Assessment and Diagnosis of Anxiety Disorder

Chief Complaint 

Patient perceives he has become worthless to family and peers. 

History of Presenting Illness 

Barnes Johnson, aged 26, is a football player. In recent months, Johnson’s coach and teammates have noticed a change in is behavior. His once cheerful self has been replaced by a paranoid, reclusive, and less confident personality. During the training sessions or competitions, Johnson has been heard severally mumbling phrases that negate from the core principles and slogan of the team. The behavior persisted, and its effects were manifested in the decline in the team’s performance. Before matches, Johnson gets sweaty and restless, making it difficult for him to focus on his role. This behavior has prompted the coach to withdraw him from the team and schedule counseling sessions for him twice a week. He also exhibits sleeping disorders, and in some instances, he talks incoherently in his sleep or wakes up shouting and panting. 

On assessment, Johnsons reiterates his admission of considerable stress, adding that there are instances when he feels like his mind is racing, and he has run out of options to cope. He admits feeling under pressure and intense fear of failing to perform and letting his team down. He admits developing aggressive and reclusive behavior as everyone seems to be ridiculing him for not being worthy enough. When asked about the effects of his condition outside football, Johnsons insists that his social life is normal and his daily mon-sporting routines remain unperturbed. He is openly displeased by this line of questioning. On further cross-examination, it is evident that he is distraught but does not want to admit it. He hits at suicidal tendencies, albeit indirectly, by saying that there are times when he wishes he would end all this forever. The two biggest worries for him are the feeling of worthlessness to those around him and ridicule from his peers. 

Demographic Information and Social/Family History 

Johnsons is 26 years old and lives with his girlfriend at his family house. His parents passed away four years ago in a fatal road accident. His father was an army veteran who had been diagnosed with advanced posttraumatic stress disorder (PTSD) and was restricted from operating heavy machinery. His mother had been diagnosed with terminal Parkinson’s disease. Johnsons lives with his younger brother and caters for his brother’s educational needs. He is unemployed as he sought to become a professional footballer and thus, he strives to excel in the game and attain the pinnacles of American football. 

Past Medical History 

Two years back, Johnson suffered a major brain trauma following an injury sustained during a match. He underwent surgery and was hospitalized for three months and was ruled fit to play after 11 months. During this period, he underwent intracranial pressure monitoring and rehabilitation therapy. He was prescribed with methocarbamol, citalopram, fluvoxamine, and opioid analgesics in different instances of his treatment. 

History of ETOH and Substance Abuse 

Patient has a history of chronic ETOH and methamphetamine abuse. He was rehabilitated three years ago, and is now restricted to occasional ETOH consumption. Last ETOH intake was a two weeks ago. 

Mental Status Examination/Cognitive History 

He is selectively responsive to the assessment and choses to respond to the questions that he feels do not offend him. However, his thought process and communication is linear. He has little insight of the required course of treatment for his condition, but welcomes the idea of hospitalization and enrollment in the psychotherapy sessions. His judgement of situations is poor, as he perceives most people as hostile. However, he is conscious of his environment. 

Clinical Presentation 

The physical examination and patient information indicate that he has difficulty concentrating, making rational decisions, and sleeping. The patient also experiences memory lapses and has difficulty recalling. Other physical symptoms are profuse sweating, changes in appetite, cramping and idiopathic gastrointestinal problems. Emotional symptoms that the patient exhibits are recurrent feelings of emptiness, worthlessness, pessimism, and loneliness. He has lost interest in what he previously did with enthusiasm, including pleasure activities, hobbies, and most conspicuously, playing football. The patient is irate and visibly restless, possibly due to the feelings of paranoia and lack of adequate sleep. On physical examination, no underlying physical problems can be observed. 

Analysis of Pertinent Information 

The patient has had difficulty coping and balancing his societal roles, thereby predisposing him to generalized anxiety and depression. He has become paranoid and perceives every opponent and teammate as better than him, inculcating feelings of worthlessness. In this case, the fear has exceeded the compulsion. The loss of a close person has been shown to have profound effects on the mental wellbeing of an individual (Stein & Sareen, 2015). Depression is often one of the common conditions associated with grief, as the individual finds ways of coming to terms with the situation. The patient may have experienced latent depression following the loss, and over the years, he tried suppressing it with alcohol (Portico, 2019). While the team’s policy requires that the players should restrict alcohol intake to as minimum as possible, occasional ETOH intake may have been helpful in suppressing the latent depression. 

The patient also suffered a major traumatic brain injury (TBI) that resulted in cranial surgery and psychiatric therapy. The doctors ruled him fit to play football again. However, the medical history does not indicate the prognosis and state of his mental health following discharge. TBI causes derangement of brain functions and may result in psychiatric conditions manifested by emotional and behavioral effects. Behavioral changes associated with TBI include frustrations, impulsivity, increased aggressiveness, perseveration, and impaired judgment. Emotional effects of TBI include increased anxiety, reduced self-awareness and self-esteem, emotional lability, and anxiety ( Stein & Sareen, 2015). While these symptoms are general for TBI patients, specific behavioral and emotional changes may have been enhanced by other factors such as the pressure to perform and the loss of both parents. The patient admits that he needs to resolve his situation, indicating the need to expedite the treatment and management approaches. 

Review of Systems 

Constitutional: Weight at 174 lbs, height 6’2”. Composed and at appropriate energy level. 

HEENT: Clear vision and hearing. No nasal obstruction or epistaxis. No history of tonsillectomy. Normal dentition with no dentures. 

Respiratory: No chest sounds, wheezing, pneumonia, or pulmonary emboli. 

CVS: Normal hearth sounds, history of sickle cell anemia at young age. No clotting complications. 

G.I: Sporadic cramping and abdominal conditions. No history of gastric or abdominal surgery. 

G.U: History of genital herpes and signs of stress incontinence. 

Neuromuscular: No history of syncope or seizures. Full range of motion and ambulatory. 

Endocrine: No history of hyperthyroidism. 

Psychiatric: Cognitive and motional instability, salient symptoms of anxiety and depression. 

Laboratory Work-up 

Thyroid Function – Evaluation of serum T4 and TSH is important to rule out hyperthyroidism as one of the causes of the patient’s anxiety. 

Kidney and Liver Function 

NA: 137 mEq/L 

K+: 4.1 mEq/L 

BUN: 13 mg/dl 

CREA: 1.12 mg/dL 

GLU: 94 mg/dL 

ALBUMLX: 4.3 G/dL 

ALT: 35 IntUnit/L 

AST: 24 IntUnit/L 

Lipid Profile 

CHOL: 163 

HDL: 40 

LDL(CAL: 116 

TRIG: 64 

Complete Blood Count (CBC) 

WBC: 14.8 

RBC: 6.9 

HGB: 15.1 

HCT: 54 

MCV: 60 

Platelet: 350 

Differential Diagnosis 

300.02 (F41.1) Generalized Anxiety Disorder 

Johnsons admits being under stress and worrying about his performance in the team. He has also manifested symptoms of emotional arousal caused the worry, nervousness, and fear that is not proportional to what he perceives to be the cause (American Psychology Association, 2019). The fear, worry, and restlessness are severe enough to impair his normal social and professional responsibilities as an athlete. There is also interrupted sleep patterns and profuse sweating without symptoms of fever and abdominal disturbances. 

296.31 (F33.0) Major Depression 

The patient exhibits symptoms of major depression, including feeling isolated and worthless, suicidal tendencies, interrupted sleep patterns (Portico, 2019). He is no longer interested in what he used to be enthusiastic about, reclusiveness, and mild aggression towards those who he perceives to invade his space. These symptoms have significantly affected key aspects of his life. 

301.83 (F60.3) Borderline Personality Disorder 

Johnsons’ self-perception and self-esteem have considerably declined as he feels that he is not good enough to face his opponents in a match. He also feels that he can no longer provide for his brother and girlfriend as he used to. He is paranoid that they will lose a match, which further reduces his self-confidence. This is especially manifested in his feeling of guilt and suicidal ideation, through which he extends his decline in self-esteem (Portico, 2019). He has intense fear of abandonment and being banished from the team, frequented by inappropriate impulsiveness and anger. Although he desires not to be abandoned, there is also the compulsion to be reclusive, withdrawn, and hostile towards those around him. Thus, his relationship with his family and colleagues has significantly been compromised. 

Evaluation Methods 

DSM-5 Criteria 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria is used to assess the patient’s conditions and derive a formal diagnosis. The assessment involves taking the history of the presenting complication and conducting a physical and mental status examination. The related interpersonal, functional, and social difficulties that the patient is experiencing are then reviewed. It is also to obtain the patient’s past medical history, especially pertaining to the chief presenting complication ( Portico, 2019). The family history and demographic information are also essential as it provides a background for the patient’s condition. 

The DSM-5 criterion is an authoritative guide for diagnosing mental disorders globally. The descriptions and symptoms of the conditions provide a common language for psychiatrists to communicate and establish reliable diagnosis. The criteria for diagnosing anxiety disorders is contingent on the manifestations of fear and highly comorbid related behavioral disturbances. The DSM-5 criteria for generalized anxiety disorders are based on the manifested level and frequency of occurrence of worry (American Psychiatric Association, 2019). According to the criteria, worry about certain events or activities, and persists for at least six months meets the diagnosis of GAD. 

Suicide Risk Assessment 

This method involves evaluating the patient’s suicidal tendencies. This is through observing the possible indicators such as warning signs, protective factors, risk factors, and the responses and changes to situations and psychiatric therapy. During the evaluation, the patient is assessed for the potential to inflict harm on themselves or others (American Psychiatric Association, 2019). An important indication for suicidal ideation in the case was the patient’s assertion that he would wish to end it all forever. The patient is categorized as having a passive suicidal desire On the Scale for Suicide Ideation (SSI). This is because the tendency is not one of the patient’s primary options, as he indicates that he only gets the suicidal thoughts occasionally. Suicide risk assessment is important, given that depression is one of the patient’s diagnosis. The assessment informs the development of psychiatric treatment and counseling approaches. 

Treatment Plan 

Based on the evaluation of the presenting symptoms and patient’s history, the provisional diagnosis is a generalized anxiety disorder. Given that the patient had been initiated on anxiety medication following his TBI and cranial surgery, it is important to follow up with the previous psychiatrist to ascertain the appropriate drug choice and dosages. The treatment plan will involve a combination of psychotherapy and pharmacotherapy approaches. Selective serotonin reuptake inhibitors are the preferred pharmacotherapy drugs as they are effective for both anxiety and depression. Lexapro (escitalopram) taken 10 mg once daily will be prescribed. The dosage may be increased to 20 mg one week after initiation of the therapy for greater benefit. Lexapro will be used in combination with Cymbalta administered at a dose of 30 mg twice daily. Mirtazapine 10 mg administered daily is also prescribed for sleep (Spiegel & Riba, 2015). 

Psychotherapy approaches involve motivational and counseling interventions to stir a change in the patient’s attitude and behavior. These interventions will be done concomitantly with suicide risk assessment to determine the patient’s compliance and response to the treatment. For effectiveness, it is important to conduct the suicide risk assessment three times an hour in the first two weeks of therapy initiation. The duration may be altered depending on the patient’s response and stability. However, increasing the duration of risk assessment will not be until the third week of treatment. Group therapy is also an important part of the psychotherapy approaches. Jonson’s will be allowed to participate in the sessions twice a week. However, this will depend on her willingness and consent. 

Family counseling is also another important aspect of the treatment plan. For effective prognosis, it is vital that the family and peers are supportive of Johnson’s treatment. His girlfriend, brother, and teammates are considered the people close to him, and will thus be taken through a counseling session in which they will be guided on how to offer emotional and physical help to Johnsons whenever required. There should be at least one person around him at all times. This support involves encouraging him that he will be well soon and being affectionate towards him. 

Web Information and Patient Referrals 

The Anxiety and Depression Association of America is an online platform where patients can get important information and counseling services on depression. The platform first requires one to register as a member. ADAA also provides referral services for their members enabling them to access the required psychiatric care. 

The American Psychiatric Association (APA) provides free access to relevant information on anxiety and depression. 

References 

American Psychology Association (APA). (2019). What Are Anxiety Disorders? Retrieved on 27 th September 2019 from https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders 

Stein, M. B., & Sareen, J. (2015). Generalized anxiety disorder.  New England Journal of Medicine ,  373 (21), 2059-2068. 

Spiegel, D., & Riba, M. B. (2015). Managing anxiety and depression during treatment.  The breast journal ,  21 (1), 97-103. 

Portico. (2019). Anxiety Disorders. Assessment and Diagnosis. Retrieved on 28 th September from https://www.porticonetwork.ca/treatments/disorders-qr/anxiety-disorders/anxiety-disorders-assessment-diagnosis 

American Psychiatric Association. (2019). DSM-5: Frequently Asked Questions. Retrieved on 27 th September 2019 from https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions