Week 3: Anxiety, Obsessive-Compulsive and Related, and Trauma and Stressor-Related Disorders
Anxiety disorders provide a good opportunity to take a close look at the nature/nurture debate as well as the gene/environment interactions that influence the nervous system and neurochemistry. A significant part of most of Sigmund Freud’s theories, the concept of anxiety has been debated and discussed over many years in the psychiatric literature. While Freud’s theories focused on the “mind” and the unconscious, another way to look at anxiety is with Hans Selye’s concept of “fight or flight” in which the sympathetic nervous system activates a response to stress. As you explore anxiety disorders, you will notice that no two cases of anxiety are the same.
Obsessive-compulsive disorder is characterized by the presence of obsessive thoughts, which manifest as persistent thoughts, images, or even “urges.” The only way that the individual can disperse the anxiety of these persistent thoughts/images and urges is to perform a behavior (the compulsion). The compulsion could be checking things, counting, reciting a silent prayer, or repeating a number of phrases. The disorder becomes so pervasive that the person can spend a significant amount of time each day attending to the compulsion in order to relieve the anxiety caused by the obsession.
Although trauma and stressor-related disorders stem from exposure to a traumatic or stressful event, not all exposures to trauma or stress will result in a disorder. However, following these types of events, patients may report symptoms that interfere with their ability to function well in one or more areas of their life, such as flashbacks, nightmares, or intense psychological or physiological distress.
This week, you will explore evidence-based treatment methods for patients with anxiety, obsessive-compulsive, as well as trauma and stressor-related disorders.
Learning Objectives
Students will:
Assess patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Develop differential diagnoses for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Develop appropriate treatment plans for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Advocate health promotion and patient education strategies for patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders
Learning Resources
Required Readings (click to expand/reduce)
Required Media (click to expand/reduce)
Medication Review
Review the FDA-approved use of the following medicines related to treating anxiety disorders, OCD, PTSD, and related disorders:
Anxiety Generalized anxiety disorder Panic disorder
alprazolam
amitriptyline
amoxapine
buspirone
chlordiazepoxide
citalopram
clomipramine
clonazepam
clonidine
clorazepate
cyamemazine
desipramine
diazepam
dothiepin
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
gabapentin (adjunct)
hydroxyzine
imipramine
isocarboxazid
lofepramine loflazepate
lorazepam
maprotiline
mianserin
mirtazapine
moclobemide
nefazodone
nortriptyline
oxazepam
paroxetine
phenelzine
pregabalin
reboxetine
sertraline
tiagabine
tianeptine
tranylcypromine
trazodone
trifluoperazine
trimipramine
venlafaxine
vilazodone alprazolam
citalopram
desvenlafaxine
duloxetine
escitalopram
fluoxetine
fluvoxamine
mirtazapine
paroxetine
pregabalin
sertraline
tiagabine (adjunct)
venlafaxine alprazolam
citalopram
clonazepam
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
lorazepam
mirtazapine
nefazodone
paroxetine
phenelzine
pregabalin
reboxetine
sertraline
tranylcypromine
venlafaxine
Posttraumatic stress disorder Reversal of benzodiazepine effects Social anxiety disorder
citalopram
clonidine
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
mirtazapine
nefazodone
paroxetine
prazosin (nightmares)
propranolol (prophylactic)
sertraline
venlafaxine flumazenil
citalopram
clonidine
desvenlafaxine
escitalopram
fluoxetine
fluvoxamine
isocarboxazid
moclobemide
paroxetine
phenelzine
pregabalin
sertraline
tranylcypromine
venlafaxine
Obsessive-compulsive disorder
citalopram
clomipramine
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
venlafaxine
vilazodone
Assignment: Focused SOAP Note for Anxiety, PTSD, and OCD
In assessing patients with anxiety, obsessive-compulsive, and trauma and stressor-related disorders, you will continue the practice of looking to understand chief symptomology in order to develop a diagnosis. With a differential diagnosis in mind, you can then move to a treatment and follow-up plan that may involve both psychopharmacologic and psychotherapeutic approaches.
Photo Credit: Photographee.eu / Adobe Stock
In this Assignment, you use a case study to develop a focused SOAP note based on evidence-based approaches.
To Prepare
Review this week’s Learning Resources. Consider the insights they provide about assessing and diagnosing anxiety, obsessive compulsive, and trauma-related disorders.
Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
Review the video, Case Study: Dev Cordoba. You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
Consider what history would be necessary to collect from this patient.
Consider what interview questions you would need to ask this patient.
The Assignment
Develop a Focused SOAP Note, 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: Assignment help – 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 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.
Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
Reflection notes: What would you do differently with this patient if you could conduct the session again? Assignment help – Discuss what your next intervention would be if you could follow up with this patient. 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.).
Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).
By Day 7 of Week 3
Submit your Focused SOAP Note.
EDWIN NJERU
AttachmentsSep 14, 2021, 10:15 AM
to Mtune
write for me the page totals at the end
Learning Resources
Required Readings (click to expand/reduce)
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer. (For review as needed)
Chapter 9, “Anxiety Disorders”
Chapter 10, “Obsessive-Compulsive and Related Disorders”
Chapter 11, “Trauma- and Stressor-Related Disorders”
Chapter 12, “Dissociative Disorders”
Chapter 26, “Physical and Sexual Abuse of Adults”
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (Eds.). (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.
Chapter 26, “Psychosocial Adversity”
Chapter 27, “Resilience: Concepts, Findings, and Clinical Implications”
Chapter 29, “Child Maltreatment”
Chapter 30, Child Sexual Abuse”
Chapter 58, “Disorders of Attachment and Social engagement Related to Deprivation”
Chapter 59, “Post Traumatic Stress Disorder”
Zakhari, R. (2021). The psychiatric-mental health nurse practitioner certification review manual. Springer Publishing Company.
Chapter 6, “Physical Assessment, Diagnostic Tests, and Differential Diagnosis”
Chapter 12, “Anxiety Disorders”
Document: Career Planner Guide
Document: Focused SOAP Note Template
Document: Focused SOAP Note Exemplar
Required Media (click to expand/reduce)
Centers for Disease Control and Prevention. (2020, April 3). Adverse childhood experiences (ACEs) [Video].
https://www.cdc.gov/violenceprevention/aces/index.html
Dartmouth Films. (2018, September 25). Resilience [Video]. YouTube. https://www.youtube.com/watch?v=bAXZVYDNURY
NCTSN. (2007). The promise of trauma-focused therapy for childhood sexual abuse [Video]. https://www.nctsn.org/resources/promise-trauma-focused-therapy-childhood-sexual-abuse-video
Walden University. (2021). Case study: Dev Cordoba. Walden University Blackboard. https://class.waldenu.edu
—-Sample Assignment Answer—
Week 3: NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric Evaluation
Student Name
College of Nursing-PMHNP, Walden University
NRNP 6675: PMHNP Care Across the Lifespan II
Faculty Name
Assignment Due Date
Subjective:
CC (chief complaint): I feel worried and I have bad dreams. I worry about my mum and my little brother while I am at school. People do not like me at school and call me names.
HPI: D.C. is a 7-year-old male child who presents to the clinic for the first time for evaluation due to past abnormal behavior. He is accompanied by the mother who complains about his worsening behavior. The patient is worried and have bad dreams. He is worried about his mum and little brother and can hardly concentrate in school. His mother complains he cannot sleep with the lights on and the door open. He has not been in psychiatric care in the past. Teachers in school can hardly make him concentrate or stop him from looking outside the window. He has difficulty sleeping. A pediatrician prescribed DDVAP but it does not seem to help. Complains of headache, stomachache almost daily. He does not eat. He has lost three pounds of weight in the last three weeks.
Substance Current Use: No history of substance use.
Medical History: Taking DDVAP but it does not seem to help.
• Current Medications: DDVAP
• Allergies: No known drug allergies
• Reproductive Hx: Not sexually active.
ROS:
• GENERAL: Untentional weight loss of 3 pounds in the past 3 weeks. No appetite.
• HEENT: No hearing loss, blurred vision, sore throat, and no bleeding or discharge. Complains of headache almost every day.
• SKIN: No skin lesions or itching.
• CARDIOVASCULAR: No chest pain, pressure, edema, or palpitation.
• RESPIRATORY: No breathing challenges.
• GASTROINTESTINAL: No abdominal pain, reflux, nausea, vomiting, or diarrhea.
• GENITOURINARY: Unable to control bladder at night. Still wets his bed despite his age and medication (DDVAP).
• NEUROLOGICAL: Complains of headache almost daily.
• MUSCULOSKELETAL: No history of itching muscles, joint, or gout.
• HEMATOLOGIC: No bleeding or bruising.
• LYMPHATICS: No enlarged nodes.
• ENDOCRINOLOGIC: No endocrine disorder.
Objective:
Diagnostic results:
Diagnosis of the condition will require a thorough medical evaluation to establish the possible cause of the symptoms. One of the likely diagnostic tools is Child PTSD Symptom Scale (CPSS-5), which effectively assesses post-traumatic stress in children between 8 and 18 years. It consists of 24 questions in both parts one and two. However, the tool cannot be applied since the child is less than eight years. A psychiatrist would require additional information to explore possible conditions such as separation anxiety disorder or generalized anxiety disorder. A psychiatrist will require a structured interview to evaluate the child’s feelings, thoughts, moods, and experiences. Separation anxiety can co-occur with other conditions. To assess the child for generalized anxiety disorder, the child may require blood and urine tests to rule out the possibility of drug abuse. Drug abuse such as marijuana can cause worry or anxiety.
Assessment:
Mental Status Examination:
D.C is a 7-year-old male who looked like the stated age. The client is calm and cooperative during the psychiatric interview. The thought process is organized, and his memory is intact. He is aware that he came to see a psychiatrist help him with his mood. He denies abusing drugs. He is often worried while at home and school. The pupil is concerned while at school about the safety of the mother and the baby brother. The patient is calm and maintains eye contact during the conversation. He has been experiencing anxiety and mood changes.
Diagnostic Impression:
F93. 0 Separation Anxiety Disorder (SAD)
SAD involves excessive anxiety involving separation from significant people such as parents, close friends, or guardians. Anxiety can occur due to separation from homes or schools where individuals had created a strong bond (Schneier et al., 2017). The condition shows a possibility of mental and mood issues. Statistics indicate that at least 4 percent of the population of children experience SAD. Some of the possible causes include life stressors such as divorce among parents, which affect children or the death of a loved one (Schneier et al., 2017).
It is most likely that the child is suffering from a separation anxiety disorder. One of the reasons is that the loss of the father makes the child feel unsafe. The mother did not explain to him that his father died in the military. The child could be feeling unsafe when he is away from his mother and baby brother. He is also worried about sleeping without putting the lights on.
F43. 12 Posttraumatic Stress Disorder (PTSD)
PTSD is a condition that occurs as a result of traumatic experiences such as natural disasters. Psychologists refer to the condition as the inability to recover after experiencing a traumatic experience (Cloitre et al., 2019). Some causes include a terrorist attack, violence, child abuse, sexual abuse, and losing a loved one. Scary thoughts of the past can affect mood in children. Failure to treat the condition can have profound effects on children (Cloitre et al., 2019).
F41. 1 Generalized Anxiety Disorder (GAD)
GAD is caused by excessive worry and anxiety about life issues. People with GAD always experience fear and anticipate disaster. Biological factors, life experiences, and background may trigger GAD (Toussaint et al., 2020). Sometimes just the thought of going through the day creates anxiety.
F40. 10 Social Phobia (Social Anxiety Disorder)
Social phobia is an overwhelming fear of social situations. The worry can be distressing and affect the quality of life (Dobos et al., 2019). Although the condition starts during the adolescent stage, it can start earlier in some children depending on the genetic background and life stressors.
Reflections:
I agree with my preceptor on the assessment and diagnostic impression.
The symptoms of the patient include mood changes and excessive worry. The patient is worried about the welfare of the mother and the baby brother. Sometimes he is worried that the mother will not come for him in school. He can barely concentrate in school due to excessive worry. The patient denies drug abuse which is likely to cause worry and anxiety. The mother did not explain to him that his father died in combat. The probable cause of the worry is that he believes the mother and the baby brother may vanish without notice. He is worried about staying away from the family.
A further psychiatric evaluation is needed to confirm the diagnosis. For instance, the patient will require urine and blood tests to rule out other causes of worry or anxiety, such as drug abuse. The mother should provide additional information on the history of the worry. The additional information will help a psychiatrist understand the possible causes of the symptoms (Schneier et al., 2017). Additional details from the teacher are needed to explain the behavior of the child. The information will help a psychiatrist to narrow down to one disorder and start treatment.
During the delivery of care, it will be critical to restoring the ability to concentrate in school and eliminate worry. Ethical considerations are vital since they will ensure professional and ethical care. For instance, the child is below the standard 18 years of consenting to treatment (McDermott-Levy et al., 2018). A psychiatrist will require the consent of the mother. Another ethical consideration is justice and fairness for the single mother. It will be essential to show respect and empathy despite what has happened before, such as failing to tell the son that his father died in the military. Veracity is another vital ethical issue that involves telling the truth (McDermott-Levy et al., 2018). For instance, it will be crucial to tell the mother to disclose the fate of the father. The disclosure combined with therapeutic interventions can lessen the worry of the child. Maleficence and beneficence are vital considerations since they involve using professional knowledge to provide the best care without the risk of medical errors (McDermott-Levy et al., 2018).
Case Formulation and Treatment Plan:
The patient’s condition requires further diagnostic tests such as urine and blood tests to rule out the impact of drug abuse on mood changes (Cloitre et al., 2019). Additional information will be required from the parent and the teacher on the history of the patient. The psychiatrist will require further medical review of the patient’s condition to ascertain the disorder the patient is suffering from (Cloitre et al., 2019).
The mother needs to learn the importance of creating rapport and a close relationship with the child. The boy requires assurance from the mother that she will always take care of his welfare. The assurance is vital to ensure the boy is not disturbed about whether the mother will come for him in school. It will be effective to educate the mother and the teachers in the schools on how to handle the boy bearing in mind his psychiatric condition. For instance, it will be crucial always to keep promises, leave with a goodbye and promise to come, and avoid exposing the child to new surroundings. The psychiatrist should educate the teacher to control the behavior of other children that bully the boy. He complains the classmates call him names which makes him feel bad.
The patient should begin treatment for at least 12 sessions using cognitive behavior therapy. The therapy will comprise sessions 45 minutes long at least for three months. After the treatment, the client should come back for follow up to prevent relapse (Schneier et al., 2017). Interventions from other healthcare workers and referrals can be made in case of co-occurring conditions. Family therapy is necessary to create trust and harmony in the family. Palliative care that involves assurance and watchful waiting are vital in the provision of care.
Treatment will involve a combination of medication and psychotherapeutic interventions to generate positive outcomes, such as selective serotonin reuptake inhibitors (SSRIs) to address anxiety (Schneier et al., 2017). Cognitive behavior therapy will change the thinking patterns and address the mood changes.
References
Schneier, F. R., Moskow, D. M., Choo, T. H., Galfalvy, H., Campeas, R., & Sanchez‐Lacay, A. (2017). A randomized controlled pilot trial of vilazodone for adult separation anxiety disorder. Depression and Anxiety, 34(12), 1085-1095.
Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019). ICD‐11 posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population‐based study. Journal of Traumatic Stress, 32(6), 833-842.
Toussaint, A., Hüsing, P., Gumz, A., Wingenfeld, K., Härter, M., Schramm, E., & Löwe, B. (2020). Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). Journal of affective disorders, 265, 395-401.
Dobos, B., Piko, B. F., & Kenny, D. T. (2019). Music performance anxiety and its relationship with social phobia and dimensions of perfectionism. Research Studies in Music Education, 41(3), 310-326.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing Outlook, d6(5), 473-481.
