Kristin is a 26-year-old client who presents to the outpatient clinic with complaints of “not liking myself.” She states she frequently feels angry without provocation and cries often. She has lost 10 lbs. in the past month and states she has no appetite. Kristin reports nightly sleep difficulty, both falling and staying asleep. Her mind just can’t seem to relax enough so she can sleep. She has tried melatonin and the Calm app mindfulness techniques; they help some nights but not always. She endorses having difficulty focusing for long periods, and she has missed several days of work within the past month due to her symptoms. No hallucinations or delusions are voiced. She states “The only thing that makes me feel better is shopping online. I love getting packages every day.” She is not experiencing financial issues from online shopping, but she has depleted her savings account. She reports that when she is not sad, she loves crafting and sometimes has days where she can craft “all day and all night.” The crafting can last for 3-4 days in a row. She denies thoughts of self-harm or suicide.
Past Psychiatric History
self-reported “panic attacks” including shortness of breath and nausea; no formal psychiatric diagnosis, no treatment
Past Medical History
no medical or surgical history
no known allergies
no alcohol use
vapes nicotine daily
no illicit drug use
single, not in a relationship currently, prefers male partners.
lives with two roommates
educational level: bachelor’s degree
employment: employed full time as a technical writer, works from home
hobbies: crochet and papercrafts
mother: alive, 55, no medical history, psychiatric history of depression
father: alive, 57, history of type 2 DM, no psychiatric history
siblings: only child
no prescriiption medications
Mental Status Examination
Casual attire, well-groomed, no motor abnormalities. Cooperative, good eye contact. Alert and oriented x 3. Speech is clear, normal rate and volume. Mood is depressed, irritable, and angry. Affect is appropriate, congruent to mood. Does not appear to respond to external stimuli. Memory grossly intact, fair concentration and attention. Thought processes are coherent with average intellectual functioning. Thought processes appear organized and content is appropriate to subject. Denies suicidality or homicidality. Insight and judgment are fair.
1.Select an appropriate screening tool for Kristin and provide a score for the tool.
2.Provide a rationale for the screening tool you selected.
3.Determine the most likely diagnosis for Kristin based on the available information.
4.Provide the ICD-10-CM code for the selected diagnosis
5.Provide a treatment plan with rationale for each plan step.
Integration of Evidence:
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