Psychiatry Assessment for Adult

Subjective:
Chief Complaint:
Maria has been experiencing social anxiety for several months, which manifests as discomfort in new settings, difficulty making eye contact, avoidance of large crowds, and overthinking social interactions. These symptoms are accompanied by periods of sadness and functional impairment.

History of Present Illness:
Maria, a 16-year-old female, presents with social anxiety. She feels uncomfortable in new settings, struggles to make eye contact, and avoids large crowds, especially when unfamiliar people are present. She experiences mild anxiety during interactions with service personnel and tends to overthink daily events and social exchanges. Negative comments from others cause her to ruminate on the reasons behind such interactions. Her anxiety moderately to severely interferes with her daily functioning, occasionally leading to sadness and feelings of being overwhelmed, though she does not feel sad every day. The severity of her anxiety fluctuates, impacting her mood, sleep, and appetite. She has never experienced panic attacks but reports that increased anxiety leads to nausea and decreased appetite. Despite this, she describes her memory, motivation, and concentration as good. She has been in supportive talk therapy for five months, which has helped her engage more socially, including joining a volleyball team.

Past Psychiatric History:
Maria has no prior psychiatric diagnoses or treatments. She has never seen a psychiatrist before and has never been psychiatrically hospitalized. There is no history of self-harm or suicide attempts. She denies current or past suicidal or homicidal ideation.

Substance Use History:
There is no information available regarding Maria's use of alcohol, nicotine, caffeine, recreational drugs, or prescription drug abuse. Additionally, there is no information on her recovery and relapse history.

Past Medical History:
Maria has no chronic illnesses and no medical problems. There is no information available regarding surgeries, allergies, or hospitalizations. Her vaccinations are up to date.

Current Medications:
Maria has never taken any psychiatric medication.

Family History:
Maria's maternal great-grandfather had depression. There is no information available on substance use. Her maternal grandmother and paternal grandmother both had colon cancer and are deceased. Her mother has a history of breast cancer, in remission for 10 years. There is a family history of heart disease on both maternal and paternal sides.

Personal/Developmental History:
Maria lives with both parents, and her three older sisters have moved out. There are no reports of domestic violence or family discord. She was born and raised in xxx, with no further details on cultural background or religion. Her mother's pregnancy was normal, and Maria was born full term, ten days late, with no exposure to drugs, alcohol, or tobacco during pregnancy. She reached developmental milestones on time, had no speech issues, and transitioned from liquids to solids appropriately. There is no history of abuse, neglect, or bullying, and her parents were present during her upbringing. She denies any history of physical, sexual, or emotional abuse, and no traumatic childhood events are reported. Maria currently attends xxx Secondary School in grade 11. She reports some social anxiety impacting her school life but has recently joined the volleyball team, and therapy has helped her engage more with peers. She is not currently employed and has no past job information available. There is no information on military service. Maria has one best friend and several acquaintances but reports difficulty making new friends due to social anxiety. She maintains a close relationship with her best friend. She is single and not in a romantic relationship, with no information available on her sexuality. There is no information available on her pre-morbid personality, changes, emotional, cognitive, or behavioral aspects. There are no legal issues reported.

Allergies:
Maria has no allergies.

The Review of Systems:
Maria reports anxiety, overthinking, and occasional sadness related to anxiety. Her sleep and appetite are fine when her anxiety level is down. She denies a history of nightmares. She weighs 110 pounds, is 5'2" tall, and has a BMI of 20.1. She reports tiredness when her anxiety is high. There is no information available on sexual health, and she reports no pain issues.

Social History:
Maria is a 16-year-old female residing in xxx with both biological parents. Her three older sisters have moved out of the family home. She is currently a student in grade 11 at xxx Secondary School. Maria is not in a romantic relationship and is not employed. She reports having one close friend and several acquaintances. There is no history of physical, sexual, or emotional abuse, and no history of bullying. She denies any gender identity concerns. She has recently joined the volleyball team and participates in supportive therapy. There is no reported substance use.

Objective:
Mental Status Examination:
Maria is well-groomed, appropriately dressed, alert, and cooperative. She is able to maintain hygiene, shower, and change clothes daily. Her psychomotor activity is normal. Her speech is of normal rate, volume, and articulation. Her mood is variable, dependent on her anxiety level, and her affect is congruent. Her thought process is logical, coherent, and goal-directed, with no evidence of delusions, obsessions, paranoia, suicidal or homicidal ideation. She is not experiencing hallucinations or delusions and does not believe her parents are imposters. There is no gender confusion. She is oriented to time, place, person, and situation. Her attention and concentration are adequate, and she is able to follow conversations. Her short-term and long-term memory are intact. She has good insight and recognizes she has a mental health condition.

Test Results:
Maria does not need blood work as recent results were fine.

Assessment:
Impression:
Maria presents with moderate to severe social anxiety and mild generalized anxiety disorder, with adjustment disorder characterized by mixed anxiety and low mood. Her symptoms fluctuate in severity and are associated with significant interference in daily functioning, particularly in social and academic settings. She has benefitted from supportive therapy and has recently increased her social engagement.

DSM-5 Assessment:
Diagnosis: Social Anxiety Disorder (300.23), Generalized Anxiety Disorder (300.02), Adjustment Disorder with Mixed Anxiety and Depressed Mood (309.28). She does not create catastrophic scenarios all the time.

Diagnosis:
Maria is diagnosed with social anxiety disorder of moderate to severe intensity, generalized anxiety disorder of mild intensity, and adjustment disorder with mixed anxiety and depressed mood. She does not have major depressive disorder, bipolar disorder, or a psychotic disorder.

Safety Assessment:
Maria has never engaged in self-harm or suicidal attempts. She denies any current suicidal ideation, intent, or plan. There are no homicidal thoughts or behaviors reported. She has no suicidal thoughts today.

Differential Diagnosis:
Maria experiences significant anxiety in social situations, discomfort in new settings, difficulty making eye contact, and avoidance of large crowds, with moderate to severe interference in daily functioning, consistent with Social Anxiety Disorder (ICD-9: 300.23). She reports excessive worry, overthinking, and overanalyzing daily events and interactions, with mild interference, consistent with Generalized Anxiety Disorder (ICD-9: 300.02). Her mood and anxiety fluctuate in response to daily stressors, with periods of sadness and anhedonia linked to anxiety levels, consistent with Adjustment Disorder with Mixed Anxiety and Depressed Mood (ICD-9: 309.28). There is no evidence of persistent low mood, anhedonia, or other core symptoms required for Major Depressive Disorder. There are no reported episodes of elevated mood, grandiosity, or decreased need for sleep, ruling out Bipolar Disorder. There are no hallucinations, delusions, or disorganized thinking, ruling out a Psychotic Disorder.

Plan:
Maria was provided with education on the nature of her diagnoses and discussed evidence-based treatment options, including the benefits of combination therapy. Pharmacotherapy was recommended, specifically selective serotonin reuptake inhibitors (SSRIs) with options including sertraline (Zoloft) starting at 25 mg daily, titrating to a target dose of 75-100 mg daily, or fluoxetine (Prozac) starting at 20 mg daily, titrating to a target dose of 30-40 mg daily. Escitalopram was also discussed as an alternative. Benzodiazepines were not recommended due to the risk of dependence. Potential side effects of SSRIs were reviewed. Psychotherapy, specifically cognitive behavioral therapy (CBT), was advised to supplement current supportive therapy. Coordination of care was offered, with treatment recommendations and dosing information to be sent to her family physician for ongoing management, per patient and family preference. No additional laboratory tests were recommended at this time. There is no current risk of self-harm or harm to others reported. Suicide and homicide risks were denied, and no safety plan is required at this time. Long-term goals include improving social functioning and reducing anxiety to enhance participation in daily and academic activities. Maria and her family declined immediate follow-up but were advised to return if symptoms do not improve or worsen.

Progress and Outcomes:
Maria has engaged in supportive talk therapy for five months, which has resulted in improved social engagement and participation in extracurricular activities such as joining the volleyball team. She reports that therapy has been beneficial in developing coping skills. Her functional status fluctuates with anxiety levels, affecting mood, sleep, and appetite. She has not previously taken psychiatric medication. The plan includes consideration of initiating a selective serotonin reuptake inhibitor, with a preference for sertraline, and a recommendation to transition to cognitive behavioral therapy. Ongoing monitoring of symptoms and functional status is advised, with follow-up as needed.