Comprehensive Psychotherapy Evaluation

Full Answer Section

She notes significant difficulty falling asleep, often ruminating about work-related issues, leading to only 4-5 hours of fragmented sleep per night. This lack of sleep exacerbates her irritability and makes it harder to cope with daily stressors. She denies panic attacks but reports occasional shortness of breath and heart palpitations when feeling particularly overwhelmed. She states she feels "on edge" most of the time and has become increasingly restless. She has lost interest in hobbies she once enjoyed, such as painting and hiking, and finds herself withdrawing from social interactions, feeling too tired or anxious to engage. She denies suicidal ideation, homicidal ideation, or psychotic symptoms. She has tried over-the-counter sleep aids with minimal benefit and increased her coffee intake to manage fatigue. She denies alcohol or illicit substance use to cope.

Past Psychiatric History (PPH):

• Previous Diagnoses: Denies formal psychiatric diagnoses prior to this presentation.
• Hospitalizations: Denies past psychiatric hospitalizations.
• Outpatient Treatment: Denies prior outpatient psychiatric therapy or medication.
• Childhood History: Reports a generally stable childhood. Denies history of significant trauma, abuse, or neglect. No history of ADHD, learning disabilities, or significant behavioral problems.

Past Medical History (PMH):

• Medical Conditions: Denies chronic medical conditions such as thyroid disorders, cardiac issues, or diabetes.
• Surgeries: Appendectomy at age 15.
• Hospitalizations (non-psychiatric): Only for appendectomy.
• Medications: Oral contraceptive pill (OCP), occasional ibuprofen for headaches. No known drug allergies.
• Immunizations: Up-to-date.
• Last Physical Exam: 6 months ago, reported as "normal."

Substance Use History:

• Tobacco: Denies.
• Alcohol: Occasional social drinking, 1-2 drinks per week. Denies binge drinking or problematic use.
• Illicit Drugs: Denies all illicit drug use (marijuana, cocaine, opioids, stimulants, hallucinogens).
• Caffeine: Reports 3-4 cups of coffee daily since onset of symptoms, increased from 1 cup.
• Prescription Drugs: Denies misuse of prescription medications.

Family Psychiatric History (FPH):

• Mother: Reports history of "nervousness" and occasional "difficulty sleeping" managed with natural remedies. No formal diagnosis.
• Father: No known psychiatric history.
• Siblings: One older brother, no known psychiatric history.
• No family history of psychosis, bipolar disorder, or completed suicide.

Social History (SH):

• Marital Status: Single, never married.
• Children: None.
• Living Situation: Lives alone in an apartment.
• Employment: Project Manager at a tech company (6 months in current role). Previously worked as a marketing coordinator for 5 years. Reports job satisfaction generally, but current role is very demanding.
• Education: Bachelor's degree in Business Administration.
• Support System: Reports a few close friends she connects with occasionally. Parents live in a different city but maintain regular contact.
• Legal History: Denies any arrests or legal issues.
• Financial Situation: Reports stable financial situation.
• Military History: Denies.
• Cultural/Spiritual Background: Identifies as non-religious but values personal growth and community.

O: Objective

General Appearance: Ms. A.B. is a well-groomed, neatly dressed female who appears her stated age. She maintains good eye contact throughout the interview. She appears somewhat fatigued with subtle dark circles under her eyes.

Speech: Clear, coherent, normal rate and rhythm, normal volume. No pressured speech or poverty of speech noted.

Motor Activity: Fidgety, taps her foot intermittently, occasionally wrings her hands. Mild psychomotor agitation observed.

Affect: Restricted, anxious. (Describes the observed emotional expression, not the stated emotion).

Mood: "Anxious," "overwhelmed," "tense." (Patient's self-report).

Thought Process: Linear, logical, goal-directed. No tangentiality, circumstantiality, loose associations, or flight of ideas.

Thought Content: Preoccupied with work-related worries and future uncertainties. No delusions, paranoid ideation, ideas of reference, or obsessions.

Perceptual Disturbances: Denies hallucinations (auditory, visual, tactile, olfactory, gustatory). Denies illusions or depersonalization/derealization.

Suicidal Ideation: Denies current or past suicidal ideation, intent, or plan. Denies passive death wishes. Homicidal Ideation: Denies current or past homicidal ideation, intent, or plan.

Orientation: Oriented to person, place, time, and situation (A&O x 4).

Memory: Intact recent and remote memory. No apparent deficits in immediate recall or new learning.

Concentration: Appears mildly impaired during the interview, occasionally losing track of a question, requiring rephrasing.

Insight: Good. Acknowledges her symptoms are impacting her life and work performance, and she needs professional help. Judgment: Good. Able to make reasonable decisions regarding her health and daily functioning.

Impulse Control: Good. No history of impulsive behaviors, aggression, or self-harm.

A: Assessment

Diagnostic Impression (DSM-5-TR Provisional Diagnoses):

1. Generalized Anxiety Disorder (GAD) F41.1:

   • Criteria Met:
     • Excessive anxiety and worry occurring more days than not for at least 6 months (present for 6 months).
     • Difficulty controlling the worry.
     • Associated with $\ge 3$ of the following 6 symptoms (only one for children):
       • Restlessness or feeling keyed up or on edge (observed fidgeting, patient report)
       • Being easily fatigued (patient report)
       • Difficulty concentrating (patient report, observed during interview)
       • Irritability (patient report)
       • Muscle tension (patient report)
       • Sleep disturbance (patient report, insomnia)
     • The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (impact on work, social withdrawal, decreased enjoyment of hobbies).
     • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
     • The disturbance is not better explained by another mental disorder (e.g., panic disorder, social anxiety disorder, specific phobia, obsessive-compulsive disorder, separation anxiety disorder, anorexia nervosa, somatic symptom disorder, or illness anxiety disorder).

2. Insomnia Disorder, F51.01 (Primary type, comorbidity with GAD):

   • Criteria Met:
     • A predominant complaint of dissatisfaction with sleep quantity or quality, associated with $\ge 1$ of the following:
       • Difficulty initiating sleep (patient report)
       • Difficulty maintaining sleep (patient report)
       • Early-morning awakening with inability to return to sleep (patient report)
     • The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning (impact on work, irritability, fatigue).
     • The sleep problem occurs at least 3 nights per week.
     • The sleep problem is present for at least 3 months.
     • The sleep disturbance occurs despite adequate opportunity for sleep.
     • The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder.
     • The insomnia is not attributable to the physiological effects of a substance.
     • Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

Differential Diagnoses Considered:

• Adjustment Disorder with Anxious Mood: Less likely given the chronicity (6 months) and pervasive nature of symptoms beyond the initial adjustment period to the new job.
• Panic Disorder: Denied discrete panic attacks.
• Major Depressive Disorder: While she reports anhedonia and fatigue, the primary and predominant symptoms are anxiety, worry, and restlessness, rather than core depressive symptoms like persistent low mood, hopelessness, or significant neurovegetative changes beyond sleep.
• Substance-Induced Anxiety Disorder: Ruled out by substance use history (no problematic use, increased caffeine is a symptom management strategy rather than primary cause).
• Anxiety Disorder Due to Another Medical Condition: Unlikely given recent normal physical exam and no specific medical symptoms.

Strengths: Ms. A.B. demonstrates good insight into her condition, is motivated for treatment, has a supportive family, and maintains employment despite her symptoms.

Risk Assessment:

• Suicide Risk: Low. Denies current or past suicidal ideation, intent, or plan. No history of attempts. No significant risk factors (e.g., severe hopelessness, psychosis, severe substance abuse, access to lethal means).
• Homicide Risk: Low. Denies.
• Violence Risk: Low. Denies.
• Overall Risk: Low risk for harm to self or others.

P: Plan

1. Further Diagnostic/Medical Workup:

• Recommend basic blood work if not recently done (e.g., TSH, CBC, CMP) to rule out underlying medical conditions contributing to anxiety/fatigue, despite recent physical.

2. Pharmacotherapy:

• Discuss initiation of a Selective Serotonin Reuptake Inhibitor (SSRI) given the persistent and impairing GAD symptoms.
  • Recommendation: Start with Sertraline (Zoloft) 25 mg daily for 7 days, then increase to 50 mg daily.
  • Rationale: SSRIs are first-line for GAD, generally well-tolerated, and can help with anxiety, sleep, and irritability. Sertraline has a relatively benign side effect profile.
  • Patient Education: Discuss common side effects (nausea, headache, agitation, sexual dysfunction), delayed onset of action (2-4 weeks for initial effect, 6-8 weeks for full effect), importance of consistent daily dosing, and potential for withdrawal symptoms if stopped abruptly.
• Adjunctive Sleep Aid (Short-Term): Consider a non-benzodiazepine hypnotic if insomnia is severe and interferes significantly with function initially.
  • Recommendation (if indicated): Zaleplon (Sonata) 10 mg PRN for sleep, max 3-4 times per week, for short-term use (2-4 weeks) until SSRI takes effect.
  • Rationale: Rapid onset, short half-life, less next-day sedation than some other hypnotics.
  • Patient Education: Discuss potential for dependence, rebound insomnia, and importance of sleep hygiene. Emphasize it's a bridge to better sleep via the SSRI and behavioral changes.
• Avoid Benzodiazepines at this time given patient's good insight and willingness to try SSRI first, and to avoid long-term dependence concerns.

3. Psychotherapy:

• Recommendation: Strongly recommend Cognitive Behavioral Therapy (CBT) for Anxiety.
  • Rationale: CBT is highly effective for GAD and insomnia. It will help Ms. A.B. identify and challenge anxious thought patterns, develop coping strategies, learn relaxation techniques, and implement sleep hygiene principles.
• Referral: Provide referrals to local CBT therapists experienced in anxiety disorders.

4. Lifestyle and Behavioral Interventions:

• Sleep Hygiene: Provide handout and discuss strict sleep hygiene practices (consistent sleep schedule, dark/cool/quiet room, avoid screens before bed, limit caffeine/alcohol, avoid daytime naps).
• Stress Management: Encourage regular physical exercise (e.g., walking, yoga), mindfulness meditation, and re-engagement in enjoyable hobbies (e.g., painting, hiking) once energy improves.
• Work-Life Balance: Discuss strategies for setting boundaries at work, delegating tasks, and taking regular breaks.

5. Follow-up:

• Pharmacology Follow-up: Schedule follow-up appointment in 2-3 weeks to assess medication tolerance, effectiveness, and make dosage adjustments.
• Therapy Coordination: Encourage Ms. A.B. to contact us once she has started therapy to facilitate communication between providers if appropriate.

Prognosis: Good, given patient's motivation, good insight, relatively recent onset of symptoms, and absence of complicating factors like severe trauma or substance use disorders.

Sample Answer

Comprehensive Psychiatric Evaluation - Hypothetical Case Study

Patient Name: Ms. A. B. Date of Birth: XX/XX/1995 (Age: 30) Date of Evaluation: May 27, 2025 Evaluator: [Fictional Psychiatrist Name/AI Demonstration]

S: Subjective

Chief Complaint (CC): "I've been feeling overwhelmed, constantly anxious, and have trouble sleeping for the past six months, especially since I started my new job."

History of Present Illness (HPI): Ms. A.B., a 30-year-old single female, presents to the clinic reporting a six-month history of escalating anxiety, irritability, and insomnia. Symptoms began shortly after she transitioned into a demanding new role as a project manager, requiring increased responsibilities and longer hours. She describes a pervasive sense of worry about performance, deadlines, and potential mistakes, even when not at work. She reports daily racing thoughts, difficulty concentrating on tasks, and muscle tension, particularly in her neck and shoulders.