Week 6 Mental Health Part 2

Week 6 Mental Health Part 2

Differential Diagnosis

Post-traumatic Stress Disorder (PTSD)

PTSD is one of the psychiatric disorders that develop following a stressful or traumatic event. PTSD is a collection of distressing symptoms related to a distinct traumatic event that lasts for more than one month following the incident (Bryant, 2019). PTSD is more common in women. The diagnosis of PTSD is principally clinical based on the DSM-5 criteria.

The criteria for diagnosis include a stressor, intrusion symptoms, avoidance, negative alterations in mood, alterations in arousal and reactivity, a duration of more than one month, causation of significant occupational, social, and functional impairment and exclusion of substance use, medication or other medical illness (American Psychiatric Association, 2022).

A stressor can be precipitated by exposure to death, injury, or sexual abuse and may be direct experience, witnessing, or hearing about these events. Meanwhile, intrusion symptoms are characterized by recurrent distressing memories, flashbacks, distressing dreams, and severe psychological distress (American Psychiatric Association, 2022).

Alterations in arousal and reactivity are distinguished by sleep disturbances, hypervigilance, poor concentration, irritable behavior, and heightened startle reflex. Negative alterations in mood manifest as the inability to feel positive emotions, altered sense of reality, loss of memory regarding important details of the event, diminished interest in activities that used to be enjoyable and persistent, and distorted negative beliefs (American Psychiatric Association, 2022). Finally, avoidance manifests as avoidance of memories, thoughts, or feelings correlated to the event or avoidance of external reminders.

S.F most probably has PTSD. She is a female who was involved in a motor vehicle accident two months ago that led to her losing her brother on the spot. She was also sexually molested by her uncle. The aforementioned indicates exposure to a stressor. Consequently, she manifested symptoms of PTSD such as insomnia, hypervigilance, irritability, nightmares, flashbacks about the event, fear, anger, agitation, hostility, and crankiness.

Additionally, the onset of symptoms followed a traumatic event two months ago and cannot be attributed to substance use or another medical condition. Finally, the symptoms have caused significant impairment in her social and occupational functioning.

Depression

Depression is chiefly characterized by anhedonia and a depressed mood lasting more than two weeks. S.F manifests with features of depression, including fatigue, irritability, sleep disturbances, and psychomotor agitation. Similarly, there is no history of a hypomanic or manic episode, and the symptomatology causes significant occupational impairment (American Psychiatric Association, 2022).

Depression is also more common in females and common comorbidity in PTSD. However, the DSM-5 criteria require the presence of at least five symptoms, with at least one being depressed mood or anhedonia (American Psychiatric Association, 2022). Besides, another psychiatric disorder must be excluded, making the diagnosis of depression less likely to be the main diagnosis. Finally, a PHQ-9 score of 6 is only indicative of mild depression.

Adjustment Disorder

Adjustment disorder refers to a maladaptive emotional or behavioral response to a stressor that lasts less than six months following the resolution of a stressor (O’Donnell et al., 2019). An emotional response may be in the form of anxiety, while a behavioral response may manifest as outbursts (O’Donnell et al., 2019). S.F experienced was involved in a motor vehicle accident and lost her brother, which is truly a stressor. Subsequently, she developed anxiety, fearfulness, irritability, fatigue, and insomnia.

Furthermore, her GAD-7 score of 5 indicates mild anxiety. The symptoms have also caused significant functional impairment, although the duration of three weeks precludes the diagnosis of a generalized anxiety disorder (O’Donnell et al., 2019). However, adjustment disorder is not the most likely diagnosis as her symptomatology can be explained better by another mental disorder such as PTSD

Primary Diagnosis

The primary diagnosis is, therefore, PTSD. S.F meets the DSM-5 criteria for diagnosis of PTSD as outlined in the previous paragraphs, including a stressor, intrusion symptoms, avoidance, negative alterations in mood, alterations in arousal and reactivity, a duration of more than one month, causation of significant occupational, social and functional impairment and exclusion of substance use, medication or other medical illness (American Psychiatric Association, 2022). Traumatic events are relatively common, with an estimated lifetime prevalence of 61 to 80%, although only approximately 5 to 10 % develop PTSD (Bryant, 2019). Finally, PTSD is four times more common in women than men.

Treatment Plan

Early diagnosis and interventions are essential for the effective treatment of PTSD and the minimization of the long-term sequelae associated with this condition (Smith et al., 2019). The following outlines the treatment plan for S.F:

• Laboratory tests including complete blood count, complete metabolic panel, lipid profile, thyroid function tests, serum vitamin B12 levels, ad random blood glucose to exclude organic causes of the symptoms and also as a baseline for initiating medical treatment (Smith et al., 2019).
• Psychotherapy- Trauma-focused cognitive behavioral therapy is considered first-line treatment (Watkins et al., 2018). Trauma-focused CBT will enable her to counter the negative effects of trauma by facilitating the processing of traumatic memories, developing effective interpersonal and coping skills, and overcoming problematic behaviors and thoughts (Watkins et al., 2018). Twelve to sixteen sessions over four to six months are required (Watkins et al., 2018).
• Sertraline 25 mg PO once daily for seven days and then 50 mg PO once daily. Sertraline an SSRI approved by FDA for the treatment of PTSD. Additionally, sertraline will improve the depressive and anxiety symptoms that she has.
• Continue lisinopril10mg, Crestor 5mg, and Zyrtec 10mg for comorbid conditions.
• Patient education- educate on the importance of treatment adherence, medication side effects, and the need for alcohol and smoking cessation. Enlighten the family to provide social support (Bryant, 2019).
• Referral- involvement of a psychiatrist, psychologist, and physician for comprehensive management.
• Follow-up- follow up weekly to monitor response to treatment and for trauma-focused CBT sessions.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 18(3), 259–269. https://doi.org/10.1002/wps.20656

O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International Journal of Environmental Research and Public Health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537

Smith, P., Dalgleish, T., & Meiser-Stedman, R. (2019). Practitioner Review: Posttraumatic stress disorder and its treatment in children and adolescents. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 60(5), 500–515. https://doi.org/10.1111/jcpp.12983

Watkins, L. E., Sprang, K. R., & Rothbaum, B. O. (2018). Treating PTSD: A review of evidence-based psychotherapy interventions. Frontiers in Behavioral Neuroscience, 12, 258. https://doi.org/10.3389/fnbeh.2018.00258

Week 6 Mental Health Part 2 Instructions

Here is the information on my fictitious patient:

Patient: S.F, 45yr old African American

Gender: Female

Setting: Family practice clinic


SUBJECTIVE:

CC: “I have not slept in the last one week. I have been overly agitated, anxious, fearful, hypervigilant, irritable and hostile because every time I close my eyes to sleep, I get nightmares. Am sick and tired of this and don’t know how much more of it I can take”

HPI: S.F is a 45yr old African American who came into the clinic today with a c/o anxiety, fearfulness, hypervigilance, agitation, irritability, hostility and insomnia in the last one week. She finds herself being very cranky. Patient was involved in a MVP 2 months ago and lost her brother on the spot in that accident. She gets nightmares about the accident every so often but it has never stopped her from sleeping until now. She denies caffeine use, which could cause her to not sleep. Patient is a clerk at a local hospital and has called in all week because of her irritability, crankiness, hostility, anxiety, agitation and fearfulness. She has tried yoga to help her relax but that has not helped much with her nightmares. Nothing seemed to have helped much so far.

Current Medication: Lisinopril 10mg, Crestor 5mg and Zyrtec 10mg

PMHx: HTN, high cholesterol and Allergic rhinitis

Allergies/Immunologic: NKDA

PSHx: None

Health Screening: UTD with vaccines, gets yearly wellness visits and lab-works

Social Hx: Smokes 1/2pk of cigarette per day, occasional alcohol intake. Denies drug use or caffeine use. Married with 2 teenage girls. Patient works as a unit clerk in a local hospital.

Family Hx: HTN, T2DM, Hypothyroidism, Cervical cancer, breast CA, stroke, MI, depression, schizophrenia, anxiety and PTSD

Major events/Risk factors: sexual molestation from an uncle, experienced fatal motor vehicle accident 2 months ago, in which she lost her brother.

 Review of Systems (ROS):

Constitutional: Denies fatigue, fever, chills, headache, vision changes, dizziness or weakness

HEENT: Denies headaches. No visual disturbances. Denies headache, vertigo or sore throat

Neck/Lymph: Denies lumps or swelling in neck or lymphadenopathy

Chest/Lungs: No dyspnea with exercise.

CV: No murmur. No edema of lower extremities.

Peripheral Vascular: No changes in coloration of extremities.

GI: Good appetite. Denies signs and symptoms of GERD.

GU: Denies any burning, or painful urination. Denies frequent urination or discharge

Skin/Hair/Nails: No excess sweating, rashes, dryness, hair loss or nail changes.

Endocrine: Denies temperature intolerance. Polyuria, polydipsia, or polyphagia.

Musculoskeletal: No muscle weakness or pain. No difficulty with ambulation.

Neurological: No dizziness, fainting, or seizure activity.

Psychiatric: Admits he gets flashbacks, anxiety, agitation, hypervigilance, mistrust issues, fear and unwanted memories/flashbacks


OBJECTIVE: PE

Height 5’ 8”. Weighs 160lbs

Vitals: BP 133/79. T 97.5, R 18, O2 94% RA, P 66

General: A 45yr old African American woman who appears her stated age, in NAD. AXOX4. Able to speak in full sentences and does not appear breathless. Skin is with no cyanosis and appears warm, dry, intact with a pale pink color.

HEENT: Head normo-cephalic. Hair thick and distribution even throughout scalp. 

Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. 

Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender.

Nose: Turbinates intact and pink. No nasal drainage, nose bleed or nasal congestion.

Throat: Oropharynx pink, moist, no lesions or exudate. Tonsils 1+ bilaterally. Teeth in good repair, no cavities noted. Tongue smooth, pink, no lesions, protrudes in midline.

Neck/Lymph: supple, no cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. No JVD noted

Lungs: Lungs clear to auscultation bilaterally. Respiration un-labored. No wheezing or SOB

CV: Heart S1 and S2 noted, RRR, no murmurs noted, no displaced PMI. Peripheral pulses equal bilaterally, no peripheral edema 

Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organo-megaly noted. 

Respiratory: Lungs CTA bilaterally. RR un-labored and even, chest rise with each breath equal bilaterally

Psychiatric: Appears hypervigilant, anxious, annoyed, agitated, fearful, irritable and hostile.


Diagnostic work-Up

PHQ-9 score = 6

GAD-7 score = 5

You suspect a mental health disorder,

1. What are the three possible differential diagnoses for this patient?

2. What is your primary diagnosis for this patient given the pattern of occurrence of symptoms, exam results, and recent history? Include the rationale and a reference for your diagnoses.

3. What is your first-line treatment plan for S.F, including medications, labs, education, referrals, and follow-up? Identify the drug class of each medication you prescribe and exactly what symptom it is targeted to address.

 Please answer three questions at the end of the scenario. the primary diagnosis for this SCENARIO is PTSD Please come up with two more. for the treatment plan reference every medication use.