NRNP 6635: Assessing and diagnosing patients with Anxiety disorders, PTSD, and OCD Example

NRNP 6635: Psychopathology and Diagnostic Reasoning

Comprehensive Psychiatric Evaluation: Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD

Subjective:

CC (chief complaint): The patient is a Caucasian male who admits to having a body image preoccupation when he enters the clinic. He believes that because he constantly feels out of shape, no one genuinely finds him attractive. He adds that for a considerable amount of time, he has been plagued with intense, persistent compulsive ideas of altering his body image at all costs. This has caused him to visit various gymnasiums in an effort to transform his body image to the ideal he dreams about. But because he has not actually achieved this goal, it keeps on worrying huim and he cannot take the thought off his mind.

HPI: The client is a 35-year-old Caucasian male who presents with the aforementioned problems. His daily life has been so greatly impacted by the fixation and compulsion that he now spends nearly every day in the gym. He has developed social, interpersonal, professional, and even self-care dysfunctions. He just considers going to the gym to alter his appearance, which is not occurring. He claims that these symptoms started in his late 20s even though he had no prior history of them. They remained there until a recent suggestion to seek mental health assistance from a family member. The signs are persistent and challenging to disregard. The manifestations are made worse by being with other people, while they are somewhat improved by isolation. He gives the obsession and compulsion a 7 out of 10 severity rating.

Past Psychiatric History:

• General Statement: The client cannot recall ever having any mental illnesses in the past.
• Caregivers (if applicable): He still does not need carers despite his self-aware disorder.
• Hospitalizations: He does not have a history of hospitalization.
• Medication trials: He denies ever being put on any medications for a mental health problem.
• Psychotherapy or Previous Psychiatric Diagnosis: The absence of a previous psychiatric diagnosis means that he has never been on any psychotherapy intervention.

Substance Current Use and History: The client claims that for the previous 15 years, he had been drinking sometimes, but recently, on the suggestion of his primary care physician, he began cutting back. He denies ever having smoked cigarettes, although he acknowledges using cannabis for a while before quitting a year ago when the business he worked for relocated. He denies ever misusing prescription drugs or utilizing illegal substances.

Family Psychiatric/Substance Use History: Neither his mother nor his father smoked tobacco or drank etoh. However, he has two brothers who are smokers. They are all non-drinkers. As far as he remembers, and the much he has been told, no one in his family has ever had a mental diagnosis or therapy.

Psychosocial History: He used to be very outgoing and frequently went out for drinks with his buddies. These days, he only infrequently still does this since he lacks the time. He spends the most of his time lifting weights in the gym to gain muscle. He makes every effort to live a healthy lifestyle, eating lots of fruits and vegetables. In order to maintain his health, he stays away from refined foods with lots of fat and overly sweetened drinks like soda. He enjoys watching movies, dancing, going to the gym, and jogging. He was a worker at the neighborhood district court until lately, when he was let go for running away from his work. He no longer works and now relies on his parents and siblings for support; he does not even consider looking for another employment because doing so would conflict with his exercise routine.

Medical History:

• Current Medications: He is not presently on any medications that he knows of.
• Allergies: He denies having any allergies that he is aware of at the moment.
• Reproductive Hx: He identifies as a heterosexual man who was previously married but recently got a divorce due to his fixation and compulsion with body image. He has two children with the wife, and the mother currently has custody of them.

ROS:

• GENERAL: He disputes any symptoms of lethargy, malaise, headache, fever, or chills.
• HEENT: Light-sensitivity, double vision, ringing in the ear, otorrhea, rhinorrhea, gum bleeding, and a sore throat are not present in him. Moreover, he refutes dysphagia.
• SKIN: Negative for itching, rashes, or eczema.
• CARDIOVASCULAR:Negative for peripheral edema, palpitations, chest tightness, or chest pain.
• RESPIRATORY: He claims he does not have shortness of breath or a wheeze.
• GASTROINTESTINAL: He disputes having diarrhoea, nausea, or vomiting. Additionally, he denies having changed bowel habits.
• GENITOURINARY: Negative for cloudy urine, frequent urination, hesitation, or dysuria.
• NEUROLOGICAL: He is negative for fainting, bowel or bladder loss of control, or paresthesia. Negative too for either hemiplegia or partial paralysis as well.
• MUSCULOSKELETAL: He disputes any joint or muscular pain. He claims that the range of motion in his limbs and joints is normal.
• HEMATOLOGIC: Negative for blood and clotting disorders.
• LYMPHATICS: Denies lymphadenopathy and splenectomy.
• ENDOCRINOLOGIC: Disputes having ever had hormonal treatment. Denies intolerance to heat or cold as well as polydipsia, polyphagia, severe diaphoresis, and polyuria.

Objective:

Physical exam: Vital Signs: BP 130/85 regular cuff, sitting; P 72, regular; T 99.0°F; RR 17, non-labored; BMI 24.8 kg/m² (normal BMI).

General: He has a regular walk, is awake, and is oriented in time, space, place, person, and event. His speech is also goal-directed. He has been properly groomed for the season and time of day.

HEENT: Normal morphology of the head (normocephalic); no evidence of trauma. Eyes: PERRLA, EOMI. No icterus or tears. The nasal turbinates are moist; rhinorrhea and sneezing are absent. There is no otorrhea and the tympanic membranes react normally and lightly. There is no thrush and the throat is not erythematous.

Cardiovascular: S1 and S2 heard on auscultation with no galloping murmurs, rubs, or Bruit.

Respiratory: The lung fields are clear bilaterally with no wheezing, rales, crepitations, or rhonchi.

Diagnostic results:

• Labs: WBC 6.7 x 10⁹/L; CRP 3 mg/L; Hb 14.2 g/dL.

• Imaging: Both MRI and CT scans show no intracerebral abnormalities or traumatic brain injury.

Assessment:

Mental Status Examination

The client, a 35-year-old Caucasian man, is conscious, awake, and well-oriented in time, space, location, and event. His speech is purposeful and well-organized. Given the time of day, the season, and the weather, his dressing seems suitable. During the interview, he continually shrugs his shoulders and jerks his neck, which are obvious tics. His self-reported mood of “fear” and the affect that was seen were somewhat in agreement. He disputes any delusions, paranoid thinking, or hallucinations. He acknowledges, though, that he may have had suicidal thoughts at some point this year. Though he denies having homicidal thoughts. His perspective is not fully developed as he muses on the possibility that an obsession with fitness could be detrimental. As such, his insight and judgment are impaired. The diagnosis is Obsessive-Compulsive Disorder or OCD, whose DSM-5-TR and ICD-10 diagnostic code is 300.3 (F42) (APA, 2022; Boland et al., 2021).

Differential Diagnoses:

Obsessive-Compulsive Disorder or OCD: 300.3 (F42)

Regarding how the patient’s mental illness is manifesting, this is the main diagnosis. The client in this case experiences intrusive, irrational ideas that won’t go away no matter what he does, which meets the diagnostic criteria for OCD according to the DSM-5. His appearance and physique type are on my mind right now. These are obsessions, and a very strong and constant want to visit the gym and stay there till his body form changes goes along with them. This compulsion, along with the fixation, is what distinguishes OCD as a disorder (APA, 2022; Boland et al., 2021). Along with being overpowered by the intrusive obsessive thoughts, there is also worry and terror.

Obsessions and compulsions are frequently present in patients with obsessive-compulsive disorder. However, it’s also possible to merely have obsessional or compulsive symptoms. Your obsessions and compulsions may or may not be severe or irrational, but they nonetheless consume a lot of time and prevent you from going about your everyday activities and functioning in social, academic, or professional settings.

Obsessions with OCD are intrusive, recurrent, unwelcome thoughts, desires, or visions that are distressing or anxious. You might try to avoid them or get rid of them by engaging in a ritual or compulsive habit. These obsessions usually interfere with your ability to think clearly or complete other tasks (APA, 2022). Compulsions are recurrent activities that you feel compelled to carry out if you have OCD. These recurrent actions, whether physical or mental, are intended to ease tension brought on by your obsessions or avert negative outcomes. However, engaging in the compulsions is unpleasant and may only provide a short-term reduction in anxiety.

Tic Disorder and Stereotyped Movements: 307.20 (F95.8)

This patient’s potential differential diagnosis is based on the existence of the stereotyped movements that were identified during the MSE as tics. It’s possible that he does not have OCD and is only experiencing tic disorder and stereotyped movements (APA, 2022; Boland et al., 2021). This discrepancy is less likely, though, given how closely his fixation and compulsion are related. According to the DSM-5, this differential’s presentation is less complex than that of OCD. In actuality, the two conditions may co-exist in the same person (APA, 2022; Boland et al., 2021; Kloft et al., 2019; Lisa et al., 2018). According to Kloft et al. (2019), Obsessive-compulsive disorder (OCD) with accompanying tics was classified as a subtype of OCD in the DSM-5-TR, mostly based on family and clinical data that demonstrated differences between OCD in dependency on accompanying tics. The differences in neurocognitive function between subtypes, however, are poorly understood.

Psychotic Disorders, such as Schizophrenia: 295.90 (F20.9)

A psychotic condition may be diagnosed if there is a lack of understanding and poor insight. However, in this patient’s situation, the lack of hallucinations and delusions makes this distinction also incredibly implausible. When a psychosis diagnosis, such as schizophrenia, is established in certain patients due to these similarities, the diagnosis of OCD may be overlooked (APA, 2022; Boland et al., 2021). Delusions and perceptual problems must be present in accordance with the DSM-5 diagnostic criteria in order for a psychotic disorder to be diagnosed.

Reflections

If given another chance, I would conduct this initial psychiatric interview the same way I did it this time. This is a result of the fact that I used the principles of psychiatric evaluation as outlined by Carlat (2017). According to Haswell (2019), I upheld all of the bioethical norms of autonomy, beneficence, nonmaleficence, justice, and fidelity. For instance, I always maintained the client’s privacy. This is fidelity, which is related to nonmaleficence in that faithfulness protected the patient’s psychological well-being by disclosing his information.

Additionally, I always sought the patient’s permission before doing anything. In order to uphold the autonomy concept, I took sure to clarify my motives before requesting his consent. I offered him health information and urged him to keep exercising, but in moderation so that it would not impair his level of performance in other areas as well. I urged him to join a social support group for OCD sufferers while they were receiving treatment because doing so would aid in the cognitive behavioral therapy, or CBT, process of rewiring his thinking (Corey, 2017). With the client, follow-up appointments were set, and he would return for a review in four weeks.

 

References

American Psychiatric Association [APA] (2022). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-5-TR), 5^th ed. Author.

Boland, R., Verdiun, M., & Ruiz, P. (Eds) (2021). Kaplan and Sadock’s synopsis of psychiatry, 12^th ed. Wolters Kluwer.

Carlat, D.J. (2017). The psychiatric interview, 4^th ed. Wolters Kluwer.

Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10^th ed. Cengage Learning.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Kloft, L., Riesel, A., & Kathmann, N. (2019). Inhibition-related differences between tic-free and tic-related obsessive–compulsive disorder: evidence from the N2 and P3. Experimental Brain Research,  237(0), 3449–3459.  https://doi.org/10.1007/s00221-019-05688-8

Lisa, K., Theresa, S., & Norbert, K. (2018). Systematic review of co-occurring OCD and TD: evidence for a tic-related OCD subtype? Neuroscience & Biobehavioral Reviews, 95(0), 280-314. https://doi.org/10.1016/j.neubiorev.2018.09.021