NRNP PRAC 6635 Assignment: Assessing and Diagnosing Patents with Anxiety Disorders, PTSD, and OCD

NRNP PRAC 6635 Assignment: Assessing and Diagnosing Patents with Anxiety Disorders, PTSD, and OCD

NRNP PRAC 6635 Assignment: Assessing and Diagnosing Patents with Anxiety Disorders, PTSD, and OCD

Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
“Fear,” according to the DSM-5, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2013). 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.

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

To Prepare:
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.
By Day 7 of Week 4
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 diagnostic criteria for each differential diagnosis and explain what DSM-5 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.).

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Assessing and Diagnosing Patents with Anxiety Disorders, PTSD, and OCD

Subjective:

CC (chief complaint): The client is a Caucasian male in his mid thirties who presents to the clinic with a confessed obsession with body image. He claims that he always feels that he is in bad shape and so no one really sees him as handsome. He also states that for quite a long time he has been having strong and repetitive compulsive thoughts about changing his body image at all costs. This has made him go to different gyms in a quest to change his body image to the ideal that he fantasizes about (Alexander Street, 2015). He has however not really realized this aspiration and it causes him worry and anxiety that he is unable to get rid of. 

HPI: The client is a 35 year-old Caucasian male who comes with the above complaints. The obsession and compulsion has affected his daily life so much that he literally spends the entire day almost always in the gym. He has become dysfunctional socially, interpersonally, at work, and even in terms of his own self care. All he thinks about is going to the gym to change his image; something that is not happening. He has not previous history of these symptoms but he states that they began somewhere in his late twenties. They have been there since until a family member recently suggested he seeks psychiatric help. The symptoms are ever present and difficult to ignore. Being in the company of people aggravates the symptoms and solitude somewhat alleviates them. He rates the severity of the obsession and compulsion at 7/10.    

Past Psychiatric History:

• General Statement: The client has no previous history of any mental disorders that he can remember.
• Caregivers (if applicable): Despite being dysfunctional in terms of self, he still does not require caregivers.
• Hospitalizations: He denies any history of hospitalization for mental or any other problem.
• Medication trials: He has never been involved in any medication trials.
• Psychotherapy or Previous Psychiatric Diagnosis: He has not been diagnosed with a psychiatric illness before and has not received any treatment for mental illness.

Substance Current Use and History: The client states that he has been taking alcohol daily in moderation for the past 15 years, although recently he started reducing the habit on advice from his PCP. He denies ever smoking cigarettes but admits that he smoked marijuana for sometime before stopping about a year ago when the company he kept moved to another city. He denies ever using any illegal substances or abusing prescription medications. 

Family Psychiatric/Substance Use History: Neither his father nor his mother drank alcohol or smoked cigarettes. He has two siblings who smoke though and both are male. None of them drinks. There is no one as far as he can remember (including what he has been told) that has had a psychiatric diagnosis or treatment in his family. This is from the great grandparents to the current generation represented by their children. 

Psychosocial History: Before he used to be very social and went out with his friends for drinks. Nowadays he does so only occasionally because he does not have the time to do so. Most of the time he is usually in the gym lifting weights to grow muscles. He tries as much as possible to lead a healthy life by taking plenty of fruits and vegetables. He avoids junk foods, sugary sweetened beverages such as soda, and processed food with fatty content to stay healthy. His hobbies include dancing, going to the gym, jogging, and watching movies. He was an employee at the local magistrate’ court until recently when he was sacked for absconding his duties. He now depends on his parents and siblings for subsistence but he does not even think of looking for another job as it will interfere with his gym program.   

Medical History:

• Current Medications: He is currently not on any medications, psychiatric or otherwise.
• Allergies: He denies having any allergies to food, medications, or environmental allergens.  

• Reproductive Hx: He is a heterosexual male who was married but divorced recently because of his            obsession and compulsive behavior. He has two children with the wife and they currently stay with the mother.  

ROS:

• GENERAL: He denies fever, chills, headache, weight loss, or malaise.
• HEENT: He is negative for photophobia, diplopia, tinnitus, otorrhea, rhinorrhea, bleeding gums, or a sore throat. He also denies dysphagia.
• SKIN: Negative for rashes, eczema, or itching.
• CARDIOVASCULAR: Negative for chest pains, chest tightness, palpitations, or peripheral edema.
• RESPIRATORY: He denies wheezing or coughing and does not have shortness of breath.
• GASTROINTESTINAL: He denies having nausea, vomiting, or diarrhea. He also denies having altered bowel habits.
• GENITOURINARY: Negative for dysuria, frequency of micturition, hesitancy or cloudy urine.
• NEUROLOGICAL: Denies paraesthesia, syncope, or loss of bowel and bladder control. Also negative for hemiplegia or hemiparesis.
• MUSCULOSKELETAL: He denies joint pains or muscle pain. He states that he has normal range of movement in his limbs and joints.
• HEMATOLOGIC: He is negative for blood and bleeding disorders.
• LYMPHATICS: Negative for lymphadenopathy and splenectomy.
• ENDOCRINOLOGIC: Denies any history of hormonal therapy. Also denies polydipsia, polyphagia, excessive diaphoresis, and heat or cold intolerance.

Objective:

Physical exam:

General: He is alert and oriented in time, space, place, person, and event; with normal gait and speech that is goal-oriented. He is appropriately groomed for the weather and the time of the day.

HEENT: Head is normocephalic with no signs of trauma. PERRLA, EOMI. No tearing or icterus. Absent rhinorrhea and sneezing; the nasal turbinates are moist. No otorrhea and normal light reaction of the tympanic membranes. The throat is not erythematous and there is also no thrush.

Cardiovascular: HS1 and HS2 audible on auscultation with no murmurs, rubs, bruits, or galloping.

Respiratory: Clear lung fields bilaterally with no wheezing, rales, rhonchi, or crepitations.

Vital Signs: BP 125/80 regular cuff, sitting; P 68, regular; T 98.3°F; RR 16, non-labored; BMI 24.3 kg/m² (i.e. normal BMI). 

Diagnostic results:

• Lab: WBC 5.3 x 10⁹/L; CRP 6 mg/L; Hb 13.2 g/dL.
• Imaging: Normal chest XR (AP).

Assessment:

Mental Status Examination: The client is a 35 year-old Caucasian male who is alert, concious, and oriented in place, person, time, space, and event. His speech is coherent and goal-directed. His grooming is appropriate considering the time of the day, the season, and the weather. He displays clear tics in terms of repeatedly shrugging his shoulders and jerking his neck during the interview. His self-reported mood is “fear” and the observed affect is dysphoria making these two somewhat congruent. He denies hallucinations, delusions, or paranoid thoughts. However, he accepts that he may have thought about taking his life sometime this year. He denies homicidal ideation though. His insight is not entirely intact as he wonders why an obsession with exercise could be a bad thing. His judgment is fair. His primary diagnosis is Obsessive-Compulsive Disorder (OCD), whose DSM-5 diagnostic code is 300.3 (F42) (APA, 2013; Sadock et al., 2015). 

Differential Diagnoses:

1. Obsessive-Compulsive Disorder or OCD

            This is the primary diagnosis as concerns the presentation of the mental illness that this patient has. The presentation fulfils the DSM-5 diagnostic criteria for OCD in that this client has irrational thoughts that are intrusive and do not go away whatever he does. These thoughts are about his appearance and his body shape. These are obsessions and they are accompanied by a very strong and persistent urge to go to the gym and camp there until his body shape changes. This is compulsion which together with the obsession provides the hallmark the diagnosis of OCD (APA, 2013; Sadock et al., 2015). There is also anxiety and fear as well as being overwhelmed by the intrusive obsessive thoughts.   

2. Tic Disorder and Stereotyped Movements

            The presence of the stereotyped movements that were noted during the MSE as tics leads to this likely differential diagnosis for this patient. It could be well that he is just suffering from a tic disorder and the presence of stereotyped movements but not OCD (APA, 2013; Sadock et al., 2015). However, the fact that his obsession is closely linked with the compulsion makes this differential less likely. The DSM-5 states that the presentation of this differential is not as complex as that of OCD. As a matter of fact, the two conditions may actually co-occur in the same individual (APA, 2013; Bryan, 2017; Sadock et al., 2015).      

3. Psychotic Disorders

            The presence of a deficiency of understanding and impaired insight may point to a diagnosis of a psychotic disorder. However, in the case of this patient the absence of delusions and hallucinations makes this differential also quite unlikely. Because of these similarities in some patients, the diagnosis of OCD may be missed when one of a psychosis such as schizophrenia is made (APA, 2013; Sadock et al., 2015). The DSM-5 diagnostic criteria are categorical that delusions and disorders of perception must be part of the criteria to be fulfilled before a diagnosis of a psychotic disorder is made.    

Reflection:

            I would perform this initial psychiatric interview the same way I did it this time if I were to be accorded another opportunity. This is because I applied the tenets of psychiatric evaluation as presented by Carlat (2017). I honored all the bioethical principles namely autonomy, beneficence, nonmaleficence, justice, and fidelity (Haswell, 2019). For instance, I kept the client’s confidentiality at all times. This is fidelity and is tied to nonmaleficence in that respect for fidelity prevented psychological hurt to the patient by sharing of his details. I also asked the patient for consent every time I wanted to do anything. This was in respect for the principle of autonomy and I made sure I explained my intentions before seeking his consent. I gave him health education and encouraged him to continue with exercise but in moderation such that it does not affect his level of functioning in other areas too. I encouraged him to join a social support group for people with OCD on treatment as this would help with remodelling his thought process à la cognitive behavioral therapy or CBT (Corey, 2017). Follow up dates were agreed upon with the client and he is to come back for review after four weeks.        

References

Alexander Street (2015). Obsessive compulsive disorders. https://video.alexanderstreet.com/watch/obsessive-compulsive-disorders  

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Bryan, D. (2017). OCD vs tics – What ‘s the difference? Anxiety House Brisbane. https://anxietyhouse.com.au/ocd-vs-tics-whats-the-difference/#:~:text=Tics%20are%20considered%20involuntary%20compulsions,that%20are%20rooted%20in%20anxiety   

Carlat, D.J. (2017). The psychiatric interview, 4^th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.