The patient, Ryan, presented with complaints of stress and anxiety related to remote learning and family dynamics. He reported difficulty sleeping, often going to bed late around midnight. He described feeling more at ease falling asleep since his phone was taken away, as it eliminated late-night distractions. He lives with his mother and three younger brothers, and currently has strained relationships with his mother. Ryan has a limited social network of two friends, which has been further impacted by his lack of access to a phone. He expressed a lack of interest in physical activity and spending time outdoors, which his mother has suggested.
Ryan's mood appeared anxious, and he had clear difficulties with stress management and sleep. He verbalized his struggles and was receptive to suggestions for improvement. He was communicative about his current home situation and its impact on his mental health.
Ryan is suffering from stress and anxiety, likely exacerbated by the current remote learning environment and family tensions. Insomnia is present, possibly due to a variety of factors including his late-night routine and stress levels. There's a potential lack of social support due to limited friendships and current familial discord.
A two-pronged approach was discussed to address Ryan's insomnia. First, Ryan agreed to implement a regular bedtime routine, including taking a warm shower approximately an hour before his new bedtime. Second, a gradual adjustment of his bedtime was suggested, aiming to roll back his current bedtime by 30 minutes each week until a more suitable time is reached. Ryan agreed to this plan and is willing to return for a follow-up in a week or two to assess progress and make any necessary adjustments.