Case 2 Anxiety Disorder or Something Else

Case 2 Anxiety Disorder or Something Else

Case Study #2

This case study reviews an 8-year-old male child who has a history of a brief illness approximately two weeks prior, is currently exhibiting excessive worrying and nervousness, frequently “keyed up,” and spends a great deal of time “worrying about germs.”  Since the current illness, the client has developed a need to “repeatedly wash his hands.”  The recommendation to wash his hands comes from the mother to prevent further illness. The child is now continually washing his hands in an attempt to avoid new illness and any direct effects related to the illness.

Case 2 Anxiety Disorder or Something Else

The recent illness has prevented his attendance in school, playtime with friends, and any time with his father for approximately the last two weeks.  However, washing his hand merely defers the feelings for a limited amount of time, and the client ultimately begins thinking, “did I wash my hands well enough? What if I missed an area?”. The child reports these thoughts related to washing his hands and has caused him such anxiety that he must repeatedly wash his hands for fear he may miss areas and return to sickness.

Case 2 Anxiety Disorder or Something Else Decision Point #1

Diagnosis, Obsessive Compulsive Disorder (American Psychiatric Association, 2013). Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder characterized by recurrent distressing thoughts and repetitive behaviors or mental rituals performed to reduce anxiety (American Psychiatric Association, 2013 Case 2 Anxiety Disorder or Something Else).  As explained by in the DSM 5, symptoms are often accompanied by feelings of shame and secrecy (American Psychiatric Association, 2013).

Also, health care professionals do not always recognize the diverse manifestations of OCD. These factors often lead to a long delay in diagnosis. The average time it takes to receive treatment after meeting diagnostic criteria for OCD is 11 years.1 Primary care physicians can play a crucial role in reducing the burden of OCD through early detection and treatment. The following DSM 5 criteria are required for OCD diagnosis:

DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder (300.3)

  1. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

  1. Recurrent and persistent thoughts urge, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.

2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

  1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
  2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
  3. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
  5. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder) (American Psychiatric Association, 2013).

Decision Point #2

Based on the diagnosis, the decision is to begin Fluvoxamine IR 25 mg by mouth at bedtime. Fluvoxamine has been reported to improve OCD and psychosocial symptoms after 12 weeks of treatment (Koran, Bromberg, Hornfeldt, Shepski, Wang & Hollander, 2010; Stahl, 2008). One year after implementation, individuals have prescribed Fluvoxamine are in remission with significantly higher levels of psychosocial functioning treatment (Koran, Bromberg, Hornfeldt, Shepski, Wang & Hollander, 2010; Stahl, 2008).

Case 2 Anxiety Disorder or Something Else Decision Point #3

At this point, the client is showing a good response to the fluvoxamine and the goal is to reach a therapeutic level (Koran, Bromberg, Hornfeldt, Shepski, Wang & Hollander, 2010; Stahl, 2008). Fluvoxamine ER has shown to be effective and tolerable in the treatment of OCD in the dose range of 100mg to 300mg/ day. Therefore, the goal is to reach the lowest therapeutic tolerable level (Koran, Bromberg, Hornfeldt, Shepski, Wang & Hollander, 2010; Stahl, 2008). The authors reported that, at the twelve-week point, individuals were noted to have an increase in mental health, social functioning, and a decrease in emotional response to situations.

The client has seen improvements as evidenced by, “frequency of handwashing has decreased,” a reduction of symptoms and the client is more “relaxed” overall. School attendance, although not continuous, has increased, in addition to independently seeking out previous friends for playtime.  With this evidence, it is justified that the dose of Fluvoxamine be increased to a therapeutic level based on tolerability (Koran, Bromberg, Hornfeldt, Shepski, Wang & Hollander, 2010; Stahl, 2008).

Case 2 Anxiety Disorder or Something Else References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Koran, L. M., Bromberg, D., Hornfeldt, C. S., Shepski, J. C., Wang, S., & Hollander, E. (2010). Extended-release fluvoxamine and improvements in quality of life in patients with obsessive-compulsive disorder. Comprehensive Psychiatry, 51(4), 373–379. https://doi-org.ezp.waldenulibrary.org/10.1016/j.comppsych.2009.10.001

Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved July 14, 2019 from http://stahlonline.cambridge.org.ezp.waldenulibrary.org/prescribers_drug.jsf?page=9781316618134c51.html.therapeutics&name=Fluvoxamine&title=Therapeutics

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