NRNP 6635: Comprehensive Psychiatric Evaluation of Anxiety, Trauma, and Obsessive-Compulsive Disorders

Summary: Complete a Comprehensive Psychiatric Evaluation for a patient presenting with anxiety, trauma, or obsessive-compulsive symptoms. Apply DSM-5-TR diagnostic criteria to formulate a primary diagnosis and at least three differential diagnoses. Document subjective and objective findings, justify your clinical reasoning, and reflect on legal, ethical, and health promotion considerations.

Assignment Context

This assessment requires you to conduct a comprehensive psychiatric evaluation using the provided template. Select one video case study from the Video Case Selections in your Learning Resources and review the accompanying Case History Reports. The evaluation must demonstrate applied diagnostic reasoning, not descriptive summary. You will justify each differential diagnosis with specific DSM-5-TR criteria and explain which criteria rule out competing diagnoses. The final submission must be 4 to 6 pages, formatted in APA style with a minimum of five peer-reviewed references published between 2018 and 2026.

Subjective Data Collection

Document the patient’s chief complaint in their own words. Record the duration, severity, and functional impact of symptoms. A patient presenting with generalized anxiety might report six months of uncontrollable worry about work performance, accompanied by muscle tension, sleep disturbance, and irritability. Obtain a detailed psychiatric history including prior diagnoses, hospitalizations, medication trials, and treatment response. Assess substance use, medical history, family psychiatric history, and social determinants of health. The subjective section must capture enough detail for a reader to independently evaluate your differential diagnosis.

Objective Findings and Mental Status Examination

Record your direct observations during the assessment. Note appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment. Document any psychomotor agitation, restricted affect, or impaired concentration you observe. Include vital signs if available and relevant laboratory results. A patient with PTSD may present with hypervigilance, exaggerated startle response, and avoidance of eye contact when discussing the trauma. Objective findings anchor your assessment in observable data rather than inference.

Differential Diagnosis and DSM-5-TR Application

List a minimum of three possible diagnoses in order from highest to lowest priority. For each, compare the patient’s presentation against DSM-5-TR criteria. Explain what criteria support the diagnosis and what criteria rule it out. For generalized anxiety disorder, the DSM-5-TR requires excessive anxiety and worry occurring more days than not for at least six months, difficulty controlling the worry, and at least three of six associated symptoms including restlessness, fatigue, poor concentration, irritability, muscle tension, or sleep disturbance (APA, 2022). For PTSD, the DSM-5-TR requires exposure to actual or threatened death, serious injury, or sexual violence, followed by symptoms from four clusters: intrusion, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity, persisting for more than one month. For OCD, the DSM-5-TR requires the presence of obsessions, compulsions, or both, with obsessions defined as recurrent and persistent thoughts, urges, or images experienced as intrusive and unwanted, causing marked anxiety or distress. The critical thinking process involves matching the patient’s specific symptom profile to these criteria and identifying which diagnosis accounts for the full clinical picture.

Reflection Notes

Discuss what you would do differently if you could conduct the session again. Address legal and ethical considerations beyond confidentiality and consent. Consider duty to warn, mandated reporting, informed consent for treatment modalities, and documentation standards. Discuss health promotion and disease prevention specific to the patient’s age, ethnic group, past medical history, and socioeconomic context. A patient with limited access to mental health services may benefit from telehealth follow-up, community resource referrals, and psychoeducation on stress management. Cultural factors influence symptom expression and treatment engagement, so the evaluation must incorporate culturally responsive care planning.

Why This Matters in Practice

Accurate differential diagnosis directly determines treatment selection and patient outcomes. A missed PTSD diagnosis in a patient presenting with anxiety symptoms leads to ineffective treatment and continued suffering. A misdiagnosis of OCD as generalized anxiety disorder results in inappropriate pharmacotherapy and delayed evidence-based intervention. Psychiatric mental health nurse practitioners sit at the front line of identification and referral. The diagnostic reasoning skills practiced in this assignment translate directly to clinical decision-making in outpatient, inpatient, and community settings.

Sample Answer Excerpt: Diagnostic Reasoning in Practice

A 34-year-old female presents with a six-month history of persistent worry about her job performance, accompanied by muscle tension, insomnia, and difficulty concentrating. She reports no history of trauma, no intrusive thoughts, and no repetitive behaviors. Her symptoms cause clinically significant distress and impair her occupational functioning. Applying DSM-5-TR criteria, the patient meets the threshold for generalized anxiety disorder: excessive anxiety and worry occurring more days than not for at least six months, difficulty controlling the worry, and three associated symptoms (muscle tension, sleep disturbance, poor concentration). PTSD is ruled out by the absence of trauma exposure, intrusion symptoms, and avoidance behaviors. OCD is ruled out by the absence of true obsessions or compulsions; her worry is ego-syntonic and does not involve intrusive, unwanted thoughts that she attempts to neutralize. The primary diagnosis is generalized anxiety disorder, with comorbid major depressive disorder as a secondary consideration given the overlapping symptoms of fatigue and concentration difficulty. This case illustrates the importance of systematic criteria matching rather than pattern recognition alone.

Supportive conclusion: Generalized anxiety disorder ranks among the most common psychiatric conditions encountered in primary care, with a 12-month prevalence of 10.1 to 21.3 percent for anxiety disorders broadly (Craske et al., 2023). The DSM-5-TR emphasizes functional impairment as a diagnostic threshold, distinguishing pathological worry from normative concern. Nurses conducting psychiatric evaluations must obtain detailed symptom timelines because the six-month duration criterion eliminates many acute stress reactions from diagnostic consideration. Differential diagnosis requires ruling out medical mimics such as hyperthyroidism, substance-induced anxiety, and medication side effects before settling on a primary psychiatric diagnosis. The diagnostic process also demands attention to cultural context because symptom expression varies across populations and treatment engagement depends on culturally responsive communication. Accurate diagnosis remains the foundation for effective, evidence-based psychiatric care.

Research, Writing, Citation & Referencing

 A comprehensive psychiatric evaluation for anxiety, PTSD, and OCD requires systematic application of DSM-5-TR criteria to differentiate among conditions with overlapping symptom profiles. The evaluation documents subjective history, objective findings, and a prioritized differential diagnosis with explicit criteria matching.

FAQ

How do I differentiate generalized anxiety disorder from PTSD when both involve worry and hyperarousal?

Generalized anxiety disorder centers on excessive worry about everyday events without a trauma trigger, while PTSD requires exposure to actual or threatened death, serious injury, or sexual violence followed by intrusion, avoidance, negative cognition and mood alterations, and arousal symptoms persisting beyond one month (APA, 2022). The presence of a qualifying trauma exposure and intrusion symptoms rules in PTSD and rules out GAD as the primary diagnosis.

Authoritative Sources

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Craske, M. G., Stein, M. B., Eley, T. C., Milad, M. R., Holmes, A., Rapee, R. M., & Wittchen, H. U. (2023). Anxiety disorders. Nature Reviews Disease Primers, *9*(1), 24. https://doi.org/10.1038/s41572-023-00434-5

Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Benjet, C., Bromet, E. J., Cardoso, G., … & Koenen, K. C. (2022). Trauma and PTSD in the WHO World Mental Health Surveys. European Journal of Psychotraumatology, *13*(sup1), 1956741. https://doi.org/10.1080/20008066.2021.1956741

Stein, D. J., Costa, D. L. C., Lochner, C., Miguel, E. C., Reddy, Y. C. J., Shavitt, R. G., … & Simpson, H. B. (2023). Obsessive-compulsive disorder. Nature Reviews Disease Primers, *9*(1), 33. https://doi.org/10.1038/s41572-023-00441-6

Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G., … & Marx, B. P. (2022). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychological Assessment, *30*(3), 383-395. https://doi.org/10.1037/pas0000486

Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease.

For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.

• Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.
• Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
• By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the “Case History Reports” document, keeping the requirements of the evaluation template in mind.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.
• Identify at least three possible differential diagnoses for the patient.Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis.Incorporate the following into your responses in the template:
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
  • Reflection notes: What would you do differently with this client if you could conduct the session over? Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

Sample Comprehensive Psychiatric Evaluation

Patient: S.K., 26-year-old female  |  Date: 15 March 2026  |  Evaluator: Psychiatric-Mental Health Nurse Practitioner

Subjective

S.K. presents today reporting distress from recurrent intrusive memories and persistent worry that have intensified over the past four months. She describes her chief concern as “constant nervousness and flashbacks I cannot switch off.” These symptoms began shortly after she witnessed an armed robbery at her workplace in late 2025. Since then, she experiences vivid, unwanted images of the event several times daily. Each episode lasts several minutes and triggers palpitations, sweating, and an overwhelming urge to flee. She actively avoids the street where the incident occurred and has declined three shifts that required her to return to the area. Her sleep has deteriorated; she estimates roughly four hours of fragmented rest per night because nightmares wake her two to three times weekly. She also reports difficulty concentrating on tasks, irritability toward colleagues, and muscle tension that persists “almost all day.” Additionally, she checks that her apartment door is locked exactly four times before leaving and repeats this ritual when she returns home, even when she has not gone out. She recognizes this behavior as excessive but feels intense anxiety if she does not complete it. She denies current suicidal ideation, intent, or plan. She has no history of psychiatric hospitalization and no prior trauma-focused therapy. Her symptoms currently prevent her from accepting full-time employment and strain her relationship with her partner, who has noted her increased emotional distance.

Objective

During the interview, S.K. maintained appropriate eye contact yet appeared visibly tense. She sat at the edge of her chair and frequently scanned the clinic door. Her speech was clear, coherent, and goal-directed, though slightly accelerated when she described the robbery. She exhibited no evidence of psychotic phenomena such as hallucinations or delusional content. Her mood was anxious, and her affect was congruent but constricted. She engaged openly with the examiner and responded to questions with reasonable detail. No gross cognitive deficits were apparent during the brief mental status assessment.

Assessment

Mental Status Examination

S.K. presents as a alert and oriented young woman to person, place, time, and situation. Her appearance is neat. She maintains good eye contact but displays psychomotor agitation through leg bouncing and hand wringing. Her speech has normal rate and volume with occasional pressure when discussing trauma cues. Her mood is “anxious and exhausted,” with congruent affect. Thought process is logical and linear, without evidence of loosening of associations or tangentiality. Thought content reveals intrusive memories and compulsive checking behaviors, but no suicidal or homicidal ideation. Perception is notable for trauma-related flashbacks; no auditory or visual hallucinations are reported. Insight and judgment are intact, as she recognizes her symptoms as problematic and seeks treatment. Attention and concentration appear mildly impaired under stress.

Differential Diagnoses

Primary Diagnosis: Posttraumatic Stress Disorder (F43.10)

S.K. meets DSM-5-TR criteria for PTSD based on criterion A exposure to actual threatened death or serious injury through witnessing an armed robbery. She reports intrusive memories and nightmares (criterion B), persistent avoidance of external reminders including the street and work shifts (criterion C), negative alterations in cognition and mood evidenced by distorted blame and persistent fear (criterion D), and marked alterations in arousal and reactivity including hypervigilance, exaggerated startle, and irritability (criterion E). These disturbances have persisted for more than one month and cause clinically significant distress and functional impairment in occupational and relational domains. The temporal link between the traumatic event and symptom onset strongly supports this as the primary diagnosis.

Differential Diagnosis 1: Generalized Anxiety Disorder (F41.1)

S.K. does report excessive anxiety and worry occurring more days than not, along with muscle tension, sleep disturbance, and concentration difficulties. These features overlap with GAD. However, her worries center specifically on trauma-related cues and their recurrence rather than on multiple everyday domains such as finances, health, or social performance. Furthermore, the presence of intrusive memories, nightmares, and active avoidance of trauma-specific stimuli aligns more closely with PTSD than with the broader, less focal apprehension characteristic of GAD. The DSM-5-TR specifies that if symptoms occur exclusively during the course of PTSD, a separate anxiety disorder diagnosis is not warranted.

Differential Diagnosis 2: Obsessive-Compulsive Disorder (F42.2)

The compulsive checking ritual involving her apartment door, performed to neutralize anxiety, raises consideration of OCD. S.K. recognizes the behavior as excessive and experiences distress when prevented from completing it. Nevertheless, the obsessions and compulsions in OCD are typically ego-dystonic and not exclusively linked to a traumatic event. In this case, the checking behavior appears specifically connected to safety fears that emerged after the robbery, suggesting a trauma-driven coping mechanism rather than independent OCD pathology. The DSM-5-TR notes that obsessive-compulsive and related disorders should be distinguished from symptoms that develop exclusively in the context of PTSD when the trauma content explains the symptom pattern.

Differential Diagnosis 3: Adjustment Disorder with Anxiety (F43.23)

Adjustment disorder presents with emotional or behavioral symptoms in response to an identifiable stressor within three months of its onset. While S.K. does show a stress-response pattern, her symptom profile exceeds the threshold for adjustment disorder. She demonstrates the full constellation of intrusion, avoidance, negative alterations in cognition and mood, and hyperarousal required for PTSD. The DSM-5-TR instructs clinicians to prioritize the more specific diagnosis when full criteria are met, thereby ruling out adjustment disorder in this case.

Critical Thinking Process

The diagnostic reasoning prioritized trauma exposure as the organizing framework for symptom interpretation. Intrusive memories and nightmares indicated intrusion symptoms; avoidance of the street and work shifts confirmed behavioral avoidance; and hypervigilance, startle, and irritability satisfied arousal criteria. Pertinent positives include the witnessed armed robbery, subsequent functional decline, and trauma-cued distress. Pertinent negatives include absence of psychotic features, absence of suicidal intent, and absence of pre-trauma obsessive-compulsive history. Although GAD and OCD partially overlap with her presentation, the trauma-specific content and temporal sequence render PTSD the most accurate and clinically useful diagnosis.

Reflection Notes

If the session could be repeated, the evaluator would allocate additional time to exploring S.K.’s developmental history, prior adverse childhood experiences, and cultural beliefs about trauma and mental illness. Early-life adversity can sensitize the stress-response system and shape how patients interpret post-trauma symptoms. A more detailed substance-use screen would also strengthen safety assessment, as trauma survivors sometimes use alcohol or cannabis to manage sleep and arousal symptoms. Legal and ethical responsibilities extend beyond basic confidentiality and consent. The clinician must consider duty-to-warn obligations if S.K. discloses identifiable threats against specific persons, and must navigate mandatory reporting frameworks if domestic violence or child endangerment emerges in future sessions. Trauma-informed care demands that the evaluator avoid re-traumatization through forced detailed recounting of the robbery before stabilization skills are established.

Health promotion should address sleep hygiene, brief behavioral activation to restore occupational functioning, and culturally sensitive psychoeducation. S.K. identifies as a second-generation immigrant from a collectivist background; therefore, family involvement in treatment planning may enhance adherence if she consents. Socioeconomic factors including lost wages from reduced shifts constitute a significant stressor that warrants social work consultation. Prevention efforts should focus on early identification of hyperarousal, normalization of trauma responses, and referral to evidence-based trauma-focused cognitive behavioral therapy or eye-movement desensitization and reprocessing. Pharmacological support with sertraline or venlafaxine may be considered if symptoms remain severe after initial psychotherapeutic intervention.

References

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