Discussion Questions / Prompts:

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.