Reference no: EM133565474

What would be the best Case Formulation and Treatment Plan for the patient scenario below:

Possible diagnoses are: Substance use disorder, Anxiety, and depression severe

A 30-year-old Caucasian male patient is present today at the clinic with concerns that he has been taking some drugs in the past related to his mental health but continues to have side effects from them. He is requesting to have medical cannabis in exchange for his drugs. The patient reported that he has been on medication trials since age nine. The patient reported his previous medications as lamictal 200 mg and prazosin 3 mg. He reported that he stopped taking these medications about a year ago. The patient said, "I don't like how the medications make me feel clammy and like a zombie." He scored 2 points on CAGE, PHQ9=19, and GAD-7=19.

The patient reports excessive and persistent anxiety that has been going on since adolescence and feels this way at least several times weekly. The patient reports occasions of worry and avoidance, all appearing out of proportion to the actual threat and impairing function. He reported some fatigue due to worry, difficulty concentrating due to worry, irritability, muscle tension, and sleep disturbance due to worry. The patient reports a history of fidgeting, squirms, periods of interruptions, loss of interest in activities, distractions, careless mistakes, and failure to finish tasks. The patient reported being sexually molested by someone he knew from ages six through eleven. He reported being physically abused by his father from age five to fourteen.

Past medications: Remeron, Adderall, Effexor, Buspar, Trazadone, Seroquel, Zyprexa, Prozac, Abilify, Lamictal, prazosin (unknown dose and frequency)