Assignment: NRNP 6635 Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
Assignment: NRNP 6635 Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
NRNP 6635: Psychopathology and Diagnostic Reasoning
Subjective:
CC (chief complaint): “My fiancé demanded I should come here”
HPI: Berry Sullivan is a 27-year-old male who came to the facility for assessment. Sullivan is a former military person with eight years of active duty in the Marines where he participated in warzones. Today, Sullivan reports that his spouse demanded that he come to the facility for assessment. Sullivan reports that he recently attended an event with her sister and husband at a county fair. According to him, he ran off fast when fireworks went off because they reminded him of his experiences in the combat wards. Sullivan also reported that he avoids loud noises because they remind him about the traumatic events in combat wars. Sullivan also expressed that the smell of diesel fuel sets him off because it reminds him of two of his colleagues who were burnt when their Humvee was blown. Sullivan reported that these memories about combat wars are too distressing. He often dreams about the events and wishes not to sleep at night. Sullivan noted that he avoids any cues that cause flashbacks or anxiety such as being stuck in traffic with people surrounding them. He reports that he is anxious when exposed to such cues because he feels that someone can roll an IED under his car. Sullivan also reported a lack of interest in things such as going outside to shop or restaurants as he prefers staying at home. Sullivan notes that he has not told his experiences to anybody else except the therapist.
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Past Psychiatric History:
General Statement: My fiancé demanded I should come here
Caregivers (if applicable): none
Hospitalizations: Sullivan has no history of hospitalizations
Medication trials: Sullivan has no history of medication trials
Psychotherapy or Previous Psychiatric Diagnosis: Sullivan has no history of psychotherapy or psychiatric diagnosis
Substance Current Use and History: Sullivan has no history or current use of substances
Family Psychiatric/Substance Use History: Sullivan reports that his father is an alcoholic. His paternal grandfather had depression that he never told anyone except Sullivan because of his combat connection.
Psychosocial History: Sullivan is a former Marine military personnel. He has eight years of service with three long tours of duty in war zones. He is currently engaged to be married in eight months. Sullivan is using his GI Education Bill to attend online college for accounting. He grew up in an abusive environment, as seen from the expression that his father used to be abusive when he was drunk. Sullivan has one younger brother and one older sister.
Medical History: Sullivan has service-connected asthma and seasonal allergies. Sullivan denied current medication use, medical history of chronic illnesses, hospitalizations, or surgeries.
Current Medications: none
Allergies: He has a history of service-connected asthma.
Reproductive Hx: Sullivan is currently in a heterosexual relationship. He denies a history of sexually transmitted infections. Sullivan denies urgency, frequency, or dysuria.
ROS:
GENERAL: Sullivan is dressed appropriately for the clinical visit. There is no evidence of weight loss, fatigue, fever, or chills.
HEENT: Eyes: Sullivan is not using corrective lenses. He denies visual loss, blurred vision, or eye pain., Nose, Throat: Sullivan denies ear pain, drainage, or fullness. He denies nasal congestion, drainage, sneezing, or a sore throat.
SKIN: Sullivan denies skin rash or itching.
CARDIOVASCULAR: Sullivan denies peripheral edema, chest pain, discomfort, or palpitations.
RESPIRATORY: Sullivan denies cough, sputum, wheezes, or shortness of breath.
GASTROINTESTINAL: Sullivan denies nausea, vomiting, diarrhea, or abdominal pains.
GENITOURINARY: Sullivan denies urgency, frequency, or dysuria.
NEUROLOGICAL: Sullivan denies headaches, paralysis, numbness, tingling, or loss of bowel and bladder control.
MUSCULOSKELETAL: Sullivan denies muscle pain, joint stiffness, or limited range of motion.
HEMATOLOGIC: Sullivan denies anemia or easy bleeding.
LYMPHATICS: Sullivan denies lymphadenopathy.
ENDOCRINOLOGIC: Sullivan denies heat or cold intolerance, polyuria, polydipsia, or polyphagia
Objective:
Physical exam: Vitals: T 98.8, P 86, RR 18, BP 122/77, Ht 5’8, Wt 160 lbs
Diagnostic results: Laboratory investigations, including thyroid function tests and a complete blood count, should be performed. Thyroid function tests should be ordered to rule out thyroid disorders such as hypothyroidism. Hypothyroidism might be associated with symptoms of major depression such as fatigue, lack of interest or pleasure, and having a depressed mood. A complete blood count test would help the provider rule out causes such as an infection in Sullivan’s case.
Assessment:
Mental Status Examination: Sullivan was dressed appropriately for the clinical visit. He was alert and oriented to himself, others, time, and events. Sullivan had a depressed mood. He reported moderate anxiety. His affect was intact. His self-expression of mood was congruent with his physical cues of communication. Sullivan was tearful when expressing some of his traumatic memories. He reported avolition. Sullivan did not show signs of illusions, delusions, hallucinations, suicidality, or abnormal mannerisms such as tremors and tics. His thought process and content were intact. He was future-oriented.
Differential Diagnoses:
Post-traumatic stress disorder (PTSD): PTSD is Sullivan’s primary diagnosis. PTSD is a mental health problem that develops in people with direct or indirect traumatic experiences. Patients experience intrusion symptoms related to traumatic events. They include recurrent distressing memories about the traumatic events, distressing dreams, flashbacks, distress when exposed to cues related to the events, and physiological reactions to the cues that symbolize the traumatic events. Patients also show persistent avoidance of any stimuli associated with the traumatic events. There are also negative alterations in mood and cognitions associated with the trauma, alterations in arousal and reactivity such as being hypervigilant, and disturbances causing significant distress in social, occupational, or other areas of functioning (Maercker et al., 2022; Schein et al., 2021). Sullivan has almost all these symptoms of PTSD such as direct traumatic experiences, flashbacks, distressing memories, nightmares, and disturbed functioning, which makes PTSD a primary diagnosis.
Generalized anxiety disorder (GAD): GAD is the other differential that should be considered for Sullivan. GAD is a mental health problem characterized by excessive worry and anxiety that is beyond the patient’s control. The accompanying symptoms associated with GAD include restlessness, irritability, muscle tension, fatigue, difficulty concentrating, and sleep disturbance (Onaemo et al., 2021; Sapra et al., 2020). Sullivan became anxious when reflecting on his traumatic experiences in the war zones. Therefore, he could be having GAD as a comorbidity in PTSD.
Major depression: Major depression is a differential diagnosis that should be considered for Sullivan. Major depression is a mood disorder that is characterized by a depressed mood most days almost every day. Patients also report other symptoms such as feeling hopeless and guilty, fatigued, changes in sleep patterns, appetite, body weight, lack of interest or pleasure, and suicidal thoughts, plans, or attempts (Almeida et al., 2021; Goetter et al., 2020). Major depression is the least likely diagnosis despite Sullivan having a depressed mood and lacking interest. Symptoms such as nightmares and avoidance of cues symbolizing traumatic events rule out major depression.
Adjustment disorder with a depressed mood:
Adjustment disorder with a depressed mood is the other differential diagnosis that might be considered in Sullivan’s case. Sullivan could be struggling with adjusting to a normal life after his military service (Dragan et al., 2021). However, the presence of symptoms that strongly align with those seen in PTSD rules out adjustment disorder as a potential diagnosis in the case study.
Reflections: I agree with my preceptor’s diagnosis of PTSD. Sullivan has symptoms that align with those of PTSD as seen in the DSM-5 manual. I learned from this case about the importance of a comprehensive psychiatric examination. Psychiatric mental health nurse practitioners should strive to obtain comprehensive information from their patients to develop accurate diagnoses and treatment plans. I also learned about the use of patient data to develop primary and secondary diagnoses that should be considered in the treatment process. Psychiatric mental health nurse practitioners should rely on evidence-based data in Sullivan’s treatment. This includes considering pharmacological and non-pharmacological interventions that would promote safety, quality, and efficiency. Mental health practitioners should incorporate Sullivan’s values, preferences, and perspectives into the care decisions for autonomous care (Maercker et al., 2022). Social determinants of health such as employment and income level affect mental health outcomes. Therefore, practitioners should investigate their impact on Sullivan’s access to mental healthcare services that would promote recovery.
References
Almeida, F. B., Pinna, G., & Barros, H. M. T. (2021). The Role of HPA Axis and Allopregnanolone on the Neurobiology of Major Depressive Disorders and PTSD. International Journal of Molecular Sciences, 22(11), Article 11. https://doi.org/10.3390/ijms22115495
Dragan, M., Grajewski, P., & Shevlin, M. (2021). Adjustment disorder, traumatic stress, depression and anxiety in Poland during an early phase of the COVID-19 pandemic. European Journal of Psychotraumatology, 12(1), 1860356. https://doi.org/10.1080/20008198.2020.1860356
Goetter, E. M., Hoeppner, S. S., Khan, A. J., Charney, M. E., Wieman, S., Venners, M. R., Avallone, K. M., Rauch, S. A. M., & Simon, N. M. (2020). Combat-Related Posttraumatic Stress Disorder and Comorbid Major Depression in U.S. Veterans: The Role of Deployment Cycle Adversity and Social Support. Journal of Traumatic Stress, 33(3), 276–284. https://doi.org/10.1002/jts.22496
Maercker, A., Cloitre, M., Bachem, R., Schlumpf, Y. R., Khoury, B., Hitchcock, C., & Bohus, M. (2022). Complex post-traumatic stress disorder. The Lancet, 400(10345), 60–72. https://doi.org/10.1016/S0140-6736(22)00821-2
Onaemo, V. N., Fawehinmi, T. O., & D’Arcy, C. (2021). Comorbid Cannabis Use Disorder with Major Depression and Generalized Anxiety Disorder: A Systematic Review with Meta-analysis of Nationally Representative Epidemiological Surveys. Journal of Affective Disorders, 281, 467–475. https://doi.org/10.1016/j.jad.2020.12.043
Sapra, A., Bhandari, P., Sharma, S., Chanpura, T., & Lopp, L. (2020). Using Generalized Anxiety Disorder-2 (GAD-2) and GAD-7 in a Primary Care Setting. Cureus. https://doi.org/10.7759/cureus.8224
Schein, J., Houle, C., Urganus, A., Cloutier, M., Patterson-Lomba, O., Wang, Y., King, S., Levinson, W., Guérin, A., Lefebvre, P., & Davis, L. L. (2021). Prevalence of post-traumatic stress disorder in the United States: A systematic literature review. Current Medical Research and Opinion, 37(12), 2151–2161. https://doi.org/10.1080/03007995.2021.1978417
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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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
Learning Resources
Required Readings
American Psychiatric Association. (2022). Anxiety disorders. In Diagnostic and statistical manual of mental disorders
Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders
American Psychiatric Association. (2022). Obsessive compulsive and related disorders In Diagnostic and statistical manual of mental disorders
Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x06_Obsessive_Compulsive_and_Related_Disorders
American Psychiatric Association. (2022). Trauma- and stressor-related disorders.. In Diagnostic and statistical manual of mental disorders
Links to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url= https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425787.x07_Trauma_and_Stressor_Related_Disorders
Boland, R. & Verduin, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.
Chapter 8, “Anxiety Disorders”
Chapter 9, “Obsessive-Compulsive and Related Disorders”
Chapter 10, “Trauma- and Stressor-Related Disorders”
Chapter 2- only sections 2.13, “Anxiety Disorders of Infancy, Childhood, and Adolescence: Separation Anxiety Disorder, Generalized Anxiety Disorder, and Social Anxiety Disorder (Social Phobia)”; 2.14 “Selective Mutism” and 2.15 “Obsessive-Compulsive Disorder in Children and Adolescence”
Document: Comprehensive Psychiatric Evaluation Template
Download Comprehensive Psychiatric Evaluation Template
Document: Comprehensive Psychiatric Evaluation Exemplar
Download Comprehensive Psychiatric Evaluation Exemplar
Required Media
Classroom Productions. (Producer). (2015). Anxiety disorders
Links to an external site. [Video]. Walden University.
Classroom Productions. (Producer). (2012). The neurobiology of anxiety
Links to an external site. [Video]. Walden University.
Classroom Productions. (Producer). (2015). Obsessive-compulsive disorders
Links to an external site. [Video]. Walden University.
Classroom Productions. (Producer). (2015). Trauma, PTSD, and Trauma-Informed Care
Links to an external site. [Video]. Walden University.
MedEasy. (2017). Anxiety, OCD, PTSD and related psychiatric disorders | USMLE & COMLEX
Links to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=-BwzQF9DTlY
Video Case Selections for Assignment
Select one of the following videos to use for your Assignment this week. Then, access the document “Case History Reports” and review the additional data about the patient in the specific video number you selected.
Symptom Media. (Producer). (2017). Training title 15
Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-15
Symptom Media. (Producer). (2016). Training title 21
Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-21
Symptom Media. (Producer). (2016). Training title 37
Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-37
Symptom Media. (Producer). (2016). Training title 40
Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-40
Symptom Media. (Producer). (2017). Training title 55
Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-55
Symptom Media. (Producer). (2017). Training title 85
Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-85
Symptom Media. (Producer). (2018). Training title 95
Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-95
Document: Case History Reports
Download Case History Reports
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-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.).
submission information
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_Week4_Assignment_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome Create documentation in the Comprehensive Psychiatric Evaluation Template about the patient you selected. In the Subjective section, provide: • Chief complaint• History of present illness (HPI)• Past psychiatric history• Medication trials and current medications• Psychotherapy or previous psychiatric diagnosis• Pertinent substance use, family psychiatric/substance use, social, and medical history• Allergies• ROS |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome In the Objective section, provide:• Physical exam documentation of systems pertinent to the chief complaint, HPI, and history• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome In the Assessment section, provide:• Results of the mental status examination, presented in paragraph form.• At least three differentials with supporting evidence. List them from top priority to least 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. |
|
25 pts | ||||
| This criterion is linked to a Learning Outcome Reflect on this case. Discuss what you learned and what you might do differently. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), social determinates of health, 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.). |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old). |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting—Paragraph development and organization:Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation |
|
5 pts | ||||
| Total Points: 100 | ||||||