Case Study
Patient Demographic: Client Age: 54 Sex: Male Gender: Male Sexuality: Heterosexual Ethnicity: Multiracial Relationship Status: Divorced Counseling Setting: Local Government Mental Health Agency Type of Counseling: Individual Presenting Problem: Opioid Use Diagnosis: Opioid Use Disorder, Severe (F11.20), Homelessness (Z59.0)
Mental Status Exam: Mental Status Exam: The client has not maintained hygiene, as evidenced by him not smelling clean and wearing clothes that are visibly dirty. He appears to have bilateral tremors in his hands. The client is oriented to person, place, situation, and time. The client appears malnourished because he is very thin and f
Presenting Problem: You are a mental health counselor working at a local government mental health agency, specializing in substance use counseling. An individual came in today to become a client for mental health case management and was encouraged to meet with a counselor to begin receiving therapy. The 54-year-old male client is currently living in a tent in the woods behind a local grocery store and reports that he lost his job a year ago following a divorce from his wife of 26 years. The client stated that about 3 years ago he had a back injury and following surgery was prescribed oxycodone. The client continued that he had difficulty stopping his use of the medication when the prescription ran out and connected with a friend to get fentanyl. He reports that he spends a lot of time on a street corner asking for money to get fentanyl and that he cannot seem to go a day without it. The client feels that he cannot sleep or function without the use of fentanyl and that this has affected his housing, marriage, employment, and social life. He acknowledges that fentanyl has negatively affected his life and that he is not sure if he wants to stop using it because he knows it would be hard to deal with life without it.
Other Contexts: The client discusses how his case manager has gotten him into a shelter and is currently working on securing housing for him. The client processes feelings surrounding the shelter and has begun a detox program for his fentanyl addiction. The client verbalizes that he is experiencing anxiety surrounding being at meetings with the case manager, talking with other residents, reintegrating into a “more normal life,” and worrying about whether he can ever have a relationship with his kids or ex-wife if he gets sober. Through processing, you realize that this anxiety was present prior to drug use and that he has experienced anxiety throughout his life

Question: Due to the presence of anxiety symptoms, which would be the most probable second diagnosis to consider?
(A): Agoraphobia
(B): Generalized anxiety disorder
(C): Social anxiety disorder
(D): Substance/medication-induced anxiety disorder

Correct Answer: Generalized anxiety disorder
Explanation: Generalized anxiety disorder appears to be the most probable diagnosis because the anxiety appears to cover many different areas of the client’s life. Although some of the anxiety is related to social situations, social anxiety disorder is specifically about fear of judgment or scrutiny (American Psychiatric Association [APA], 2013). Although the client does use substances, the anxiety predates the substance use and it is possible that the substances helped the client feel a reduction in anxiety. Agoraphobia is the fear of being in public spaces alone, closed in with others, and it generally results in an individual being afraid to leave home (APA, 2013). Although the client does express anxiety about living in a shelter, that anxiety is likely less specific to his living situation than it is a generalized sense of being overwhelmed by all of the issues that he is currently confronting. Therefore, the correct answer is (D)
Competency: intake, assessment, and diagnosis