I.G. is a 23-year-old African American single female who reports experiencing palpitations, racing thoughts, and panic attacks for the past 3 days. She states that symptoms have been increasing in frequency. She attributes the exacerbation to recently switching to the night shift at work, which has significantly reduced her sleep. Her current routine involves working overnight at Amazon and attending an internship during the day. She reports sleep deprivation, increased irritability, feelings of guilt, and difficulty concentrating. Appetite remains normal, and she denies suicidal ideation (SI), homicidal ideation (HI), audio/visual hallucinations (AVH), delusions, or self-injurious behavior.
Denies use of tobacco, alcohol, and illicit drugs. Reports good relationships with both parents, with no specific family psychiatric or substance use history noted. Patient is currently on school vacation from college, where she is studying software engineering. She works night shifts at Amazon and attends a daytime internship. Reports a close relationship with her family and socializes with school friends. Identifies as Christian.
Denies any current or past medical conditions. No known allergies. Current medications: Vistaril (25 mg as needed) for anxiety, and Prozac (10 mg daily) for anxiety and depression.
I.G. presented as appropriately groomed and dressed, with a demeanor that was cooperative throughout the interview. She was fully alert and oriented to person, place, and time. Her motor behavior appeared normal and unremarkable. Speech was spontaneous, coherent, and within normal limits in rate and tone. Her mood was described as anxious, and her affect was reactive, congruent with the reported mood. Insight and judgment were assessed as fair. Although memory was intact, attention and concentration were mildly impaired, as evidenced by distractibility during the session. Thought processes were logical and goal-directed, with no evidence of disorganized thinking or derailment. Thought content was appropriate and free of delusions or obsessions. There were no perceptual disturbances such as hallucinations. Her functional status remained intact, and there were no signs of acute psychosis or cognitive deficits.
1. Panic Disorder (primary diagnosis). Panic Disorder is the most fitting and urgent diagnosis for I.G., given the acute presentation of sudden and intense episodes of palpitations, racing thoughts, shortness of breath, and anxiety lasting several minutes (Afshari, 2022). She sought emergency medical attention due to the severity of the panic symptoms, which have persisted and increased over the last three days. These episodes are spontaneous and not directly triggered by identifiable stressors, a hallmark of Panic Disorder. I.G.'s racing thoughts, physical symptoms (palpitations), and heightened anxiety are consistent with the DSM-5 criteria. Although sleep deprivation and work-related stress contribute to her mental state, the central issue is the emergence of recurrent panic attacks. Prompt identification and treatment of Panic Disorder are critical due to its potential to cause significant dysfunction and increased ER visits if left untreated. SSRIs like Prozac and PRN medications such as Vistaril are appropriate first-line treatments (Ziffra, 2021). Psychotherapeutic support focusing on panic management and grounding techniques is also essential.
2. Generalized Anxiety Disorder (GAD). I.G. also presents with symptoms that meet the criteria for GAD. Her excessive worry about work, school, and her internship, compounded by physical symptoms such as sleep disruption, irritability, and poor concentration, suggest a broader, persistent pattern of anxiety beyond isolated panic attacks. The anxiety is difficult for her to control and has been interfering with her daily functioning. Although the panic episodes are more acute, the underlying chronic anxiety exacerbates her vulnerability to these attacks. This supports the diagnosis of GAD as a comorbid condition (DeGeorge et al., 2022). Her worry spans across multiple domains and occurs more days than not, as evidenced by her report of feeling overwhelmed and emotionally exhausted. Treating her GAD alongside the panic disorder will help manage baseline anxiety, thereby reducing the likelihood of future panic episodes. Interventions should include continued use of SSRIs, psychoeducation, cognitive behavioral therapy (CBT), and sleep hygiene strategies.
3. Unspecified Depressive Disorder. Though not the most prominent issue at this time, I.G. shows signs suggestive of depressive symptoms, including feelings of guilt, irritability, and fatigue (Wissow & Green, 2022). However, she does not endorse core symptoms such as anhedonia, persistent sadness, or suicidal ideation, and her appetite remains intact. Given this, an unspecified depressive disorder diagnosis is appropriate to acknowledge the presence of depressive symptoms that do not fully meet the criteria for Major Depressive Disorder. This diagnosis is particularly relevant given her high levels of stress and sleep deprivation, both of which can exacerbate mood instability. Monitoring these symptoms is crucial, as untreated anxiety often coexists with and contributes to depressive episodes. Early identification of emerging depression allows for timely intervention and supports comprehensive mental health care.
4. Adjustment Disorder, Unspecified. This diagnosis accounts for the transient psychological response to a significant life change — in this case, her new night shift work schedule and demanding routine. Adjustment Disorder is characterized by emotional or behavioral symptoms in response to a stressor occurring within three months of onset. I.G.'s symptoms, such as irritability, anxiety, and functional impairment, are plausibly linked to her recent change in employment and resulting lifestyle disruption (Karatzias et al., 2021). However, the presence of more specific, diagnosable anxiety conditions like GAD and Panic Disorder takes precedence. Adjustment Disorder remains a secondary diagnosis that can evolve or resolve depending on how I.G. adapts to her new responsibilities. Supportive therapy focused on stress management and resilience building can aid in her adjustment process.
One pertinent social determinant of health in I.G.'s case is economic stability. Her employment at Amazon's night shift, combined with a daytime internship, suggests financial necessity may be impacting her sleep and overall well-being. Addressing economic stability involves ensuring access to employment opportunities that offer fair wages and reasonable working hours, contributing to better mental health outcomes.
As a future advanced provider, implementing targeted health promotion activities is crucial. Physical activity has been shown to alleviate symptoms of anxiety and depression. Encouraging I.G. to engage in regular exercise could enhance her mood and reduce stress (Pérez-Jorge et al., 2024).
Regarding patient education, providing psychoeducation about anxiety and panic attacks is essential. Educating I.G. on recognizing early signs, understanding triggers, and developing coping strategies can empower her to manage symptoms effectively. Psychoeducation has been linked to positive treatment outcomes for various conditions, including stress and anxiety.