An Assessment and Diagnosis Case Study Is Not a Closed Case.

PROBLEM: The presenting problem of anxiety is found to be one of many psychiatric symptoms resulting in a lack of clarity in diagnosis and treatment.

METHOD: The case of a 17-year-old reporting escalating anxiety and migraine headaches is presented. A mental health assessment, parental information, screening tools, the Personality Assessment Inventory, ongoing observation, review of treatment regimens, consultation, and test results from other healthcare professionals are included in the ongoing assessment.

FINDINGS: Symptoms including anxiety, auditory and tactile hallucinations, mood alterations, substance use, insomnia, and hypomanic symptoms are identified. The symptoms are suggestive of various diagnostic categories/diagnoses: mood disorder, prodromal schizophrenia, schizoaffective disorder, and generalized anxiety disorder.

CONCLUSION

A thorough assessment does not necessarily lead to clarity of a diagnosis or diagnoses. Clarity may evolve over time; however, this does not eliminate the responsibility to treat the patient. It is important to consider and utilize evidence-based treatments for the symptomatology and possible diagnoses.