CASE NUMBER: 2023-001

PART I. A-DEMOGRAPHIC PROFILE

Date Evaluated: December 14, 2023
Date of Birthday: Not stated, this lack of information
Name: Hussain, Nadiya needs further investigation during the follow-up
session
Age: Age not stated but patient looks like on
her late 30’s. This lack of information needs
Sex: Female Civil Status: Married
further investigation during the follow-up
session.
Address: Not stated but patient is located at United Kingdom, this lack of information needs further
investigation during the follow-up session.
Educational Attainment: Not stated, this lack
of information needs further investigation Race: British Bangladesh
during the follow-up session
Contact Number: Not stated and need for
Language Spoken: English
further investigation during the follow-up
Mark Check for type of client: ☐ Walk-in ☐ Referred/Specify which facility___________

Reason for Referral:

Nadia has been suffering from severe anxiety and obsession for thinking and caring too much for
everything, she’s been worrying a lot about the daily routine, the thought of forgetting someone to
her prayers, dying, the crowd, and her anxiety from living with it forever. Patient reported to have
excessively worry about little details and things that aren’t supposed to be worried by the general
population such as the unavailability of the grocery item she’s been purchasing, forgetting to include
a member of her family from her prayers, that she might die, and she reported to have been isolated
from making friends. Her visitation to seek for a help from a GP was her voluntary choice, she is
determined to seek for help because she stated that she is also afraid of living from this “monster” she
called as her anxiety, forever. Patient also wanted to undergo to a therapy and medication to better
help her in progress.

Presenting Problem

The Client manifested excessive worries about little details, fear from going to other place, sweating,
escalated heartbeat, unexpected panic attacks, obsession and compulsion, and intense worries for her
family’s security.

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When and how did the symptoms start?

The onset of the symptoms wasn’t specified by the Client, it was a sudden experience of excessive
worries about little details and her kin anxiety about not achieving what her minds tell her to do. An
excessive perfectionism was also manifested by the Client. History of physical bullying from her
childhood and elementary days was narrated by the patient as she experienced banging her hands at
the door and her head being flushed at the toilet bowl.

Are any possible stressors involved?

Client narrated the possible stressors that trigger her panic attacks are: Fear of forgetting a family
member from her prayers, household chores not done perfectly, and her thought that manifest almost
every day that she might die.

Any history of abuse, bullying, or traumatic experience?

Client narrated her childhood experience of being physically abused by her classmates who banged
her hands at the door where her nails fell off and her head was flushed at the toilet.

B-DEVELOPMENTAL HISTORY
(Kindly fill out the form - all that applies based on your assessment)
1. During pregnancy, was the mother on medication?
☐ Yes ☐ No ✔ Others/Specify: not stated, this lack of information is subjected
for further investigation during follow-up session.
2. During pregnancy, did the mother smoke or drink alcoholic beverages?
☐ Yes ☐ No ✔ Others/Specify: not stated, this lack of information is subjected
for further investigation during follow-up session.
3. Was the child premature?
☐ Yes ☐ No ✔ Others/Specify: not stated, this lack of information is subjected
for further investigation during follow-up session.
4. Was the child breastfeeding from 1 to 6 months?
☐ Yes ☐ No ✔ Others/Specify: not stated, this lack of information is subjected for further
investigation during follow-up session.
5. Was the child taking medicines or any supplements from 1 to 6 months?
☐ Yes/ Specify_____________ ☐ No ✔ Others/Specify: not stated, this lack of
information is subjected for further investigation during follow-up session.
6. Was the child quiet in her 0-2 years old?
☐ Yes ☐ No ✔ Others/Specify: not stated, this lack of information is subjected
for further investigation during follow-up session.
7. Was the child conceived in an unwanted pregnancy?
☐ Yes ☐ No ✔ Others/Specify: not stated, this lack of information is subjected for
further investigation during follow-up session.

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 C- RELEVANT CHILDHOOD EXPERIENCE
(Kindly fill out the form - all that applies based on your observation and assessment)
1. Did the child grow up with both his parents?
✔ Yes ☐ No: Please Specify_____________________________
2. Describe the child’s relationship with her parents/guardians and siblings.
Patient is closed her family, however, she’s expressive about her experiences from the
school since she didn’t want to cause any disturbances to her parents who are both
busy. She is also close to her siblings as manifested by her excitement upon visiting them
and having conversation about her experiences and their previous stories as children.
3. Describe his/her relationship with his/her friends.
Patient reported to have no friends, this information might be subject for further
investigation to strengthen the assessment since social interactions is also relevant to
the assessment of the patient.
4. Any history of bullying? If yes kindly describe the experience:
Patient narrated her childhood experience of being physically abused by her classmates
who banged her hands at the door where her nails fell off and her head was flushed at
the toilet.

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D- FAMILY BACKGROUND
(Kindly fill out the form - all that applies based on your observation and assessment)
Marital Status of Parents
✔ Married ☐ Widowed ☐ Divorced ☐ Others: Kindly specify
D1-Family Composition:
Age: Sex Occupation

Fathers Name: Not stated and for further Not stated Not stated Not stated and for
investigation. and for and for further investigation
further further
investigation investigation
Mothers Name: Not stated and for further Not stated Not stated Not stated and for
investigation and for and for further investigation
further further
investigation investigation
Siblings: Not stated Not stated Not stated and for
1. “Didi” and for and for further investigation
2.” Sisi” further further
3.” Titi” investigation investigation
4. “Rumi”
The other sibling wasn’t mentioned.
D2- FAMILY MEDICAL HISTORY
(Kindly fill out the form - all that applies based on your observation and assessment)
Relationship Specific Medical Condition
Father Not stated and for further investigation
Mother Not stated and for further investigation
Sibling/s: A life-threatening disease wasn’t specifically
mentioned and is subject for further investigation.
Relative/s: Not stated and for further investigation
If the patient is married or living with his/her partner kindly proceed to D3: Household
Composition.
D3-Household Composition.
Name Age Relationship
1. “Abdel” Not stated. Husband
2. Her Child’s name and sex wasn’t stated
Other Comments:

Client’s family background, relationship and interaction to the family members, and the relevant
situation of her status has no strong and detailed information. This part of the assessment if subject
for further investigation.

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 E- MEDICAL HISTORY
(Kindly fill out the form - all that applies based on your observation and assessment)
☐ Loss of consciousness ☐ Chronic pain
☐ Sleep Disturbances ☐ Heart/Vascular problems
☐ Appetite changes ☐ Thyroid problems
☐ Asthma ☐ Pneumonia
☐ Weight changes ☐ Adverse reactions to medicine
☐ Respiratory Problems ☐ Seizures
☐ Allergy, Specify______________________
☐ Others, please specify:_________________
History of medication:
☐Yes /Specify How long:
✔No ☐Others/specify
Past Surgical History:
☐Yes; Specify________________ Date:_____________
✔No ☐Others/please specify_________
Personal/ Social History:
Smoking: ☐Yes ✔No ☐Quit ☐No. of packs
Alcohol: ☐Yes ✔No ☐Quit ☐No. of bottleshrs/day?

Part II: PSYCHOLOGICAL HISTORY

(If the client reports any of the following Mental Conditions/Concerns. Kindly check all
that applies based on your evaluation and assessment)
Mental Condition
☐ Psychosis ☐ Depressive episodes
☐ Bipolar episodes ☐ Childhood Anxiety Disorders
☐ Mood swings ☐ Defiant behavior
✔ Panic Attacks ☐ Problematic Emotional Response
☐ Tourette Syndrome ☐ Hyperactivity
☐ Derealization/Depersonalization ☐ Others, please specify:
☐ Attention-deficit ☐ Impulse control problems
✔Others, Please Specify: excessive perfectionism.
SOCIO-EMOTIONAL HISTORY
• How does the client express his/her emotions?
Client exhibited intense emotion, she reported her experiences on the highest scale and has
an idea that her situation might not get better and a tap-up fear of recurrence. Her
isolation to have friends and being in the crows gives her an idea of safety and that she
prefers to just do her daily routine; baking and cooking.
• How does the client understand oneself and others?
As the client narrated her experiences, she manifested her understanding as if she is too
worried about her safety and for her family’s rather than looking for emotional support
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 from the neighbor. She doesn’t want to become a burden to everybody so she kept her
experiences (as stated to her narration that she never told her parents about the bullying).
She has a clear awareness about herself, she knows what she wants, the client also aware
about her experiences that forced her to seek for a professional help.

PART III. FOUR P’S FACTOR MODEL

FOUR P’S FACTOR Biological Social Psychological
Client wasn’t assessed Discrimination and Client wasn’t assessed
about her Racism from her about her Attachment
temperament yet. No childhood bullying style yet. Family
genetic predisposing experience. dynamics wasn’t
factor was investigated assessed but her
nor narrated during narration as to her
the interview with the relationship towards
client. her husband and child
Predisposing has no relevant details
that would suffice her
condition’s
predisposing factor.
She chose not to seek
help from her parents
as a child when she was
bullied, her husband
has a good behavior.
Client has no medical No social precipitating Her faith wasn’t
records on injury or factor was stated. Her specifically stated,
illnesses. Medication choice of having no however, client
non-adherence wasn’t friends as narrated narrated that failing to
Precipitating assessed and stated. isn’t a strong detail for mention names of her
No pregnancy related the assessment and is family makes her
detail wasn’t need for further worry.
presented. investigation.

Client has no Client has lack of Client manifested a

functional impairment narration on her negative thought of dying
or chronic disease. relationship with as she it might happen to
This lack of others and how she her or to her family. This
thought is with her
information is subject interacts since she
almost every day. Her
for further manifested her
Perpetuating attitude of thinking too
investigation. isolation from much about every detail
friendship. This detail affects her general
is subject for further perspective and has a
investigation. domino effect as to her
perspectives in safety and
perfectionism.
Client has a good over- Client’s faith helped Client’s coping skills
Protective all health condition, her to keep herself has good effect to her
family has not feel safe. She has a at some point since she
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 mentioned psychiatric supportive and resorts to cooking,
history, client has also patient husband that baking, and household
no substance helped her in chores that benefits
use/abuse history. understanding her the orderliness and
experiences. A good management of the
and professional GP house. Her awareness
also assist her in to her experiences,
everything she symptoms, and how to
needed for the look for professional
appropriate therapy help is also a good
plan. factor for her.
Part IV: Brief Mental Status Exam (MSE) Form

(tick all items that apply, add notes as needed)

1. Appearance ✔ Casual dress

✔ normal grooming; hygiene
✔ Neat
☐ Disheveled
☐ Inappropriate
☐ Other (describe):
2. Attitude
☐ Calm and cooperative

Other (describe): Tense and cooperative

3. Motor Behavior ✔ No unusual movements or psychomotor changes
☐ Tic
☐ Restless
☐ Slowed
Other (describe):
4. Speech ☐ Normal rate; tone; volume; w/out pressure
✔ Pressured
☐ Soft
☐ Tangential
☐ Impoverish
☐ Mute
☐ Slurred
☐ Loud

Other (describe):
5. Affect
✔ Normal range

☐ Consistent with mood mood-congruent)

☐ Labile
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 ☐ Tearful

☐ Constricted

☐ Flat

☐ Other (describe):
6. Mood
☐ Normal or euthymic

✔ Anxious

☐ Irritable

☐ Depressed

☐ Elevated

☐ Other (describe):

7. Thought Processes
☐ Linear and goal-directed;
☐ Tangential
☐ Loosening of associations
☐ flight of ideas
✔ Other (describe): Coherent
8. Thought Content
Suicidal ideation: Homicidal ideation:

✔ None ✔ None

☐ Passive ☐ Passive

☐ Active ☐ Active

If active: yes/no is there: ☐ If active: yes/no is there:

☐ Plan ☐ Plan

☐ Intent ☐ Intent

☐ Means ☐ Means

☐ Delusions

☐ Obsessions/compulsions

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 ☐ Phobias

☐ Other (describe):
9. Perception
✔ No hallucinations or delusions during an interview

☐ Other (describe):
10. Orientation Oriented:
✔Time
✔ Place
✔ Situation
☐ Other (describe):
11. Memory/
☐ Short-term memory intact
Concentration
✔ Long-term memory intact

✔ Attentive

☐ Distractible/inattentive

☐ Other (describe):
12. Insight/
✔ Good
Judgment
☐ Fair

☐ Poor

☐ Describe:
General Comments:
Client manifested an awareness to her situation, experiences, and decisions. She’s been worrying a
lot for almost everything which are not common to the general population hence manifestation of
excessive perfection is observed.

Significant Findings:

Client has manifested abrupt surge of intense fear or intense discomfort that reaches a peak, Fear of
losing control or “going crazy.”, Fear of dying, has excessive worry of a recurrence of anxiety and also
fear of not finding a solution for its discomfort.

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Overall Recommendation:

Client’s assessment isn’t sufficient, impressions to her diagnosis requires further investigation and
follow-up since some details were lacking and narrations are affected with the biases from other
people’s presence. Due to the absence of dysfunction and danger, client is recommendation to
undergo for several tests on Personality disorder. Group dynamics is also effective to explore more
her experiences and thoughts.

PART V: DIAGNOSTIC CHECKLIST FOR GENERALIZED ANXIETY DISORDER

These are the DSM V-TR diagnostic criteria for GENERALIZED ANXIETY DISORDER (F 41.1). Please
review your diagnostic assessment using the checklist below. Please put a check on the boxes
applicable to the case being studied and write the descriptions if needed to support the criteria
being evaluated.
Generalized Anxiety Disorder is persistent and excessive anxiety and worry about various
domains, including work and school performance, that the individual finds difficult to control. In
addition, the individual experiences physical symptoms, including restlessness or feeling keyed up
or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle
tension; and sleep disturbance.
Diagnostic Criteria from the DSM V-TR Met Not Description of
Met Symptoms Observed
A. Excessive anxiety and worry (apprehensive ☐ ✔ Duration of experience
expectation), occurring more days than not wasn’t specified.
for at least 6 months, about a number of Needs further
assessment.
events or activities (such as work or school
performance)
B. The individual finds it difficult to control the ✔ ☐ Client has been
worry worrying about her
safety everyday and us
thinking of difficult.
Despite the support of
the husband, GP, and
further exploration
online with her
experiences, client
reported to have
thoughts of failing for
improvement.
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 is required in children.

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 1. Restlessness or feeling keyed up or on edge. ☐ ✔ Client didn’t report
any issues on sleep
pattern.
2. Being easily fatigued. ☐ ✔ Client manifested
activity as a resort to
her excessive worries
and fears.
3. Difficulty concentrating or mind going blank. ☐ ✔ Client manifested to
have concentration to
her routines and are in
full awareness.
4. Irritability. ☐ ✔ Client has composure
in narrating her
experiences and has
no report with conflict
towards her family.
5. Muscle tension. ☐ ✔ Client has no
manifestation of
muscle tension.
6. Sleep disturbance (difficulty falling or staying ☐ ✔ Client has no issue on
asleep, or restless, unsatisfying sleep). sleep pattern.
D. The anxiety, worry, or physical symptoms cause ✔ ☐ Client reported to
clinically significant distress or impairment in social, have “no friends” and
occupational, or other important areas of not “has no contact”, a
manifestation of her
functioning.
isolation from the
crowd which might
implicate a significant
impairment towards
her ability to open up
with other people.
E. The disturbance is not attributable to the ☐ ✔ Client has no record
physiological effects of a substance (e.g., a drug of on substance
abuse, a medication) or another medical condition use/abuse.
(e.g., hyperthyroidism).
F. The disturbance is not better explained by ✔ ☐ Client narrated to have
another mental disorder (e.g., anxiety or worry been experiencing an
about having panic attacks in panic disorder, unexpected and
expected panic attacks
negative evaluation in social anxiety disorder,
which led her to
contamination or other obsessions in obsessive- though of it every day.
compulsive disorder, separation from attachment This fear of having
figures in separation anxiety disorder, reminders of another panic
traumatic events in posttraumatic stress disorder, episodes resulted to
gaining weight in anorexia nervosa, physical her excessive
complaints in somatic symptom disorder, perceived perfectionism and
eagerness to look for a
appearance flaws in body dysmorphic disorder,
solution.

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 having a serious illness in illness anxiety disorder, or
the content of delusional beliefs in schizophrenia or
delusional disorder)

DIFFERENTIAL DIAGNOSIS:
In order to provide a clear basis for the client's discomfort and circumstances, more examination
and assessment must be conducted as quickly as feasible. This is because the information provided
is insufficient to support the differential diagnosis that the client has a condition.

Social Anxiety Disorder- in Social Anxiety Disorder, a client must experience the feeling of fears that
he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be
humiliating or embarrassing; will lead to rejection or offend others) according to criterion A. of
F40.10. Individuals with social anxiety disorder often have anticipatory anxiety that is focused on
upcoming social situations in which they must perform or be evaluated by others, whereas
individuals with generalized anxiety disorder worry, whether or not they are being evaluated.

Panic Disorder- in panic disorder, a client must experience four or more symptoms according to
criterion A1 from F41.0. Panic attacks that are triggered by worry in generalized anxiety disorder
would not qualify for panic disorder. However, if the individual experiences unexpected panic attacks
as well and shows persistent concern and worry or behavioral change because of the attacks, then
an additional diagnosis of panic disorder should be considered.

Obsessive Compulsive Disorder- in obsessive compulsive disorder, client must exhibit compulsion
in response with their obsession but the client exhibits much of an OCPD. Several features
distinguish the excessive worry of generalized anxiety disorder from the obsessional thoughts of
obsessive-compulsive disorder. In generalized anxiety disorder the focus of the worry is about
forthcoming problems, and it is the excessiveness of the worry about future events that is abnormal.
In obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of
intrusive and unwanted thoughts, urges, or images.

RECOMMENDATIONS:
further intake interview is necessary, during which the client's life history will be covered. As well
as the fundamental data required to complete the client's requirements prior to diagnosis.
Recognition of, we must take into account the 4Ds.

Completed By:

GIDEON DONAIRE-BAYONA December 14, 2023

______________________________________ ___________________
Name of Psychologist-In-Training and Signature Date
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References:
Gaines, J. (2022, March 14). Mental status exams: 10 best templates, questions & examples.
PositivePsychology.com. https://positivepsychology.com/mental-status-examination/

American Psychiatric Association. (2022). DSM-5-TR (tm) classification. American

Psychiatric Publishing.

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