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Name: PRAC_6675_Week4_Discussion_Participant_Rubric

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	Excellent	Good	Fair	Poor
Responses	Points: Points Range: 77 (77%) – 85 (85%) Responses exhibit synthesis, critical thinking, and application to practice settings. Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources. Responses demonstrate synthesis and understanding of Learning Objectives. Communication is professional and respectful to colleagues. Presenters’ prompts/questions posed in the case presentations are thoroughly addressed. Responses are effectively written in standard, edited English. Feedback:	Points: Points Range: 68 (68%) – 76 (76%) Responses exhibit critical thinking and application to practice settings. Responses provide clear, concise opinions and ideas that are supported by 2 or more credible sources. Communication is professional and respectful to colleagues. Presenters’ prompts/questions posed in the case presentations are addressed. Responses are effectively written in standard, edited English. Feedback:	Points: Points Range: 60 (60%) – 67 (67%) Responses are on topic and may have some depth. Responses may lack clear, concise opinions and ideas, and only one or no credible sources are cited. Responses posted in the Discussion may lack effective professional communication. Presenters’ prompts/questions posed in the case presentations are inadequately addressed. Feedback:	Points: Points Range: 0 (0%) – 59 (59%) Responses may not be on topic and lack depth. No credible sources are cited. Responses posted in the Discussion lack effective professional communication. Responses to colleagues’ prompts/questions are missing. Feedback:
Participation	Points: Points Range: 14 (14%) – 15 (15%) Meets requirements for participation by responding at least twice to each colleague who presented this week. Responses are carried out over multiple days between Days 4 and 7. Feedback:	Points: Points Range: 12 (12%) – 13 (13%) Meets requirements for participation by responding at least twice to each colleague who presented this week, over at least 2 days. Feedback:	Points: Points Range: 11 (11%) – 11 (11%) Participants respond at least twice to each colleague who presented this week, but responses may occur all in 1 day. Feedback:	Points: Points Range: 0 (0%) – 10 (10%) Does not meet requirements for participation by responding at least twice to each colleague who presented this week. Feedback:

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Responses–

Levels of Achievement:

Excellent
77 (77%) – 85 (85%)

Responses exhibit synthesis, critical thinking, and application to practice settings.

Responses provide clear, concise opinions and ideas that are supported by at least two scholarly sources.

Responses demonstrate synthesis and understanding of Learning Objectives.

Communication is professional and respectful to colleagues.

Presenters’ prompts/questions posed in the case presentations are thoroughly addressed.

Responses are effectively written in standard, edited English.

Good
68 (68%) – 76 (76%)

Responses exhibit critical thinking and application to practice settings.

Responses provide clear, concise opinions and ideas that are supported by 2 or more credible sources.

Communication is professional and respectful to colleagues.

Presenters’ prompts/questions posed in the case presentations are addressed.

Responses are effectively written in standard, edited English.

Fair
60 (60%) – 67 (67%)

Responses are on topic and may have some depth.

Responses may lack clear, concise opinions and ideas, and only one or no credible sources are cited.

Responses posted in the Discussion may lack effective professional communication.

Presenters’ prompts/questions posed in the case presentations are inadequately addressed.

Poor
0 (0%) – 59 (59%)

Responses may not be on topic and lack depth.

No credible sources are cited.

Responses posted in the Discussion lack effective professional communication.

Responses to colleagues’ prompts/questions are missing.

Feedback:

Participation–

Levels of Achievement:

Excellent
14 (14%) – 15 (15%)

Meets requirements for participation by responding at least twice to each colleague who presented this week. Responses are carried out over multiple days between Days 4 and 7.

Good
12 (12%) – 13 (13%)

Meets requirements for participation by responding at least twice to each colleague who presented this week, over at least 2 days.

Fair
11 (11%) – 11 (11%)

Participants respond at least twice to each colleague who presented this week, but responses may occur all in 1 day.

Poor
0 (0%) – 10 (10%)

Does not meet requirements for participation by responding at least twice to each colleague who presented this week.

Feedback:

Total Points: 100

Name: PRAC_6675_Week4_Discussion_Participant_Rubric

Please choose two questions each from each discussion questions for a total of 6 questions you are familiar with and include 2-3 references. Please know that it is just short answers. Please zero plagiarism.

Please see if they can be ready tonight. Thank you.

Discussion Questions

1. Identify other ways to encourage medication compliance in a patient with a paranoid personality disorder.

2. Identify other alternative therapies that will be beneficial in managing an individual with a paranoid personality disorder.

3. Identify one other type of psychotherapy that will effectively manage paranoid personality disorder.

Discussion Questions / Prompts:

1. Distinguish anxiety disorders and their common symptoms, specifically panic disorder, and generalized anxiety disorder

1. Identify screening instruments for anxiety and depression

1. Demonstrate understanding of the pharmacologic and nonpharmacologic treatments for panic and anxiety disorders

Discussion Questions:

1. Would you have another differential diagnosis for this patient? If yes, why?

2. Would you recommend any other medications for the patient? What is your rationale?

3. What other therapy would you have recommended for the patient and his family?

Participants: Review the Grand Rounds Participant Rubric to ensure you meet the scoring criteria. Rubric is enclosed.

College of Nursing-PMHNP, Walden University

NRNP 6675 PRAC: Care Across the Life Span II

Date:

Objectives:

At the end of this presentation, this class will be able to:

1. Distinguish anxiety disorders and their common symptoms, specifically panic disorder and generalized anxiety disorder

2. Identify screening instruments for anxiety and depression

3. Demonstrate understanding of the pharmacologic and nonpharmacologic treatments for panic and anxiety disorders

Subjective:

CC: “I am having panic attacks and can’t sleep; I’m just not right and I need help.”

HPI: S.A. is a 54-year-old white male who presents for initial psychiatric evaluation with complaint of panic attacks, anxiety and insomnia for the past two years. He reports one episode of psychosis two years ago while undergoing divorce. He was off his prescription opiods then. He married his wife for 26 years but got divorced in 2021. He was unexpectedly served with a divorce paper after returning from searching for a job in Los Angeles. He feels it’s difficult to get back to work. . He reports low self-esteem and self-doubts. He feels broken, hopeless, and helpless. He is positive for dysphoria and anhedonia. He reported recurrent panic attacks that occur 3-4 times daily, followed by shortness of breath, shaking, flushing, and fear of death. He previously visited the emergency department few times for help. He reports increased appetite, eating excessively, and insomnia. He worries a lot about work and finances, which worsens his insomnia. He reports feeling anxious, poor concentration, his mind going blank, and feeling restless and on the edge. His rates his anxiety level 7-9/10. He denies any suicidal or homicidal ideations stating “ I’m a spiritual person, I don’t believe in that.” After the divorce in 2021, he reports feeling the devil’s presence in the house, which continued for three months. He did not seek for help. He reports increased alcohol consumption during that time. Also, then, he talked much, became impulsive, had nervous twitching, and made poor decisions.

Past Psychiatric History: No impatient psych. Reported psychotherapy treatment due to his back injury, no longer attending.

Medication Trials: No psychotropic medication, reported he was prescribed opiods for back injury he sustained at work.

Substance Current Use and History: He reports increased alcohol consumption while undergoing divorce and after, but received no treatment. He usually drinks 2-3 drinks, three times a week. He is a non-smoker. He deniesr illicit substance use.

Psychosocial History: Patient is divorced white, heterosexual male who was born and raised in NY. He moved to San Diego at 8 y/o, parents were married, mom died in 2000, father in 2016, he has an older brother and a youger sister. He currently lives alone and is unemployed. He holds a graduate degree. He previously worked as an electrician. He denies any history of abuse. He denies current legal issues. He is obese, exercises 1-2 times per week. He consumes 1-2 caffeinated drinks a week.

Family Psychiatric/Substance Use History: Both his parents are deceased and no known psychiatric history reported. Reports sister has a hx of hallucination, brother with no known psychiatric history.

PMH: Ankylosing Spondylitis, chronic back pain, hip surgery

Current Medications: None reported

Allergies: PCN

Review of Systems (ROS):

GENERAL: Denies any fever or chills. Reports eating excessively and recent weight gain of 20 lbs.

HEENT: Denies any complaint of headache, no sore throat or difficulty swalowing

SKIN: No lesions or open wound

CARDIOVASCULAR: no chest pain or chest discomfort

RESPIRATORY: No difficulty breathing or shortness of breath

GASTROINTESTINAL: No nausea, vomiting or diahrrea os stomach pain

GENITOURINARY: No burning urination or bladder discomfort

NEUROLOGICAL: No involuntary movements or motor tics

MUSCULOSKELETAL: No joint stiffness, moves all extremities.

HEMATOLOGIC: No bleeding problems or disorders

LYMPHATICS: No enlarged lymph nodes

ENDOCRINOLOGIC: Denies heat or cold intolerance

Psychitric ROS

· Mood; Client reports feeling sad, + low self-esteem and has self-doubts.

· Anxiety; + sensations of shortness of breath, shaking, flushing, and fear of dying. He worries, restless, has difficulty concentrating, his mind goes blank, and he feels on edge.

· Sleep; + sleeping difficulties.

· Psychotic symptoms; Client has no history of manic or hypomanic episodes, reports one psychotic episode two years ago, and has no suicidal or homicidal ideations.

· Appetite; + increased appetite, and he severely feels hungry

· Behavioral; He reports Hx of being impulsive, talking a lot, nervous twitching, and making poor decisions.

· Trauma; Divorce is the major contributing event. No history of abuse.

Objective:

Physical exam: Unable to assess

Diagnostic results:

Wt- 220 lbs, Ht- 70 in

Diagnostic reports are not available on the patient’s chart. To determine other possible underlying medical conditions, obtaining lab tests should be included in a psychiatric work up. I would recommend checking CBC, CMP, Thyroid panel, Vitamin D level, and liver enzymes.

Last Physical was in 2019 – Recommend referral to PCP for physical

Recommend Rheumatologist order MRI scan of the spine for further monitoring and management of the ankylosing spondylitis. Also, assess patient for possible eligibility for disability due to this condition.

Screening tools: Both GAD-7 and PHQ-9 screening tools results are pending completion.

Assessment:

Mental Status Examination: S.A is 54-year-old male, well-oriented to person, place, time, and situation. He is appropriately groomed and clean and appears his stated age. He has a coherent speech with normal rate, volume, and articulation. He maintained good eye contact during the interview and responded to questions appropriately. He has a logical thought process, is goal-oriented, and is organized. He has a good and intact memory. His judgment is intact. No abnormal motor movements are evident during the interview. He has a depressed mood and is anxious. He denies suicidal or homicidal thoughts.

Differential Diagnoses:

1. Panic disorder [Episodic Paroxysmal Anxiety] [F41.0]: Panic disorder is a type of anxiety disorder characterized by sudden panic attacks or fear. This comes as a response to a stressful event. The DSM-5 criteria for diagnosis of the panic disorder require the occurrence of frequent panic attacks whereby one or more of the attacks follow one month after the other. Nevertheless, panic attacks can follow significant maladaptive behavior related to the attacks (Ziffra, 2021). In this case, patient reports experiencing several panic attacks and feelings of intense fear for 2 years. The patient has positive signs of distress. The client reports panic attacks that cause him difficulty in sleeping. He reports recurrent and unexpected panic attacks that occur 3-4 times every day, followed by other symptoms such as sensations of shortness of breath, shaking, flushing, and fear of death. Therefore, I choose this as a probable diagnosis.

2. Generalized Anxiety Disorder ( F41.1); GAD is an anxiety disorder characterized by excessive, uncontrollable, and irrational worry that interferes with the normal functioning of the individual. Although some literature considers panic attacks as the hallmark of anxiety disorders, in GAD generally, there are no associated panic attacks. The DSM-5 for diagnosing GAD considers factors like excessive worry associated with various physical symptoms to make a diagnosis and rule out others. Patients with GAD may present with symptoms such as excessive anxiety and worry, reduced concentration, difficulty falling asleep, or insomnia (Park & Kim, 2020). Besides, they may become restless, become irritable, report increased muscle aches or soreness, and get fatigued. In this case, the patient experiences four of the symptoms which includes; feeling restless, easily fatigued, the mind going blank, and difficulty falling asleep/sleep disturbances meeting the criteria. Thus, I chose this also as a probable diagnosis.

3. Major depressive disorder, recurrent, severe w/ psych SX [F33.3]: The causes of M.D. with psychotic features is usually unknown; however, a family history of depression or a psychotic disorder can increase the vulnerability of developing the disorder. Patient’s sister has a history of hallucination. Depressive disorders can occur with psychosis or without; thus, psychosis is not considered a determinant of depression severity. Growing evidence demonstrates no inextricable link between psychosis and depression severity (Zimmerman et al., 2019). Nevertheless, the DSM-5 criteria for MDD diagnosis require the occurrence of at least five symptoms over a period of 2 weeks. This includes; depressed mood, loss of interest, weight loss or gain, psychomotor agitation or retardation, insomnia or hypersomnia, feeling worthless, presence of death or suicidal thoughts, and reduced concentration or fatigue. In this case, the patient is has about eight symptoms present including, dysphoria, anhedonia. Besides, the patient reports one episode of psychosis. Therefore,this is also a probable diagnosis as the patient meets the criteria.

Case Formulation and Treatment Plan: 

Pharmacological Intervention: the pharmacological treatment ia as follows: start with Cymbalta 30 mg PO after dinner for the first week, then increase to 60 mg. Cymbalta (duloxetine) is an SNRI that has proven effective in the treatment of patients with anxiety, MDD and chronic back pain. Duloxetine demonstrated efficacy in 80% of MDD cases (Rodrigues-Amorim et al., 2020). Besides, evidence-based research demonstrates that Cymbalta is safe and well-tolerated among geriatric patients with MDD and chronic pain. The patient should also take Gabapentin 300mg PO prn Q8h for anxiety. Gabapentin is not FDA approved medication for anxiety treatment; however, growing evidence suggests that it can be a potential treatment for anxiety (Ahmed et al., 2019). Gabapentin will address both the anxiety and chronic back pain. The client is also having sleeping difficulties; thus, Trazodone 50 mg 1-2 tabs at bedtime would be recommended. Current evidence shows that Trazodone can be used in the treatment of insomnia effectively (Yi et al., 2018). However, if the symptoms fail to improve, mood stabilizers should be considered.

Non-pharmacological Intervention: referal to therapy; the first-line treatment of anxiety disorders is cognitive-behavioral therapy. Multiple research demonstrates the efficacy and effectiveness of CBT in the treatment of anxiety disorders, including PTSD, OCD, panic disorder, GAD, and social anxiety disorder. Nevertheless, combined therapy of CBT and medications presents stronger evidence of effectiveness. The patient should be referred to a rheumatologist to manage the Ankylosing Spondylitis. Collaborating with the rheumatologist and PCP is essential for efficient patient care management.

Health promotion:

Patient education is an empowerment tool for improving patient health. Patient should be educated on behavior modification. He should be advised to reduce the intake of ethyl alcohol consumption and eat well balanced diet. Psychoeducation should also be provided on the diagnosis, the risks and benefits of the treatment plan, targeted symptoms and side effects of prescribed psychotropic medications. The patient should be follow up in two weeks or sooner if needed.

Reflection:

I agree with my preceptor giving the patient the three probable diagnoses as the patient’s presentation meets the criterias. What I would do differently if I were to conduct this interview again is to explore the specific opioid patient was taking, the dosage and prescription timeline. Opiod use or withdrawal can trigger anxiety disorders, thus obtaining more information about the history of the Opioid use can be helpful in the case formulation. I would follow up on the results of the screening tools and modify treatment intervention if needed. I believe further evaluations are needed to determine the following; if patients symptoms are genetically vs chemically induced; to r/o bipolar disorder w/ manic episode ( possibly trigerred by his divorce) and alcohol consumption use disorder. I would assess if he has children, their age, and working status to establish the presence of family support. Nevertheless, the provision of individualized and culturally sensitive care has been demonstrated to improve treatment outcomes and client satisfaction.

Questions:

1. Do you agree with the differential diagnoses of the patient? Why or why not

2. What other screening tools would you suggest for this case?

3. What other pharmacologic or non-pharmacologic intervention would you recommend for this patient?

References

Ahmed, S., Bachu, R., Kotapati, P., Adnan, M., Ahmed, R., Farooq, U., … & Begum, G. (2019). Use of gabapentin in the treatment of substance use and psychiatric disorders: a systematic review. Frontiers in psychiatry, 10, 228.

Park, S. C., & Kim, Y. K. (2020). Anxiety Disorders in the DSM-5: changes, controversies, and future directions. Anxiety Disorders, 187-196.

Rodrigues-Amorim, D., Olivares, J. M., Spuch, C., & Rivera-Baltanás, T. (2020). A systematic review of efficacy, safety, and tolerability of duloxetine. Frontiers in psychiatry, 11, 554899.

Yi, X. Y., Ni, S. F., Ghadami, M. R., Meng, H. Q., Chen, M. Y., Kuang, L., … & Zhou, X. Y. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep medicine, 45, 25-32.

Ziffra, M. (2021). Panic disorder: A review of treatment options. Ann Clin Psychiatry, 33(2), 124-133.

Zimmerman, M., Martin, J., McGonigal, P., Harris, L., Kerr, S., Balling, C., … & Dalrymple, K. (2019). Validity of the DSM‐5 anxious distress specifier for major depressive disorder. Depression and anxiety, 36(1), 31-38.

Week 4: Complex Case Study – Presentation

Master of Science in Nursing, Walden University

PRAC-6675-33: PMHNP Care Across the Lifespan 11 Practicum

Date:

Complex Case Study

This case study is about a 13-year-old Caucasian female to male transgender patient. He wanted to be addressed with masculine pronouns, but his parents are not accepting his transgender identity causing him a lot of stress, anxiety, and depression for the past two years (Sadock et al,2015). The purpose of this paper is to assess and diagnose a transgender youth, develop a focused SOAP note with differential diagnosis, and formulate a treatment plan of care and a case presentation.

Learning Objectives:

By the end of this presentation, my audience should be able to :

· Recognized the signs and symptoms contributing to distress in a transgender individual.

· Outline the typical presentation of transgender youth with gender dysphoria.

· Identify the appropriate treatment plan for transgender youth with depressive and anxiety disorder and the rationale for the treatment (Garg et al., 2022).

Patient Information: Initials: PK Age: 13 years Sex: Male Race: Caucasian

Subjective

Chief complaint: “They don’t understand is my life.”

HPI: 13 years old Caucasian female to male transgender youth presented to the clinic for psychiatric evaluation. The patient reports he recently came out as transgender. Stated, “when I told my parents and other family members to call me Alex and address me as he and him they refuse to honor my wish”. He stated I like to wear only boys’ clothes and want to do things like boys but my parents are not accepting my wish and won’t let me. Reports increased anxiety, depression, difficulty concentrating on school work, and afraid he is going to fail his final examination (Sadock et.al, 2015). He expresses frustrations in developing secondary characteristics associated with females. Reports feeling very sad for the past month and sleeping a lot during the day because he does not want to see anybody. He endorses low self-esteem, eats a lot more causing him to gain 7 pounds weight within a month, anger, and suicidal thought. But he denies any plans of harming herself, and others currently (Walkup, 2017).

Past Psychiatric History:

Medications trials and current medications: No medication trial reported

· Currently taking Fluoxetine 40 mg orally daily. For anxiety and depression.

Psychotherapy or previous psychiatric diagnosis:

· Reports family psychotherapy- 6 months ago.

· History of anxiety and depression r/t gender identity issues.

Substance Current Use:

· Denied any past or current substance use.

Family Psychiatric/Substance Use History

Brother: Died from Opioid overdose at 21 years old.

Psychosocial History:

· PK is in 8th grade and lives at home with his parents and younger sister.

Medical History: Denied any

· Current Medications: Fluoxetine 40 mg orally daily. For anxiety and depression.

· Allergies: Denied any food or drug allergies

· Reproductive History: Full-term child, currently not sexually active.

ROS:

· GENERAL: Claims he gained 7 pounds in a month. No fever/ chills.

· HEENT: Normal headache size, no dizziness, hearing loss, runny nose, or sore throat.

· CARDIOVASCULAR: No palpitation or chest discomfort.

· RESPIRATORY: No SOB, cough, or wheezing.

· NEUROLOGICAL: No tremors or seizures activity

· HEMATOLOGIC: No bruises or bleeding issues.

· ENDOCRINOLOGIC: Reports weight gain, no heat or cold intolerance.

Objective

· Vital signs: BP =108/66, P = 68, T = 97.2°F, R = 17, Wt.:112 lbs.; Ht: 5’0; BMI = 21.87.

Diagnostic results:

· The SIGECAPS: – this tool was utilized in the screening process to come up with the diagnosis. Each letter in this mnemonic represents the criteria for diagnosing depressive disorder (American Psychiatric Association,2013).

· Studies have shown that thyroid-stimulating hormone (TSH) abnormality such as high or low can contribute to the patient’s behavioral issues. It is therefore important to assess to rule out other diseases and as a baseline for treatment (Naidu et al., 2017).

· Assessing the level of the patient’s hemoglobin A1c (HbA1c) is important to serve as the baseline for the choice of antipsychotic medication and also to rule out the risk for metabolic syndrome, and diabetes (Naidu et al., 2017).

· The initial evaluation of Complete Blood Count(CBC) and Comprehensive Metabolic Panel(CMP) is necessary as the baseline for treatment and any electrolytes abnormality which can interfere with the patient’s behavior (Sadock et.al, 2015).

Assessment

Mental Status Examination

13-year-old Caucasian female to male transgender youth, well-groomed with good eye contact. Presented to the clinic for psychiatric evaluation. Appears to be sad, and anxious with a depressive mood, but cooperative with the evaluation. Rapid pressured speech with a coherent goal-directed thought process. He denied any auditory or visual hallucination but endorses suicidal thoughts with no intention of harming himself or others currently. He is alert and orientated to place, time, and person. Intact memory during the assessment with moderate insight and judgment (Mullen, 2018).

Differential Diagnoses

Major depressive disorder (MDD), severe, single episode: 296.23 (F32.2): MDD would be the primary diagnosis for PK. The rationale for this disorder is that PK reported feeling depressed most of the day, nearly every day over the past two weeks, as evidenced by reporting increased anxiety, depression, difficulty concentrating on school work, and afraid he is going to fail his final examinations (American Psychiatric Association,2013). He also presented with feeling sad, sleeping a lot during the day, and eating a lot, causing her to gain weight and even thought of suicide but with no intent currently. He denied symptoms of mania and psychosis. His symptoms are contributing to his distress. These manifestations are classic signs of MDD and meet the DSM-5 criteria for the diagnosis (APA,2013).

Gender dysphoria (GD) in Adolescents: 302.85 (F64.0):- This would be the first differential diagnosis for this patient. The symptoms the patient presented meet the criteria for gender dysphoria. He has expressed a cross-gender identity from female to male for the past two years. He expressed a strong desire to be addressed as Alex and be treated as a boy but his parents are not accepting his transgender identity causing him a lot of distress, anxiety, and depression (Garg et al., 2022). This disparity has been ongoing for over six months now. PK exhibit at least two or more of the DSM-5 criteria for diagnosing gender dysphoria (American Psychiatric Association, 2013).

Body Dysmorphic Disorder ( BDD): 300.7 (F45.22): This is the second differential diagnosis for PK. It is a condition in which the individual has an extreme preoccupation with self-perceived defects in the appearance of the body, leading to distress and impairment of social and occupational functioning (APA,2013). Studies have shown that the typical age of onset of Body Dysmorphic Disorder is ages 12-13 (American Psychiatric Association, 2013). PK is 13 years old transgender female to male who expresses distress in developing secondary characteristics associated with females. Reports being self-conscious, obsessively examining himself in the mirror, and grooming to hide or fix his perceived flaw as evidenced by binding his breast to create the shape of a flatter chest (Garg et al., 2022). These identifiable symptoms meet the DSM-5 diagnostic criteria for BDD.

Treatment Plan

The first line of the treatment plan for this patient is to initiate cognitive-behavioral therapy (CBT) to address depression and anxiety symptoms (Mullen, 2018). The cognitive part focuses on the patient’s thinking and negative ideas, while the behavioral component focuses on the client’s emotions and behavior modification (Mullen, 2018). In view of this, CBT with a focus on the patient’s specific anxiety and concerns was initiated. The patient was referred to a support group for transgender youth for increased peer support. He was also referred to support therapy to address gender-related stressors. The patient and his parents and other family members were referred to family psychotherapy (David et al,.2018). Psychoeducation was also initiated to educate the patient and his parents about gender identity. The parents were also encouraged to be advocates for their transgender youth. Studies have also shown the effectiveness of psychotherapy in conjunction with psychopharmacology in the management of psychotic issues such as anxiety disorder and depressive mood (Mullen, 2018). In view of this fluoxetine (SSRI) was increased to 50 mg orally daily. The rationale for this is that Fluoxetine has been approved by FDA for children between the ages of 8-18 years (Walkup, 2017). The patient reports he has been taking this medication and has experienced some benefits from the medication but his symptoms have not improved, therefore an increase in the dose would be indicated. The patient was educated about the importance of being compliant with treatment and the signs and symptoms to watch for and when to report to the provider (Walkup, 2017). He was also advised to return to the clinic as needed and in four weeks. He was also provided with and advised to call the 1-800- 273-8255 suicidal hotline or to go to the nearest emergency room if the thought of suicide becomes an instance (Sadock et al., 2015).

Reflections

What I learned from this case is, that as healthcare providers, we are our patient’s advocates. One of the responsibilities we have is to help the patients through their health journey by providing culturally competent care (Sadock et.al, 2015). I also learned about the need for family involvement in the treatment plan as support to promote healing (Sadock et.al, 2015). Education about informed consent, in order to be able to collaborate with other health care providers as needed, was given to the patient. The legal and ethical considerations during this assessment were assuring the patient about confidentiality as well as ethical decision-making on their behalf (Goldsmith et al., 2016). PK would return to the clinic in a month’s time for follow-up. He would be assessed about his family situation and identity since they have started going to family psychotherapy.

Discussion Questions:

· Would you have another differential diagnosis for this patient? If yes why?

· Would you recommend any other medications for the patient? What is your rationale?

· What other therapy would you have recommended for the patient and his family?

Summary

Transgenders have a gender identity problem from actual birth gender leading to increased stress, anxiety, and other mental health problems (Goldsmith et al, 2016). Most transgenders experience discrimination, alienation, unappreciated, and scorned, as a result of living in a society composed of a stratified gendered cultural environment (Goldsmith et al., 2016). It is important that healthcare providers, family members, and friends accept them unconditionally (Sadock et al., 2015).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). https://doi.org/10.1176/appi.books.9780890425596

David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the

Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4.

https://doi.org/10.3389/fpsyt.2018.00004

Garg G, Elshimy G, Marwaha R. Gender Dysphoria. [Updated 2022 May 5]. In: StatPearls

[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:

https://www.ncbi.nlm.nih.gov/books/NBK532313/

Goldsmith, M., & Roberts, L. W. (2016). Ethical issues in child and adolescent psychiatry. Focus

(American Psychiatric Publishing), 14(1), 64–67. https://doi.org/10.1176/appi.focus.20150032

Mullen, S. (2018). Major depressive disorder in children and adolescents. The mental health clinician, 8(6), 275–283. https://doi.org/10.9740/mhc.2018.11.275

Naidu, P., Churilov, L., Kong, A., Kanaan, R., Wong, H., Van Mourik, A., Yao, A., Cornish, E.,

Hachem, M., Hart, G. K., Owen-Jones, E., Robbins, R., Lam, Q., Samaras, K., Zajac, J. D., & Ekinci, E. I. (2017). Using Routine Hemoglobin A1c Testing to Determine the Glycemic Status in Psychiatric Inpatients. Frontiers in endocrinology, 8, 53. https://doi.org/10.3389/fendo.2017.00053 

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of

psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Wolters Kluwer.

Walkup, J. T. (2017). Antidepressant efficacy for depression in children and adolescents:

industry-and NIMH-funded studies. American Journal of Psychiatry, 174(5), 430-437. https://doi.org/10.1176/appi.ajp.2017.16091059

Week 4: Grand Rounds Discussion: Complex Case Study Presentation

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan II

Graduate Studies

Date:

At the end of the presentation, the audience will understand the objectives below.

Objectives for this presentation:

1. The audience will be able to summarize the defining characteristics of paranoid personality disorder as identified in the DSM 5 manual.

2. The audience will understand how to diagnose paranoid personality disorder accurately.

3. The audience will gain insight into possible pharmacological management of paranoid personality disorder

4. The audience will be able to identify nonpharmacological management of paranoid personality disorder.

Subjective:

CC (chief complaint): “ I suspect my neighbors want to hurt me”.

HPI: R.H is a 46-year-old African American female who presents for follow-up with a concern of feeling suspicious of her neighbors. She reported feelings of suspicion, which began when she was about 22 years old. She explained that she suspects her neighbor is conspiring to hurt her, but she cannot justify her suspicion. She explained that her neighbor insulted her, which led her to bear grudges toward her neighbor. This incident resulted in her paying her friend to have the windscreen of her neighbor’s car shot. She reported that her friend took her money and did not shoot the neighbor’s car windscreen resulting in her developing homicidal thoughts towards her friend. She narrated going to a psychiatric hospital for homicidal ideation towards the said friend and got hospitalized for two days. She reported explaining to the hospital that she was under the influence of drugs when she thought of having her neighbor’s windscreen shot. The hospital then signed a duty to warn against her. She highlighted that after being discharged from the hospital, she was free of homicidal thoughts toward her friend and attempted to apologize to her neighbor for the intention to have her car windscreen shot. But her neighbor had a peace order issued against her.

She reported that she constantly grudges against people and is unforgiving of insults. She highlighted feeling afraid to confide in anyone to prevent such information from being maliciously used against her. She also reported another incident with a different friend who plans to ruin her reputation. She explained that this new friend deceived her into allowing her to walk with her dog, and afterward, the dog bit the friend. She said she doubts her friends and close associates as everyone seems to be plotting ways to indict her. She highlighted that her suspicions make her react very angrily in most situations causing recurrent fights and altercations. She reported feeling irritable and angry as she quickly reads meanings into people’s remarks that she feels are designed to hurt her. She also highlighted her need for assistance to relocate from her present house to a different home to avoid her neighbors and friends. She also reported hearing voices that are non-commanding. She further explained that she does not think anything is wrong with her and does not take her medications every day. She is prescribed paroxetine 30mg p.o daily, buspirone 10mg p.o tid, prazosin 1mg nightly, and depakote 750 mg p.o daily.

Substance Current Use: The patient denies substance/ illicit drug current use.

Substance Use History: Previous marijuana (cannabis) use.

Previous Psychiatric Hospitalization: The patient reported one-time psychiatric hospitalization.

Family Psychiatric History/Substance Use: The patient reports autism (son) and denies family suicide attempts and substance use.

Medical History: seizure disorder, hypothyroidism.

Current Medications: paroxetine (paxil) 30mg p.o daily (depression), buspirone 10mg p.o tid ( anxiety), prazosin 1mg nightly (nightmares), 750 mg deparkote p.o daily (seizures / mood stabilization), Synthroid 50mcg p.o daily (hypothyroidism).

Medication Trial: Abilify 5mg p.o daily, risperidone 2mg p.o.daily.

Psychotherapy or Previous Psychiatric Diagnosis: The patient is non-compliance with individual psychotherapy. Previous psychiatric diagnoses include post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder.

Allergies: medication reaction, Abilify ( causes seizures per patient), risperidone (causes rashes).

Reproductive Hx: heterosexual (sexually active), denies pregnancy and lactation.

Social History: The patient was raised in Maryland by her mother. She is single, unemployed, and lives in Maryland with her nine-year-old autistic son. She has one elder sister. Her highest level of education is a high school diploma. She reported childhood sexual and emotional abuse and multiple legal histories.

ROS:

GENERAL: patient appears anxious, with no complaints of weight loss.

HEENT: No complaints of visual loss or double vision. Ears, Nose, Throat: No complaints of hearing loss, sneezing, congestion, and sore throat.

SKIN: No complaints of rashes or itching on the skin.

CARDIOVASCULAR: No complain of chest pain, and palpitations.

RESPIRATORY: No complaints of shortness of breath and cough.

GASTROINTESTINAL: Patient reported feeling a little nauseous.

GENITOURINARY: No complaints of burning on urination or urgency.

NEUROLOGICAL: The patient reports slight headache, but denied syncope and recent seizures.

MUSCULOSKELETAL: No complaints of muscle pain, and joint pain.

HEMATOLOGIC: Denies complaint of anemia, and bruising.

LYMPHATICS: No complaints of enlarged nodes.

ENDOCRINOLOGIC: The patient denies sweating, cold, polyuria, or polydipsia.

Objective:

Diagnostic results: Review of patient’s labs revealed.,

Urine Drug Screening (UDS): Normal.

Comprehensive metabolic panel (CMP): Normal.

Complete Bood Count (CBC): Normal

Liver Function Test: Normal.

Thyroid Function Test: Normal.

Ammonia Level: Normal. Performed to assess the possibility of hepatic encephalopathy.

Alcohol Level: Normal.

Deparkote (Valproic acid) Level: 20mcg/ml. This indicates medication noncompliance.

Pregnancy Test: Negative.

Assessment:

Mental Status Examination:

R.H is a 46-year-old African American female who appeared appropriately dressed. She was calm, attentive and intermittently avoided eye contact. She did not reveal signs of psychomotor retardation but had a crying episode during the interview. The speech was coherent, fluent, and normal in rate, rhythm, and articulation. Language skills were average. The mood was depressed, affect was anxious and irritable. Orientation to self, place and time was accurate. She was appropriately oriented to the right time, place, and person. Her thought process was normal, with no signs of delusions. The patient showed some lack of insight into her present condition and impaired judgment. Her recent and remote memory were slightly impaired. She reported hearing noncommanding auditory hallucination sometimes but denied visual hallucination, self harm, suicidal and homicidal thoughts.

Diagnostic Impression:

Paranoid Personality Disorder: 301.0 (F60.0)- Primary Diagnosis

Paranoid Personality disorder is associated with a pattern of enormous distrust and suspicion towards people, which results in impairment in the misinterpretation of others’ intentions causing violent and criminal behaviors (Doustkam etal., 2017). Paranoid personality is known to begin in early childhood, and the patient confirmed her symptoms started when she was about 22 years old. Symptoms linked with this disorder include suspecting people of harm without enough evidence, unjustified doubts of trustworthiness and reliability of companions, reading frightening meanings into friendly comments, and always bearing grudges towards other people, difficulty confiding in others due to the fear of the information being spitefully used and the perception that attacks are directed to their character or reputation that are not directed towards others and quick anger. The patient reported all the above symptoms which led to my selecting paranoid personality disorder as my primary disorder.

Borderline Personality Disorder: 301.83 (F60.3)

A borderline personality disorder is linked with an extensive pattern of unpredictable interpersonal relationships, self-image, and affect with noticeable impulsivity, which begins in early adulthood ( American Psychiatric Association, 2013). Symptoms of borderline personality disorder include averting thoughts of abandonment, constant feelings of emptiness, unstable interpersonal relationship with intense idealization and devaluation, identity disturbance, repeated suicidal behaviors or threats, affective instability such as intense anxiety or irritability lasting for some hours, disproportionate excessive / consistent anger causing frequent fights and short-term stress-related paranoid ideations. I choose borderline personality disorder as a differential diagnosis due to symptoms of anger and the onset of early adulthood like paranoid personality disorder. But the patient did not report other symptoms of borderline personality disorder. Therefore the symptoms presented by this patient do not meet the full criteria to make borderline personality disorder my primary diagnosis. Borderline personality disorder is a psychological disorder characterized by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image ( Miller etal., 2022).

Delusional Disorder Persecutory Type: 297.1 (F22)

Delusional disorder is characterized by one or more delusions occurring within 1 month or more ( American Psychiatric Association, 2013). Symptoms of Persecutory delusional disorder include the belief that there is a conspiracy against the individual, feelings of being cheated, spied upon, spitefully maligned or followed. People with persecutory delusion are usually infuriated, angry and violent towards the individuals they believe may be hurting them. This individual reported conspiracy thoughts, suspicion of harm, and quick/uncontrolled anger, which caused fights that began when she was 22. The individual deliberately engaged in the altercations because there was no evidence of delusion to justify the diagnosis of a persecutory delusional disorder. Delusional ideations may evolve from personality disorders, with paranoid traits and paranoid personality disorder being the strongest predictor of delusional severity (Tonna etal., 2018).

Reflections:

R.H is a 46-year-old African American female who reports feelings of suspicion towards her neighbors. This patient said that her anger and distrust has caused several fights. She also reported noncompliance to her medications and intermittent non commanding auditory hallucinations.

Firstly, obtaining the patient’s consent and right to confidentiality of care is essential. Furthermore, educating the patient and her family on medication compliance; involving her family members (mother and sister) with her consent in her care will help remind her to take her medications and adhere to the treatment plan. Non-adherence to psychotropic medications can result in increased illness, reduced treatment effectiveness, re-hospitalization, poor quality of life, relapse of symptoms, increased co-morbid medical conditions, and suicide attempts (Semahegn etal., 2020).

Due to previous medication allergies, the patient was encouraged to undergo gene testing to dictate which medication would be most effective for her. Starting the patient on Haldol ( first-generation antipsychotic) 5mg p.o to target auditory hallucination as the patient is allergic to abilify, and risperidone (second-generation antipsychotic) will enhance management of this patient. Since I cannot follow up with this patient, I will plan to switch to Haloperidol decanoate IM if the patient tolerates Haldol p.o over time to encourage medication compliance.

Educating the patient on the need for cognitive behavioral therapy is vital to help change dysfunctional thoughts, beliefs, and negative behaviors and aid appropriate thinking patterns, behavior, and mood adjustment. Cognitive-behavioral therapy (CBT) assists individuals in removing avoidant and safety-seeking behaviors that hinder self-correction of faulty beliefs, reduce stress-related disorders and enhance mental health (Nakao etal.,2021).

Based on the patient’s low socioeconomic status and History of marijuana use, the patient was educated against associating with individuals and events that cause drug use. This is because drug use increases impaired judgment and hinders the treatment plan. Substance use has been shown to impact the ongoing stagnation of life expectancy in the United States, which is more evident in lower socioeconomic strata than higher socioeconomic strata (Rehm & Probst, 2018).

Case Formulation and Treatment Plan:

Continue paroxetine (paxil) 30mg p.o daily (depression), buspirone 10mg p.o tid (anxiety), prazosin 1mg p.o nightly (nightmares), 750 mg deparkote p.o daily (seizures / mood stabilization).

Start Haldol 5mg p.o daily for psychotic symptoms. The patient is allergic to abilify, and risperidone. The patient is willing to be compliant with Haldol 5mg p.o daily.

The benefit of the medication was reviewed with the patient. Possible side effects / life-threatening side effects of Haldol and her other prescribed medications were reviewed with the patient. Side effects of Haldol include akathisia, tardive dyskinesia, sedation, dizziness, dry mouth, hypotension, neuroleptic malignant syndrome.

The patient was educated against suddenly stopping the medications without professional advice from the provider. The patient was made aware to contact the office immediately with any questions or proceed to the ER with life-threatening side effects. The patient verbalized understanding. The patient was advised to avoid over the counter drugs, illicit drugs without seeking professional advise.

Initiation:

Start Haldol 5mg p.o daily for psychotic symptoms.

Referral:

Therapist: Recommend individual cognitive-behavioral therapy.

Social worker: to determine if the patient qualifies for Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) to encourage adherence to the medications and plan of care, assist with better coping skills, and provide resources to enhance better living.

Alternative Therapy :

Mindfulness Meditation: helps reduce stress, depression, anxiety, and feelings of paranoia.

Art therapy: helps to serve as a source of distraction from disturbing or paranoid thoughts.

Health Promotion: I reviewed medical /psychiatric histories with the patient and educated the patient on the need for medication compliance to prevent decompensation, possible seizure activity, and life-threatening symptoms which may lead to inpatient hospitalization. The patient was also encouraged to set phone reminders to promote medication compliance. I enlightened the patient to give about 4 – 6 weeks to experience the maximum effect of the medications.

· Encouraged the patient to engage in physical activities/exercise to improve mood, sense of control, coping ability, and overall self-esteem.

· Encouraged the patient to eat a balanced diet and sleep hygiene such as consistent sleep time and avoiding noise at bedtime.

· Abstinence from marijuana or any illicit drug use and social events that will encourage use.

· The patient was encouraged to contract to safety to call 911, or the Baltimore Crisis Line at 410 433 5175 with active self-harm, suicidal and/or homicidal thoughts.

Phone calls: Called mother and sister to encourage patient’s medication compliance.

Time spent: about 15 minutes was set aside for the patient for questions and answers.

Labs reviewed include: CMP, CBC, UDS, Pregnancy, Liver function test, thyroid function test, alcohol level, and ammonia.

Order placed: Gene testing to identify which medication will be most effective for the patient.

Return to clinic: in 1 week.

To evaluate the patient’s response to new medication, Haldol 5mg p.o daily, medication compliance, and attitude towards the treatment plan/recommendations.

Suppose the patient continues to comply with Haldol 5mg p.o daily and can tolerate the drug over time. The plan will be to switch Haldol p.o to Haloperidol decanoate IM ( 10 – 20 times the p.o dosage), following all relevant safety protocols to manage this patient and further ensure medication compliance.

Discussion Questions / Prompts:

1. Identify other ways to encourage medication compliance in a patient with a paranoid personality disorder.

2. Identify other alternative therapies that will be beneficial in managing an individual with a paranoid personality disorder.

3. Identify one other type of psychotherapy that will effectively manage paranoid personality disorder.

References

American Psychiatric Association. (2013). Personality disorders. In Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, V: Author.

American Psychiatric Association. (2013). Delusional Disorder. In Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, V: Author.

Doustkam,M., Pourheidari, S., Mansouri, A. (2017). Interpretation bias towards vague
faces in individuals with paranoid personality disorder traits. Journal of
Fundamentals of Mental Health, 19(6), 441–450.
https://doi.org/10.22038/jfmh.2017.9550

Mendez-Miller, M., Naccarato, J., Radico, J. (2022). Borderline Personality Disorder.
American Family Physician, 105(2), 156–161.

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for
management of mental health and stress-related disorders: Recent advances in
techniques and technologies. BioPsychoSocial Medicine, 15(1), 1–4.
https://doi.org/10.1186/s13030-021-00219-w

Rehm, J., Probst, C. (2018). Decreases of life expectancy despite decreases in non-
communicable disease mortality: The role of substance use and socioeconomic
status. European Addiction Research, 24(2), 53–59.
https://doi.org/10.1159/000488328

Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2020).
Psychotropic medication non-adherence and its associated factors among
patients with major psychiatric disorders: a systematic review and meta-analysis.
Systematic Reviews, 9(1), 1–18. https://doi.org/10.1186/s13643-020-1274-3

Tonna, M., Paglia, F., Ottoni, R., Ossola, P., De Panfilis, C., Marchesi, C. (2018).
Delusional disorder: The role of personality and emotions on delusional ideation.
Comprehensive Psychiatry, 85, 78–83.
https://doi.org/10.1016/j.comppsych.2018.07.002