Generalized Anxiety Disorder

Generalized Anxiety Disorder

Conduct a Comprehensive Psychiatric Evaluation on a patient (Create/make up a psychiatric patient encounter) you saw during clinicals using the template provided in the Learning Resources.

· Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

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APA

Generalized Anxiety Disorder

Comprehensive Psychiatric Evaluation

Patient Information:

• Name: John Doe
• Age: 35
• Gender: Male
• Date of Evaluation: January 13, 2025
• Referred By: Self-referred
• Presenting Problem: Anxiety and insomnia

Chief Complaint:
“I’ve been feeling anxious for months and can’t sleep properly. I feel on edge all the time and worry about everything, even when there’s nothing to worry about.”

History of Present Illness (HPI):
John Doe is a 35-year-old male who presents with a 6-month history of persistent anxiety and difficulty sleeping. He reports excessive worry, difficulty relaxing, and physical symptoms such as increased heart rate and muscle tension. His sleep disturbances include difficulty falling asleep, waking up frequently during the night, and feeling unrefreshed upon waking. The symptoms occur daily and significantly impact his ability to function at work and in social situations. He denies any panic attacks or obsessive thoughts but expresses a constant sense of dread.

John reports that the anxiety started after a major life change (losing his job) but has progressively worsened despite attempts to manage it through exercise and self-care strategies. He has no history of psychiatric treatment and has never been hospitalized for mental health reasons. He has tried over-the-counter sleep aids with minimal relief. He denies any recent substance use or abuse.

Psychiatric History:

• No prior psychiatric diagnoses.
• No history of psychiatric hospitalizations or suicide attempts.
• No previous treatment with psychotherapy or medications.
• No known family history of mental illness, though he notes that his mother experiences chronic stress-related issues.

Medical History:

• Chronic back pain (treated with NSAIDs).
• No chronic medical conditions such as hypertension or diabetes.
• Up-to-date with immunizations.
• No history of surgeries.
• No current medications aside from over-the-counter sleep aids.

Substance Use History:

• No alcohol use.
• No tobacco use.
• No recreational drug use.
• No history of misuse of prescription medications.

Family History:

• Father: Alive, no psychiatric issues.
• Mother: Alive, reports chronic stress and anxiety but no formal psychiatric diagnosis.
• Siblings: Two brothers, both healthy with no psychiatric issues.

Social History:

• Occupation: Recently unemployed due to downsizing. Previously worked in retail management.
• Living Situation: Lives alone in an apartment.
• Relationships: Has a few close friends but reports that his…