Assessing and Diagnosing Patients With Anxiety Disorders PTSD and OCD

Assessing and Diagnosing Patients With Anxiety Disorders PTSD and OCD

Biodata

Initials: Z.W     Gender: Female      Age: 23             Ethnicity: African American

Subjective

CC (chief complaint): Embarrassment, feelings of loss of control, shame

HPI: The patient is a 23-year-old African-American female who presents to the clinic with feelings of shame, embarrassment, and loss of control. The patient states that these feelings are strong and started when she started pulling her hair. This was about five to six years ago. She is, however, not sure about the onset of these symptoms. She stated that she rubbed her eyebrows when proofreading reports she wrote as a habit. This happened when she was nervous. Her co-worker, however, told her that she was plucking her eyebrows, and when she checked the mirror, she noticed that she had fewer eyebrows. The patient then started pulling hair from her scalp. She felt sorry when she realized she was doing this. She feels ashamed because of her bald head. The patient has a habit of plugging and unplugging her hairdryer. She states that she constantly switches on and off her light switch eleven times. She has had this behavior since she was a child. She further states that she always thinks about cats since they carry diseases.

Past Psychiatric History:

General Statement: This patient has no treatment experience.

Caregivers (if applicable): Not applicable

Hospitalizations: No previous hospitalizations

Medication trials: No medication trials.

Psychotherapy or Previous Psychiatric Diagnosis: No previous mental health diagnosis

Substance Current Use and History: Denies any use of alcohol, tobacco, or any illicit substances

Family Psychiatric/Substance Use History: The mother has a history of anxiety. The brother has a history of cannabis use.

Psychosocial History: The patient was born and raised in Jacksonville with her mother and two older brothers. She has an associate of arts degree and works for an Amazon warehouse. She is not in a relationship but identifies as a lesbian. She has not come out to the family yet—no history of legal issues.

Medical History: Diabetes since she was five years.

Current Medications: No current medications

Allergies: No known drug or medication allergies

Reproductive Hx: She is not pregnant or lactating. She is a lesbian who has not come out yet to her family.

ROS:

GENERAL: Denies fatigue, weight loss, or fever.

HEENT: Head: Minimal hair and wears wigs. Eyes: No diplopia, blurred vision, or vision loss. Ears: Denies hearing loss. Nose: Denies nasal congestion or rhinorrhea. Throat: No sore throat.

SKIN: No rash or skin itching

CARDIOVASCULAR: Denies chest pressure, pain, discomfort, palpations, or peripheral edema.

RESPIRATORY: Denies dyspnea, sputum, or wheezing

GASTROINTESTINAL: Denies appetite loss, vomiting, nausea, or abdominal pain

GENITOURINARY: Denies urinary urgency or burning sensation

NEUROLOGICAL: No ataxia, dizziness, paralysis, tingling sensations, syncope, or changes in bowel control.

MUSCULOSKELETAL: Denies joint pain, muscle pain, muscle stiffness, or back pain.

HEMATOLOGIC: Denies easy bruising, bleeding, or anemia.

LYMPHATICS: Denies lymphadenopathy

ENDOCRINOLOGIC: Denies polyuria, polydipsia, heat/cold intolerance

Objective

Vitals

T- 97.5 P- 86 R 18 112/64 Ht 5’2 Wt 130lbs

Physical exam:

HEENT: Head is normocephalic and atraumatic. PERRLA. Visual acuity is 18/20. The TM is intact and grey. Lips are moist and pink. No tonsillitis was noted. No discharge in the ears or eyes.

Neck:  No lymphadenopathy on palpation

Lungs/ Cardiovascular: S1, S2 heard. Capillary refill is less than three seconds. Chest is clear to

auscultation bilaterally. No labored breathing with normal rhythm and depth.No peripheral edema

Breast: No nodes or lump palpated.

Abdominal: Normoactive bowel sounds were heard on all four quadrants. The abdomen is non-tender in palpation.

Skin: Skin is moist and warm on the touch.

Cervix: Firm, smooth, with no vaginal sores.

Uterus: Mobile and non-tender

Adnexa: No mass or tenderness palpated.

Diagnostic results:

No diagnostic tests were ordered, but the DSM-V diagnostic criteria were used to establish a diagnosis based on the patient’s symptoms.

Assessment

Mental Status Examination:

The patient is a 23-year-old African American female dressed appropriately for the weather. She is alert and oriented to time, place, and person. She had psychomotor agitation with fidgeting and hand wringing. The patient’s mood was hopeless, worthless, and frustrated. The patient denied the problems, which were only noticed by her co-workers. Her emotions were guarded, and she was cautious in revealing information. The patient had a negative view of herself with feelings of shame and embarrassment. The patient was ego-dystonic with good insight. Her judgment was also intact. Her short-term and long-term memory were intact.

Differential Diagnoses:

Obsessive-Compulsive Disorder (OCD)

Involves obsessions and/or compulsions. Obsessions involve recurrent images or thoughts that cause anxiety or distress, while compulsions involve performing acts in response to the obsessions (Fineberg et al., 2017). The patient constantly thinks about cats, and she removes her hair to help suppress these thoughts. The patient also has obsessive behaviors, such as switching on and off the hairdryer eleven times. The obsessions are time-consuming (American Psychiatric Association, 2013). The patient used to take a long time to prepare due to her compulsions. The other criteria, according to DSM-V, are that the physiological effects of substances do not cause the symptoms, and the symptoms cannot be explained by another mental disorder (American Psychiatric Association, 2013). The patient meets the DSM-V diagnostic criteria for OCD. This is the presumptive diagnosis.

Generalized Anxiety Disorder

Avoidant behaviors and recurrent thoughts may also be present in individuals with anxiety disorders (Andrews et al., 2016). However, the recurrent thoughts present in anxiety disorders such as generalized anxiety disorders are due to real-life issues, while the obsessions in OCD do not involve real issues and include content that is irrational and odd. The patient had recurrent thoughts of cats being dirty and carrying dirt, affecting individuals. This caused her to worry all the time. These are irrational and odd thoughts.

Specific Phobia

The patient fears that cats carry germs and may cause diseases to individuals. This phobia causes the patient anxiety and endures it with anxiety (Coelho et al., 2020). The patient fears the disease nature of cats. However, this fear is out of proportion (APA, 2013). The DSM-V criteria, however, states that the fear should not be explained by a mental disorder such as OCD, which rules out this diagnosis (APA, 2013)

Reflections:

This case was very interesting and challenging. My presumptive diagnosis was OCD, but the patient’s symptoms can also be diagnosed as OCD with comorbid anxiety. Specific phobia was also a likely diagnosis since the patient met all the criteria for this diagnosis. Furthermore, the patient could be diagnosed with major depressive disorder, but she did not meet the DSM-V threshold for this disorder. The diagnosis was OCD since the patient had compulsions to subconsciously remove her hair. I managed to correctly diagnose this patient by relying on the DSM-V criteria and the use of scholarly articles. If I were to do this session all over, I would still do it the same way since I believe everything was done according to current clinical guidelines.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Andrews, G., Mahoney, A. E., Hobbs, M. J., & Gunderson, M. (2016). DSM-5 generalized anxiety disorder: The product of an imperfect science. Treatment of generalized anxiety disorder, 1-18. https://doi.org/10.1093/med:psych/9780198758846.003.0001

Coelho, C. M., Gonçalves-Bradley, D., & Zsido, A. N. (2020). Who worries about specific phobias? – A population-based study of risk factors. Journal of Psychiatric Research, 126, 67-72. https://doi.org/10.1016/j.jpsychires.2020.05.001

Fineberg, N. A., Apergis-Schoute, A. M., Vaghi, M. M., Banca, P., Gillan, C. M., Voon, V., Chamberlain, S. R., Cinosi, E., Reid, J., Shahper, S., Bullmore, E. T., Sahakian, B. J., & Robbins, T. W. (2017). Mapping Compulsivity in the DSM-5 obsessive-compulsive and related disorders: Cognitive domains, neural circuitry, and treatment. International Journal of Neuropsychopharmacology, 21(1), 42-58. https://doi.org/10.1093/ijnp/

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Complete and submit your Comprehensive Psychiatric Evaluation, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis.

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 rule 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.
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, etchttps://video-alexanderstreet-com.eu1.proxy.openathens.net/watch/training-title-95.).
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