Case Formulation and Treatment Plan Essay

Case Formulation and Treatment Plan Essay



Name: AB

Age: 22

Gender: Female

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Ethnicity: Caucasian

Occupation: Medical Student

Marital Status: Divorced

Chief Allegation: I feel stressed all the time and constantly worry about anything and everything.

History of Presenting Illness

            AB arrives at the clinic after a five-year period of excessive worry and stress. Her concern stems from her mother’s illness-diagnosed with myocardial infarction 5 years ago. Since the diagnosis, AB was diagnosed with a moderate depressive illness, and she underwent counseling, attending five sessions and reporting improvements. However, she reports that her stress and worry have worsened in the last six months. This is exacerbated by the overwhelming stress of medical school, and she reports she is no longer capable of controlling her worry. She claims to have recently divorced. She also reports shoulder, stomach, and leg tension, palpitations, occasional dyspnea, and disturbed sleep as a result of her worrying and frequent waking. She claims she does not consume any alcohol.

Mental State Description

Appearance and behavior: A 22-year-old female Caucasian, seated on a chair, restless, crosses her legs, and feels uneasy in the examination room.

Speech: Clear and coherent speech

Mood: Stable

Affect: Appropriate

Thought content: Excessive fear of the unknown situation

No thought process abnormality; no perception disturbance

Cognition: Conscious, oriented to time, place, and person, memory intact

Appropriate judgment, abstract and good insight

DSM-5 Diagnosis and Differentials

Axis I: Generalized Anxiety Disorder (GAD) with a differential diagnosis of depressive illness.

Axis II: No developmental or personality disorder

Axis III: No physical disease

Axis IV: Psychosocial stressors include mother’s illness, medical school, and recent divorce.

Description of the Diagnoses


            GAD is a type of stress-related disorder. The following are the DSM 5 diagnostic criteria: (a) excessive anxiety and worry on most days for at least 6 months; (b) the individual struggles to control their anxiety; (c) the anxiety is accompanied by one or more of the following symptoms: agitation, irritability, difficulty concentrating, muscle tension, fatigue, and sleep disturbance. (d) the symptoms are associated with significant dysfunction in social, occupational, and other significant areas; (e) the symptoms are not attributed to the effects of substance abuse or a medical condition; and (f) the disturbance is better explained by any other mental disorder (APA, 2013).

The client meets the criteria outlined above, as evidenced by the history. First, she has had stress and excessive worry for the last 5 years, with an exacerbation in the last 6 months. She has difficulty controlling her worry and suffers from associated symptoms such as irritability, disturbed sleep, and muscle tension. Her symptoms cause significant dysfunction in areas of her daily functioning, including school, and cannot be explained by the physiological effects of substance abuse because she does not consume alcohol or other recreational drugs.

Depressive Illness

Following her mother’s diagnosis of myocardial infarction, the patient reports suffering from a depressive illness. Furthermore, she reports having associated disturbed sleep.

Treatment Plan


  1. Fluoxetine 20 mg PO OD for 8 weeks
  2. Lorazepam 5mg PO BD PRN


Habilitative: Teach the patient to do something while she is anxious. She can, for example, cook or knit dishcloths or table mats while feeling anxious. These activities can assist AB in managing her anxiety and, according to Chand et al. (2022), have the greatest efficacy when used in conjunction with pharmacology and psychotherapy.



Cognitive-behavioral therapy

Evidence-Based Literature and Justification of Treatment

            Selective serotonin reuptake inhibitors (SSRIs) are the first-line medications for GAD in the armamentarium of agents. Fluoxetine is an example of an SSRI. The starting dose of Fluoxetine is 20mg PO OD, which can be gradually increased by 20mg/day over several weeks, not exceeding 80mg/day. During the first 1-2 months of therapy, patients should be closely monitored for behavioral changes, clinical worsening of symptoms, and suicidal ideation, as well as dosage adjustments (Ströhle et al., 2018). According to Rickels and Moeller (2019), benzodiazepines should only be used as an adjunct until the SSRI becomes therapeutic. However, because benzodiazepines have the potential for addiction, oversedation, and cognitive impairment, they should be used with caution (Rickels & Moeller, 2019). Lorazepam, a benzodiazepine, is prescribed as a PRN-only medication to help manage AB’s anxiety states.

CBT is one of the most effective psychosocial interventions for GAD. Several studies have demonstrated the effectiveness of CBT in the treatment of anxiety. The intervention focuses on identifying and replacing negative thought patterns and behaviors with positive ones (Chand et al., 2022). AB had previously attended counseling sessions; however, the specific intervention she received is not specified. CBT would be an effective intervention, and 5 sessions every two weeks would suffice.

Client’s Strengths, Goals, and Expected Outcomes

Client’s Strengths

The client demonstrates a willingness to recover from her illness by attending all five of her previous counseling sessions. Furthermore, she is employed and receives a regular income, so she can afford the medications. Moreover, the patient has mild depression and anxiety symptoms and has the potential to recover.

Patient Goals

The primary prioritized goal is to reduce the patient’s anxiety. This will be accomplished through the use of medications and the aforementioned psychotherapeutic interventions. Another goal is to allow the patient to return to her normal social and occupational life, including school. For the next eight weeks, the patient will take Fluoxetine medications daily and Lorazepam as needed. During the ten weeks, the client will also attend CBT sessions once every two weeks.

Expected Outcomes

  1. Reduction of symptoms such as stress, worry, disturbed sleep, and motor symptoms like restlessness.
  2. Reducing problems at school or work because the client is in medical school and poor performance may jeopardize her academic progress.
  3. To generally improve the patient’s quality of life.


Finally, GAD is a stress-related disorder that occurs after a stressful life event. The patient described has recently divorced, is a medical student, and her mother is ill. These conditions are the precipitants of her illness.  Anxiety disorders have a good prognosis with effective pharmacotherapy combined with psychotherapy. The prognosis is also affected by an individual’s behaviors, such as adherence to medications. The prognosis is also affected by socioeconomic factors such as the ability to pay for medications. Although AB appears to be surrounded by stressful life events, she is likely to progress well because she can afford the drugs and attend the CBT sessions as scheduled.


American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders-5th Edition. New School Library.

Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2022). Cognitive Behavior Therapy. In StatPearls [Internet]. StatPearls Publishing.

Rickels, K., & Moeller, H. J. (2019). Benzodiazepines in anxiety disorders: Reassessment of usefulness and safety. The World Journal of Biological Psychiatry: The Official Journal of the World Federation of Societies of Biological Psychiatry20(7), 514–518.

Ströhle, A., Gensichen, J., & Domschke, K. (2018). The diagnosis and treatment of anxiety disorders. Deutsches Arzteblatt International155(37), 611–620.

The student will be required to provide a DSM-5 diagnosis, a treatment plan and a summary integrating evidence-based literature and justifying the treatment plan the student developed for the client. The student will also cross reference the diagnosis with the DSM 5 and note patient symptoms matching criteria.


AB is aged 22 years Caucasian female divorced with no kid, employed part time, full time med school and cares for her mother who has stroke.
History: AB has no significant past medical history. She was moderately depressed following her mother MI attack 5 years ago and was offered antidepressants but declined them. She was referred for five sessions of counselling, which led to some improvement in her symptoms. On examination AB complains of feeling ‘stressed’ all the time and constantly worries about ‘anything and everything’. She describes herself as always having been a ‘worrier’ but her anxiety has become much worse in the past 6 months since her mother condition is becoming worse with little improvement, and her school work is overwhelming, and she no longer feels that she can control anything. When worried, AB feels tension in her shoulders, stomach and legs, her heart races and sometimes she finds it difficult to breathe. Her sleep is poor with difficulty getting off to sleep due to worrying and frequent wakening. She feels tired and irritable. She does not drink any alcohol.

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