Week 4: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

“Fear,” according to the DSM-5, “is the emotional response to real or perceived imminent threat, whereas anxiety is the anticipation of future threat” (APA, 2013). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease (assessment for generalized anxiety disorder)

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For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5 criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5 criteria. 

To Prepare:

• Review this week’s Learning Resources and consider the insights they provide about assessing and diagnosing anxiety, obsessive-compulsive, and trauma- and stressor-related disorders.
• Download the Comprehensive Psychiatric Evaluation Template, which you will use to complete this Assignment. Also review the Comprehensive Psychiatric Evaluation Exemplar to see an example of a completed evaluation document.
• 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 “Case History Reports” 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.

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By Day 7 of Week 4

Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a 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?
• Assessment: Discuss the patient’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 rule 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 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.).assessments for anxiety and depression
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Week 4: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD

Subjective:

Name: Tony Patelli, Gender: Male,  Age: 18 years, Race: Italian American

CC (chief complaint): “I went to the Emergency Department (ED) last week because I felt like I was dying from a heart attack. TheEKG was normal, but I was sweating, and I was having trouble catching my breath.”

HPI: Patelli is an 18-year-old male of Italian American origin who presented to the client with a complaint of sweating, dyspnea, and a pounding heart that lasts for 12 -15 minutes. A week before visiting the clinic, he reports having gone to the ED after feeling like he would die of a heart attack. An electrocardiogram ( EKG ) test ordered indicated normal cardiac functions. Despite the expected findings, he reports having an episode that lasted for between 10 and 15 minutes, during which he sweats profusely and had trouble catching his breath. The heart was pounding hard, giving him a sickening feeling where he felt like his chest would explode. It felt like that moment in the woods when you sense someone or something is chasing after you. After 12-15 min, the symptoms resolved of their own accord only to reappear the following day when Patelli was preparing coffee. The symptoms popped all over again for no apparent reason and with no concrete triggers.

Past Psychiatric History:

• General Statement: The client seems to be a healthy teenager who has enjoyed relatively good health until the recent panic attacks.
• Caregivers (if applicable): Not applicable(N/A)
• Hospitalizations: None that he is aware of.
• Medication trials: No medications
• Psychotherapy or Previous Psychiatric Diagnosis: No previous psychiatric history and no history of psychiatric treatment.

Substance Current Use and History:

Denies drugs or alcohol use.

Family Psychiatric/Substance Use History:

Nobody in the client’s family has a history of psychiatric illness or substance use. However, he reports his mother would get those panic attacks probably 3-4 a week, like him for no particular reason.

Psychosocial History:

Lives alone in New York, an only child, raised by both parents in New Jersey. He is a full-time student enrolled in a graphic design course in a local community. He admits he is a teetotaler taking no alcohol or drugs. He reports sleeping 7.5 hours, has a good appetite, and eats three meals a day. He likes to keep a routine schedule. (mental status examination of anxiety disorder)

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Medical History:

• Current Medications: Not taking any medications
• Allergies:NKDA
• Reproductive Hx:Deferred

ROS:

• GENERAL:  The patient is nontoxic,  in no acute distress, and T-98.8 P-94 R 20 126/88 Ht 5’4 Wt 131 lbs
• HEENT: Eyes no loss of vision, blurred vision, or double vision, Ears, Nose, Throat, No loss of hearing, sneezing nasal congestion, runny nose, or sore throat
• SKIN: No itching or rash
• CARDIOVASCULAR: Increased chest pressure, chest discomfort, chest pain, palpitations, or edema.pounding heart
• RESPIRATORY: shortness of breath when having an attack.
• GASTROINTESTINAL: No nausea, vomiting, or diarrhea. No anorexia, no abdominal pain, or blood in stool
• GENITOURINARY: No burning sensation on urination
• NEUROLOGICAL:  No headache, dizziness, paralysis, numbness, or tingling in the extremities.
• MUSCULOSKELETAL: No joint,  back, muscle pain, or stiffness
• HEMATOLOGIC: No anemia, bleeding, or bruising
• LYMPHATICS:  No enlarged nodes
• ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance

Objective:

Physical exam: A complete physical exam

Blood test to check the patient’s thyroid

EKG

A psychological evaluation (psychological assessment of anxiety)

Diagnostic results:

Physical exam reports indicate a normal complete blood count with RBC 5.1 trillion cells/L Hematocrit 42.3 percent WBC 5.2 billion cells/L, a normal complete metabolic panel indicating no issues with the kidneys, liver, blood chemistry, and immune system.

Thyroxine test 3.5mlU/mL (anxiety diagnosis)

EKG results in 180 -197 ms

Assessment:

Mental Status Examination:

Patelli presents as calm, and attentive, but on edge. He exhibits speech that is normal in volume, rate, and articulation. Language skills are intact. Body posture and attitude display an anxious mood, as do facial expressions and general demeanour. Manifests appropriate affect, complete range with congruent mood. Apparent signs of bizarre behavior, delusions, or other psychotic process indicators are absent. Thinking is logical, and thought content appears appropriate. Denies suicidal ideation, homicidal intentions, or ideas. The patient appears normal; judgment seems fair. No signs of intoxication or withdrawal signs are absent.

Differential Diagnoses

            Panic disorder( episodic paroxysmal anxiety) F41,0(ICD-10) Active- confirmed the patient reports sudden episodes of intense fear and anxiety that last for between 12- 15 minutes. The patient reports physical symptoms like chest pain, rapid heartbeat, and shortness of breath that resolve independently. The panic attack in Patelli’s case happens sporadically and for no apparent reason. In some cases, panic attacks occur due to a stressful or scary situation like a car accident (Cackovic et al., 2020). A panic disorder test confirmed that chest discomfort, a pounding heartbeat, shortness of breath, and sweating are not secondary to a physical condition like a heart attack (Locke et al.,2015). DSM-5 guidelines for panic disorder informed the confirmation as the patient, like his mother, reports frequent unexpected attacks(two in less than 48 hours), ongoing worry about having another panic attack, Fear of losing control, and the absence of any other probable cause for a panic attack like a stressful situation, physical disorder, or drug use. Additionally, the mnemonic STUDENTS FEAR the 3C’s was utilized with the client confirming most of these symptoms Sweating, Trembling. Unsteadiness, dizziness, Depersonalization, derealization, Excessive heart rate or palpitations, Nausea, Tingling, Shortness of breath, Fear of Dying, Fear of losing control, fear of going crazy, and the presence of Chest, Chills, Choking (Davies et al., 2017).

I want Patelli if life stressors could have triggered the attacks, like relationship issues with his girlfriend or academic pressure to excel. Other questions will target if he has suicidal ideations. I would also ask the patient about his family history since genes influence health and behavior besides the mother. I would also do an anxiety screening exam and a suicide screening exam.

Generalized Anxiety Disorder (GAD) F41.1 (ICD-10) (Active)- Refuted

The patient presents panic attacks that could also indicate GAD (Curth et al., 2017). However. However, Patelli’s panic attacks have no apparent trigger, like drug or substance, and no presence of another mental health condition like post-traumatic stress disorder (Patriquin & Msathew, 2017). Similarly, the client answers negatively to the GAD mnemonic of WATCHERS. Before the attack, despite the presence of a robust and fast heartbeat, excessive sweating, and shortness of breath, Patelli reports no Worry, Anxiety, Tension in muscles, Concentration challenges, Hyperarousal or irritability, Energy loss, Restlessness, Sleep disturbance, thus guiding me to refute a GAD diagnosis. 

Acute Myocardial infarction (ICD-10) 121.9(unspecified) –Refuted

The patient indeed reports shortness of breath, sweating, and chest discomfort that lasts for some minutes. However, Patelli does not complain of nausea, vomiting, or coughing. Most importantly, cardiac troponins elevations in peripheral blood is a mandatory requirement to establish a diagnosis of myocardial infarction(Mythili & Malathi, 2015) The EKG results of ST elevation, ST depressions, and T- wave inversions, and pathological Q- waves could have indicated myocardial ischemia and infarction were absent. All these lab findings and symptoms helped me refute a diagnosis of AMI.

 Reflections:

Studies indicate that youth who experience panic attacks may progress and develop mood disorders like major depressive disorder, personality disorders, eating disorders, bipolar disorder, and psychotic disorders if the panic disorder is untreated and poorly managed (Narmandakh et al., 2020). Panic disorder can negatively impact an individual’s psychological and physical function besides the stress on interpersonal (Karthikeyan et al., 2020). Individuals diagnosed with panic disorders also have a higher risk for suicide, meaning Patelli’s condition should be managed effectively. 

References

Cackovic, C., Nazir, S., & Marwaha, R. (2020). Panic disorder (attack). StatPearls [Internet].

Curth, N. K., Brinck-Claussen, U. Ø., Davidsen, A. S., Lau, M. E., Lundsteen, M., Mikkelsen, J. H., … & Eplov, L. F. (2017). Collaborative care for panic disorder, generalized anxiety disorder and social phobia in general practice: study protocol for three cluster-randomized, superiority trials. Trials, 18(1), 1-13.

Davies, S. J., Nash, J., & Nutt, D. J. (2017). Management of panic disorder in primary care. Prescriber, 28(1), 19-26.

Karthikeyan, V., Nalinashini, G., & Raja, E. A. (2020). A Study of Panic Attack Disorder in Human Beings and Different Treatment Methods. Journal of Critical Reviews, 7(8), 1166-1169.

Locke, A., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American family physician, 91(9), 617-624.

Mythili, S., & Malathi, N. (2015). Diagnostic markers of acute myocardial infarction. Biomedical Reports, 3(6), 743-748.

Narmandakh, A., Roest, A. M., de Jonge, P., & Oldehinkel, A. J. (2020). Psychosocial and biological risk factors of anxiety disorders in adolescents: a TRAILS report. European Child & Adolescent Psychiatry, 1-14.

Patriquin, M. A., & Mathew, S. J. (2017). The neurobiological mechanisms of generalized anxiety disorder and chronic stress. Chronic Stress, 1, 2470547017703993.

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