Comprehensive Psychiatric Evaluation Essay

Comprehensive Psychiatric Evaluation Essay

Comprehensive Psychiatric Evaluation

            Some clinical symptoms characterize more than one psychiatric condition. In such cases, a comprehensive psychiatric evaluation is required to determine the mental illness that a particular client is suffering from. The evaluation involves the development of a SOAP note. In this paper, a SOAP note will be utilized to develop a comprehensive evaluation of Lisa is a 35-years-old African American woman who comes to the clinic complaining of being scared to go to the rehab. The note will include the client’s subjective data, objective information obtained during the physical examination, assessment based on present details, and an appropriate treatment plan for the client.Comprehensive Psychiatric Evaluation Essay

Subjective Data

Chief Complaint: Scared of going to the rehab


            Lisa is a 35-years-old African American woman who comes to the clinic complaining of being scared to rehab. She claims that going to rehab will prevent her from being hired, and she will be stigmatized. She has been taking alcohol for some time now. Later she became a regular user of cocaine that her boyfriend, Jeremy, introduced to her. She reveals that people say she is addicted, but she is not. However, she states that she cannot get enough of cocaine. She feels horrible, which worsens if she does not smoke it but feels good upon taking it. It clears after some time, and she requires some more. Her uncontrollable use of cocaine and alcohol commercials has an adverse impact on her functioning in life, particularly her local businesses and designing websites.

Past Psychiatric History

General Statement: The client denies any history of psychiatric conditions.

Hospitalizations: Does not disclose details of any previous hospitalization.

Medication trials: Denies trying any medication treatment.

Psychotherapy: She does any previous psychotherapy.

Substance UseHistory

Lisa reveals that she has been taking alcohol for some time. She later started using crack cocaine that her boyfriend, Jeremy, introduced to her. She has become a regular user of cocaine, and she cannot get enough of it. She feels horrible if she fails to take it and feels good upon taking it. However, she denies being addicted to it, but something is wrong with her personality. Comprehensive Psychiatric Evaluation Essay

Family Psychiatric/Substance Use History

Her family does not have a history of a psychiatric conditionor substance use. However, her boyfriend Jeremy uses drugs. In particular, he drinks a lot, cracks cocaine, and smokes weed.

Psychosocial History

Lisa currently lives with his boyfriend, Jeremy, in her new home. She has a daughter, Sarah, who stays with her friends. Lisa and Jeremy have been doing a commercial for local businesses and building websites for clients for the last nine months.

Medical History

            She denies being under any medication.

Current Medications

Currently, she is not under any medication.


She denies any allergies, including food, medication,and environmental allergies.

Reproductive History

The client is not currently pregnant nor lactating.However, she has a daughter, Sarah, who lives with some friends.


GENERAL: Denies fatigue, fever, weight gain, or weight loss.


Head:Denies headache

Eyes: Denies blurred vision.

Ears: Denies loss of hearing.

Nose:Reports runny nose and persistent nosebleeds.

Throat: Denies sore throat. Comprehensive Psychiatric Evaluation Essay

SKIN: Denies skin rashes or itchiness.

CARDIOVASCULAR: Reports rapid heart rate

RESPIRATORY: Reports excessive perspiration

GASTROINTESTINAL: Denies diarrhea, vomiting, or nausea.

GENITOURINARY:Denies odd color of urine or burning on urination.

NEUROLOGICAL:Denies numbness or tingling in the extremities.

MUSCULOSKELETAL: Denies muscle pain.


ENDOCRINOLOGIC: Denies excessive coldor sweating.


Physical Examination


Height: 63.7 inches, weight is 170.6 pounds, BP: 140/70 Temperature 42 heart rate 130 beats per minute

General Observations: She is smartly dressed, well-groomed,presentable, and looks slightly younger than her actual age.


Eye: Dilated pupils

Nose: Running nose

Cardiovascular: Rapid heart rate

Respiratory: Excessive perspiration



Mental Status Examination 

Lisa is a 35-years-old African American woman who looks younger than her age. She is smartly dressed, well-groomed, and presentable. She strives to remain cool and composed throughout the interview. Nonetheless, she sorbs when asked an agitating question and use vulgar language at some points during the interview. She seems to have increased energy and relatively high self-confidence. However, her mood keeps changing throughout the interview. She becomes angry and nervous, particularly upon remembering how her boyfriend, Jeremy cheated on her with Alisa in their office. Finally, she is paranoid about going to the rehab claiming that the place is dirty, she would not secure employment after that, and she would be stigmatized. Comprehensive Psychiatric Evaluation Essay

Differential Diagnosis

            Differential diagnosis is conducted to rule out the client’s condition based on the presented clinical symptoms, medical history, and physical examination results. The diagnosis will contain three mental conditions listed from highest priority to lowest priority.

Primary Diagnosis: Addiction

The primary diagnosis for this client is an addiction to crack cocaine. Cocaine is among the most powerful stimulants, which is highly addictive to uses due to the intense high. Crack cocaine refers to the freebase form of cocaine that occurs when a person inhales the cocaine vaporswhen the drug is in its natural state. Taking cocaine in this form results in euphoria and stimulating symptoms that occur rapidly due to the faster absorption rate. In most cases, symptoms of cocaine addiction vary between individuals. Nonetheless, persons who have been addicted to cocaine portray some common behavioral, psychological, and physical andsymptoms(O’Hagan& Shiels,2020).Most of these symptoms are depicted by the client, thus selecting addition as the primary diagnosis.

Cocaine addiction is primarily characterized by various behavior symptoms, including being fearful and paranoid, aggressiveness, restlessness and agitation, and poor hygiene(O’Hagan & Shiels, 2020). Most of these symptoms are evident in this client. First, Lisa is fearful and paranoid about going to the rehab claiming that the place is dirty, she would not secure employment after that, and she would be stigmatized.Moreover, she is restlessand agitated during the interview, especially when speaking about her boyfriend, Jeremy. Therefore, Lisa is likely to be suffering from cocaine addiction. Comprehensive Psychiatric Evaluation Essay

Additionally, cocaine addictionis characterized by multiple psychological symptoms, including poor decision-making capabilities, a sudden overabundance of confidence, and mood swings(O’Hagan & Shiels, 2020). These clinical presentations are evident in the client. First, Lisa’s decision-making capabilities are poor. She continues to live with his boyfriend, Jeremy, in her new home despite his past, including cheating on her and withdrawing money from their business account without informing her. Additionally, she decides to let her daughter Sarah live with some friends, instead of staying with her. Secondly, Lisa demonstrates a sudden overabundance of confidence at some points during the interview. In particular, this quality is evident when she speaks about staying in the hospital and get cleaned up. Finally, Lisa demonstrates mood swings during the interview. She is happy when speaking about her achievements and becomes sad to the extent of crying when speaking about what Jeremy did to her. For instance, she cries when explaining that Jeremy introduced her to crack. Thus, this client is much likely to be suffering from cocaine addiction. Comprehensive Psychiatric Evaluation Essay


Lastly, cocaine addiction is characterized by some physical symptoms, including rapid heart rate, elevated body temperature, dilated pupils, high blood pressure, runny nose, persistent nosebleeds, and excessive perspiration(O’Hagan & Shiels, 2020).Lisa reports having a runny nose and persistent nosebleeds. Secondly, the clinician observes dilated pupilsduring physical examination. Additionally, she has a rapid heart rate of 130 beats per minute and high blood of 140/70. Her temperature reading is also high (42 degrees). Therefore, Lisa is likely to be suffering from cocaine addiction.

Post-Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD) is the second diagnosis for this client. A terrifying event primarily triggers this mental health condition. According to the DSM-5 diagnostic criteria, PTSD is mainly characterized by nightmares, flashbacks, avoidance of the situation, heightened reactivity to stimuli, and severe anxiety(Morina et al., 2016).This mental disorder may last for a long duration, including months or years, and the triggers are likely to bring back memories of the traumatic incident. The memories result in intense physical and emotionalreactions.

Some symptoms of PTSD, including heightened reactivity to stimuliand severe anxiety, are portrayed by the client. Lisa demonstrates heightened reactivity when speaking about how she caught her boyfriend, Jeremy, naked, having sex with Alisa in her office while cracking cocaine. She also depicts severe anxiety. Lisa is restless throughout the interview. Nonetheless, she does not depict some major symptoms of PSTD, including nightmares, flashbacks, avoidance of the situation. Shahini and Shala (2016) state that having nightmares is the primary symptom of PSTD. Therefore, Lisa is not likely to be suffering from PSTD. Comprehensive Psychiatric Evaluation Essay

Generalized Anxiety Disorder (GAD)

This client is lastly diagnosed with Generalized Anxiety Disorder (GAD). According to the DSM-5 diagnostic criteria GAD, is an anxiety disorder in which patients demonstrate chronic anxiety,irritability, restlessnessor tension, lack of concentration, unwanted thoughts, and exaggerated fear. In most cases, fear occurs even without being provoked.

The client demonstrates some of the major symptoms of Generalized Anxiety Disorder (GAD), including exaggerated fear, irritability, and restlessness. Lisa comes to the clinic due to the fear of being taken to a rehabclaiming that the place is dirty, she would not secure employment after that, and she would be stigmatized. She becomes irritated and restless, particularly upon remembering how her boyfriend, Jeremy cheated on her with Alisa in their office.However, Lisa does not depict GAD’s major symptoms, including lack of concentration and unwanted thoughts. Thus, she is less likely to be suffering from GAD.


The treatment plan for cocaine addiction primarily involvesdetoxification and therapy in an inpatient rehabilitation center. According to Regan and Kelley(2020), detoxification is the first step after which an addict is rehabilitated in an inpatient center. Such a plan is appropriate for Lisasince cocaine detox will be supervised and withdrawal symptomstreated while in the rehabilitation center. A rehab process entails various programs such as mental health counseling, art therapy, equine therapy, cognitive behavioral therapy, support groups, dialectical behavioral therapy, alternative programs, aftercare planning, and relapse prevention education. Therefore, enrolling in the rehab program will enable her to recover from cocaine addiction and lead a healthy life without using cocaine. Comprehensive Psychiatric Evaluation Essay

Secondly, the treatment of cocaine addiction includes cognitive-behavioral therapy (CBT). CBT is among the most popular therapies for treating individuals with addictions. According to Carroll & Kiluk(2017), cognitive-behavioral interventions effectively treat individuals with alcohol and drug use disorders. In this therapy, individuals are taught how to recognize harmful thoughts about themselves, which are likely to lead to relapse and incidents that might trigger them to use cocaine again. Therefore, Lisa can use this knowledge to develop coping strategies to avoid tempting incidents and prevent relapse-oriented thoughts from getting into her mind.

Finally, the treatment plan for cocaine addicts includes a support system. A support system is recommended when a cocaine addict is leaving therapy. The best way to prevent a relapse is through participating in support groups consistently. These groups bring recovering addicts, thus allowing them to share their experiences and challenges. Additionally, recovery addicts get help and psychological support from former cocaine addicts who understand the situation better. Therefore, Lisa should join a support group specifically tailored for individuals recovering from cocaine addiction, including Cocaine Anonymousand Narcotics Anonymous. The group will provide her with psychological support, thus enhancing her recovery process. Comprehensive Psychiatric Evaluation Essay

Reflection Notes

I would make some changes with this client if I could conduct the session again. First, I would involve someone close to Lisa, especially her boyfriend, Jeremy, during the interview. Jeremy would provide details of Lisa’s medical history that she is unable or she feels uncomfortable to share. Such information would act as a guide during diagnosis, assessment, and development of a treatment plan. Additionally, the presence of Jeremy would reveal Lisa’s actual behavior during the interview. For instance, Lisa might be violent to him, which is significant during diagnosis and treatment. In that case, I would conduct a further assessment for conditions characterized by aggressiveness. I would also include members of the multidisciplinary team during the interview. Sharing Lisa’s details with other practitioners will facilitate the provision of optimal patient care. Involving third parties during the interview is against the ethical privacy of confidentiality and privacy, which requires patient’s personal information to be protected from third parties. Nonetheless, breach of this ethical principle is permitted in some situations, such as during referrals where a practitioner is supposed to handle over client’s medical history (Abuse et al., 2016). Furthermore, I would educate the client about the dangers of long-term use of cocaine, such as developing kidney failure and financial challenges due to the high cost of this drug. Being an African American, the possibility of developing this condition is relatively high(Laster et al., 2018). Therefore, she can prevent kidney disease by quitting using cocaine. Finally, I would educate the client about contraceptives and protection during sexual intercourse to prevent contracting sexually-transmitted diseases. Comprehensive Psychiatric Evaluation Essay


            Differential diagnosis for this client is conducted based on the presented clinical symptoms, medical history, and physical examination’s results. The client is primarily diagnosed with an addiction to cocaine since she presented various symptoms that characterize this condition. Secondly, the client is diagnosed with PTSD. Nonetheless, this condition was ruled out due to the lack of some major symptoms that characterize PSTD. Finally, the client is diagnosed with GAD. However, this condition was ruled out due to the absence of GAD’s major symptoms, such as lack of concentration and unwanted thoughts. Therefore, it is concluded that the client is suffering from cocaine. An appropriate treatment plan that includes detoxification and rehabilitation in an inpatient center, CBT, and support system is recommended for this client.


Abuse, S., US, M. H. S. A., & Office of the Surgeon General US. (2016). Early Intervention, Treatment, And Management of Substance Use Disorders. In Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health [Internet]. US Department of Health and Human Services.

Carroll, K. M., & Kiluk, B. D. (2017). Cognitive behavioral interventions for alcohol and drug use disorders: Through the stage model and back again. Psychology of addictive behaviors31(8), 847.

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine170(7), ITC49-ITC64.

Khan, A. M., Siddiqui, S., Rizvi, S., Haq, W. U., Haq, M. F., Ahmed, M. M., … & Kherani, D. CBT as an Adjunct in Panic Disorders. Anxiety27(2), 93-112.

Laster, M., Shen, J. I., & Norris, K. C. (2018). Kidney disease among African Americans: A population perspective. American Journal of Kidney Diseases72(5), S3-S7.Comprehensive Psychiatric Evaluation Essay

Morina, N., Sulaj, V., Schnyder, U., Klaghofer, R., Müller, J., Martin-Sölch, C., & Rufer, M. (2016). Obsessive-compulsive and posttraumatic stress symptoms among civilian survivors of war. BMC psychiatry16(1), 1-8.

O’Hagan, A., & Shiels, Z. (2020). Cocaine and cannabis abuse in the UK: psychological effects, social prevalence and treatment. Forensic Research and Criminology International Journal, 8(1), 31-40.

Regan, J & Kelley, R. (2020). Cocaine Abuse, Addiction & Treatment. American Addiction Centers.

Shahini, M., & Shala, M. (2016). Post-traumatic stress disorder in Kosovo veterans. Sage Open6(1), 2158244016633737. Comprehensive Psychiatric Evaluation Essay