Anxiety and Insomnia Case Study

Migraines

• Migraine with aura since age 12 (increased prevalence before menses)
• Dysmenorrhea monthly
• Burned finger on stove

Inpatient and Outpatient Psychiatric/Mental Healthcare

• No previous psychiatric inpatient care.
• Does recall seeing a therapist for approximately 3 months around the age of 14 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 14. Completed approximately 10 therapy sessions.

Past Psychotropic Medication Trials: None.

Past Psychiatric Medication Trials/Therapy Trials: Reports 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: None identified.
• 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 and stay asleep, says she can just chill out to rest. Reports only occasional alcohol use.
• Trauma History: Denies any history of trauma.

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

• 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 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 prior to attending class, mainly morning classes, but forces herself to go anyway. Spends about an hour a night on homework, states her grades are okay with mostly Bs, one A, 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 a lot of time after school on social media on phone or on computer. Does not have a car at campus, is very nervous to drive after brother’s accident. Always wears a seatbelt when in the car with others and when driving self. Hangs out with boyfriend and 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 occasionally smoked marijuana when anxious and when she has difficulty falling asleep. Drinks alcohol at 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 she’s worse since my brother passed away in a car accident.” No family history of suicide. Does not feel like she has any relationships that involve anger or discord. Sleeps about six hours each night, reports trouble falling asleep. Awakens frequently during the night.

Spirituality: Catholic

• Mother: 54, hypothyroidism, MDD, GAD
• Father: 59, HTN
• Brother: deceased MVA (18 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 three months ago, flu shot yearly, no COVID vaccine.

Regularly wears seatbelt when driving and as passenger.

No weapons in the dorm as far as the patient knows; father has guns at home in locked cabinet.

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

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

Denies chest pain, palpitations.

• G0T0P0AOL0
• LMP x 7 days ago
• Menarche age 13, cycle 28 days

• Migraines monthly at time of menses.
• Occasional syncope from migraine.
• 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 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 after 6 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 or legal problems. Reports some increased stress with move away from family to college out of town, misses family and mother especially, new boyfriend of six months, worries about having sex, worries about grades.

Alert and oriented X 4. Appearance is 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.