Question

Case # 3: Ms. A

Ms. A is a 27 y.o. computer analyst employed at Intel, Inc. She is unmarried, has no children and has been in a significant relationship with a female partner, Tina, for 5 years.   Tina and Ms. A live together in a home they own in Albuquerque.

For the past 9 months, Ms. A has been experiencing consistent and regular shakiness, sweating, shortness of breath and an exaggerated startle response. In addition, she experiences significant, unfocused worry and anxiety. Ms. A has tried to control the “worry” but to no avail. Ms. A comes to you, a Licensed Independent Social Worker in private practice, as she believes she is on the verge of having a “nervous breakdown”.

While conducting the biopsychosocial history, Ms. A advises you she has always been a “worrier”. In high school she displayed perfectionistic tendencies, often worried she would be late to school, was very compliant and had excessive concern about her school performance. Additionally, Ms. A reports regularly feeling inadequate and avoidant of people or situations for fear of being rejected or criticized. These characteristics continued through college and have become increasingly more prevalent, impacting her performance at work as well as her relationship with Tina.

Currently, Ms. A is anxious about most situations and experiences this most every day of the week. Sundays tend to be worse for her as she is thinking about returning to work on Monday.   Ms. A reports she is frequently irritable and agitated with co-workers and Tina. Since her worries have intensified, she has not been able to sleep due to restlessness, is chronically tired and fatigued, has trouble concentrating and generally feels “on edge”. Her work performance has declined as she is not able to meet deadlines and frequently misses meetings. Her boss has expressed concern and urged Ms. A to seek assistance.

You note these symptoms have been present during the last 9 months. Ms. A has seen her primary care physician who indicated Ms. A is in good health. Additional history you obtain indicates no use/abuse of substances.

While exploring Ms. A’s sense of inadequacy, you discover this has been a pervasive pattern beginning in late adolescence. One of the reasons Ms. A became a computer analyst was to avoid working in “teams” which would require a great deal of interpersonal contact and interactions. She has few friends and rarely socializes for fear of being unaccepted and spurned. Ms. A’s preoccupation with being criticized or rebuffed is emotionally debilitating. Developing her relationship with Tina was extremely difficult. Ms. A felt inferior to her and attempted to sabotage the relationship several times. Only after Tina “proved” she loved Ms. A did Ms. A allow a relationship to develop. Presently, Ms. A is concerned about her relationship as Tina is regularly frustrated with Ms. A’s constant worry, feelings of inadequacy, reluctance to socialize or doing things Tina likes, such as snowboarding and cycling.

Based on the above vignette for Case #3, list the principal diagnosis/diagnoses (including any and all appropriate subtypes and specifiers)

Answer 1

The most appropriate diagnosis of Ms. A would be an intense Generalized anxiety disorder coupled with social anxiety disorder .

The symptoms displayed by Ms. A are in line with the dsm 5 diagnostic criteria wit generalised anxiety disoder(given below).In tandem with this Ms.a Also displays the symptoms of social anxiety disorder that have been there since here high school days of being judged or rejected in the unprecedented situations.The symptoms of shown by Ms. A for te past 9 months, such as shakiness ,worrying ,sweating, sleep issues and other worries, are due to GAD whearaas her issues with interpersonal contanct and the fear of being rejected stem from SAD.

DSM5 Diagnostic criteria for Generalized Anxiety Disorder (APA,2013)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item required in children.

1. Restlessness, feeling keyed up or on edge.

2. Being easily fatigued.

3. Difficulty concentrating or mind going blank.

4. Irritability. 5. Muscle tension.

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

DSM5 Diagnostic Criteria for Social Anxiety Disorder (APA ,2013)

A. A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.

B. Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally pre-disposed Panic Attack.

C. The person recognizes that this fear is unreasonable or excessive.

D. The feared situations are avoided or else are endured with intense anxiety and distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

F. The fear, anxiety, or avoidance is persistent, typically lasting 6 or more months.

G. The fear or avoidance is not due to direct physiological effects of a substance (e.g., drugs, medications) or a general medical condition not better accounted for by another mental disorder.