Case Synopsis

J.T., a 20-year-old college male, reports feeling depressed and stressed about school and
remarks that he will “probably flunk out.” He finds little pleasure in his day which is spent in his
dorm room playing video games. J.T. seldom attends class and likewise has not reached out to
professors to manage his grades. He self-reports that he is a shy person with a small group of
friends. J.T. noticed an increase in his stress when he began college.
Diagnosis
According to the 2022 Diagnostic and Statistical Manual of Mental Disorders Fifth
Edition, Text Revision (DSM-5-TR), J.T. is exhibiting the qualities of major depressive disorder
(MDD) as evidenced by an estimated two-week or longer episode of depressed mood, loss of
interest and pleasure in doing things, and feelings of worthlessness. Anxiety disorder is a second
diagnosis based on his description of his worry. Onset of anxiety disorders in early adulthood can
be attributed to the onset of a life stressor which in this case is the beginning of college. Social
anxiety disorder may be a better description for J.T. based on the information provided where he
reports excessive worry when meeting new people and their evaluation of him. He also has
difficulty conversing and begins to sweat and stutter. Lastly, he is avoiding going to class or out
with friends/roommate thereby avoiding social situations (American Psychiatric Association
[APA], 2022; Barlow et al., 2022). The fact that he does not answer his phone when it rings is
not unusual and is quite actually the norm, culturally speaking. J.T.’s level of worrying and
rumination is a cognitive feature exhibited in both MDD and anxiety disorder (Joubert et al.,
2022)
The differential diagnosis may include bipolar with a depressed mood onset. Borderline
personality disorder is also considered due to self-image and instability of interpersonal
relationships. Antisocial personality disorder cannot be excluded due to isolating and issues with
authority figures. Avoidant personality disorder as evidenced by social inhibition and feelings of
inadequacy may be moved from the differential to active diagnosis pending further evaluation.
Most frequently avoidant personality disorder occurs in individuals with social anxiety disorder
(APA, 2022).
Biopsychosocial Plan of Care
A biological, psychological and sociological plan of care in broad strokes encompasses
referrals to other providers as indicated, discussion and education of self-help measures,
counseling, medication and follow up. J.T. is encouraged visit his primary care to rule out
physiological causes for MDD and anxiety including but not limited to endocrine dysfunction,
brain disorder, vitamin/mineral deficiencies or environmental causes (Barlow et al., 2022).
Cognitive behavioral therapy (CBT) is considered the gold standard in the treatment of MDD
and anxiety however it does not satisfactorily eliminate rumination which can result in relapse of
MDD or anxiety (Joubert et al., 2022). Anxiety disorder is considered a chronic condition with
crescendos and decrescendos (Barlow et al., 2022). Medication management for his MDD and
anxiety would be appropriate to restore function however it demonstrates complexity in
prescribing. Typically, patients suffering from both MDD and anxiety fair well on tricyclic
antidepressants or selective serotonin reuptake inhibitors. Care must be exhibited in prescribing
due to an increased risk of suicide as he is under 24 years of age. An alternative may be
bupropion, a dopamine and norepinephrine receptor uptake inhibitor, as it does not carry the
same caution but it is only useful for MDD and not his accompanying anxiety. Beta-blockers are
useful in reducing social anxiety symptoms of increased heart rate, sweating and tremor could be
considered pending the situation. Beta-blockers do not change the internal feelings of anxiety but
can be used for episodic control of outward symptoms such as during a presentation for school or
public speaking (Carlat and Puzantian, 2022). The plan is to avoid benzodiazepines due the risk
for abuse and dependence as well as propensity for impairment of cognitive and motor
functioning (Barlow et al., 2022) Self help measures include exercise, proper nutrition,
meditation, journaling and sleep hygiene. These are all examples of lifestyle medicine
recommended for this young patient that would be beneficial across his lifespan (Correll et al.,
2023)
Compare and Contrast
Fear, worry, anxiety and panic share a place in anxiety disorders. Anxiety can also find its
place in a variety of other disorders. Worry is the apprehensive expectation about activities or
events. Worry is typically defined as a negative emotion that concerns the future that can be
repetitive in nature, unwanted, uncontrolled and associated with physical symptoms or sensations
(Joubert et al., 2022). While some amount of worry is natural, excessive worry by contrast can
instigate fear and anxiety behaviors or at the very extreme a panic attack.
Fear occurs as a response to real or imminent threat as in driving on I-95 and a car
swerves out of the lane in front of you causing a near-miss event. Anxiety is an anticipatory
feeling that occurs as in driving on I-95 again in the future based on previous experience. Fear
elicits an expression of the fight-flight response, an immediate appraisal of danger and exercising
escape behaviors. Thinking back to I-95, this is the pounding heartrate, sweating and increased
respiratory rate as you swerve to prevent an accident. Anxiety on the other hand is characterized
by muscular tension, hypervigilance and cautious or avoidant behaviors. This could be when
behind the wheel again going towards I-95 and you begin gripping the wheel and constantly
checking on cars in the lane next to yours to see if there is enough room to maneuver if you need
to. In this instance fear and anxiety can be reduced by avoiding I-95 all together however
excessive avoidance, such as driving an extra hour, may indicate a need for intervention (APA,
2022).
Panic is an abrupt surge from a calm or anxious state to intense fear or discomfort that
reaches a pinnacle within minutes. Panic is associated with the activation of the autonomic
system via the sympathetic nervous system and as such explains the physical symptoms. Physical
manifestations include palpitations, increased heart rate, sweating, trembling, shortness of breath
or smothering, chest pain, choking, nausea, dizzy, unsteady, chills, numbness, tingling, being
detached from self, or fear of dying to name a few. Full blown panic attacks exhibit more than
four symptoms whereas limited attacks are less. Panic can also be expected or unexpected (APA,
2022).

References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental
disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Barlow, D. H., Durand, V. M., & Hofmann, S. G. (2022). Psychopathology: An integrative
approach to mental disorders (9th ed.). Cengage Learning.
Carlat, D., & Puzantian, T. (2022). Medication fact book for psychiatric practice (6th ed.).
Carlat Publishing.
Correll, T., Gentile, J., & Correll, A. (2023). Healthy Lifestyle Interventions Augmenting
Psychotherapy in Anxiety and PTSD. Innovations in Clinical Neuroscience, 20(7–9),
18–26.

Joubert, A. E., Moulds, M. L., Werner-Seidler, A., Sharrock, M., Popovic, B., & Newby, J. M.
(2022). Understanding the experience of rumination and worry: A descriptive qualitative survey
study. British Journal of Clinical Psychology, 61(4), 929–946. https://doi.org/10.1111/bjc.12367