175 lbs
Temperature: 97.0°F
BP: 116/68
Pulse: 70
RR: 18
Diagnostic results : None
Assessment:
Mental Status Examination:
This is a 19-year-old Caucasian male who appears his stated age. He appears to be well-groomed and appropriately dressed during the evaluation. He is cooperative during the interview and actively engages with the examiner. His speech is clear and coherent and has normal volume and tone. His thought processes are goal-directed and logical, and he showed no signs of looseness of associations or flight of ideas. His mood seems anxious, with the effect being congruent with his mood. During the interview, he demonstrated appropriate social responsiveness. Has no evidence of delusional thinking. Denied having current suicidal or homicidal ideation. He is alert and oriented to person, place, time, and situation. His recent and remote memory is noted to be intact. He demonstrates having good insights into his current situation and exhibits appropriate judgment.
Differential Diagnoses:
Adjustment Disorder with Anxiety (ICD 10 Code F43.22) – adjustment disorder is a maladaptive emotional and/or behavioral response to a recognized psychosocial stressor, including those who experience challenges adjusting after a stressful event at a level disproportionate to the severity or intensity of stressor (O’Donnell et al., 2019). The symptoms are characterized by stress responses that are out of step with socially or culturally expected reactions to a stressor, causing significant distress and impairment in daily functioning (O’Donnell et al., 2019). The stressor that the patient faced was his military activation and fears of informing his unit members about his sexuality. It can be noted that this contributed to significant anxiety that appears to be out of proportion to the stressor.
Acute Stress Disorder (ICD 10 Code – F43.0) – Acute stress disorder is a mental health condition that occurs when an individual experiences a traumatic event for less than a month (Hagos et al., 2024). In this case, the condition may be supported due to the presence of an identifiable stressor and anxiety symptoms. However, it was ruled out since the patient was not exposed to an actual or serious threat and lacked the dissociative symptoms needed to make the diagnosis.
Generalized Anxiety Disorder (ICD 10 code – F41.1): Generalized anxiety disorder is a common psychiatric disorder that involves general apprehensiveness and excessive worry (Fagan & Baldwin, 2023). In this case, the condition was considered due to the presence of anxiety symptoms and difficulty in controlling worry. However, it was ruled out since there was a clear precipitating event, as opposed to having generalized worry; it had taken place in less than 6 months, and the symptoms were directly associated with a specific stressor.
Reflections:
This case involved a patient who presented with anxiety symptoms associated with an upcoming military deployment. The symptoms presented are consistent with adjustment disorder due to the precipitating stressor and lack of prior psychiatric history. The patient was noted to be able to maintain good functioning in daily activities, even with anxiety, which was suggestive of moderate severity. I would agree with the preceptor’s diagnosis of adjustment disorder with anxiety due to the precise temporal relationship between symptom onset and the military activation notice, along with the maintained functional status despite distress.
An emerging legal or ethical consideration from the case is the importance of maintaining patient confidentiality. The patient was worried whether the therapist would report what he told the evaluator. It is important to assure the patient of ethical privileges protected under the HIPPA laws, even after the repealing of the “Don’t ask, don’t tell policy.”
Social Determinants of Health
One significant social determinant of health is gender/cultural factors as part of the social and community context. The male gender identity influences help-seeking behaviors and symptom expression, especially within the military culture. Another social factor is health care access and quality, where the patient, as a member of the military, has access to health care, including psychiatric care.
Health Promotion/Disease Prevention
The patient faces significant risk factors for anxiety-related issues, including deployment at a young age, living alone, and lack of an established mental health support system. Similarly, the patient has some protective factors, including local family support, employment, no reported substance use, stable sleep, and good oral intake.
References
Fagan, H. A., & Baldwin, D. S. (2023). Pharmacological treatment of generalized anxiety disorder: current practice and future directions. Expert Review of Neurotherapeutics , 23 (6), 535–548. https://doi.org/10.1080/14737175.2023.2211767
Hagos, T. G., Tamir, T. T., Workneh, B. S., Abrha, N. N., Demissie, N. G., & Gebeyehu, D. A. (2024). Acute stress disorder and associated factors among adult trauma patients in Ethiopia: a multi-institutional study. BMC psychiatry , 24 (1), 418. https://doi.org/10.1186/s12888-024-05861-6
O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International journal of environmental research and public health , 16 (14), 2537. https://doi.org/10.3390/ijerph16142537
