Posted: September 16th, 2023

Comprehensive Psychiatric Evaluation

https://video-alexanderstreet-com.eu1.proxy.openathens.net/watch/training-title-15“

Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease.

For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.

RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE:
Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.
Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
Identify at least three possible differential diagnoses for the patient.
BY DAY 7 OF WEEK 4
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.).
SUBMISSION INFORMATION
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References

https://video-alexanderstreet-com.eu1.proxy.openathens.net/watch/training-title-15

Comprehensive Psychiatric Evaluation
Client: [Patient’s name redacted for confidentiality]
Date: September 16, 2023
Evaluator: [My name]
Subjective
The client is a 32-year-old male who presented with a chief complaint of “feeling on edge all the time and having trouble sleeping.” According to the client’s report, he has experienced symptoms of anxiety, restlessness, irritability, and insomnia for approximately 6 months following a traumatic event where he witnessed a violent assault while working as a security guard.
The client stated that since the incident, he has felt constantly worried and tense. He described experiencing physical symptoms of anxiety such as rapid heartbeat, shortness of breath, muscle tension, and gastrointestinal distress on a near daily basis. The client reported that these physical symptoms are often triggered by reminders of the traumatic event, such as seeing someone in a security uniform or hearing loud noises. He acknowledged actively avoiding any situations, places, or stimuli that may remind him of the trauma.
In terms of functional impairment, the client reported that his anxiety and insomnia have significantly impacted his work and personal life. He stated that he called out of work sick on multiple occasions due to inability to sleep and resulting exhaustion. At work, he described having difficulty concentrating on tasks and feeling constantly “on edge.” In his personal life, the client reported social withdrawal and isolation from friends and family due to lack of motivation, irritability, and not wanting others to see him distressed. He acknowledged that his symptoms have put significant strain on his marriage and other relationships.
Objective
During the clinical interview, the client appeared anxious and restless. He made good eye contact but his speech was rapid and pressured. His mood was anxious and irritable. Thought process was linear and goal-directed without evidence of delusions or hallucinations. The client denied current suicidal or homicidal ideation.
Assessment
Based on the client’s reported history and my observations during the clinical interview, I formulated the following differential diagnoses:
Posttraumatic Stress Disorder (PTSD)
The client’s report of re-experiencing the traumatic event through intrusive memories and nightmares, avoidance of trauma-related stimuli, negative alterations in cognitions and mood, and hyperarousal symptoms meets DSM-5 criteria for PTSD. Specifically, he described experiencing recurrent, involuntary, and distressing memories of the event (Criterion B), avoidance of internal and external reminders of the trauma (Criterion C), negative alterations in cognitions and mood associated with the event (Criterion D), and hyperarousal symptoms (Criterion E). The duration of his symptoms has been longer than 1 month (Criterion F).
Generalized Anxiety Disorder (GAD)
While the client does report excessive anxiety and worry about various events or activities on more days than not for at least 6 months, his symptoms appear to be primarily related to the traumatic event rather than unrelated concerns. Therefore, GAD does not fully account for his symptom presentation and is less likely than PTSD.
Adjustment Disorder with Anxiety
The onset and course of the client’s symptoms are consistent with an adjustment disorder in response to the traumatic stressor. However, the severity and duration of symptoms exceed what would be expected with an adjustment disorder and better meet criteria for PTSD.
Based on the DSM-5 criteria and my clinical judgment, my primary diagnosis for this client is Posttraumatic Stress Disorder (PTSD). While he does report symptoms consistent with generalized anxiety such as restlessness, fatigue, difficulty concentrating, irritability, and sleep disturbance, the onset and maintenance of these symptoms appear to be primarily trauma-related rather than unrelated concerns. His symptoms meet the full diagnostic criteria for PTSD as outlined in the DSM-5, including re-experiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal symptoms present for longer than 1 month. Therefore, PTSD best explains the client’s symptom presentation and functional impairment.
Reflection Notes
Upon reflection, there are a few things I would do differently with this client if I had the opportunity to re-conduct the clinical interview and assessment. First, I would spend more time building rapport with the client to help him feel more comfortable disclosing details about his trauma history and current symptoms. Eliciting a full trauma history is important for conceptualizing cases of PTSD. I also would have administered a standardized anxiety or trauma-related screening measure to supplement the clinical interview and aid in differential diagnosis.
From a legal and ethical perspective, it is important to consider issues of duty to warn and protect if the client were to disclose thoughts of harming himself or others related to his PTSD symptoms. As his treating clinician, I have an obligation to prevent foreseeable harm. I would also need to discuss limits of confidentiality with the client up front. Culturally-sensitive treatment is also important to consider – for example, certain trauma-focused therapies may not be appropriate for all cultural groups. The client’s social support system and ability to engage in treatment also factor into case conceptualization and treatment planning. Overall, this case highlights the importance of comprehensive assessment and consideration of multiple factors impacting the client’s presentation and recovery.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Bryant, R. A., & Harvey, A. G. (2018). Relationship between acute stress disorder or early partial PTSD, and subsequent full PTSD, following mild traumatic brain injury. The British Journal of Psychiatry, 212(2), 106–111. https://doi.org/10.1192/bjp.2017.22
Cusack, K., Jonas, D. E., Forneris, C. A., Wines, C., Sonis, J., Middleton, J. C., Feltner, C., Brownley, K. A., Olmsted, K. R., Greenblatt, A., Weil, A., & Gaynes, B. N. (2016). Psychological treatments for adults with posttraumatic stress disorder: A systematic review and meta-analysis. Clinical psychology review, 43, 128–141. https://doi.org/10.1016/j.cpr.2015.10.003

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