DSM-5 OCD, PTSD and Anxiety

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 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.DSM-5 OCD, PTSD and Anxiety

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.).

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Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD

Subjective Data

Chief Complaint: Persistent and excessive worry

HPI

Carol is a 38-year-old Caucasian woman who presents to the clinic following her husband’s request to seek help due to her persistent and excessive worry. She keeps calling her kids because she is afraid that they will be harmed by serial rapists. The client reports homeschooling her children because of school violence. She started homeschooling her children after an incident that happened at a nearby school where 12 students were murdered, three teachers gunned down trying to protect students as they could not protect themselves. The client mentions that these violent events are still in her mind and keeps seeing the children’s faces. She worries that those children could be her children. She also reports having stronger feelings about losing people as she lost her parents at 19 following a car accident. She seems to be very stressed by her missing cell claiming that her children cannot reach out to her in case of any problem.DSM-5 OCD, PTSD and Anxiety

The symptoms started when the client was 19 years following the death of her parents after were involved in a car accident. Nonetheless, the severity of the symptoms has increased recently due to various incidents that are happening in the surrounding such as gun deaths, rape cases, and children missing. These symptoms have an impact on the client’s functioning in life. For instance, the client decided to start homeschooling for her children due to the lack of protection in public schools. She quotes an incident where 12 students were murdered in a school. Additionally, three teachers were gunned down as they were trying to protect students.

Past Psychiatric History:

• General Statement: The client denies having a past psychiatric history
• Hospitalizations: Denies any previous hospitalization
• Medication trials: Denies being under any medication
• Psychotherapy or Previous Psychiatric Diagnosis: No any psychotherapy or previous psychiatric diagnosis

Substance Current Use and History: Denies alcohol use and cigarette smoking. Denies illicit drug abuse

Family Psychiatric/Substance Use History: No family psychiatric and substance use history.

Psychosocial History: Carol was born and raised in North Carolina by both her parents until the age of 19 when they died in a car accident. She is the sixth born in a family of seven, three brothers and three sisters. The patient currently lives in Minnesota with her husband and three children. She holds a master’s degree in Communication and Media. She loves cooking, watching tv, and playing with her children. The patient quit her job one year ago after giving her to her last child. She denies having a history of a criminal offense. The client reports two trauma incidents. First was when she lost her parents in a road accident when she was 19 and another when a school violence event happened in her nearby school. She is greatly concerned about the safety of her children and tries so much to protect them against any harm through homeschooling.

Medical History:

• Current Medications: She is not under any medication
• Allergies: NKDA
• Reproductive Hx: LMP: 12/11/2020; no contraceptive;

Objective Data

GENERAL: No fatigue, weakness, chills, fever, or weight loss.

HEENT: Eyes: No yellow sclerae, double vision, blurred vision, or visual loss. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No itching or rash.

CARDIOVASCULAR: No chest pressure. No edema or palpitations.

RESPIRATORY: No shortness of breath or cough.

GASTROINTESTINAL: No diarrhea, vomiting, nausea, or anorexia. No blood or abdominal pain.

GENITOURINARY: No odd color, hesitancy, odor, urgency, or burning on urination.

NEUROLOGICAL: No tingling in the extremities, numbness, or headache. No change in bowel control or bladder.

MUSCULOSKELETAL: No stiffness or muscle pain.

HEMATOLOGIC: No bruising, or bleeding.

LYMPHATICS: No history of enlarged nodes.

ENDOCRINOLOGIC: No polydipsia or polyuria. No heat intolerance, cold, or sweating.

Physical exam:

Height:  5’4″   Weight: 151 pounds BMI: 23.2   BP: 110/70    P: 72 regular    R: 17

Heart: Regular rhythm and heartbeat.

Lungs: Normal respirations.

Appearance: Unsteady gait. She is neatly dressed.

General behavior: She struggles to maintain eye contact. She was swaying while standing during periods of agitation.

Attitude: The patient is calm and composed while answering questions but sometimes displays anger.DSM-5 OCD, PTSD and Anxiety

Orientation: Oriented to place, time, and person.

LOC: alert.

Thought process: Not goal-directed. Not willing to be helped.

Thought content: Appears paranoid, has a mood disorder.

Judgment: The patient is not aware of the problem she is having, does not understand the facts, and is not ready to walk with us in the recovery process.

Diagnostic results: No appropriate diagnostic test performed

Assessment

Mental Status Examination

The Mental Status Exam (MSE) was conducted to assess the mental state and behaviors of the client. It included the subjective descriptions that were provided by the patient and objective observations made by the clinician. The client’s general appearance and behavior indicated that she was excessively worried particularly about the safety of her three children. However, the client’s attention, orientation, and memory were normal. Consequently, a differential diagnosis was conducted to rule out her condition.

Differential Diagnosis

            The differential diagnosis for the client included anxiety disorders, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). According to Henkelmann et al. (2019) are mental disorders are characterized by anxiety and excessive worry.

Anxiety Disorders

            The client was primarily diagnosed with an anxiety disorder. According to the DSM-5 diagnostic criteria, this condition is mainly characterized by persistent and excessive worry, which interferes with one’s daily activities (Locke et al., 2015). The client was referred to the clinic following her persistent and excessive worry that had interfered with her daily functions. For instance, the client had started homeschooling for her children claiming that public schools lacked protection. Additionally, anxiety disorders are associated with some physical symptoms, including restlessness, feeling easily fatigued, difficulty concentrating, insomnia, and muscle tension. Nonetheless, the client did not present any of these symptoms. This primary diagnosis was guided by the critical-thinking process. The client is likely to be suffering from anxiety disorders since she portrays excessive worry throughout the interview. Pertinent positives for the patient’s case include excessive and persistent worry pertinent negatives include physical symptoms such as restlessness, feeling easily fatigued, difficulty concentrating, insomnia, and muscle tension.

Posttraumatic Stress Disorder (PTSD)

PTSD was the second diagnosis for this client. According to the DSM-5 diagnostic criteria, this condition is mainly characterized by severe anxiety, agitation, irritability, social isolation, hostility, self-destructive behavior, fear, flashback, fear, nightmares, severe anxiety, mistrust, loss of interest or pleasure in activities, or guilt (Morina et al., 2016). Pertinent positives for this client include severe anxiety and fear. The client seems to have severe anxiety and fear, particularly concerning her children. On the other hand, pertinent negatives for this specific patient case, include agitation, irritability, social isolation, hostility, self-destructive behavior, flashback, fear, nightmares, severe anxiety, mistrust, loss of interest or pleasure in activities, or guilt. According to Shahini and Shala (2016), PSTD is usually characterized by nightmares. Therefore, the absence of some key symptoms of PSTD in this client rules out the possibility of this condition.DSM-5 OCD, PTSD and Anxiety

Obsessive-Compulsive Disorder (OCD)

Finally, the client was diagnosed with Obsessive-Compulsive Disorder (OCD). According to the DSM-5 diagnostic criteria, this condition is mainly characterized by compulsive behavior, compulsive hoarding, agitation, hypervigilance, meaningless repetition of own words, impulsivity, repetitive movements, social isolation, ritualistic behavior, anxiety, apprehension, guilt, panic attack, fear, food aversion, or nightmares (Fenske & Schwenk, 2019). Pertinent positives for this client include fear and anxiety. The client seems to have severe anxiety and fear, particularly concerning her children. On the contrary, pertinent negatives for this particular client include compulsive behavior, compulsive hoarding, agitation, hypervigilance, meaningless repetition of own words, impulsivity, repetitive movements, social isolation, ritualistic behavior, apprehension, guilt, panic attack, food aversion, or nightmares. The absence of some of the key symptoms of OCD in this client rules out the possibility of this condition.

Plan

The combination of psychotherapy and pharmacotherapy is effective in treating this particular patient. Psychotherapy will involve the use of cognitive-behavioral therapy (CBT). This psychotherapy has been effective in the treatment of anxiety disorders (Clark, 2019). It allows the patients to record, evaluate, and analyze their feelings and thoughts paying special attention to those, which provoke anxiety. Additionally, CBT allows psychologists to assist the patients to understand their unrealistic thinking, thus teaching them new techniques of responding to anxiety-provoking situations (Clark, 2019). Therefore, professionals will use this approach to guide the client on how to respond to the incidents that provoke anxiety.

On the other hand, Pharmacotherapy treatment will involve the use of antidepressants. Antidepressants are primarily used to treat anxiety disorders among adult patients. In particular, citalopram, which is a selective serotonin reuptake inhibitor (SSRIs) was preferred in this case due to its high level of safety and efficacy. The medicine was initially administered in low dosage 20mg/d (Bushnell et al., 2016).

Reflection Notes

Upon conducting the session again, I would make some changes to improve the subjective data provided by the client. This information is vital, especially during the mental status examination. In particular, I would involve the client’s husband during the interview. The husband would be in a position to provide more details regarding the client’s medical history and symptoms of the presented illness. Additionally, I would consider ethical guidelines during the session. Although ethical guidelines advocate for the protection of the client’s confidential data, sharing the information with multidisciplinary team members would enhance the outcomes of the treatment process. Additionally, I embark on a health promotion and disease prevention campaign to prevent the client from suffering from other conditions especially lifestyle disease. Therefore, I would discourage the client from using any form of illegal drugs or smoking. Avoiding smoking will reduce the probability of chronic diseases that are associated with smoking (Wang et al., 2019). Additionally, I would advise the client to avoid taking food with cholesterol to avoid obesity, which is common among females than in males (Pinto et al., 2018).

References

Bushnell, G. A., Stürmer, T., Swanson, S. A., White, A., Azrael, D., Pate, V., & Miller, M. (2016). Dosing of selective serotonin reuptake inhibitors among children and adults before and after the FDA black-box warning. Psychiatric services, 67(3), 302-309.

Bystritsky, A. (2019). Pharmacotherapy for generalized anxiety disorder in adults. UpToDate.

Clark, D. A. (2019). Cognitive-behavioral Therapy for OCD and Its Subtypes. Guilford Publications.

Fenske, J. N., & Schwenk, T. L. (2019). Obsessive compulsive disorder: diagnosis and management. American family physician, 80(3), 239-245.

Gers, L., Petrovic, M., Perkisas, S., & Vandewoude, M. (2018). Antidepressant use in older inpatients: current situation and application of the revised STOPP criteria. Therapeutic Advances in Drug Safety, 9(8), 373-384.

Henkelmann, J. R., de Best, S., Deckers, C., Jensen, K., Shahab, M., Elzinga, B., & Molendijk, M. (2019). Mental Disorders in Refugees: A Systematic Review and Meta-Analysis. Available at SSRN 3471994.

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.

Morina, N., Sulaj, V., Schnyder, U., Klaghofer, R., Müller, J., Martin-Sölch, C., & Rufer, M. (2016). Obsessive-compulsive and posttraumatic stress symptoms among civilian survivors of war. BMC psychiatry, 16(1), 1-8.

Pinto, K. A., Griep, R. H., Rotenberg, L., da Conceição Chagas Almeida, M., Barreto, R. S., & Aquino, E. M. (2018). Gender, time use and overweight and obesity in adults: Results of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). PloS one, 13(3), e0194190.

Shahini, M., & Shala, M. (2016). Post-traumatic stress disorder in Kosovo veterans. Sage Open, 6(1), 2158244016633737.

Wang, R., Jiang, Y., Yao, C., Zhu, M., Zhao, Q., Huang, L., … & Zhao, G. (2019). Prevalence of tobacco related chronic diseases and its role in smoking cessation among smokers in a rural area of Shanghai, China: a cross sectional study. BMC public health, 19(1), 753.

(The comprehensive evaluation is typically the initial new patient evaluation. You will practice writing this type of note in this course. You will be ruling out other mental illnesses so often you will write up what symptoms are present and what symptoms are not present from illnesses to demonstrate you have indeed assessed for all illnesses which could be impacting your patient. For example, anxiety symptoms, depressive symptoms, bipolar symptoms, psychosis symptoms, substance use, etc.)DSM-5 OCD, PTSD and Anxiety

CC (chief complaint): A brief statement identifying why the patient is here. This statement is verbatim of the patient’s own words about why presenting for assessment. For a patient with dementia or other cognitive deficits, this statement can be obtained from a family member.

HPI: Begin this section with patient’s initials, age, race, gender, purpose of evaluation, current medication and referral reason. For example:

N.M. is a 34-year-old Asian male presents for psychiatric evaluation for anxiety. He is currently prescribed sertraline which he finds ineffective. His PCP referred him for evaluation and treatment.

Or

P.H., a 16-year-old Hispanic female, presents for psychiatric evaluation for concentration difficulty. She is not currently prescribed psychotropic medications. She is referred by her therapist for medication evaluation and treatment.

Then, this section continues with the symptom analysis for your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis.

Paint a picture of what is wrong with the patient. This section contains the symptoms that is bringing the patient into your office. The symptoms onset, duration, frequency, severity, and impact. Your description here will guide your differential diagnoses. You are seeking symptoms that may align with many DSM-5 diagnoses, narrowing to what aligns with diagnostic criteria for mental health and substance use disorders.

Past Psychiatric History: This section documents the patient’s past treatments. Use the mnemonic Go Cha MP. 

General Statement: Typically, this is a statement of the patients first treatment experience. For example: The patient entered treatment at the age of 10 with counseling for depression during her parents’ divorce. OR The patient entered treatment for detox at age 26 after abusing alcohol since age 13.

Caregivers are listed if applicable.

Hospitalizations: How many hospitalizations? When and where was last hospitalization? How many detox? How many residential treatments? When and where was last detox/residential treatment? Any history of suicidal or homicidal behaviors? Any history of self-harm behaviors?

Medication trials: What are the previous psychotropic medications the patient has tried and what was their reaction? Effective, Not Effective, Adverse Reaction? Some examples: Haloperidol (dystonic reaction), risperidone (hyperprolactinemia), olanzapine (effective, insurance wouldn’t pay for it)

Psychotherapy or Previous Psychiatric Diagnosis: This section can be completed one of two ways depending on what you want to capture to support the evaluation. First, does the patient know what type? Did they find psychotherapy helpful or not? Why? Second, what are the previous diagnosis for the client noted from previous treatments and other providers. Thirdly, you could document both.

Substance Use History: This section contains any history or current use of caffeine, nicotine, illicit substance (including marijuana), and alcohol. Include the daily amount of use and last known use. Include type of use such as inhales, snorts, IV, etc. Include any histories of withdrawal complications from tremors, Delirium Tremens, or seizures.

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Family Psychiatric/Substance Use History: This section contains any family history of psychiatric illness, substance use illnesses, and family suicides. You may choose to use a genogram to depict this information. Be sure to include a reader’s key to your genogram or write up in narrative form.

Social History: This section may be lengthy if completing an evaluation for psychotherapy or shorter if completing an evaluation for psychopharmacology.  However, at a minimum, please include:

Where patient was born, who raised the patient

Number of brothers/sisters (what order is the patient within siblings)

Who the patient currently lives with in a home? Are they single, married, divorced, widowed? How many children?

Educational Level

Hobbies:

Work History: currently working/profession, disabled, unemployed, retired?

Legal history: past hx, any current issues?

Trauma history: Any childhood or adult history of trauma?

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Medical History: This section contains any illnesses, surgeries, include any hx of seizures, head injuries.DSM-5 OCD, PTSD and Anxiety

Current Medications: Include dosage, frequency, length of time used, and reason for use. Also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Provide a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs. intolerance.

Reproductive Hx: Menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis.  Please note: THIS IS DIFFERENT from a physical examination!

You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination, urgency, hesitancy, odor, odd color

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Physical exam (If applicable and if you have opportunity to perform—document if exam is completed by PCP): From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e., General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). DSM-5 OCD, PTSD and Anxiety

Assessment

Mental Status Examination: For the purposes of your courses, this section must be presented in paragraph form and not use of a checklist! This section you will describe the patient’s appearance, attitude, behavior, mood and affect, speech, thought processes, thought content, perceptions (hallucinations, pseudohallucinations, illusions, etc.)., cognition, insight, judgment, and SI/HI. See an example below. You will modify to include the specifics for your patient on the above elements—DO NOT just copy the example. You may use a preceptor’s way of organizing the information if the MSE is in paragraph form.

He is an 8-year-old African American male who looks his stated age. He is cooperative with examiner. He is neatly groomed and clean, dressed appropriately. There is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. His thought process is goal directed and logical. There is no evidence of looseness of association or flight of ideas. His mood is euthymic, and his affect appropriate to his mood. He was smiling at times in an appropriate manner. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking.   He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is good. His insight is good.

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s assessment and diagnostic impression of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection a discussion related to legal/ethical considerations (demonstrating 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.).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. DSM-5 OCD, PTSD and Anxiety