Psychiatric Diagnostic Evaluation and Treatment Plan for Adolescent with Generalized Anxiety Disorder and Depression

QUESTION

Formulate a Psychiatric Diagnostic evaluation of a 16-year-old male adolescent exhibiting symptoms of Generalized Anxiety Disorder and depression and justification for diagnosis and treatment plan. Include differential diagnoses. Include a pharmacology and psychotherapy treatment plan and also discuss a case hypothesis and how it fits into the treatment plan. He is alert and oriented x 4. His PHQ-9 is 9 and GAD-7 is 10. His chief complaints are fatigue, irritability, poor concentration, poor sleep, and decreased interest in activities. He reported a fair appetite. He denies suicidal or homicidal ideations and audio or visual hallucinations. Include a mental status examination He uses marijuana use. His parents recently divorced, lives with his mother. Three key learning points in this case, strengths and deficits of write up.

ANSWER

Psychiatric Diagnostic Evaluation and Treatment Plan for Adolescent with Generalized Anxiety Disorder and Depression

Introduction

This psychiatric diagnostic evaluation aims to assess a 16-year-old male adolescent presenting with symptoms consistent with Generalized Anxiety Disorder (GAD) and depression. The evaluation will justify the diagnosis, discuss differential diagnoses, formulate a treatment plan combining pharmacology and psychotherapy, and explore the case hypothesis in relation to the treatment plan. The patient’s chief complaints, mental status examination, and relevant background information will be considered.

Diagnostic Justification

Based on the presented symptoms, including fatigue, irritability, poor concentration, poor sleep, decreased interest in activities, and fair appetite, the patient meets the criteria for both GAD and depression. His PHQ-9 score of 9 and GAD-7 score of 10 further support these diagnoses. The absence of suicidal or homicidal ideations and hallucinations is notable in ruling out certain conditions such as major depressive disorder with psychotic features.

Differential Diagnoses

While the primary diagnoses are GAD and depression, it is essential to consider differential diagnoses to ensure accurate assessment. Other potential diagnoses may include adjustment disorder with mixed anxiety and depressed mood, substance-induced mood and anxiety disorders related to marijuana use, and dysthymia. Thorough assessment and evaluation will help differentiate these conditions.

Treatment Plan

Pharmacological Treatment: Considering the patient’s symptoms and diagnosed disorders, selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, may be prescribed to target both GAD and depression. Close monitoring of side effects and regular follow-ups with the prescribing physician are crucial.

Psychotherapy Treatment: Cognitive-Behavioral Therapy (CBT) is recommended as an effective psychotherapeutic intervention. CBT can help the patient identify and challenge maladaptive thoughts and behaviors, develop coping skills, and improve emotional regulation. Family therapy may also be beneficial to address the impact of the recent parental divorce.

Case Hypothesis and Treatment Plan Integration

The case hypothesis suggests that the adolescent’s symptoms of GAD and depression are exacerbated by the recent parental divorce, which has likely contributed to increased stress and disrupted family dynamics. The treatment plan aims to address both the individual and family aspects of the adolescent’s difficulties. Pharmacotherapy with SSRIs can alleviate symptoms, while CBT can provide coping strategies and address maladaptive thinking patterns.

Three Key Learning Points

The importance of considering comorbid conditions: The presence of both GAD and depression in this case highlights the need to evaluate and treat multiple psychiatric disorders simultaneously.
The impact of environmental factors: The recent parental divorce and disrupted family structure may have contributed to the adolescent’s symptom presentation, emphasizing the significance of assessing and addressing psychosocial stressors.
Integrated treatment approaches: The combination of pharmacological and psychotherapeutic interventions allows for a comprehensive treatment plan, targeting symptoms, underlying causes, and building coping skills.

Strengths and Deficits of the Write-up

Strengths of this write-up include the clear presentation of the patient’s symptoms, appropriate utilization of diagnostic tools (PHQ-9 and GAD-7), and the inclusion of a comprehensive treatment plan integrating both pharmacological and psychotherapy approaches. However, the write-up could be enhanced by providing more detailed information about the patient’s psychosocial history and contextual factors related to the symptoms.

Conclusion

This psychiatric diagnostic evaluation confirms the presence of Generalized Anxiety Disorder and depression in a 16-year-old male adolescent. The treatment plan, incorporating pharmacotherapy and psychotherapy, provides a holistic approach to address symptoms and underlying psychosocial stressors. By implementing this plan, healthcare providers can work towards improving the patient’s well-being and supporting his transition through this challenging period of his life.