Generalized Anxiety Disorder:

-more common in females, onset of symptoms usually occurs in early 20s

*Diagnostic Criteria:

1) Excessive anxiety or worry a majority of days for at least 6 months about various aspects of life [the anxiety is usually out of proportion to the event]

2) Associated with at least 3 of the following symptoms: fatigue, restlessness, difficulty concentrating, muscle tension, sleep disturbance, irritability, shakiness, headaches

3) NOT episodic (as in panic disorders), situational (as in phobias), nor focal

4) The symptoms cause significant social or occupational dysfunction

5) Not due to medical illness/ substance abuse

*Management:

~Antidepressants [SSRIs= first line: Fluoxetine, Paroxetine, Escitalopram], SNRIs [Venlafaxine]

~Buspirone can be an adjunct to SSRIs (does not cause sedation)

~Cognitive behavioral therapy and psychotherapy [Psychotherapy + Pharmacotherapy= more effective than either alone]

~Benzodiazepines can be used for short-term use only until long-term therapy takes effect (watch for dependence or abuse)

~Beta blockers or TCAs

 

Write-Up:

Identifying Information

Name: Emily

Race: White

Sex: Female

Location: Elmhurst, NY

DOB: 1/2000

Source: Patient herself; patient is reliable

 

CC: “I’m feeling worried and stressed all the time”

 

HPI: 20 year old female college student with no significant past medical or psychiatric history was brought in by EMS after her boyfriend called 911. Patient states that she has been experiencing an excessive amount of worry and stress over the past year. She is in her second year of college and has recently been skipping class because she feels she “just can’t concentrate anymore.” Admits to feeling stressed about schoolwork and tests in addition to smaller things like getting together with family/friends. She finds it difficult to make decisions (i.e. what to have for dinner, whether to go to a party with friends) and often finds herself stressed out over minor problems. States that the anxiety and worry began gradually as she began college (Fall 2018) but has become worse and experiences it constantly. Patient admits to having small amount of anxiety growing up regarding schoolwork and tests but denies feeling the way she does now at any previous point in her life. Admits to feeling fatigued and restless despite being able to sleep regularly at night. She has occasional headaches and feels shaky at times as well. Admits to morbid thoughts such as wondering what would happen if she was gone, but denies any active suicidal ideations or plan of action. Denies use of EtOH or illicit drugs.

When obtaining information from patient’s boyfriend he explains that her worry is “extreme for the situation.” He felt he had to bring her in for emergency attention because she was not doing anything to help herself and it had been going on for quite some time. He is mainly concerned that she is giving up on college and her dream to become a lawyer. He explains that “as the days go by the worry and stress keep getting worse.”

 

Past Medical History:

Denies any significant past medical history

 

Past Surgical History:

Denies any past surgical history

 

Medications:

Denies use of any current medications

 

Allergies:

Denies any known drug, food, environmental allergies

 

Family History:

Denies any known family history of psychiatric disorder, however, explains that her mother has expressed similar “behavior of worry/stress” at times (no recorded diagnosis).

 

Social History:

Tries to eat a well-balanced diet but does admit that she is eating less due to decreased appetite. Also denies any form of exercise due to her current state. Denies drinking alcohol, smoking, or any illicit drug use. States she sleeps 8-9 hours a night and is sexually active with her boyfriend and uses condoms as contraception. Denies any recent travel. She currently lives in the university dormitory with one roommate.

 

ROS:

General​: admits to loss of appetite and fatigue. Denies fever, chills, night sweats, unintentional weight loss.
Skin, hair, nails​: denies changes in texture, excessive dryness/sweating, discoloration, changes in pigmentation, moles/rashes, pruritus, changes in hair distribution
Head​: denies vertigo, lightheadedness and head trauma
Eyes​: denies blurring, diplopia, fatigue w/ eye use, scotoma, halos, lacrimation, photophobia, pruritus, and glasses use
Ears​: denies deafness, pain, discharge, tinnitus and hearing aid use.
Nose​: denies discharge, epistaxis, obstruction.
Mouth​/​throat​: denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes and dentures.
Neck​: denies localized swelling/lumps/stiffness and decreased ROM
Pulm​onary: denies dyspnea, cough, wheezing, hemoptysis, cyanosis, orthopnea, and PND

Cardiovascular: denies CP, palpitations, edema/swelling of ankles/feet, syncope, known heart murmur.
GI​: ​Admits to decrease in appetite. ​Denies intolerance to certain foods, N/V, dysphagia, pyrosis, abdominal pain, flatulence, eructation, diarrhea, jaundice, changes in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, hx of GI bleed

GU​: denies nocturia, dysuria, frequency, oliguria, polyuria, change in color of urine, incontinence and flank pain.
Breast​: denies lumps, nipple discharge and pain.
MSK​: denies muscle fatigue, arthritis, muscle deformity/swelling, and redness.

Peripheral​: denies intermittent claudication, cold or trophic changes, varicose veins, peripheral edema, color changes
Heme​: denies easy bruising, lymph node enlargement, anemia hx of DVT/PE
Endo​: denies polyuria, polydipsia, polyphagia, heat or cold interlace, goiter, excessive sweating, hirsutism

Nervous​: denies seizures, loss of consciousness, numbness, paresthesia, dysesthesia, hyperesthesia, ataxia, loss of strength, changes in cognition/mental status/memory, weakness and trauma

Psych​: admits to depression/sadness, anxiety. Denies OCD, seeing a mental health professional in the past or use of medications

MSE:

Appearance: Emily is a tall, medium build white female. Her hygiene is clean and her clothes are well kept. She does not have any scars or tattoos.

Attitude: Emily cooperated with the examiner throughout the interview and was pleasant and friendly.

Behavior: Emily’s verbal responses and psychomotor behavior were normal and she was able to maintain eye contact throughout

Speech: Emily’s speech was normal in terms of rate, rhythm and volume and had fluent content throughout

Mood: Emily’s mood was anxious

Affect: Emily’s affect was anxious as well

Thought process: Emily’s thinking was logical and coherent without any abnormal thought patterns

Thought content: Emily displayed thoughts of anxiety with slight depression as well

Orientation: Emily was alert and orientated to person, time and place throughout the interview

Attention: Emily’s attention and concentration was satisfactory throughout the interview by providing relevant answers to the questions asked

Memory: Emily’s remote and recent memory were both intact

Insight: Emily had good insight into her psychiatric condition and the need for medication to treat her problem

Judgement: Emily displayed good judgement to various situations

 

Labs:

Beta HCG: negative

Urine Tox: WNL

CBC: WNL

BMP: WNL

LFTs: WNL

TSH: WNL

EKG: unremarkable

 

Differential Diagnosis:

• Generalized Anxiety Disorder
  1. Patient’s presentation meets the diagnostic criteria for GAD by having the following: excessive anxiety/worry a majority of days for over 6 months about various aspects of life, along with symptoms of fatigue, restlessness, difficulty concentrating, shakiness and headaches. Additionally the symptoms are causing significant dysfunction socially as well as academically, and the anxiety is typically out of proportion to the event.
• Major Depressive Disorder
  1. Patient’s presentation includes some of the criteria for MDD by having the following symptoms for over 2 weeks: decreased energy/motivation, decreased focus/concentration, and decreased appetite. However, her predominant symptoms of anxiety and worry solidify the diagnosis of GAD over MDD
• Adjustment Disorder
  1. The patient’s signs/symptoms began around the time she began college, which at the time could potentially have made the diagnosis of adjustment disorder. However, her worry and anxiety persisted into her second year of school qualifying the diagnosis to be generalized anxiety disorder rather than adjustment.

Assessment & Plan:

20 year old female college student with no significant past medical or psychiatric history presents with feelings of anxiety and worry x 2 years.

-Discharge from hospital (at this time patient does not pose threat to self or others nor does she present with any acute psychotic features)

-Start Prozac (Fluoxetine) 10mg PO QD for anxiety; discuss adverse effects/risks with patient and determine if patient will be compliant with the treatment plan

-Arrange for follow up with outpatient psychotherapy in the next 2-3 weeks

-Patient instructed to call 911 if she has thoughts of hurting herself and/or others