NRNP 6635: Psychopathology and Diagnostic Reasoning
Week 10 Assignment 2: Comprehensive Psychiatric Evaluation and Patient Case Presentation
CC (chief complaint): “My kidneys are failing even if my PCP denies.”
HPI:
G.L is a 68-year-old White female referred for psychiatric evaluation by her PCP after insisting that she had kidney failure despite physical exam and diagnostic tests showing otherwise. The client is preoccupied with a serious illness that the PCP has not diagnosed. Her preoccupation with having a severe illness began when she was diagnosed with recurrent UTI and urinary incontinence ten months ago. The PCP prescribed antibiotics for each UTI infection, and finally, the infection was eliminated after being prescribed a combination of strong antibiotics. However, G.L believes that the urinary incontinence and the recurrent UTIs were due to a kidney problem and insists that she is developing kidney failure.
The client’s PCP could not persuade her that she has no major illness, even after conducting numerous diagnostic studies. The conviction about her kidneys failing has persisted despite negative diagnostic results and reassurances from several physicians and renal specialists. She has also become addicted to Internet searches about the feared illness of kidney failure. The client states that she has anxiety about developing kidney failure, which has caused her marked emotional distress and inability to function in her social life.
Past Psychiatric History:
- General Statement: The client first presented for psychiatric evaluation due to abnormal illness behavior.
- Caregivers (if applicable): None
- Hospitalizations: None
- Medication trials: None
- Psychotherapy or Previous Psychiatric Diagnosis: None
Substance Current Use and History: The client has a history of smoking which she stopped at 44 years due to elevated BP. She reports taking beer occasionally.
Family Psychiatric/Substance Use History: The client’s mother had a history of Major depression and suicide attempts. She has a maternal uncle with a history of opioid use disorder.
Psychosocial History: The client is married and lives with her spouse in Riverside County, CA. They have three children who are currently married. She is a retired accountant and currently works alongside her husband in managing their family businesses. Her hobbies include watching drama movies and visiting museums. She denies having any legal history.
Medical History:
- Current Medications: Vitamin D and Calcium Supplements.
- Allergies: No allergies.
- Reproductive Hx: Para 3+1. Incomplete abortion in the third pregnancy at 14 weeks.
ROS:
- GENERAL: Negative for fever, chills, fatigue, or weight changes.
- HEENT: Negative head trauma, blurred vision, eye pain, visual changes, hearing loss, nasal discharge, nasal blockage, epistaxis, sore throat, or pain in swallowing.
- SKIN: Negative for rashes, bruises, lesions, or skin color changes.
- CARDIOVASCULAR: Denies chest discomfort, palpitations, edema, or exertional dyspnea.
- RESPIRATORY: Denies breathing difficulties, wheezing, chest pain, or cough.
- GASTROINTESTINAL: Denies nausea, vomiting, appetite changes, abdominal pain, flatulence, or altered bowel patterns.
- GENITOURINARY: Denies abnormal PV discharge, urinary urgency/frequency, or dysuria.
- NEUROLOGICAL: Negative for headache, fatigue, muscle weakness, tingling sensations, or black spells.
- MUSCULOSKELETAL: Negative for muscle pain, joint pain/stiffness, or back pain.
- HEMATOLOGIC: Negative for bleeding, bruising, or history of anemia.
- LYMPHATICS: Denies lymph node enlargement.
- ENDOCRINOLOGIC: Denies polyuria, heat/cold intolerance, polyphagia, or increased sweating.
Physical exam:
Vital Signs: BP- 132/84; HR- 88; RR- 16; Temp-98.4
Diagnostic results: Diagnostic results from previous tests are within normal limits.
Assessment
Mental Status Examination:
The client is well-groomed and appropriately dressed. She is alert, oriented, and maintains adequate eye contact. The self-reported mood is anxious, and the affect is blunt. Her speech is clear with normal rate and volume, and has a coherent thought process. She is preoccupied with thoughts of having kidney failure and beliefs that her kidneys will soon stop functioning. No apparent hallucinations, phobias, delusions, or suicidal ideations were noted. Long-term and short-term memory is intact, and she demonstrates good judgment. Insight is lacking.
Differential Diagnoses:
Illness Anxiety Disorder: Illness anxiety disorder is characterized by a preoccupation with and fear of having or acquiring a serious illness. The preoccupation is based on an individual’s interpretation of physical sensation as evidenced by severe physical disease (Espiridion et al., 2021). A person misinterprets non-pathologic physical symptoms or normal bodily functions for illness. This causes clinically significant distress or impairment in a person’s social and occupational functioning. The diagnosis is made when the fears and symptoms persist for more than six months despite reassurance following a thorough medical evaluation (Arnáez et al., 2021). Illness anxiety disorder is a presumptive diagnosis based on the client’s preoccupation with fear of having kidney failure after misinterpreting recurrent UTIs and urinary incontinence.
Somatic Symptom Disorder: Somatic symptom disorder presents multiple constant physical complaints associated with excessive and maladaptive feelings, thoughts, and behaviors related to those symptoms. The symptoms are not deliberately produced or an act of pretense and may or may not accompany known medical conditions (Nazzal et al., 2021). Patients often present with multiple physical complaints affecting various body organs. They are also mostly sick and have a complicated medical history. It is a chronic disorder associated with psychological distress, impairment in social functioning, and excessive help-seeking behavior (Nazzal et al., 2021). The client’s complaints of developing kidney failure make Somatic symptom disorder a differential diagnosis. However, the patient has no multiple physical complaints, and she only has a preoccupation with fear, which makes this an unlikely primary diagnosis.
Body Dysmorphic Disorder: Body dysmorphic disorder is characterized by a false belief of a defective body part. Individuals have a subjective feeling of having an ugly appearance and feeling unattractive, which usually require reassurance. As a result, they attempt to conceal the presumed deformity and visit plastic surgeons to correct the imagined defect (Singh & Veale, 2019). The client, in this case, has a false belief about having failing organs based on previous urinary symptoms. However, she does not have perceived flaws or defects in physical appearance, ruling out Body dysmorphic disorder as a primary diagnosis.
Reflections:
In a different situation, I would aim to create a trustful provider-client relationship and reassure the patient since it helps relieve anxiety and psychological distress. I have learned that the health provider must exclude physical disease by evaluating various neurological, endocrinological, and other systemic disorders (Higgins-Chen et al., 2019). Illness anxiety disorder can be diagnosed in a patient with a medical illness if the anxiety is out of proportion to the extent of the illness. Literacy levels are one of the SDOHs related to this case. Patients with low literacy and health literacy levels tend to misinterpret physical symptoms and normal body physiology, increasing the risk of Illness Anxiety Disorder (Higgins-Chen et al., 2019). In my future APN practice, I would consider educating the patient on the manifestations of Illness anxiety disorder. Health promotion would focus on educating the patient to increase the level of physical exercises since it helps reduce anxiety, improve mood, and improve sleep in persons with related psychological distress (Lebel et al., 2020).
References
Arnáez, S., García-Soriano, G., López-Santiago, J., & Belloch, A. (2021). Illness-related intrusive thoughts and illness anxiety disorder. Psychology and Psychotherapy, 94(1), 63–80. https://doi.org/10.1111/papt.12267
Espiridion, E. D., Fuchs, A., & Oladunjoye, A. O. (2021). Illness Anxiety Disorder: A Case Report and Brief Review of the Literature. Cureus, 13(1), e12897. https://doi.org/10.7759/cureus.12897
Higgins-Chen, A. T., Abdallah, S. B., Dwyer, J. B., Kaye, A. P., Angarita, G. A., & Bloch, M. H. (2019). Severe illness anxiety treated by integrating inpatient psychotherapy with medical care and minimizing reassurance. Frontiers in Psychiatry, pp. 10, 150. https://doi.org/10.3389/fpsyt.2019.00150
Lebel, S., Mutsaers, B., Tomei, C., Leclair, C. S., Jones, G., Petricone-Westwood, D., Rutkowski, N., Ta, V., Trudel, G., Laflamme, S. Z., Lavigne, A. A., & Dinkel, A. (2020). Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates. PloS one, 15(7), e0234124. https://doi.org/10.1371/journal.pone.0234124
Nazzal, Z., Maraqa, B., Abu Zant, M., Qaddoumi, L., & Abdallah, R. (2021). Somatic symptom disorders and utilization of health services among Palestinian primary health care attendees: a cross-sectional study. BMC Health Services Research, 21(1), 615. https://doi.org/10.1186/s12913-021-06671-2
Singh, A. R., & Veale, D. (2019). Understanding and treating body dysmorphic disorder. Indian Journal of Psychiatry, 61(Suppl 1), S131–S135. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_528_18