Care Across the Lifespan Il

Lovelyne

Introduction: 

Signs and symptoms of various mental health conditions can be vague, overlapping, and confusing to the untrained clinician (Owoyemi et al., 2021).  One of the requirements for the role of a Psychiatric Mental Health Nurse Practitioner involves possesing a thorough understanding of different psychiatric conditions, understand their clinical presentation, signs, and symptoms to provide the best care possible for each individual patient (Owoyemi et al., 2021).  Gathering information during the interview process is also a crucial component of the process as well as having access to collateral history that may provide additional information about the patient’s past and current condition and symptoms (Owoyemi et al.,2021).  Unfortunately, though there is medical imaging and lab work that may help identify certain mental health conditions, for the most part practitioners rely on the presentation of the condition to devise an appropriate treatment plan (Owoyemi et al.,2021). For this paper, we will conduct a comprehensive Focused SOAP psychiatric evaluation for a patient with Autism with the objective of finding out if there are any other internal or external contributing factors to his condition. Additional objectives include devising an effective treatment plan to help improve patient’s functioning back to his baseline.

· Practitioner introduced herself. Patient was able to state his name and age.  Visit lasted 55 minutes.

Subjective:  

CC (chief complaint): “I don’t have friends because I get in trouble”. 

HPI: Joey is a 12-year-old Caucasian male who presents with increased episodes of aggression as well as engaging in self injurious behaviors.  Joey was accompanied by both parents; they were referred to this practitioner for an evaluation and possible medication to address the increased aggression and self-injurious behaviors. Per mom, this is a new development, though the patient struggled with emotional dysregulation from a young age, his primary symptoms were tearfulness and being withdrawn. Joey is fully verbal and was able to actively participate in the discussion as well as answering questions regarding current symptoms with some redirection.  Minimal eye contact was noted during the interview and the patient required multiple redirections to task and people.  Joey’s appearance was clean yet disheveled, mom reports that he has been pulling and tugging at his tops and occasionally chewing on his shirt, while rocking and running into the house furniture. Joey also gets angry easily and throws things at his younger siblings.   He is a sixth grader who continues to struggle to adjust to his new middle school building and environment. Per mother, the transition has been difficult for the Joey, and she believes it is the primary cause for his regression. Joey patient was recently suspended from school for throwing a chair against the wall after being reprimanded by his teacher. Patient reports that he does not know why he engages in such behaviors and seems to enjoy running and banging into things despite the risk of getting hurt.  Patient denies SI/HI/AVH, reports that he doesn’t like the art murals at his new school and there are too many children in the hallway which Inhibits his ability to get to classes quietly and quickly.  Patient also reports he doesn’t have friends and that students constantly talk in the classroom as he tries to concentrate and focus on his work.  “They are annoying, and it drives me crazy!” Mom reports that the Joey struggled with change from a very young age, he also struggled with language, interpersonal skills, and sensory issues.

Past Psychiatric History: Per mother, Joey was initially diagnosed with a communication disorder due to lack of age- appropriate expressive skills at age two and he benefitted from intensive speech therapy.  In kindergarten, teachers observed that Joey was isolated to self and engaged in repetitive behaviors and stimming. Joey was then re-evaluated and was diagnosed with autism spectrum disorder.  Psychological testing revealed average IQ.  Patient is currently enrolled in general education with in-class support.  

Psychosocial History:  Joey is a 12-year-old male with Autism presenting with increased aggression. He lives with both parents, his three younger siblings and his maternal grandmother.  Patient is the oldest of four children, he has two younger brothers and one younger sister.  Per mom, her pregnancy was complicated and very stressful.  Mom reports that she developed gestational diabetes which required daily insulin shots. Joey was born at 37 weeks gestation via c-section, his Apgar score was 9. Joey met all developmental milestones except for language and at age two, he was evaluated and started speech therapy. Mom reports that his first seizure was at age 7 and it is now well managed with medication. The family attends church regularly, the father is an engineer at the local plant while the patient’s mother is a stay-at-home mom. Joey enjoys anime, reading, and plans to attend the University of California and major in software engineering. 

Substance Current Use: No family history of psychiatric hospitalization, substance abuse, or suicide .

Medical History: Patient has a history of WPW, eczema, and seizure disorder. All resolved and his seizure controlled with medication. Last physical was in October 2022.

· Current Medications: Keppra 40 mg po daily for Seizure disorder.

· Allergies: No known drug allergies .  Positive for environmental and food dye allergies. Mom reports that behaviors increase after eating certain foods and patient has eczema and certain clothing items may irritate and cause scratching .

· Reproductive Hx: Patient is showing signs on entering puberty. Patient denies being sexually active and no history of sexual abuse was reported.

ROS: 

· GENERAL: Patient appears healthy. 

· HEENT: No history of head injury, normal vision, hearing.  No sinus infection, no congestion, no abnormal discharges.  Current with dental visits.

· SKIN: Intact, no visible rashes, lesions, scars, lacerations observed, warm with normal capillary refill of less than 2 seconds.

· CARDIOVASCULAR: No chest pain reported, normal heart sound, rate and rhythm, patient with history of WPW which was resolved via ablation in 2020. No subsequent concern per cardiologist.

· RESPIRATORY: Normal breath sounds, normal pulmonary effort.

· GASTROINTESTINAL: Intermittent periods of constipation, no diarrhea, no vomiting.  negative for abdominal distention, tenderness, pain, or mass.

· GENITOURINARY: No urinary retention, hesitation no history of UTI.

· NEUROLOGICAL: No history of head injury, LOC , Alert, Positive for ASD, positive for history of Seizure but no SZ activity noted during assessment .

· MUSCULOSKELETAL: Normal and steady, normal ROM and neck supple.  History of toe walking until age Seven.

· HEMATOLOGIC: No abnormal bleeding or bruising reported. 

· LYMPHATICS: No swollen lymph nodes noted. 

· ENDOCRINOLOGIC: Normal blood sugar, normal TSH.

Objective:

Vitals:  T = 98.2, P= 90, R=18, BP= 100/55, O2= 100%, Height = 5.0, Weight = 100, BMI= 19.5

Diagnostic results: Recent labs from PCP are within normal limits. Normal EKG with resolved WPW. 

Mental Status Examination: Joey is a 12-year-old male presenting for assessment and possible medication recommendations for increased agitation and aggression.  Patient made minimal eye contact during the interview and required multiple redirections. Patient observed rocking back and forth while smiling inappropriately. Patient was responsive, respectful, and easily redirectable. Patient ‘s speech was clear, coherent, and purposeful.  Patient denies SI/HI/AVH. No signs of delusion, grandiosity noted. Patient’s cognition appears to be appropriate for age. Patient exhibited good rote, short term, and long-term memory skills. Patient was able to complete complex mental math problems without difficulty.  Judgment and insights are fair, and his thought process was logical and relevant.

Differential Diagnosis 

1. Post-Traumatic Stress Disorder (PTSD): A mental health disorder characterized by an individual’s inability to cope and recover from a traumatic life event they experienced or witnessed (Stavropoulos et al.,2018). Signs of the condition include recurrent nightmares, avoidance to triggering situations, flashbacks, heightened sense of fear, stress, anxiety without cause, difficulty in daily functioning and forming lasting bonds and relationships with others, unexpected outbursts, anger, and agitation (Stavropoulos et al.,2018). PTSD is treated with medication and psychotherapy (Stavropoulos et al.,2018).  In this case, the patient is not likely to have PTSD due to a lack of history of trauma.

2. Anti NMDA Receptor Encephalitis is an auto- immune encephalitis causing brain inflammation and multiple complex neuropsychiatric symptoms (Whiteley et al.,2021). This type of encephalitis was only recently identified, and research is ongoing to determine the possible triggers (Whiteley et al.,2021). In some cases, autoimmune encephalitis can be linked to an infection, or a tumor as the triggering culprit (Whiteley et al.,2021). This condition may affect thinking, memory, mood, and behaviors, it is a very serious condition that needs to be diagnosed as early as possible and treated for best outcome (Whiteley et al.,2021). Some believe that many children with autism may be suffering from variations of this condition (Monti et al., 2020). The term “acquired autism” often refers to autoimmune brain inflammations that cause autism like signs and symptoms or psychosis (Monti et al., 2020). Researchers agree that autoimmune encephalitis may be an underlying cause of autism or is often misdiagnosed as autism, however further studies are required to solidify that hypothesis (Monti et al., 2020).

3. Mood Disorders are a collection of different psychiatric disorders involving unusually strong emotions (Twenge et al, 2019).  These emotions are often an inappropriate and unwarranted reaction to a situation. Mood disorders include, depressive mood disorder, bipolar type I, bipolar type II, disruptive mood dysregulation disorder (DMDD), and premenstrual dysphoric disorder (Twenge et al, 2019).  Mood disorders are prevalent in the US, an estimated 21.4 % of the population experience a mood disorder at some point in their life (Twenge et al, 2019).  Therapy and medication are usually recommended for the treatment of mood disorders (Twenge et al, 2019). Joey does not meet the criteria for a mood disorder currently.

4. Reflections:  Joey’s case was new and unique to me. I found it interesting that this patient never engaged in aggressive behaviors until the past few months.  Some researchers believe there is a correlation between puberty and an increase in maladaptive symptoms and behaviors in children with autism (Kern et al., 2016). Middle school and adolescence represent a difficult period for children, but it can be particularly taxing and stressful for those with Autism (Kern et al., 2016).  Individuals with autism struggle to adapt to change, the size of the school and the loud noises may contribute to the Joey’s inability to cope, hence to aggression. The sudden appearance of new symptoms could point to other conditions; however, the patient was diagnosed with autism at an early age. I want to consider additional lab testing to rule out Anti-nmda receptor encephalitis, starting with a blood serum and ultimately spinal fluid screening if warranted. I plan to partner with Joey’s PCP to ensure that follow up is done. Patient is started on two psychotropic medications simultaneously; I would have liked to start him on one and monitor for progress.

Case Formulation and Treatment Plan: 

Medication:

a. Start Risperidone 0.5 mg po daily for agitation.

b. Start Depakote to 250 mg po BID for mood.

c. Continue Keppra 40 mg po daily

d. Conduct a 72 hour at home continuous monitoring of brain activity using EEG to check for Seizures.

e. Blood Serum screening to rule out or confirm anti-nmda encephalitis.

f. Start psychotherapy once a week to help develop better coping skills and reduce aggression.

g. Begin social skills groups to help appropriate interactions with peers and reduce isolation.

h. Consider noise canceling headphones and accommodation in the patient’s IEP for smaller class size as this may relieve patient of some of the everyday stressors.

i. Education provided to family regarding the patient's current diagnosis of Autism, prescribed medication, and recommended psychotherapy. Practitioner answered questions and addressed concerns.

J. Family members are aware to call 911 or take patient to the nearest ER should the patient exhibit extreme aggression or attempts to self- harm.

k. Family to follow up with this practitioner in two weeks. 

Questions:

Is Risperidone FDA approved for patients with Autism?

Do you agree with current medications?

Should patient start one psychotropic medication at a time?

Would you consider an additional diagnosis or diagnoses for this patient?

Do you believe that the implementation of psychotherapy will benefit this patient?

Should Joey see an endocrinologist to address possible hormonal changes affecting patient’s mood?

References

 Beer, R. (2018). Efficacy of EMDR therapy for children with PTSD: A review of the literature.  Journal of EMDR Practice and Research,  12(4), 177-195.

Campisi, L., Imran, N., Nazeer, A., Skokauskas, N., & Azeem, M. W. (2018). Autism spectrum disorder.  British Medical Bulletin,  127(1).

Coleman, J. R., Gaspar, H. A., Bryois, J., Byrne, E. M., Forstner, A. J., Holmans, P. A., ... & Lawson, W. B. (2020). The genetics of the mood disorder spectrum: genome-wide association analyses of more than 185,000 cases and 439,000 controls.  Biological psychiatry,  88(2), 169-184.

Dalmau, J., Armangué, T., Planagumà, J., Radosevic, M., Mannara, F., Leypoldt, F., ... & Graus, F. (2019). An update on anti-NMDA receptor encephalitis for neurologists and psychiatrists: mechanisms and models.  The Lancet Neurology,  18(11), 1045-1057.

DePierro, J., D'Andrea, W., Spinazzola, J., Stafford, E., van Der Kolk, B., Saxe, G., ... & Ford, J. D. (2019). Beyond PTSD: Client presentations of developmental trauma disorder from a national survey of clinicians.  Psychological Trauma: Theory, Research, Practice, and Policy.

Heine, J., Kopp, U. A., Klag, J., Ploner, C. J., Prüss, H., & Finke, C. (2021). Long‐Term Cognitive Outcome in Anti–N‐Methyl‐D‐Aspartate Receptor Encephalitis.  Annals of neurology,  90(6), 949-961.

Kern, J. K., Geier, D. A., Sykes, L. K., & Geier, M. R. (2016). Relevance of Neuroinflammation and Encephalitis in Autism.  Frontiers in cellular neuroscience,  9, 519. https://doi.org/10.3389/fncel.2015.00519

Monti, G., Giovannini, G., Marudi, A., Bedin, R., Melegari, A., Simone, A. M., ... & Meletti, S. (2020). Anti-NMDA receptor encephalitis presenting as new onset refractory status epilepticus in COVID-19.  Seizure-European Journal of Epilepsy,  81, 18-20.

Owoyemi, P., Salcone, S., King, C., Kim, H. J., Ressler, K. J., & Vahia, I. V. (2021). Measuring and Quantifying Collateral Information in Psychiatry: Development and Preliminary Validation of the McLean Collateral Information and Clinical Actionability Scale.  JMIR Mental Health,  8(4), e25050.

Stavropoulos, K. K. M., Bolourian, Y., & Blacher, J. (2018). Differential diagnosis of autism spectrum disorder and post-traumatic stress disorder: Two clinical cases.  Journal of Clinical Medicine,  7(4), 71.

Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E., & Binau, S. G. (2019). Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005–2017.  Journal of abnormal psychology,  128(3), 185.

Van’t Hof, M., Tisseur, C., van Berckelear-Onnes, I., van Nieuwenhuyzen, A., Daniels, A. M., Deen, M., ... & Ester, W. A. (2021). Age at autism spectrum disorder diagnosis: A systematic review and meta-analysis from 2012 to 2019.  Autism,  25(4), 862-873.

Whiteley, P., Marlow, B., Kapoor, R. R., Blagojevic-Stokic, N., & Sala, R. (2021). Autoimmune Encephalitis and Autism Spectrum Disorder.  Frontiers in psychiatry,  12, 775017. https://doi.org/10.3389/fpsyt.2021.775017