please see attached file
2 PATIENTS NAME: Kara ADDRESS: 82 DATE OF BIRTH: 19 REFERRAL SOURCE: Mother DATE OF EVALUATION AND REPORT: n/a IDENTIFYING DATA AND REASON FOR REFERRAL: Kara is a single, white, 19 year/old female, who is a sophomore at Allegheny College. CHIEF COMPLAINT: “I have anxiety and am not sure if it is normal or not.” HISTORY OF PRESENT ILLNESS (HPI): Patient reports that she has anxiety at intervals throughout the day and especially in social situations. It is sometimes difficult for her to get through the day and she is often exhausted at the end of the day from pushing herself to do social activities. A Beck Anxiety Inventory reveals a score of 27 indicating severe anxiety. Her main symptoms include inability to relax, fear of the worst happening, flushed face, hot sweats, nervousness, unsteadiness, fear of losing control, fear of dying, and terrified, scared feelings. She also has tension in her neck but is unsure if it is related to anxiety or being on the computer too much. She finds herself becoming easily fatigued and in the late afternoon frequently needs a nap. Her symptoms are with her most of the day but increase in intensity in social situations. She has increased anxiety in particular situations such as when driving. She also has increased anxiety when meeting unfamiliar people and when being observed eating. She is fearful of behaving in a way that will be embarrassing. She endures these situations but with high levels of anxiety. She states she has had these symptoms for many years, but they have become worse since starting college. She has difficulty falling asleep at night and ruminates about things that she has to do or things that might go wrong the next day. Once asleep, she remains asleep, however complains of frequently not feeling restored in the morning and feeling tired most of the day. She has not had a panic attack. There is no indication of bipolar disorder, depressive disorder, ADHD, substance use disorder, or primary sleep disorder. PAST PSYCHIATRIC TREATMENT HISTORY: Kara describes herself as a shy, self-conscious, and anxious person. Her mother states that she had separation anxiety as a young child and especially when having play dates and starting school. At playdates, she would often stay on her mother’s lap and not join in social activities. She also had behavioral inhibition and it would take her a long time to join in social activities as a young child. During her latency years, she developed more generalized anxiety and as a teenager and she developed social anxiety. Her mother reported that at the age of 14, she attended a few psychotherapy sessions with Sharon Lettinger, PhD, for she had thoughts of suicide related to not having many friends. Kara does not remember this situation. Later, at the age of 17, she became very anxious about driving a car and soon after receiving her license, had an accident when she had to make a quick driving decision; her anxiety when driving increased afterward. In the past year, after starting college, her social anxiety increased and often leaves her irritable and anxious. Her cognitions include self-talk such as, “I don’t want to be here,” when she does push herself to involve herself in social situations. She worries that her anxiety may get even worse. PAST & CURRENT SUBSTANCE USE: Patient states that she does not use substances. She drinks coffee approximately four times/week. MEDICAL HISTORY: Patient reports that she has Idiopathic Thrombocytopenic Purpura (ITP), a blood disorder that can lead to easy or excessive bruising and bleeding resulting from unusually low levels of platelets. It developed after a viral infection when she was 10-years-old. She does not take medication for ITP but she was unable to take gym in elementary and high school or play sports. This may have contributed to her anxiety, but is unclear. She also has hypertension. Her blood pressure during this office visit was 128/88 and she states that without the medication, her BP is much higher. She is on the following medication: Metoprolol, a beta blocker for hypertension Norelgestromin/ethinylestradiol (Xulane Patch), an estrogen/progestin oral contraceptive agent for regulation of her period FAMILY HISTORY: Kara is the oldest of three children born to Joseph and Julia Knoble. Her brother Joey is 15 years old (b: 12/25/04) and her sister Anna is 13 years old (b: 03/06/05). Her mother, Julia, has bipolar disorder and is on the following medication (Lamotrigine 100 mg BID; Olanzapine 2.5 mg HS; Clonazepam 0.25 mg BID prn; Trazadone 100 mg HS). Her mother has had three hospitalizations prior to starting therapy and medication management with this clinician. She has been stabilized with few mild hypomanic breakthroughs over the past 10 years, at which time her Olanzapine is increased to 5-7.5 mg). Her father, Joseph, has no psychiatric disorder, but does engage in cross dressing, which has put a major strain on the marital relationship. The client has no knowledge of her father’s crossdressing. Kara has a paternal uncle with severe anxiety and a maternal first cousin with severe anxiety. Her siblings both have mild anxiety but have never received treatment. PERSONAL HISTORY: Kara has a long history of shyness and anxiety. She was successful in school and had a small group of friends. She is attending college and was successful during her freshman year. CURRENT FAMILY & SOCIAL SITUATION: Patient currently lives with her parents and siblings and two dogs (Ty and Pika) and two cats (Mimi and Bubblegum) in a large home in Clinton. She will be returning to college in September. PERSONALITY CHARACTERISITCS: Patient has limited awareness of feelings and is unable to express them effectively. She has dysfunctional cognitive thoughts that increase her anxiety. She has no stress management techniques to help decrease her anxiety. MENTAL STATUS EVALUATION: Patient is open and cooperative and looks younger than her stated age. Her speech, communication, and behavior are normal. Her affect is appropriate and her mood is anxious. There is no indication of suicidal or homicidal ideation. Her thoughts are logical and goal directed. Her cognition is unimpaired. Her judgment and insight are fair. CONCEPTUALIZATION: Kara has a long history of anxiety probably related to her temperament of shyness and behavioral inhibition as well as genetic predisposition. As well, life events, such as a car accident, served to increase her anxiety as a young adult. Now, with leaving home and going to college, she does not have the emotional skills to tolerate this increasingly stressful environment. What is your diagnosis or diagnoses? What type of therapy would you start? Would you start with one or several different types? What medication would you prescribe and in what dosage to start? If the client gets some relief from the medication when you increase to the maximum level, what two medications might you augment? Or, would you switch? What complementary interventions might you try?