Neurocognitive and Neurodevelopmental Disorders
CC (chief complaint): “My boss has accelerated job deadlines, which puts a lot of pressure on me, and makes me feel like I can’t concentrate.” The patient reports
Mr. Harold Brown, a 60-year-old male patient, comes to the psychiatric clinic for an evaluation after his boss recommends that he visit a psychiatrist. He reports having difficulties focusing at work. He recently reported making silly mistakes while working on his architectural projects. For example, he was tasked to build air ducts, but he did so through a solid wall, a firewall, and a supporting wall, and he claims not even to realize what he was doing.
Another time, he was tasked with drawing window openings, and he drew them much too small. He claims that the difficulty with concentration began when they were forced to work under ridiculously tight deadlines. He did not have similar difficulties before when he was relaxed and on a flexible schedule.
He reports having had similar difficulties in school. During exams, when people would cram in the library, he would have trouble maintaining sustained concentration while reading. He would be easily distracted by what was going on outside the windows, such as the snow. If anyone whispered next to him, he would go to another side of the library, reporting being easily distracted by the whispers.
At work, the patient and all the other architects and engineers get daily lectures from the chief of the department on the mission of the day. He admits having difficulty concentrating during the lectures since he continues thinking about his dog, lunch, and other things.
He also reports failing to finish his duties. Recently, when designing the gutters for a penthouse, his attention was instantly attracted to the Italian tile floor slanted the wrong way, and he abandoned the gutter task to examine how to rectify the misaligned floor tiles. He also claims to have trouble arranging duties and activities at school and home.
“At home, I lose my shoes, socks, phone, and jacket, and I can’t locate them,” he says. One of his employees suggested that he maintain a calendar and mark key dates and events on it, but he seldom looks at it and considers it a waste of time. He also describes being hyperactive and being a bit uncomfortable on a chair. His recent trouble concentrating and low productivity at work led his employer to schedule a psychiatric assessment for him.
Past Psychiatric History:
- General Statement: despite glaring difficulties with concentration which began while in school, this is the first time the patient is seeking a psychiatric assessment
- Caregivers (if applicable): None
- Hospitalizations: No history of previous hospitalization due to medical or surgical illnesses
- Medication trials: No previous medication trials
- Psychotherapy or Previous Psychiatric Diagnosis: No previous psychotherapy. There have been no past psychiatric diagnoses; nonetheless, he states that his mother felt he had a problem and often threatened to send him for psychiatric examination, which never occurred.
Substance Current Use and History: He takes a little coffee now and again to help him focus. On weekends, he enjoys one scotch drink with a cigar.
Family Psychiatric/Substance Use History: He dates casually, never married, no children. He has one younger brother. No substance use disorders in the family.
Psychosocial History: He was raised by his mother. He has one younger sibling (brother). He now lives alone, dates casually and has never married, and has no children. He is an engineer with a bachelor’s degree. He works as an engineer for a prominent architectural engineering firm. He has never had a legal problem.
He has a history of hypertension, angina, hypertriglyceridemia, and benign prostatic hyperplasia (BPH).
- Current Medications:
- Cozaar 100mg daily for hypertension
- ASA 81mg PO daily and Valsartan 80mg daily for angina
- Fenofibrate 160mg daily for hypertriglyceridemia
- Tamsulosin 0.4mg PO at bedtime for BPH
- Allergies: Dilaudid
- Reproductive Hx: Heterosexual
- GENERAL: Reports hotness of body. Denies hills, weight loss, weakness, or fatigue
- HEENT: Head: denies head trauma. Eyes: Denies visual loss, blurred vision, or double vision. Ears: Denies loss of hearing, pain, or discharge. Nose: Denies nasal congestion, loss of smell, runny nose, and sneezing. Throat: Denies sore throat
- SKIN: Denies rashes, or itching
- CARDIOVASCULAR: Denies palpitations, chest pain, orthopnea, paroxysmal nocturnal dyspnea (PND), or lower limb edema
- RESPIRATORY: Denies dyspnea, coughs, or sputum
- GASTROINTESTINAL: Denies nausea and/or vomiting, diarrhea, constipation, abdominal tenderness, or swelling
- GENITOURINARY: Denies dysuria, frequency, hesitancy, color changes, or odor
- NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, gait disturbances, numbness, or tingling sensations.
- MUSCULOSKELETAL: Denies joint pains, swelling, stiffness, or limb deformity
- HEMATOLOGIC: Denies bleeding diathesis, easy bruising, anemia, or jaundice
- LYMPHATICS: Denies lymphadenopathies
- ENDOCRINOLOGIC: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, or excessive sweating
He is in a general fair condition but febrile, with no obvious respiratory distress. He does not have any pallor, jaundice, cyanosis, lymphadenopathy, or edema. His vital signs are as follows:
T- 98.8 F
P- 74 beats/minute
RR 18 breaths/minute
BP 134/70 mm Hg
Neurologic: GCS 15/15. Oriented to time, person and place. He has intact memory. Sensory and motor systems are intact
Cardiovascular: S1 and S2 sounds were heard, with no additional sounds. Apex heard at the 5th intercostal space, mid-clavicular line.
Respiratory: Lungs are bilaterally clear to auscultation
Montreal Cognitive Assessment (MOCA): 28/30 difficulty with attention and delayed recall
Adult ADHD Self-Report Scale for DSM-5 (ASRS): 21/24
Mental Status Examination:
A 60-year-old male patient looking his age walks into the clinic. He is well-groomed, has a slim physique, and is quite uncomfortable remaining seated on the chair as he continues to stand and gaze out the window. He makes no eye contact with the examiner, does not listen when spoken to directly, and continues to blurt out answers even before the questions are completed.
His speech is fast-paced, loud, and hyper-talkative, and he loses the spontaneity of the conversation by jumping from one topic to the next. When asked about his mood, he says, “I’m sad because I can’t concentrate.” His affect is sad, which is appropriate considering his sad mood.
His thought content is preoccupied with feeding his dog and deciding what to eat for lunch, whereas his thought process is positive for a flight of ideas, jumping from one topic to the next. He has no abnormalities in his perception. His memory is intact, and he is oriented to time, person, and place. His abstract, judgment, and insight are all intact, and he admits to having a problem that requires assistance.
Primary Diagnosis: Adult ADHD
Adult ADHD is diagnosed using the DSM-5 criteria, which include inattention and hyperactivity-impulsivity as critical features. To establish the diagnosis in persons 17 years and older, at least five symptoms of inattention or at least five symptoms of hyperactivity-impulsivity must be present in criteria A and B, respectively (APA, 2022; Salvi et al., 2019).
In several ways, the 60-year-old patient displays inattention or trouble focusing. He makes careless mistakes at work, such as drawing window openings much smaller, he fails to complete his tasks, such as jumping to examine how to fix the Italian tiled floor before finishing the gutters, he does not maintain sustained attention during lectures at work, and while in school could not sustain concentration in the library; he reports that he could easily be distracted by extraneous stimuli, such as whispers or snow outside the windows, and finally, he has trouble arranging his belongings and often misplaces his shoes, phones, and socks at home.
Furthermore, he has hyperactivity-he reports that he is quite uncomfortable on the chair and always wants to move about freely.
In criterion B, the symptoms of inattentiveness or hyperactive-impulsivity must have been apparent before the age of 12. The patient had inattentive symptoms while in school, but the age at which they began is unknown. Furthermore, the symptoms must have shown in more than two places (criterion C), as Harold did at school, home, and work., and they must cause considerable social, occupational, and academic dysfunction, as evidenced in the patient who had problems at school and now at work.
On MSE, he feels uneasy sitting in the chair and prefers to stand and look out the window. When talked to directly, he does not listen and blurts out replies even before the inquiry is finished. Furthermore, he is hyper-talkative and babbles, is preoccupied with thoughts of feeding his dog and determining what to eat for lunch, and displays a flight of ideas. His symptoms of inattention-hyperactivity, suggestive MSE findings, MOCA of 28/30 30 with problems in attention and delayed memory, and ASRS5 of 21/24, which suggests a likely ADHD, all support the diagnosis of ADHD.
Autism spectrum disorder: Individuals suffering from ADHD or autism spectrum disorder may demonstrate inattention, social dysfunction, and difficult-to-control behaviors (Antshel & Russo, 2019; Hayes et al., 2018). However, social dysfunction in autism spectrum disorder is caused by difficulties in social communication and social interaction, as indicated by a lack of social-emotional reciprocity and deficits in nonverbal communication behaviors that are not present in the patient, ruling out the diagnosis.
Alzheimer’s: Individuals suffering from Alzheimer’s disease have cognitive deficits in areas such as complex attention, executive function, and social cognition (Knopman et al., 2021). Harold Brown’s inattention is caused by ADHD rather than cognitive impairment, ruling out Alzheimer’s disease.
This case has helped me better understand ADHD, especially in adults, and how to utilize the DSM-5 and other assessment instruments, such as the MOCA and the ASRS5 to validate ADHD diagnosis. In terms of ethics, elderly psychiatric patients need to be treated with the greatest justice, taking into consideration their mental health requirements, financial status, and social support.
Furthermore, Mr. Harold’s psychiatric treatments must be tailored in such a way that they are beneficial (beneficence), do not cause harm (non-maleficence), and do not violate the patient’s autonomy. In terms of social determinants of health, the patient, based on his medical history, has little social support since he has never married and has just one brother.
As a result, when he is discharged from the mental clinic, the lack of adequate social support may signify a poor prognosis (Wang et al., 2018). He is employed as an engineer at an architectural firm and consequently can afford to access mental care services. In addition to his psychiatric comorbidity, his chronic medical illnesses are expensive in the long term, and he may need health insurance to assist him access and utilizing healthcare services.
American Psychiatric Association. (2022). Neurocognitive Disorders. In Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787.x17_neurocognitive_disorders
Antshel, K. M., & Russo, N. (2019). Autism spectrum disorders and ADHD: Overlapping phenomenology, diagnostic issues, and treatment considerations. Current Psychiatry Reports, 21(5), 34. https://doi.org/10.1007/s11920-019-1020-5
Hayes, J., Ford, T., Rafeeque, H., & Russell, G. (2018). Clinical practice guidelines for the diagnosis of autism spectrum disorder in adults and children in the UK: a narrative review. BMC Psychiatry, 18(1). https://doi.org/10.1186/s12888-018-1800-1
Knopman, D. S., Amieva, H., Petersen, R. C., Chételat, G., Holtzman, D. M., Hyman, B. T., Nixon, R. A., & Jones, D. T. (2021). Alzheimer disease. Nature Reviews. Disease Primers, 7(1), 33. https://doi.org/10.1038/s41572-021-00269-y
Salvi, V., Migliarese, G., Venturi, V., Rossi, F., Torriero, S., Viganò, V., Cerveri, G., & Mencacci, C. (2019). ADHD in adults: clinical subtypes and associated characteristics. Rivista Di Psichiatria, 54(2), 84–89. https://doi.org/10.1708/3142.31249
Wang, J., Mann, F., Lloyd-Evans, B., Ma, R., & Johnson, S. (2018). Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry, 18(1). https://doi.org/10.1186/s12888-018-1736-5
Assignment: Assessing and Diagnosing Patients With Neurocognitive and Neurodevelopmental Disorders
Neurodevelopmental disorders begin in the developmental period of childhood and may continue through adulthood. They may range from the very specific to a general or global impairment, and often co-occur (APA, 2013). They include specific learning and language disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, and intellectual disabilities. Neurocognitive disorders, on the other hand, represent a decline in one or more areas of prior mental function that is significant enough to impact independent functioning. They may occur at any time in life and be caused by factors such brain injury; diseases such as Alzheimerâ€™s, Parkinsonâ€™s, or Huntingtonâ€™s; infection; or stroke, among others. For this Assignment, you will assess a patient in a case study who presents with a neurocognitive or neurodevelopmental disorder. To Prepare: Review this weekâ€™s Learning Resources and consider the insights they provide. Consider how neurocognitive impairments may have similar presentations to other psychological disorders. Review the Comprehensive Psychiatric Evaluation template, which you will use to complete this Assignment. By Day 1 of this week, select a specific video case study to use for this Assignment from the Video Case Selections choices in the Learning Resources. View your assigned video case and review the additional data for the case in the â€œCase History Reportsâ€ document, keeping the requirements of the evaluation template in mind. Consider what history would be necessary to collect from this patient. Consider what interview questions you would need to ask this patient. Identify at least three possible differential diagnoses for the patient. Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate primary diagnosis. Incorporate the following into your responses in the template: Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life? Objective: What observations did you make during the psychiatric assessment?â€¯ Assessment: Discuss the patientâ€™s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, listed in order from highest priority to lowest priority. Compare the DSM-5 diagnostic criteria for each differential diagnosis and explain what DSM-5 criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case. Reflection notes: What would you do differently with this client if you could conduct the session over?â€¯Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).