Case Study: 64-Year-Old African American Female Essay

Case Study: 64-Year-Old African American Female Essay

 

Summary of the Case

            A 64-year-old retired African American lady, married with three independent children, presents to the clinic with chief allegations of anxiety and increased worry about her health. She has experienced two episodes of non-severe Covid 19 last year, neither of which warranted hospitalization. Furthermore, she is depressed, unable to sleep, and feels guilty, frequently blaming herself for not receiving the Covid 19 vaccine, an event she claims is the cause of two previous episodes of Covid 19 infections. She has hypertension, which she manages with Hydralazine, and asthma, which she manages with Breo.

Multiaxial Diagnostic Formulation

Axis I: Generalized anxiety disorder (GAD) with differential diagnoses of mild depressive episode and anxiety disorder due to another medical condition (hypertension, asthma).

Axis II: No personality/developmental disorder

Axis III: Hypertension, Asthma

Axis IV: Two previous Covid 19 infections

DSM V Diagnostic Criteria

Definitive Diagnosis

            According to the DSM V, the following criteria are used to diagnose GAD: (a) persistent, excessive, and uncontrollable anxiety/worry for 6 months or more; (b) the individual struggles to control the worry; (c) at least three of the following symptoms are present: fatigue, restlessness, disturbed sleep, muscle tension, irritability, impaired concentration; (d) symptoms are not better accounted for by another psychiatric illness; (e) symptoms are not attributed to substance abuse, any other medication, or medical illness; and (f) the symptoms cause clinically significant distress or impairment in social, occupational or any other important functioning (APA, 2013). The patient described above has heightened anxiety and worry about her health status as a result of illness from Covid 19 a year ago, finds it difficult to control her worry, has associated disturbed sleep and restlessness, and her symptoms are not attributed to the psychological effects of a substance or medical illness, thus justifying the diagnosis.

Neurobiology: The disease has been linked to a strong genetic link. Anxiety disorders affect approximately 15-20% of first-degree relatives of patients with anxiety disorders (Ströhle et al., 2018). GABA is the most crucial neurotransmitter in the pathogenesis of anxiety, as evidenced by the use of benzodiazepines in treatment, which facilitate GABA transmission, resulting in a generalized inhibitory effect on the CNS, alleviating anxiety (Munir & Takov, 2022). Other transmitters implicated in the cause of anxiety include serotonin, norepinephrine, and dopamine (Munir & Takov, 2022). Anxiety has a neuroanatomical basis in the locus coeruleus, limbic system, and prefrontal cortex. Among the recognized theories of anxiety, causation is the psychodynamic theory, in which anxiety is attributed to something disturbing the internal psychological equilibrium; behavioral theory, in which anxiety is viewed as a response to painful or dangerous stimuli; and biological theory, which involves neurotransmitters (Munir & Takov, 2022). The manifestation of GAD varies significantly across cultures. While some cultures exhibit primarily somatic symptoms, others exhibit cognitive symptoms. As a result, it is essential to consider the individual’s cultural context when assessing anxiety patients.

Differential Diagnosis

Mild Depressive Episode

The DSM criteria for major depressive illness are as follows: at least two weeks of depressed mood, anergia, or loss of interest and enjoyment, plus two of the following: decreased self-esteem and self-confidence; diminished concentration and attention; feelings of guilt and unworthiness; bleak and pessimistic views of the future; diminished appetite; disturbed sleep, and thoughts or acts of self-harm or suicide (APA, 2013). The criteria also include an additional difficulty in some level of functioning. The patient described above reports being depressed after being diagnosed with Covid 19, has disturbed sleep and is frequently disturbed by thoughts, or often feels guilty for not receiving the Covid 19 vaccine, thus justifying the diagnosis of a mild depressive episode.

Neurobiology: Regarding depression genetics, first-degree relatives of depressed individuals have a two to a four-fold higher risk of major depressive episodes than the general population (APA, 2013). Monoamines, including norepinephrine and dopamine, are essential neurotransmitters in the pathophysiology of depression. A drop in levels has been linked to depressive episodes. Other neurotransmitters, such as acetylcholine and GABA, are also thought to be involved (Liu et al., 2018). In terms of depression neuroanatomy, the prefrontal cortex exhibits a dysfunctional metabolic state known as hypofrontality, which is characterized by decreased blood flow, neural activity, and neuronal metabolism (Liu et al., 2018). Among the important theories in the causation of depression are the biological theory, which suggests that the patient’s first-degree relatives are at a higher risk of major depressive illness; the biochemical theory, which involves neurotransmitters; and the neuroendocrine theory, which suggests that depression is associated with other endocrine disorders such as hypothyroidism (Liu et al., 2018). Studies have shown a significant difference in the expression of depression across cultural contexts. The male to female ratios, ages at diagnosis, and the extent to which the presence of the disorder increases the likelihood of comorbid substance abuse vary by culture (APA, 2013). Clinicians must, therefore, be aware of various people’s cultural contexts when evaluating patients.

Management Plan

The patient’s management begins with various investigations to rule out potential causes of the patient’s condition. In the case described, relevant laboratory studies would include Covid 19 testing to rule out infection, a complete blood count to rule out other infectious causes, and an arterial blood gas to confirm the acid-base status, which may be deranged in asthma. Because the patient had a known diagnosis of hypertension, vital signs such as blood pressure, temperature, oxygen saturation, respiratory rate, and pulse rate would be vital. The patient described will benefit from the following medications: alprazolam PRN for anxiety, zolpidem PRN for insomnia, fluoxetine 20 mg PO daily for depressive episodes, and the continuation of hydralazine for hypertension.

Alprazolam’s effects are mediated by the GABA receptor system; it has an enhanced inhibitory effect on GABA, relieving anxiety. Its benefits include reduced anxiety and panic attacks, but its side effects include drowsiness, light-headedness, and headaches (George & Tripp, 2022). Because of the potential for profound sedation and respiratory depression, Alprazolam should not be administered in conjunction with opioids (George & Tripp, 2022). The drug is contraindicated in cases of documented hypersensitivity, acute narrow-angle glaucoma, and when CYP3A4 inhibitors such as itraconazole and ketoconazole are used concurrently (George & Tripp, 2022). Zolpidem is a ligand of high-affinity positive modulator sites of GABA A receptors that increases GABAergic inhibition of neurotransmission in the CNS, resulting in sedative and hypnotic effects (Xiang et al., 2021). Zolpidem’s side effects include dizziness, headaches, and drowsiness. The medication is contraindicated for patients with a known zolpidem hypersensitivity and those who have experienced complex sleep behaviors such as sleepwalking and sleep-driving (Xiang et al., 2021). Fluoxetine, on the other hand, is a selective serotonin reuptake inhibitor that raises serotonin levels while also increasing serotonergic neurotransmission. Insomnia and gastrointestinal effects such as nausea, anorexia, and diarrhea are among the side effects (Safhi et al., 2019). It is contraindicated in hypersensitivity, breastfeeding, or taking pimozide or thioridazine (Safhi et al., 2019). Following all management attempts, the patient should be referred to a psychiatrist or a psychiatric mental health nurse practitioner.

Conclusion

Mental health is an important aspect of a person’s overall well-being. The World Health Organization includes mental health as a component in its definition of health. Mental health problems in the elderly are often triggered by life events such as illnesses, financial difficulties, and the loss of loved ones.  In the patient described above, two previous Covid 19 infections are the precipitants of her anxiety. Patient management necessitates not only pharmacotherapy but also non-pharmacotherapeutic interventions, as well as adequate family support. As evidenced, psychiatrists and mental health nurse practitioners, in addition to general practitioners, play an integral role in the treatment of psychiatric patients.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5) author: American psychiatric association publisher: American psychiatric association year published: 2013 edition. New School Library.

George, T. T., & Tripp, J. (2022). Alprazolam. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538165/

Liu, Y., Zhao, J., & Guo, W. (2018). Emotional roles of mono-aminergic neurotransmitters in major depressive disorder and anxiety disorders. Frontiers in Psychology, 9, 2201. https://doi.org/10.3389/fpsyg.2018.02201

Munir, S., & Takov, V. (2022). Generalized anxiety disorder. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Safhi, M. M., Qumayri, H. M., Masmali, A. U. M., Siddiqui, R., Alam, M. F., Khan, G., & Anwer, T. (2019). Thymoquinone and fluoxetine alleviate depression via attenuating oxidative damage and inflammatory markers in type-2 diabetic rats. Archives of Physiology and Biochemistry, 125(2), 150–155. https://doi.org/10.1080/13813455.2018.1443141

Ströhle, A., Gensichen, J., & Domschke, K. (2018). About 15-20% of first-degree relatives of the patients with anxiety disorder exhibit anxiety disorders themselves NCBI – Search. Bing.Com. https://doi.org/10.3238/arztebl.2018.0611

Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of Zolpidem in the treatment of insomnia disorder for one month: a meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250–256. https://doi.org/10.1016/j.sleep.2021.09.005

64 years old female African American, marriage with 3 kids, all grown and independent, retired, came to the clinic stated: FEELS DEPRESSED ,ANXIOUS ,WORRIED ABOUT HEALTH ,HAD COVID INFECTION TWICE IN LAST 1 YR BUT BOTH TIME WAS NOT VERY SEVERE DID NOT REQUIRE TO BE ADMITTED TO HOSPITAL, 2 ND COVID INFECTION SHE HAD 3 MONTHS AGO SINCE THEN SHE FEELS VERY ANXIOUS , DEPRESSED, RESTLESS, UNABLE TO SLEEP WELL, FEELS GUILTY, BLAMIMG SELF FOR COVID INFECTION BECAUSE SHE DID NOT GET VACINATED FOR COVID.

PT WAS SEEN ALONG WITH HUSBAND WHO CAME ALONG WITH HER
History of HTN, and Asthma. On hydralazine, and Brio

 

 

Upon your assessment make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and other Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors);
Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up).