Case Vignette Assignment 3 (10 points)

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Brandon
Im not good with or around people, Brandon reports. Ever since high school he has experienced challenges when meeting new
people or being around large groups of people, especially if he does not know them. This seems to be the case in most all social situations no
matter where he is-at school, out and about in town, or at work. Rarely if ever can he be in one of these situations and not feel anxious. When he
gets around these settings he is confident that people are looking at him and thinking about him critically, judging his appearance and making fun
of how he comes across. Often when it gets close to the time for these events he will feel tense, hot, have trouble breathing, and trembles.
Sometimes he can grit his teeth and get through these situations, but other times he decides to avoid them altogether.
While avoiding these situations has an immediate effect of reducing his anxiety, it has come at a significant cost. Brandon has few friends, and the
ones he has he has had for a long time. He would like to meet new people, but he cant seem to get himself to interact with others. His has created
a significant strain on his ability to date and have a romantic relationship, and he feels depressed and hopeless when he thinks about that. He was
not very active in high school with social and extracurricular activities, and he has avoided applying for and accepting a few jobs because of the
amount of social interaction they require. Sometimes he is better able to tolerate social situations if he has some alcohol, which has raised some
issues in times when he has been out with friends and he has drank to excess.
1. Based upon this vignette identify the likely diagnosis/diagnoses, including any applicable rule out (R/O) diagnoses (if any). List ICD code
number, diagnosis, and any applicable specifiers

Diagnosis: F40.10 Social Anxiety Disorder

2. How would you support or justify your diagnosis? What details support what criteria? Explain
these in narrative form, meaning that each answer needs to be at least a paragraph or more (one
to two sentences will not suffice) with attention to writing using complete sentences, appropriate
grammar (spelling, punctuation) and clear organization and expression of content.
The details I feel support the diagnosis are his anxiety relating to being around people at
school, out with friends or at work. He also stated that he feel people judge, think about him
critically, make fun of how he comes across. He also reported that he can sometimes grit his
teeth and get through the situations but other times decides to avoid them. He stated this has
gone on since high school (longer than 6 months since he is able to buy alcohol). He reports
significant strain on his ability to have relationships or meet new people. He has avoided jobs or
activities that require being around lots of people.
3. What conditions would you look to rule out?
Major Depressive Disorder, Substance Abuse Disorder (Alcohol)
4. What are three pieces of information you would like to know that would help you to either
better support the diagnosis or to better understand this individual?
1. I would ask a question for more information about depressive symptoms?
2. I would ask a question related to how much and often he consumes Alcohol or other
substances?
3. I would ask how often he is able to maintain being in these situations vs. completely
avoiding them?

Malcolm
I dont drive beyond old Mr. McHenrys barn. Malcolm actively avoids going into stores and being in crowds. He does not like to
drive, but he will within his town, but he has points where he will go no further away from his home. Its like I have a radius, like a dog chained
to post that can only go so far. Malcolm has avoided driving and getting out ever since he began having periods that would seem to happen for
no reason where he would sweat, feel clammy and dizzy, seem disoriented and as if he is losing his mind, where his heart beat increases
significantly and he cant seem to catch his breath. These now happen anywhere from 2-5 times per week, just out of the blue. Even once these
periods subside he worries about when and where they will return.
Ever since this time he has stopped leaving his home as much. He worries that if he is in public or around a crowd that one of these
episodes might hit and that he will not be able to get away, to get to a safe place or to get help. When he walks outside or goes into a store or
office he begins to have trouble breathing, his heart rate goes up, and he feels sick and dizzy. He worries how this looks to others and believes
they are laughing at him and judging him, so he just stays home, or when he absolutely must go out he rushes in and out very quickly. If he cant
seem to get out fast he has left food in his cart and left a store or has not made a payment, deciding to come back to the bank another time.
This has really impacted his life. He has had difficulties maintaining relationships with family and friends due to his isolation and not
getting out. His mother tries to help him, but his brother thinks he is being ridiculous and refuses to show him any regard. While it has been
difficult having relationships, he does have a girlfriend that he has been with for two years. She tries to be loving and supportive, and he is able to
tolerate some situations better when she goes with him and when she drives, but his constant need for her presence, assurance and assistance
places a strain on their relationship.
1. Based upon this vignette identify the likely diagnosis/diagnoses, including any applicable rule out (R/O) diagnoses (if any). List ICD code
number, diagnosis, and any applicable specifiers

Diagnosis: F41.0 Panic Disorder, F40.00 Agoraphobia

2. How would you support or justify your diagnosis? What details support what criteria? Explain
these in narrative form, meaning that each answer needs to be at least a paragraph or more (one
to two sentences will not suffice) with attention to writing using complete sentences, appropriate
grammar (spelling, punctuation) and clear organization and expression of content.
I would support my diagnosis by him needing his girlfriend with him to tolerate some
situations. He also has unexpected panic attacks multiple times per week out of the blue. He
has worries of when and where the panic attacks will return as well as what will happen if they
occur while he is in public. He has anxiety and fear when he is out of his home as well as in
public places (stores, bank) or around crowds because he will not be able to get to a safe place or
away from the location fast enough. Just walking outside of places (store, bank) he starts
developing panic attack symptoms (hear rate increase, feeling sick, dizzy). He fears what other
people will say or think if he has a panic attack in public. He reports difficulties maintaining his
relationships with family and friends.
3. What conditions would you look to rule out?
Social Anxiety Disorder
4. What are three pieces of information you would like to know that would help you to either
better support the diagnosis or to better understand this individual?
1. When did the symptoms first start and what was occurring when they did?
2. When did you stop going out of your home?
3. How were the symptoms before you had a girlfriend compared to now?