Clinical Assessment: Case Study

Anxiety is one of the most common mental health issues people face around the world. The World Health Organization says about 284 million folks globally deal with anxiety disorders, making it a big public health problem. In this case study, we're gonna look at the assessment, diagnosis, and treatment of a 30-year-old woman named Sarah, who has symptoms of generalized anxiety disorder (GAD). Our goal is to help Sarah feel better and improve her quality of life through a thorough evaluation and treatment plan.

Clinical Assessment

We started the clinical assessment by carefully looking at Sarah's symptoms and medical history to see if she had an anxiety disorder. Sarah mentioned she's been feeling worried, restless, and irritable for the past six months. She also had trouble concentrating and sleeping, plus physical issues like muscle tension and fatigue. These symptoms match the diagnostic criteria for GAD in the DSM-5, which involves excessive anxiety and worry about lots of different things.

Besides a detailed interview, Sarah took some standardized tests to check her symptoms and how bad her anxiety was. We used the Beck Anxiety Inventory (BAI) and the Generalized Anxiety Disorder 7-item (GAD-7) scale. The results showed she had moderate to severe anxiety and it was affecting her daily life, confirming she had GAD.

Diagnosis

Based on what we found during the assessment and the DSM-5 criteria, Sarah was diagnosed with GAD. This disorder involves excessive worry and anxiety about various events or activities, and it’s hard to control. People with GAD often have physical symptoms like muscle tension, fatigue, and trouble sleeping, which can really mess with their quality of life. Sarah's symptoms fit the criteria for GAD, showing she needed specific treatments and interventions.

Treatment Plan

After diagnosing GAD, we made a detailed treatment plan to help Sarah's symptoms and overall well-being. The plan had both medication and non-medication approaches to tackle both the mental and physical parts of anxiety. Sarah was given an SSRI antidepressant to help lower her anxiety and improve her mood.

Along with meds, Sarah started cognitive-behavioral therapy (CBT) to deal with the thoughts and behaviors behind her anxiety. CBT is a well-proven therapy that focuses on spotting and challenging negative thoughts and finding ways to cope with anxiety. Through weekly sessions, Sarah learned relaxation techniques, cognitive restructuring, and problem-solving skills to handle her anxiety better.

Outcome

Six months into the treatment, Sarah showed a lot of improvement in her anxiety symptoms and daily life. She said she worried less, felt less irritable, and her sleep and focus got better. The mix of medication and CBT worked well for her, helping her manage anxiety and improve her quality of life. We kept track of her progress through regular check-ins and assessments, adjusting treatments as needed.

Conclusion

Sarah's case study shows how important it is to catch anxiety disorders early, get the diagnosis right, and use targeted treatments. With a thorough evaluation and treatment plan, Sarah got the support she needed to manage her GAD effectively. The combination of medication and CBT worked well for her, helping her mental health and overall well-being. By continuing to monitor and tweak her treatment plan, Sarah can keep getting better and stay on a positive path to recovery.