Anxiety and Insomnia Case Study

• Recent strep throat diagnosis X one week, treated, seen at on-campus clinic
• Vaginal candidiasis X four days, treated

• Migraine with aura since age 12 (increased prevalence before menses)
• Dysmenorrhea monthly

Inpatient and Outpatient Psychiatric/Mental Healthcare

• No previous psychiatric inpatient care.
• Does recall seeing a therapist around the age of 15 for mild anxiety and difficulty managing relationships with peers with lots of fear of rejection, noted she was timid and socially isolated. Saw a female therapist for approximately three months. Reports missing school during this time but therapy helped.
• No psychotropic medication history. Denies any suicidal ideation or past attempts.

Past Psych Diagnosis(es)

• None

Treatments: Outpatient psychotherapy at age 15. Completed approximately 10 therapy sessions.

• Past Psychotropic Medication Trials: None.
• Past Psychiatric Medication Trials/Therapy Trials: Reports the therapist assisted her with coping strategies to relax, be less anxious, and manage peer relationships without fear.
• Outcomes: Reports anxiety subsided and returned to feeling “less stressed” after therapy.

• Birth History: Fetal alcohol exposure, marijuana exposure in utero.
• Developmental delays: Denies any developmental delays.
• How were they managed? None identified.
• If any delays, what therapies were used, and did they help? N/A
• Substance use and treatment: Denies any use of non-prescription medication, does smoke marijuana two to three times per week as she reports it helps her fall asleep and stay asleep, says she can just chill out to rest. Reports only occasional alcohol use. Denies use of tobacco-non-smoker.
• Trauma History: Denies any history of trauma.

Freshman at local college and lives in dorm. Parents married and live in New Jersey.

• H— Lives in a college dorm with four roommates. No pets in room. Has good relationship with all roommates and is closest with one friend. Worries sometimes if all her friends actually like her. No recent changes in relationships. Does not think there are any guns in the house but does not have access to all roommate areas.
• E— Patient does not have a job currently since attending school full-time; works on occasion for catering company at big events (only occasional weekends not regular hours). Patient is a freshman in college. She is starting to feel anxious and nervous before attending her classes, mainly morning classes, but forces herself to go anyway. Spends about an hour a night on homework, states her grades are okay with mostly As, one B, and one C. Is concerned the anxiety is interfering with studies as she has some trouble concentrating when studying.
• A— Goes to campus gym three times a week but has reported avoiding the gym if anxious. “I’m not going much at all anymore.” Would like to go more often but does not have time with studying and social time. Spends much time after school on social media on phone or on computer. Does not have a car at campus; almost always wears a seatbelt when in the car with others and when driving self. Hangs out with boyfriend; several women she lives with are friends, while one is her closet friend. Has been with boyfriend for about six months; met before attending college on campus at an admissions event.
• D— Does not smoke. Has smoked marijuana when anxious some and when she has difficulty falling asleep. Drinks alcohol on social occasions, never fully drunk she states. Has never been in the car driving herself under the influence of drugs or alcohol or with others who are under influence.
• S— Never had sex in the past but discussing sex with boyfriend after she begins contraception. Wants to move forward with boyfriend as she feels he is “the one” but states she feels very anxious about it.
• S— Some family history of depression and anxiety. “My mom has some anxiety and depression I think.” No family history of suicide. Does not feel like she has any relationships that involve anger or discord. Sleeps about four hours each night, reports trouble falling asleep. Awakens frequently during the night.

Spirituality: States “I am spiritual but do not practice anything you should be aware or that would affect my care.”

• Mother: 54, hypothyroidism, depression, and anxiety
• Father: 59, HTN
• Brother: 18, no complaints or diagnoses
• Sister: 20, deceased hiking fall accident (20 at death, 2 years ago)

• Family History of Psychiatric Mental Illness: Unknown
• Family History of Suicide: Denied

All immunizations up to date per patient (no records in hand) and no recent travel outside of the United States.

Dental exam six months ago, flu shot yearly, COVID-19 vaccine, non-smoker

Regularly wears seatbelt when driving and as passenger

No weapons in the home

Reports usual health as “fine, no issues.” Denies fever, chills, weight changes.

• Denies cough, dyspnea, or wheezing.
• Denies history of asthma, recurrent infections.

Denies chest pain, palpitations.

• G0T0P0AOL0
• LMP x 7 days ago
• Menarche age 13, cycle 30 days
• Current, vaginal itching and burning after starting antibiotics.

• Migraines monthly at time of menses.
• Denies coordination problems, numbness, tingling, weakness, tremors. Denies seizures.

Denies depression but reports feeling anxious most days with worsening anxiety before classes begin at 10 a.m. and also in late afternoon and evening. Anxiety present for the past eight months. Affect is full range. Feels irritable when anxiety worsens, acknowledges feeling tearful and crying for no reasons she can note, reports the presence of some significant stressors: missing family and mother a lot, body image worry, stresses over college courses being hard. States hard time wakening when sleep is disrupted intermittently through night due to worry.

Reports trouble falling asleep almost every night, and some middle-night awakening, waking not feeling rested, four hours of sleep total. Does admit to smoking marijuana two to three nights per week when anxiety keeps her from sleeping.

No loss of interest or pleasure in activities although reports she has started to sometimes avoid going out with friends for fear of having anxiety.

No feelings of hopelessness, helplessness, hostility, reports she has always had low self-esteem, denies any feelings of guilt or shame or lack of motivation.

No increased energy, reports feeling fatigued most days when sleep is poor.

Some difficulty concentrating when anxiety is increased.

No delusions, hallucinations, feelings of persecution, hearing sounds which seem to be voices, preoccupation with religion.

No self-inflicted injuries, no frequent thoughts of death, lack of desire to continue living, or suicidal tendency.

No homicidal thoughts.

No pressured speech, impulsive behavior, feelings of grandeur, inflated self-esteem; not easily distracted.

• No interpersonal relationship problems, family problems, poor school/work performance, recent separation, job loss, legal problems.
• Reports some increased stress with move to college out of town away from family, misses family and mother especially, new boyfriend of a couple months, worries about having sex, worries about grades.

Alert and oriented X 4, appearance normal dress and appropriate, behavior speech appropriate. Calm and cooperative.

No tremors or tics; normal gait and stance; no involuntary movements.

Normal rhythm, rate, speed, tone and volume of speech, logical connection of thoughts expressed.

No dysthymic or depressed appearance; moderately anxious; not dysphoric, euphoric, angry, elevated, expansive, irritable only when more anxious.

Full-ranging, not blunted or constricted, correlates to mood expressed.

No language abnormalities; speech fluent; no dysphonia; no stuttering; language fluent and intact for naming, normal sentence structure.

Patient oriented X 4, no disorientation, short-term memory impairment, reduced abstraction ability, stated diminished cognitive functioning only when anxiety is at highest, worries grade will decline, worries will need to leave school and return home.

No deficiency on evaluation of connectedness, organized.

No thought content impairment; denies suicidal ideation, homicidal ideations, denies delusions or hallucinations, denies paranoid ideations, poverty of thought, thought insertions, obsessions, irrational fears, does report fears about others noticing anxiety and avoids friends at times.

No impaired insight, impaired judgment, poor problem-solving.