NRNP 6635: Psychopathology and Diagnostic Reasoning
Comprehensive Psychiatric Evaluation: Assessing and Diagnosing Patients with Anxiety Disorders, PTSD, and OCD
“Fear,” according to the DSM-5-TR, is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat (APA, 2022). 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.
For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.
name: Mr. Newsome
Chief Complaint: intense feeling of terror for two months
History Of Presenting Illness: Mr. Newsome is a 19-year-old male at the emergency department with a concern of persistent and overwhelming worry about the future, which has been affecting their daily life. The symptoms began in the last two months when he discovered he was being activated with Navy reserves. The patient describes how their excessive worry has progressed from occasional concerns to a constant preoccupation with what might go wrong in the future. In addition to excessive worry, the patient may describe a variety of physical and psychological symptoms, such as restlessness, muscle tension, fatigue, difficulty concentrating, irritability, and sleep disturbances. These symptoms often worsen during periods of heightened worry.
Past psychiatric history: the patient denies previous diagnosis of mental diseases.
Medication trials and current medications: he has no record of psychotropic use and he is not on any treatment.
Psychotherapy or previous psychiatric diagnosis: the patient denies attending psychotherapy sessions and psychiatric diseases.
Pertinent substance use: he denies the use of drugs and alcohol.
Social History: the patient lives in Columbus, OH with his dog Chance, he is single and has never married. his parents live locally. he works as a part-time in construction. he has no history of legal issues. he has a good appetite and sleeps for 8 hours.
Family History: he is the only child in his family. his parents are alive without a record of illness. he denies a family history of mental illness and chronic diseases.
Allergies: the patient has no known food or drug allergies.
Review Of Systems
General: the patient denies fatigue, weakness, fever, and unexplained weight loss.
Skin: he denies skin rashes, itching, bruising, or lesions.
HEENT: The patient denies headaches, vision changes, eye pain, hearing problems, tinnitus, vertigo, nasal congestion, rhinorrhea, sore throat, dental issues, or changes in taste or smell.
Cardiovascular System: the patient denies chest pain or discomfort, palpitations, irregular heartbeats, swelling in the extremities, and changes in blood pressure.
Respiratory System: the patient denies shortness of breath, cough, sputum production, wheezing, and chest pain.
Gastrointestinal System: he denies appetite changes, nausea, vomiting, and abdominal pain.
Genitourinary: the patient denies urinary frequency, urgency, dysuria or incontinence.
Neurological: the patient denies headaches, dizziness, and seizures
Musculoskeletal: the patient denies joint pain, muscle pain, stiffness, and weakness.
Hematologic: the patient denies excessive bleeding, easy bruising, or history of anemia or blood disorders.
Lymphatics: the patient has no enlarged nodes.
Endocrinologic: the patient denies thirst, excessive sweating, changes in hair or nail growth.
General: the patient is calm and oriented to time, place, and person.
Vitals: the temperature is at 97.0, pulse rate is at 70, respiratory rate is at 18, blood pressure at 116/68mmHg, height at 5’9, and weight at 175Ibs
Mental State Examination
The patient appears tense, restless, or agitated, with signs of physical discomfort such as fidgeting, pacing, or muscle tension. He exhibits avoidance behaviors, such as avoiding eye contact or withdrawing from social interactions. The patient describes his mood as anxious, worried, or fearful. The thought process is characterized by racing thoughts, excessive worry, or preoccupation with concerns related to their activation or deployment. The content of the patient’s thoughts may revolve around themes of danger, harm, or catastrophic events related to their military service. His cognitive functioning is intact because he has good decision-making and problem-solving skills. his insight is intact because he fully recognizes the impact of their anxiety on their daily life. The patient’s speech is rapid, pressured, and difficult to follow, reflecting their inner restlessness and anxiety.
Anxiety disorders are a group of mental health conditions characterized by excessive and persistent feelings of anxiety, fear, or worry that are often irrational and disproportionate to the situation. The patient experiences chronic and excessive worry or fear about various aspects of life, including health, work, relationships, or everyday situations (Emmelkamp et al., 2020). Feeling on edge or restless, making it difficult to relax or sit still. Anxiety can manifest physically with symptoms such as muscle tension, trembling, sweating, rapid heartbeat, shortness of breath, and stomach discomfort. Risk factors for developing anxiety disorders include Having a family history of anxiety disorders may increase the risk. Experiencing trauma or significant life stressors can trigger the development of anxiety disorders, especially PTSD. There may be a genetic predisposition to anxiety disorders. Imbalances in brain chemistry, particularly involving neurotransmitters like serotonin and GABA, can contribute to anxiety (Emmelkamp et al., 2020). The specific diagnostic criteria for anxiety disorders vary depending on the subtype, but, in general, a diagnosis of an anxiety disorder is made when the individual experiences excessive anxiety and worries about a variety of topics or events. The excessive anxiety and worry persist for at least six months.
A panic attack is a sudden and intense episode of extreme fear or discomfort that typically reaches its peak within minutes. These attacks can be overwhelming and may feel life-threatening to the person experiencing them. Panic attacks can occur unexpectedly or in response to a specific trigger, such as a phobia or a stressful situation (Perrotta, 2019). During a panic attack, individuals may experience a combination of a feeling of racing or pounding heart, Profuse sweating, often accompanied by cold, clammy skin, Involuntary trembling or shaking, often in the hands or legs, Difficulty in breathing, or a feeling of choking Chest pain or discomfort, often described as a pounding, Upset stomach, nausea, or a sensation of abdominal discomfort, A sense of dizziness, unsteadiness, or a fear of passing out, Feeling detached from oneself or feeling that the environment is unreal or strange (Perrotta, 2019). Panic Disorder is diagnosed when a person experiences recurrent, unexpected panic attacks and has a persistent concern or worry about having additional attacks or the consequences of an attack. To meet the DSM-5 diagnostic criteria for Panic Disorder, the patient must have at least two unexpected panic attacks have occurred. The person is preoccupied with the fear of having more panic attacks, or there is a significant change in behavior related to the attacks e.g., avoiding situations where attacks have occurred.
Acute Stress Disorder (ASD) is a psychological condition that can occur in response to a traumatic event. It is characterized by a range of distressing symptoms that typically occur within three days to four weeks following the traumatic event (Shahrour & Dardas, 2020). ASD can be a precursor to Post-Traumatic Stress Disorder (PTSD) if the symptoms persist for an extended period. To receive a diagnosis of Acute Stress Disorder, an individual must meet the following criteria: The person has been exposed to or witnessed a traumatic event that involves actual or threatened death, serious injury, or sexual violation. The individual experiences at least one or more intrusive symptoms, such as recurrent and distressing memories, flashbacks, nightmares, or distressing reactions to reminders of the event (Shahrour & Dardas, 2020). There are negative alterations in mood and cognition related to the traumatic event, such as an inability to remember certain aspects of the event, persistent negative beliefs about oneself or others, distorted blame of self or others, persistent fear, guilt, or shame, or a diminished interest in significant activities (Shahrour & Dardas, 2020). ASD typically develops shortly after the traumatic event, with symptoms appearing within three days and lasting for up to four weeks. If the symptoms persist beyond this period, the diagnosis may change to PTSD. The severity of ASD symptoms can vary widely, and individuals may experience different combinations of symptoms. Certain factors, such as prior trauma exposure, a history of mental health issues, or a lack of social support, can increase the risk of developing ASD.
Assessing and diagnosing patients with anxiety disorders is a crucial aspect of psychiatric nursing practice. It involves a comprehensive evaluation of the patient’s mental and emotional well-being, as well as the formulation of an accurate diagnosis to guide treatment. I’ve learned that taking a patient-centered approach is vital when dealing with anxiety disorders. Effective communication and active listening are fundamental skills when assessing patients with anxiety disorders. Anxiety disorders can have a significant impact on a patient’s physical health and overall well-being. I’ve learned to conduct a holistic assessment that includes evaluating the patient’s physical symptoms, sleep patterns, appetite, and any comorbid medical conditions.
Emmelkamp, P. M., Meyerbröker, K., & Morina, N. (2020). Virtual reality therapy in social anxiety disorder. Current psychiatry reports, 22, 1-9. https://doi.org/10.1007/s11920-020-01156-1
Perrotta, G. (2019). Panic disorder: definitions, contexts, neural correlates and clinical strategies. Current Trends in Clinical & Medical Sciences, 1(2), 1-10. https://doi.org/10.3390/healthcare9060664
Shahrour, G., & Dardas, L. A. (2020). Acute stress disorder, coping self‐efficacy and subsequent psychological distress among nurses amid COVID‐19. Journal of nursing management, 28(7), 1686-1695. https://doi.org/10.1111/jonm.13124
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.
- 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.
- 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.
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.
- 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.
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).
- 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.
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.
American Psychiatric Association [APA] (2022). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (DSM-5-TR), 5th ed. Author.
Boland, R., Verdiun, M., & Ruiz, P. (Eds) (2021). Kaplan and Sadock’s synopsis of psychiatry, 12th ed. Wolters Kluwer.
Carlat, D.J. (2017). The psychiatric interview, 4th ed. Wolters Kluwer.
Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th 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