Generalized Anxiety Disorder Coursework Sample

Paper Instructions

Academic level – Undergrad. 1-2
Type of paper – Coursework
Topic Title – Generalized Anxiety Disorder: SOAP Notes
Instructions:

Please see the template provided to guide your writing of SOAP notes.

Follow the rubric to develop your SOAP notes for this term.

The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.

Coursework Sample

Subjective

The patient is a middle-aged male who presents with chronic anxiety persisting for the past six months. He describes feelings of tension and restlessness that usually continue throughout the day, regardless of his environment or activities. The patient believes his anxiety does not relate to specific events or circumstances because he experiences it as an underlying unease that varies in intensity. He acknowledges the difficulty in managing his worries, which occasionally impact his daily functioning. Additionally, the individual experiences muscle tension, headaches, and sleep disturbance. He also denies any history of substance abuse and is not currently taking any medications influencing his mental state.

Objective

The patient’s general appearance and hygiene are appropriate, physical examination reveals no abnormalities, and vital signs are within normal limits. However, the patient appears nervous and reports feeling overwhelmed during the assessment. He displays signs of increased muscle tension and restlessness, while his speech is rapid. The assessment revealed no symptoms of psychosis or other mental health disorders.

Assessment

The patient meets the criteria for Generalized Anxiety Disorder (GAD) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2022). The factors that support the diagnosis are the patient’s persistent and excessive worry, multiple physical symptoms, and difficulties controlling his anxiety. The assessment has ruled out other contributing factors, such as medical conditions or substance use.

Plan 

• Main treatment: Initiate individual cognitive-behavioral therapy (CBT) sessions to detect and address cognitive distortions, negative thought patterns, and maladaptive coping strategies. Hirsch et al. (2019) find that previous research supports CBT as an effective management tool for GAD symptoms, while their study indicates recovery for 74% of cases. During therapy sessions, focus on identifying triggers for the patient’s anxiety and explore potential sources of stress in his life. Implement cognitive restructuring techniques to challenge and alter negative thought patterns.
• Support interventions: Combine CBT with other therapeutic approaches based on the patient’s needs and preferences. The most likely additional course of action is to teach the patient relaxation techniques, such as deep breathing exercises, muscle relaxation, and mindfulness meditation. These techniques will help manage his anxiety symptoms, reduce overall stress levels, and empower him to deal with GAD outside psychotherapy.
• Lifestyle interventions: Encourage the patient to adopt a healthy lifestyle, including regular exercise, a sleeping schedule, and a nutritious diet. On the same note, assess the patient’s support system and involve family members or close friends in treatment and lifestyle changes. Combining healthy habits and a strong support system can contribute to sustained progress and better outcomes.
• Alternatives: Consider pharmacotherapy if the patient’s symptoms persist despite psychotherapy and lifestyle interventions or if GAD continues to affect his daily functioning. Collaborate with a psychiatrist to assess the need for anxiolytic medications based on evidence-based guidelines. In the case of using pharmacotherapy, monitor the patient closely for any side effects or changes in symptoms.
• Follow-up: Schedule regular follow-up visits with the patient to monitor progress, assess treatment response, and adjust the care plan. Use these visits to provide educational materials about his condition, symptoms, and available treatment options. These steps will establish a balance between supervision and self-management, empowering the patient to participate in his care and make informed decisions. Celebrate any progress, offering reassurance and encouragement to help him deal with the constant tension that might discourage him from treatment.

References

Hirsch, C. R., Beale, S., Grey, N., & Liness, S. (2019). Approaching cognitive behavior therapy for generalized anxiety disorder from a cognitive process perspective. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00796

Diagnostic and statistical manual of mental disorders: DSM-5. (2022). American Psychiatric Publishing.