Case Presentation: Nevaeh

 

Diagnosis:

F41.1- Generalized Anxiety Disorder, moderate, need to control thoughts

Z65.8- Other problem related to psychosocial circumstances, death of a parent

F42- Obsessive-compulsive disorder, moderate, need to keep everything germ free

Z91.89- Other personal risk factors, excessive cleaning

Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis

I would diagnosis Nevaeh with Generalized Anxiety Disorder due to her constant worrying. She is anxious, experiences nausea, dizziness, sweating when she thinks her home is not clean, obsessed with cleanness. She argues with her fiancé for not helping with keeping the house clean, spends an extended period cleaning, to the point she forgets her daily schedule. Reports excessive cleaning as therapy, concerned with germs since adolescence, here is where I would consider Obsessive-compulsive disorder.

For GAD, Nevaeh meets criteria: A, B, C(1,2,5,6’D, E&F

For OCD, Nevaeh meets criteria: A(Compulsions: 1&2)B, C, D

Discuss other disorders you considered for this diagnosis and eliminated (the differential diagnoses)

The differential diagnosis considered is Panic Disorder because of Nevaeh’s symptoms of nausea, trouble breathing, intense discomfort, and feelings of being out of control. Her constant worrying leads to attacks which lead to obsessive cleaning.

Describe an evidence-based assessment scale that would assist in the ongoing validation of your diagnosis

The evidence-based assessment scale I would consider using would be the Hamilton Rating Scale for Anxiety. This assessment scale is widely used during interviews to assess a client’s level of anxiety and several other symptoms of GAD(Rodriguez-Seijas et al., 2020).

Recommend a specific intervention and explain why this intervention may be effective in treating the client

Because Nevaeh’s issues consist of behavior, I would recommend Cognitive Behavioral Therapy. CBT is used to reframe an individual’s thoughts surrounding their mental instability. It’s essential in minimizing the symptoms and negative behaviors for the individual to function in everyday living. This form of psychotherapy uses interpersonal cognition to determine the level of anxiety when processing social information(Gómez Penedo et al., 2021).

 

 

References

Association, A. P. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Gómez Penedo, J., Hilpert, P., grosse Holtforth, M., & Flückiger, C. (2021). Interpersonal cognitions as a mechanism of change in cognitive behavioral therapy for generalized anxiety disorder? a multilevel dynamic structural equation model approach. Journal of Consulting and Clinical Psychology89(11), 898–908. https://doi.org/10.1037/ccp0000690

Rodriguez-Seijas, C., Thompson, J. S., Diehl, J. M., & Zimmerman, M. (2020). A comparison of the dimensionality of the hamilton rating scale for anxiety and the dsm-5 anxious-distress specifier interview. Psychiatry Research284, 112788. https://doi.org/10.1016/j.psychres.2020.112788

 

 

F41.1 – Generalized anxiety disorder, moderate

Z56.9 Other Problem Related to Employment

Z63.0 Relationship Distress with Spouse or Intimate Partner

 

 

I would consider diagnosing Neveah with a generalized anxiety disorder based on the evidence provided in the case study and her symptoms as recently as May 2021, a full seven months after her initial assessment. Her preoccupation with her work performance, punctuality, and ability to focus may be affecting her diagnosis, as well as her annoyance with her boyfriend’s lack of support in reflecting her level of organization and cleanliness. As a result, additional issues that may require clinical treatment are classified as Other Employment Problems and Relationship Distress with Spouse or Intimate Partner. Neveah’s increased anxiety is classified by the following specifiers: worry, concern, disrupted sleep, and fatigue. Additionally, when Neveah is anxious, she notes nausea, dizziness, sweating, and difficulty breathing. Neveah exhibits a moderate grade of generalized anxiety disorder based on her symptoms and ability to cope (American Psychological Association [APA], 2013a).

An explanation of the diagnosis by matching the symptoms to the specific criteria for the diagnosis.

As indicated in the scenario, Neveah exhibits a variety of symptoms on a daily basis. Neveah’s primary concern is how her lack of focus is affecting her work. As a result, she frequently engages in housecleaning to cope with her inability to concentrate on work. She also cleans because she is concerned about germs in the house and as a means to alleviate her continual worry that she will have a visitor and that her house will be unprepared when they arrive. Neveah and Dion’s relationship has been strained by Neveah’s desire to clean more than he is willing to, and they sometimes argue over it. Consequently, each time she begins cleaning, her anxiety increases, and she feels nauseated and dizzy, sweats profusely, and has difficulty breathing. When these conditions occur, Neveah has somatic symptoms that are indicative of generalized anxiety disorder (APA, 2013a). Neveah is also sleep deprived and exhausted, which may be a result of her anxiety about being late for work. People with generalized anxiety disorder often worry about how others will judge them in real life social encounters, which is why Neveah is so preoccupied with how others perceive her performance at work and the appearance of her home (APA, 2013a).

A discussion of other disorders you considered for this diagnosis and reasons for their elimination (the differential diagnoses).

I initially considered obsessive-compulsive disorder in the case of Neveah due to her concern of germs and the fact that her daily house cleaning was time-consuming enough to cause disruptions in her daily schedule. However, Neveah’s need to clean could be interpreted as a coping method for expressing underlying concerns, rather than as obsessive and irrational dislike for germs. According to Keith et al. (2015), marijuana use has been connected to an increase in anxiety levels, and frequent use has been linked to other substance use. That is why, in consideration of Neveah’s social drinking and marijuana use, I also considered Medication/Substance-Induced Anxiety Disorder. However, I was able to rule out this condition because she has discontinued marijuana use and does not consume an excessive amount of alcohol, which could have negative consequences. Lastly, because of Neveah’s anxiety of unexpected visitors and reluctance to spend time with friends in their houses, Social Anxiety Disorder was also explored, but was eliminated, as social anxiety disorder is defined as a fear of social situations, yet Neveah continues to socialize with her friends in other circumstances (APA, 2013a).

Evidence-based assessment scale that would assist in ongoing validation of the above diagnosis.

The use of assessment tools such as the Beck Anxiety Inventory (BAI) is critical in confirming Neveah’s diagnosis of generalized anxiety disorder and associated conditions. This scale assesses the emotional, physiological, and cognitive symptoms of anxiety, as well as their severity, across four expressed dimensions: subjective, neurophysiologic, autonomic, and panic-related (Grant, 2011). The scores of this assessment can be utilized to develop a treatment plan to address the case study’s specifiers. Due to the fact that BAI can be used throughout a patient’s treatment process, it can help validate the diagnosis made at the onset of the assessment.

A recommendation of a specific intervention

Cognitive behavioral therapy (CBT) has been the subject of the most research and is still the first choice for treating generalized anxiety disorder (GAD). It has been established that CBT is as effective as medication in reducing anxiety and more effective six months or more after therapy is completed (Mitchell et al., 2012). Techniques like relaxation training can help alleviate the physiological responses associated with anxiety, such as accelerated heart rate, difficulty breathing, and dizziness (Kim & Kim, 2018). CBT, which assists in transforming pathological fears into normal concerns, is a recommended treatment for GAD, which has been a history of present symptoms for Nevaeh.

References

American Psychiatric Association. (2013a). Anxiety disorders. In Diagnostic and statistical manual of mental disorders, 5th edition: DSM-5 (5th ed., pp. 189–234). American Psychiatric Publishing.

Grant, M. M. (2011). Beck Anxiety Inventory. Encyclopedia of Child Behavior and Development, 215–217.

Keith, D. R., Hart, C. L., McNeil, M. P., Silver, R., & Goodwin, R. D. (2015). Frequent marijuana use, binge drinking and mental health problems among undergraduates. The American Journal on Addictions24(6), 499–506.

Kim, H. S., & Kim, E. J. (2018). Effects of relaxation therapy on anxiety disorders: A systematic review and meta-analysis. Archives of Psychiatric Nursing32(2), 278–284.

Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Family Practice13(1), 2–11.

 

Social workers take particular care when diagnosing anxiety due to its similarity to other conditions. In this Discussion, you carefully assess a client with anxiety disorder using the steps of differential diagnosis. You also recommend an intervention for treating the disorder.

To prepare: Read the case provided by your instructor for this week’s Discussion. Review the decision trees for anxiety and OCD in the Morrison (2014) text and the podcasts on anxiety. Then access the Walden Library and research interventions for anxiety.

By Day 3

Post a 300- to 500-word response in which you address the following:

· Provide the full DSM-5 diagnosis for the client. Remember, a full diagnosis should include the name of the disorder, ICD-10-CM code, specifiers, severity, and the Z codes (other conditions that may be a focus of clinical attention).  Keep in mind a diagnosis covers the most recent 12 months.

· Explain the diagnosis by matching the symptoms identified in the case to the specific criteria for the diagnosis.

· Discuss other disorders you considered for this diagnosis and eliminated (the differential diagnoses).

· Describe an evidence-based assessment scale that would assist in ongoing validation of your diagnosis.

· Recommend a specific intervention and explain why this intervention may be effective in treating the client. Support your recommendation with scholarly references and resources.

 

 

 

 

 

CASE of STORMÉ Intake Date: November 2020

IDENTIFYING/DEMOGRAPHIC DATA: Stormé is a 62-year-old, single, Lesbian, African American female who receives Social Security income and is not currently employed. Stormé is financially comfortable, the social security is decent, although her living expenses are always a concern to her. She lives alone in a subsidized apartment in the same building as her 72-year-old, unmarried sister so increasing the rent will not happen.

CHIEF COMPLAINT/PRESENTING PROBLEM: Stormé seeks treatment for anxiety. She says she is very concerned and the anxiety has led to pulling her hair out and it has become noticeable on top of her head. She is taking to wearing hats and wigs to hide the bald spots. Stormé reports that germs have been a regular concern of hers since adolescence, when she learned in health classes about the risks of serious diseases including sexual transmittable disease. Her sister encouraged her to seek treatment rather than “hiding her ways.” She agreed to this session even though she is pessimistic about anything working.

HISTORY OF PRESENT ILLNESS: After Stormé move to her own apartment and began pulling her hair out she reported feeling better but does not always notice how much she is pulling. She fears losing control of herself. Her sister learned of her hair pulling after Stormé’s wig slipped off one evening to reveal bald spots. She set up a schedule over the past few months with her sister to help stop the hair pulling. Sometimes it worked and sometimes it didn’t. She is worried that she will be disappointing her sister by not sticking to the schedule to reduce her hair pulling. Stormé feels tired a lot trying to keep up with the cleanliness of the house especially with her lack of mobility and finds herself napping often. This then interferes with a restful sleep at night.

PAST PSYCHIATRIC HISTORY: Stormé worries about so many things, which is not new to her and she finds that by scrubbing her home clean is her best therapy to ease her anxiety. SUBSTANCE USE HISTORY: Stormé denies any abusive use of alcohol and denies any drug use.

PAST MEDICAL HISTORY: Stormé has arthritis in her spine and knees and uses a walker to help her manage mobility safely. With her physical disabilities it is challenging sometimes to scrub clean the house daily. This worries her in case she gets a visitor and the house is not in order as she would like. Luckily she is no longer working so the amount of time it takes her to scrub the house clean doesn’t delay her daily schedule as it used to. FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Stormé shared that when she was 2 years old her mother died from tuberculosis, and the following year her father, an army officer, died from colon cancer. After his death, Stormé lived with her paternal aunt from whom she felt no love. Her older brother and sister were placed in an orphanage and Stormé was permitted to see them on Sundays. When it became apparent that the children were entitled to death benefits, Stormé aunt agreed to take custody of all three siblings. The household then consisted of Stormé paternal aunt, her husband (who Stormé described as an alcoholic), their three children, Stormé and her two older siblings. Stormé was briefly married in her early 20s (4 years) but was disappointed and hurt by her husband’s infidelity. She moved in with her sister at that time. Stormé reported it as an “anxious” time but denied hair pulling then. Stormé also enrolled in a cosmetology school and liked her work. She had to stop working “for health reasons” when she was 58 years old. CURRENT FAMILY ISSUES AND DYNAMICS: Stormé shared an apartment for over 30 years with her sister, beginning when each of their marriages dissolved. Stormé reported that when her sister began a romantic relationship 5 years ago, Stormé began to feel very anxious and cried often. She continues to cry periodically for no known reason. Stormé moved into an apartment down the hall in the building and began to pull the hair from her head, hiding her hair loss by wearing wigs. This behavior occurred at different times and resulted in scabbing. is reliant upon her sister for transportation and for a sense of social and emotional connection. Stormé worries about bothering the sister due to her transportation needs and worries if she doesn’t have her sister what would she do. She knows she is edgy with her sister often and worries that might be from lack of good sleep. The worrying has interfered with her concentration.

MENTAL STATUS EXAM: Stormé presented with meticulous grooming, although the knees of her pants were noted as worn. She looks her stated age. Stormé was collaborative during this assessment and engaged after a reluctant start. She denies suicidal and homicidal ideation. There was no evidence of hallucinations or delusions

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