Psychosocial Assessment and GAD Treatment Planning

Patient Background and Assessment Framework

The patient is an 18-year-old female college student enrolled at a university and residing in a dormitory with friends. She is currently seeking treatment for stress, anxiety, and low self-image. No significant life stressors were initially indicated. Her father works as a truck driver and the patient describes their relationship as quite strong; her mother is an elementary school secretary, and the mother-daughter relationship appears to require clinical attention. The patient is not currently taking any mental health medication.

Psychosocial assessment forms a key component of all nursing evaluation, as it aids nursing professionals by informing disorder management and patient care planning. Individuals typically present with diverse surgical or medical issues, and social or psychological factors may impact their adherence to therapy and their recovery. The rationale for conducting a psychosocial evaluation is to explicitly articulate distinct issues in the patient's life that may affect her psychological or physical wellbeing. The patient intake document serves as the basis for carrying out this preliminary evaluation.

The evaluation encompasses the following elements:

• The cause of the patient's visit or admission
• Medical history and medications consumed (medicine, dosage, prescribing physician, side effects or allergies, and patient adherence to treatment)
• Psychiatric history
• Present legal or forensic issues
• Social condition (housing status, family, religion, cultural background, and finances)
• Abuse or violence (including incidents related to any children in the care of the individual, along with knowledge of reporting obligations)
• The Mental Status Examination (MSE) — an objective evaluation of behavioral, emotional, and cognitive aspects
• Current functioning level
• Substance use
• Assessment of suicide risk

A preliminary standard Level 1 CCM (Cross-Cutting Measure) would be carried out to determine whether any additional problem areas emerge that require attention. If further problem areas are identified, additional questions would need to be explored in connection with the anxiety the patient appears to be experiencing.

Psychosocial Evaluation Findings and Diagnosis

The patient's evaluation corroborated the following facts about her condition. At the start of the session, the patient stated that she had decided to undertake counseling after being caught with alcohol in her alcohol-free university campus dormitory. She explained that her friends' rowdiness caused the Resident Assistants (RAs) to be called in, and the group was found with alcohol upon the RAs' arrival. The patient asserted that she was not drunk — only mildly intoxicated — unlike her friends, who were fully inebriated. She added that her sole reason for consuming alcohol that night was social conformity, and that she did not drink to the point of inebriation.

The patient identified university life as a significant stressor. She reported difficulty making friends, which she described as an additional stressor alongside the more demanding academic requirements. She denied having any substance use disorder related to alcohol or drugs, and noted that she had tried marijuana once during high school, disliked the experience, and did not use it again. She reported that she began drinking alcohol in high school after being introduced to it by friends, and that she drinks moderate quantities occasionally on weekends without ever drinking excessively or experiencing hangover symptoms.

Regarding leisure activities, the patient stated that she plays an online Massively Multiplayer game. She denied any pornography or gambling issues and had no prior medical or mental health hospital admissions. While she experienced some teasing in high school, she denied any prior or current abuse or violence. She does not display any suicidal or homicidal tendencies and identifies as agnostic.

With respect to family background, the patient is an only child. She describes her mother as somewhat "controlling" and her father as the "good guy." She disclosed that her parents frequently bring their marital concerns to her, and she reported occasionally feeling like a mediator within the family while living at home. Her family life appears to be a source of ongoing stress.

Based on the evaluation, the patient meets the criteria for a DSM Generalized Anxiety Disorder diagnosis, coded as ICD-10 300.02 (F41.1).

Treatment Recommendations: Medication and CBT

Medications for anxiety disorder treatment offer the following benefits:

• Effectiveness — Approximately half of individuals taking these medications experience at least some degree of symptom relief.
• Easy availability — The medications are prescribed by healthcare professionals (typically psychiatrists) and are widely accessible.
• Convenient use — The medication works effectively within the patient's body without requiring extensive behavioral engagement outside of sessions.

In this patient's case, Paxil will be prescribed as the pharmacological component of treatment.

Cognitive Behavioral Therapy (CBT) represents a collection of psychological therapeutic methods that treat patients or clients as active participants in addressing their psychological issues. The approach is most effective when the client clearly understands what treatment entails and why specific methods are being used. The methods employed by cognitive behavioral therapists have been extensively researched and validated with large numbers of individuals diagnosed with anxiety disorders. For these reasons, CBT is recommended as a core component of this patient's treatment plan.