Carmen Matthews is a 41-year-old separated Hispanic mother of two children, ages 10 and 12. She works full-time as a real estate agent. She is referred by her counselor.
“I am so worried all the time. I feel like I’m caught in a nightmare.”
History of Present Illness:
The patient reports increased anxiety since her husband abruptly left town with his secretary about 8 months ago. She complains of constant worrying about paying her bills because of downturn in the real estate market that reduced her income. Three months ago, she began to have more difficulty falling asleep, reporting that it can take her as much as 2 to 3 hours because she can’t stop worrying about how to provide for her children and how she will ever keep up with her mortgage and auto payments.
She estimates her total sleep to be 4 hours a night. In addition to difficulty falling asleep, she complains fatigue, impaired concentration, and muscle tension, which are having a detrimental effect on her performance at work She also complains of frequent headaches, which are not typical for her. She denies depressed mood or suicidal ideation, intent, and plan. She describes herself as a strong, positive person who has always been able to deal with her own problems, although she admits that she has always had a tendency worry. She has no family in town and few close friends.
Carmen denies use of alcohol, tobacco, and all other licit or illicit drugs. She drinks about 4 cups of tea a day.
what would be the patient’s psychiatric diagnosis using the DSM 5
What additional information would have been helpful?
What would you include in a biopsychosocial treatment plan for the patient in addition to pharmacotherapy?