Captain of the Ship Project – Obsessive Compulsive Disorders Paper
“Captain of the Ship” Project – Obsessive-Compulsive Disorders Paper
Walden University NURS 6670, PMH Nurse Practitioner Role II: Adult and Older Adult
Thirty years ago, a diagnosis of OCD was a life sentence in the psychiatry world because it was almost untreatable, but now it is a manageable one (Lack, 2012). OCD is ‘characterized by having intrusive, troubling thoughts (obsessions), and repetitive, ritualistic behaviors (compulsions)’ which takes time and impairs the patients functioning or causes significant distress (DSM-5). These thoughts, feelings, ideas, or sensations (Sadock, 2014) push the patient to be very anxious and elicits certain repeated behaviors to reduce anxiety (Lack, 2012). Men and women are likely to be affected by the mean age of onset, about 22 years, with a 67% lifetime prevalence for major depression (Sadock, 2014).
HPI and clinical impression of VB
VB is a 41-year-old Caucasian woman who comes in today for her routine follow up.
V.B. has Down syndrome and was diagnosed with OCD in her early twenties. Other diagnoses include depression, intermittent explosive disorder, mood disorder, hyperlipidemia, and hypothyroidism. She is very independent in her activities of daily living. V.B. has a history of physical aggression and property destruction and takes Depakote ER 500mg BID, Haldol 0.5MG BID, Neurontin 100mg TID, and Cogentin 0.5mg BID.
VB works at the local grocery store and lives at home with her mother. She understands prices and can make simple purchases at the store but needs some assistance with her finances. V.B. was married at one point, though divorced now and had no children. She comes in alone today for a follow-up. V.B. has ‘a thing about her bra not on the right’ or the strings in her pants and tries to fix it until she gets it right. Her mother explains that she uses more than an hour to get dressed because she will hook and unhook her bra numerous times before she gets out of her room and then after.
V.B. does not care where she is to set her clothes straight. She can stop in the middle of the mall, lift her dress, and try to fix her bra. In the clinic, she will usually spend about 45 minutes in the bathroom because her bra is not right or her pants strings are not tied a specific way. Her mother tries to encourage her to buy clothes without strings to no avail. And it is better the pant string than stripping in public to get to her bra.
V.B. gets very agitated when asked to hurry up or when told her clothing are fine and will begin to act aggressively towards whoever is saying that to her. She will throw objects, scream, scratch, pinch, and sometimes in extreme cases, induce urinary and fecal incontinence due to her frustration. V.B. has fair insight that her beliefs may or may not be accurate (Sadock, 2014).
Psychopharmacologic treatments for V.B.
People diagnosed with OCD are said to have a lower level of serotonin in the neural synapses; thus, SSRIs are considered first-line medication treatment (Storch, 2006). Studies show that SSRIs benefit adults with OCD (Lack, 2012). V.B. was previously on Zoloft, and it is unclear why she stopped taking it. She states today that she responded well to Zoloft with minimal side effects.
The FDA has approved Zoloft for treating OCD, though a higher dose is needed for adequate symptoms control (Sadock, 2014). I will thus start her on Zoloft 50mg and titrate accordingly till her symptoms are reduced. Her maintenance target will be at 150mg daily. Many prescribers augment the SSRIs with Depakote, Lithium, or Tegretol if SSRI alone is unsuccessful, so it is a good thing that V.B. already takes Depakote. The goal of treatment is to reduce V.B.’s current symptoms and continue indefinitely for maintenance (Stahl, 2017)
Psychotherapy choices for V.B.
Behavior therapy is as effective as medications in patients with OCD and has long-lasting effects (Sadock, 2014). Effective behavior therapy for V.B. will include exposure and ritual/response prevention to allow her to form a habit of not needing all her rituals to reduce her anxiety (Goddard, 2014). CBT with exposure and response prevention has been proven to work for both children and adults with OCD (Storch, 2006).
Controlled trials in adults have given an 85% response rate with complete remission of symptoms (Storch, 2006 “Captain of the Ship” Project – Obsessive-Compulsive Disorders Paper). This common-sense approach will allow V.B. to confront her fears and teach her ways to cope with the anxiety that will arise and process it without performing any rituals (Goddard, 2014). Having the family involved will help her succeed; most families try to pressure patients to avoid the behavior.
Family therapy will allow the family to reassure V.B and understand the disorder’s delays (Storch, 2006). Supportive psychotherapy, like showing empathy, having a therapeutic alliance, strength support, optimism, explanations about the disease process, etc., benefits all clients (Sadock, 2014), so V.B. can benefit from this type of therapy well.
V. B Medical management needs
V.B. suffered a stroke on 12/31/2011 and has recovered fully. She sees her PCP every 90 days. She takes a slew of medications to include fish oil, Vitamin D, B6, B12, C.Q. 10, Multivitamin, folic acid, Synthroid 50mcg, Lipitor 10mg. Her health is stable at this time, and she has no new medical issues or complications. She has other specialists that she sees annually and follows up as needed. She is compliant with all her medical needs. She sees a nutritionist every year. She is not one to exercise, but she tries to make healthy choices and has kept a healthy weight. Cardiology is every six months to do her EKG – no issues present. Neurology is every year- no medications prescribed. GYN is every two years- no issues found. Mammogram every two years and the dentist every year.
Community support resources for V.B
V.B. has support from her family. Her mother and brother are her surrogate decision- makers though she is her legal guardian. She can think clearly for herself and make good choices. V.B. works with the Division of Rehabilitation Services (DORS) program. This entity help people with disabilities go and succeed at the job site. V.B. has a caseworker who assists her with navigating available resources in the community.
V.B. gets worried about her future without her mother or brother and is seeking alternative housing just in case of the inevitable to avoid homelessness. V.B. is in contact with her caseworker once a month. V.B sometimes has a job coach present at the job site to assist. In combination with her medication compliance and psychotherapy, V.B. is living her best life as she usually puts it.
Follow-up plan for V.B
V.B. will follow-up in a week to assess how she is tolerating the new medication. V.B. will be asked to monitor the side effects and call or visit if she has mood swings or suicidal thoughts. Weekly follow up will be for another visit, and if she has no side effects, I will increase the Zoloft to 100mg and have bi-weekly follow ups. I will start her on a routine four-week follow-up when I reach her daily target of 150mg/day with symptoms reduction. V.B. will see her therapist weekly and work on ways to deal with her anxiety and rituals. The therapist and V.B. will decide on the schedule for her visits.
Conclusion
The course of OCD is chronic and unremitting if left untreated as symptoms fluctuate over time and become worse (Storch, 2006). Today OCD is manageable with pharmacological and non- pharmacological treatment that is effective for patients (Lack, 2012). Many patients do not respond to medications alone, so augmenting it with therapy is the most effective option (Storch, 2006). An early and accurate diagnosis will give V.B. and her family a festive look at life.
Reference for Captain of the Ship Project – Obsessive Compulsive Disorders Paper
- Diagnostic and statistical manual of mental disorders (5th Ed). (2013). Washington DC: American Psychiatric Association.
- Gabbard, G. 0. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, D.C.: American Psychiatric Publications.
- Lack C. W. (2012). Obsessive-compulsive disorder: Evidence-based treatments and future directions for research. World journal of psychiatry, 2(6), 86–90. https://doi.org/10.5498/wjp.v2.i6.86
- Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11 th ed). Philadelphia, PA: Wolters Kluwer.
- Stahl, S. M. (2017). Prescribers Guide: Stahl’s Essentials Psychopharmacology (6th ed.). New York, NY: Cambridge University Press.
- Storch, E. A., & Merlo, L. J. (2006). Obsessive-compulsive disorder: Strategies for using CBT and pharmacotherapy. Journal of Family Practice, 55(4), 329–333.
Pharmacological Treatment for Anxiety Disorders and OCD
Anxiety disorders are psychiatric disorders associated with a high burden of illness. These disorders include generalized anxiety disorder (GAD), Panic disorder (PDA), and Social anxiety disorder (SAD). Treatment of anxiety disorders is recommended when patients show marked distress or complications from the disease. First-line drugs for treatment are selective serotonin reuptake inhibitors (SSRIs) (Bandelow et al., 2017). Citalopram 20 -40 mg, escitalopram 10-20 mg, Fluvoxamine, paroxetine 20-50 mg, and sertraline 50-150 mg are recommended for the treatment of both PDA and SAD. Fluoxetine can also be used for the treatment of PDA. Escitalopram, paroxetine, and sertraline are recommended for the treatment of GAD. Serotonin and norepinephrine reuptake inhibitors (SNRI) such as venlafaxine 75-225 mg and Duloxetine 60-120 mg are also recommended for the treatment of GAD. Venlafaxine can also be used for the treatment of PDA and SAD. Tricyclic antidepressants such as Clomipramine can be used for the treatment of PDA (Bandelow et al., 2017).
Obsessive-compulsive disorder (OCD) is often a disabling condition. It consists of intrusive thoughts that lead to discomfort. To reduce the discomfort, the patient employs rituals. Treatment of OCD involves the use of SSRIs as the first-line drug. These include Citalopram, escitalopram, sertraline, fluoxetine, paroxetine, and fluvoxamine. Higher doses of SSRIs are used to treat OCD compared to the doses used in depression and anxiety disorders (Stein et al., 2019). Higher doses are more efficacious but come at the cost of poor drug adherence because of the many adverse effects associated with SSRIs. Therefore, adverse effects should be monitored to identify the correct dose for the patient. Also, past treatment response should be assessed when choosing the appropriate SSRI. Low to medium-dose treatment can be used if a patient cannot tolerate higher SSRI doses. The maximally tolerable dose should be continued for at least 12 weeks (Stein et al., 2019). SSRIs can be augmented using NMDA receptor antagonists like memantine.
Captain of the Ship Project – Obsessive Compulsive Disorders Paper References
Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in Clinical Neuroscience, 19(2), 93–107. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow
Stein, D. J., Costa, D., Lochner, C., Miguel, E. C., Reddy, Y., Shavitt, R. G., van den Heuvel, O. A., & Simpson, H. B. (2019). Obsessive-compulsive disorder. Nature Reviews. Disease primers, 5(1), 52. https://doi.org/10.1038/s41572-019-0102-3
Therapy for Patients with ADHD
One of the major roles of the primary healthcare provider is referring a patient to the relevant specialist after suspecting the signs and symptoms that the client is presenting with require special attention. Primary healthcare providers refer patients to mental health specialists for conditions such as attention deficit hyperactive disorder (ADHD). Attention deficit hyperactive disorder is one of the neurodevelopmental disorders mainly diagnosed in childhood (CDC.gov, n.d.). However, the condition may last into adulthood, especially when it is not diagnosed early, and adults can also get it.
ADHD in children is mainly associated with trouble paying attention, being overly active, and difficulty controlling impulsive behavior. The psychiatric and mental health nurse practitioner assesses the patient based on the presenting signs and symptoms, diagnoses the patient, and decides on the most appropriate medication and treatment therapy depending on the patient’s pharmacokinetic and pharmacodynamic processes. The focus of this essay is evaluating the medication decisions made for an ADHD patient regarding the medication response at given points of interaction.
In this case, the client, Katie, is an 8-year-old Caucasian female. Her parents were referred to the department by their PCP after Katie’s teacher suggested that she may have ADHD. However, the parents actively deny the case citing that Katie is never defiant, has no temper outbursts, and does not run around like a wild person. From the report presented to the PMHNP, Katie is inattentive, loses interest in things she likes, is easily distracted, forgets things she learned quickly, and is poor in arithmetic, reading, and spelling. Her attention span is short, and she lacks interest in schoolwork. She finds it hard to follow instructions.
Katie offers no concern and reports that school is okay. She states that she finds some subjects boring and hard and feels lost. She also admits that her mind wanders during class to things she thinks are more fun. In addition, Katie appears appropriately developed for her age, with clear speech, coherence, and logic. She is dressed appropriately and is oriented to time, place, and person. Her affect is bright, and she denies any suicidal and homicidal ideations or hallucinations. Subjective and objective information is required developing treatment objectives and evaluates treatment outcomes.
Decision Point One
The first decision is to begin Ritalin (Methylphenidate) 10mg chewable tablets orally in the morning. Ritalin is one of the most widely prescribed drugs to stimulate the central nervous system and treat attention deficit hyperactive disorder and narcolepsy. Ritalin is FDA-approved as the first-line CNS stimulant meant to treat ADHD for patients aged six years and above. According to Verghese and Abdijadid (2022), methylphenidate has been found clinically effective for ADHD since it works by increasing the concentration of dopamine, thus improving concentration and enhancing cognitive performance. Therefore, this is the best treatment option for the patient. Some of the drug’s side effects include dizziness, nausea, trouble getting sleep, and loss of appetite. The drug has minimal withdrawal symptoms, and the dosage and time depend on the treatment response.
The second option is beginning Intuniv extended release 1mg orally daily. Intuniv is a non-stimulant selective adrenergic-selective agonist. Intuniv is an FDA-approved second-line medication for the treatment of ADHD. Despite intuniv being known to improve ADHD symptoms, studies show its efficacy to completely overcome some ADHD symptoms is poor (Hendrix, 2020). It has various side effects, including nausea, low blood pressure, fatigue, and sedation, which may negatively affect the child. Hence, it is not the best treatment intervention choice in this case.
The third option is beginning Wellbutrin (bupropion) XL 150mg orally daily. Bupropion is an FDA-approved medication for smoking cessation, treating adult depression and seasonal affective disorder (Huecker, Smiley & Saadabadi, 2021). However, it is an off-label approved drug for treating ADHD among the pediatric population. The drug has several side effects occurring in more than 10% of users that may adversely affect them, including weight loss, insomnia, headaches, dizziness, and blurred vision. In addition, the drug has high dependence and thus can be easily abused. Therefore, this is not the best choice for the patient.
After choosing Ritalin for the patient, the anticipated results were increased symptom resolution, concentration in class, and minimal side effects. As confirmed by Katie’s teacher, the outcomes of using Ritalin in four weeks included improved symptoms presentation. However, the patient is only attentive in the morning, and in the afternoon, she daydreams again. The PMHNP notes that the patient has developed tachycardia due to the stimulant medication.
Decision Point Two
Based on the patient’s evaluation after administering Ritalin 10mg POD for four weeks, the second decision is to change the medication to Ritalin LA 20mg orally daily in the morning. When a patient is experiencing partial remission of symptoms, the Food and Drugs Act recommends a titration of the current dose to ensure total remission. According to Pheils and Ehret (2021), Ritalin LA 20mg has longer-lasting effects and provides efficacy in controlling ADHD symptoms. In addition, Verghese and Abdijadid (2022) note that increasing Ritalin doses helps prevent palpitations and achieve total remission of ADHD symptoms.
The second choice, maintaining the current dose of Ritalin 10mg POD in the morning and re-evaluating after four weeks, was ruled out since the patient was experiencing partial remission of ADHD symptoms. More so, she has presented with one of the side effects of stimulant medications. Maintaining the dosage would not help achieve the desired treatment outcomes.
The other option, discontinuing Ritalin and beginning Adderall XR 15mg daily, was also ruled out. It was not the best option for the patient since the medication is a second-line FDA-approved drug for treating ADHD when other options fail to achieve the desired outcomes. However, in our case, the current medication and dosage were already showing a positive response; thus, discontinuing the medication is unnecessary.
The anticipated results of administering Ritalin LA 20mg POD include achieving total remission of the symptoms, increased attentiveness, and minimizing the side effects experienced. The actual results are positive; the patient’s attentiveness in class has improved, and the pulse rate has gone back to normal. Thus, the patient has a positive response.
Decision Point Three
After re-evaluating the patient, she seems to be achieving total remission of the ADHD symptoms. The side effects have also subsided, and she reports that the funny feeling is completely gone. The primary goal at this point is to maintain a total remission of the symptoms and minimize the possible side effects of the drug. The decision chosen is to maintain Ritalin LA 20mg POD for four weeks and re-evaluate the outcomes. According to Childress, Komolova & Sallee (2019), long-term use of Ritalin is safe and is associated with minimal withdrawal effects. Therefore, this is the best choice for maintaining total symptom remission.
The other choices were increasing Ritalin LA to 30mg POD and obtaining EKG based on the current heart rate. The current Ritalin dosage was already producing the desired effects; thus, increasing the dose is unnecessary. Also, it is advisable to use the lowest effective dose for stimulant medications. Additionally, increasing the dose may cause a recurrence of the side effects. Therefore, this choice was ruled out. Katie’s heart rate is appropriate for her age. Hence obtaining EKG will be a management intervention.
The anticipated results for this decision point included maintaining total symptom remission and minimizing the possible side effects. These results were achieved following a report of declining side effects and improved academic performance.
Ethical Considerations
Ethical considerations in healthcare enable care providers to make sound judgments and decisions based on the values and laws that govern them (Haddad & Geiger, 2022). Legal and ethical considerations were maintained throughout the decision point of Katie’s treatment and management. The decisions made were based on the beneficence and non-maleficence ethical principles. The PMHNP ensured that the decisions made were the most appropriate for the patient, aiming at minimal harm and likely to produce optimal health outcomes, thus benefiting the patient. Caucasian females are known to adhere to treatment more than males. Thus, the female was more likely to respond positively to medication. In addition, effective communication on the medication, dosages, and reasons for changing the treatment therapy was made to the parents effectively, thus boosting treatment adherence.
Conclusion
After Katie’s diagnosis with ADHD, the best interventions were to put her under first-line FDA- approved stimulant medications as a treatment therapy. Ritalin 10mg POD was selected, and her response to the medication was re-evaluated every four weeks. At first, she presented a side effect of low-dose Ritalin and partial remission of ADHD symptoms. The dose was increased to 20mg POD, where she responded positively to total remission. The dose and medication were then maintained since it is safe for long-term therapy. PMHNPs must select the most appropriate treatment therapies for their patients, evaluate the response and make the necessary changes while ensuring ethical considerations.
Captain of the Ship Project – Obsessive Compulsive Disorders Paper References
Childress, A. C., Komolova, M., & Sallee, F. R. (2019). An update on the pharmacokinetic considerations in the treatment of ADHD with long-acting methylphenidate and amphetamine formulations. Expert Opinion on Drug Metabolism & Toxicology, 15(11), 937-974. https://doi.org/10.1080/17425255.2019.1675636
Haddad, L. M., & Geiger, R. A. (2022). Nursing Ethical Considerations. StatPearls [Internet].
Hendrix, C. (2020). Attention Deficit Hyperactivity Disorder (ADHD). Clinically proven alternatives for treating inattention, hyperactivity, and impulsivity. Evidence-Based Use of Supplements. 32, 34. https://www.migrelief.com/wp-content/uploads/2021/07/ADHD-White-Paper.pdf
Huecker M.R., Smiley A., & Saadabadi A. (2021). Bupropion. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470212/
Pheils, J., & Ehret, M. J. (2021). Update on methylphenidate and dexmethylphenidate formulations for children with attention-deficit/hyperactivity disorder. American Journal of Health-System Pharmacy: AJHP: Official Journal of the American Society of Health-System Pharmacists, 78(10), 840–849. https://doi.org/10.1093/ajhp/zxab069
The Centers for Disease Control and Prevention. (n.d.). Attention Deficit/Hyperactive Disorder. https://www.cdc.gov/ncbddd/adhd/facts.html#SignsSymptoms
Verghese C, Abdijadid S. (2022) Methylphenidate. In: StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK482451/
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