What screening tools are used in practice for patients who present with sleep, difficulty concentrating, and excessive worrying?
Give explanations to the following diagnosis
1. Obsessive Compulsive Disorder (OCD)
3. Generalized Anxiety Disorder (GAD)
Answer the following to #1, Treatment plan for Obsessive compulsive disorder (OCD), medication, referral, education, and follow up.
Part 2 (Example)
Given the case study, the diagnoses are as follows:
1. Post Traumatic Stress Disorder
2. Adjustment Disorder
3. Generalized Anxiety Disorder
Primary diagnosis: Post Traumatic Stress Disorder (PTSD)
PTSD is categorized as a traumatic or stress related disorder that is characterized by hyper reactivity to a traumatic event [American Psychological Association (APA), 2017]. Trauma can then trigger a physiologic and psychological stress response (APA, 2017). Once reactions to trauma become persistent they become symptoms of post traumatic illnesses (APA, 2017). Symptoms may occurs day to months after the traumatic event or they may occur up to years later, also known as delayed expression PTSD(APA, 2017). The symptoms fall into four categories, recurrent recollections of the trauma, avoidance of reminders of the trauma, negative mood associated with the trauma or numbing, and altered reactivity or hyper reactivity (APA, 2017). The patient may experience hyper vigilance and alienation (APA, 2017). In this case, although it is unknown when the symptoms started to occur, the patient is experiencing nightmares, hyper vigilance, and alienation. The patient has also stated that he avoids triggers such as traveling. Lastly, the patient is a retired Marine veteran with 30 years of experience in the military.
Adjustment disorder is described as distress and emotional disturbance that has social detriments to the patient during a time of adjustment to a stressful life event (Doherty, Lorenz, Jabbar, O’Leary, & Casey, 2019). In order to have a diagnosis of adjustment disorder the patient should not be diagnosed with another mental health disorder and there must be a life stressor causing the psychological response (Doherty, Lorenz, Jabbar, O’Leary, & Casey, 2019). Additionally, the reaction to the stressor is out of proportion to the social norm (Doherty, Lorenz, Jabbar, O’Leary, & Casey, 2019). Dysfunction can present in the patients personal relationships and job performance (Doherty, Lorenz, Jabbar, O’Leary, & Casey, 2019). In this case study, it is uncertain when the patient retired from the military and became divorced. Sudden changes in a patients’ life can lead to adjustment to occur creating a hyper reactive response to the stressor. Additionally, in the case study the patient expresses distancing himself from his friends. Symptoms of adjustment disorder include sleep disturbances, excessive worrying, anxiety, and avoidance (Strain, 2018). Additionally, it is discussed in the literature that adjustment disorder has characteristics of depression and anxiety (Doherty, Lorenz, Jabbar, O’Leary, & Casey, 2019).
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is associated with physical symptoms such as sleep disturbances, irritability, feeling of fear, and increased worrying (Shultz, Kirst, & Locke, 2015). In patients with GAD the psychological disturbances may manifest into physical symptoms of headaches, gastrointestinal upset, and muscle tension (Shultz, Kirst, & Locke, 2015). The symptoms cause distress and impede the patients quality of life by impacting the patients functional abilities to work and maintain relationships (Shultz, Kirst, & Locke, 2015). In this case study the patient is experiencing nightmares and hyper vigilance that can be attributed to anxiety. The patient is also reporting decreased appetite which is common in patients who are anxious. The patient also meets the risk factors for anxiety such as being unmarried, middle aged, and life stressors such as a career in the military and divorce (Shultz, Kirst, & Locke, 2015).
Treatment plan for PTSD:
A diagnostic tool such as the Primary Care PTSD screen can be used facilitate a diagnosis of PTSD and used throughout treatment to evaluate effectiveness of treatment(Shalev, Liberzon, & Marmar, 2017).
· Medication: Fluoxetine 20 mg one tablet by mouth daily #30 RF: 2 (APA, 2017).
· Referral: Refer to Psychiatrist for trauma focused cognitive behavioral therapy (APA, 2017). Cognitive behavioral therapy that focuses on the traumatic event and the patients’ feelings towards the traumatic event has the goal of symptom reduction, eliminating the diagnosis, improve quality of life, and to prevent co morbidities (APA, 2017).
· Education: The patient is educated to seek immediate medical attention if feelings of suicide or homicide occur. Withdrawal symptoms may occur if medication, Fluoxetine, is suddenly stopped. Side effects of Fluoxetine include odd dreams. Participation in activities of daily living is encouraged(Shalev, Liberzon, & Marmar, 2017). Support groups with other veterans can be beneficial to the patients recovery.
· Follow up: The patient is to follow up in one month for effectiveness of PTSD treatment
American Psychological Association. (2017). Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder(PTSD) in Adults. American Psychological Association, 1-119.
Doherty, A. M., Lorenz, L., Jabbar, F., O’Leary, E., & Casey, P. (2019). Sleep disturbance in adjustment disorder and depressive episode. International Journal of Environmental Research and Public Health, 1-11. doi:10.3390/ijerph16061083
Shalev, A., Liberzon, I., & Marmar, C. (2017). Post-Traumatic Stress Disorder. The New England Journal of Medicine, 2459-2469. doi:10.1056/NEJMra1612499
Shultz, C. G., Kirst, N., & Locke, A. B. (2015). Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults. American Family Physician, 617-624.
Strain, J. J. (2018). The psychobiology of stress, depression, adjustment disorders and resilience. The World Journal of Biological Psychiatry, S14-S20. doi:10.1080/15622975.2018.1459049