Post-Starr

22 Jan Post-Starr

 Respond to at least two of your   colleagues who were assigned to a different case than you. Explain how   you might apply knowledge gained from your colleagues case studies to   you own practice in clinical settings.  

NOTE: Positive comment

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 Case  Study: Volume 2, Case #21 focuses on the treatment of an adult client  diagnosed with Attention Deficit Hyperactivity Disorder (ADHD).  

Questions 

Question 1: Are you having problems with your loved ones due being argumentative and temperamental?  

Rationale:  The client may have additional stress due to broken relationships and  this could be due to his disorder.  Emotional dysregulation is  increasingly recognized as a core feature of ADHD (Stralen, 2016).  Signs of ADHD include low frustration tolerance and explosive behavior  (Stralen, 2016).  

Question 2: 

What causes you the most anxiety?

It  is important to determine the triggers of the anxiety to help the  patient prepare for times when he is likely to be in high stress  situations. Planning a response when feeling overwhelmed can help the  patient remain in control of his emotions and allow the patient to  monitor his behavior. 

Question 3: 

You  stated that your father was abusive, was this physical or verbal abuse  or both? Do you contribute some of your anxiety from previous issues  with your father? 

It  is important for the provider to understand the clients point of view  in regards to his upbringing. He realizes it has affected in him in some  way, as he has obtained psychotherapy in the past. I would want to know  if he has ever spoken to his father about this and if his father has  ever apologized for his actions. 

Questions for family

I  would want to talk with his mother to ask her how he did as a child in  school and at home in regards to schoolwork, chores and would want to  know if he had friends. Although  social problems are not part of the diagnostic criteria for ADHD, the  peer relationship difficulties faced by youth with this disorder are  profound (Hoza, 2007)

Diagnostics & Exams

A  full psychiatric evaluation which would include the Adult Self-Report  Scale (ASRS). ASRS was been developed by the World Health Organization  to determine if an individual (adult) may have ADHD. The scale is made  up of 6 questions, and if a client has at least 4 of 6 symptoms, there  may need to be a diagnosis of ADHD made by a professional (ADDA, 2018). Seay  et al. (2009) suggests the PMHNP should utilize intelligence test,  broad-spectrum scales, tests of specific abilities, and brain scans to  confirm the diagnosis and to rule out other disabilities, autism,  auditory processing disorders or mood disorders. In addition, a full medical work-up by a PCP in order to rule out other medical conditions that could present similarly to ADHD. 

Differential DX

General Anxiety Disorder: The  patient exhibits symptoms of generalized anxiety disorder, DSM-5 300.02  (F14.1). He has had the symptoms for greater than six months with the  symptoms being severe enough to interfere with the patients daily  functioning. The patient complains of feels of worry that is difficult  to control, irritability, restlessness, difficulty concentrating and  feeling on edge. The patient symptoms have not been linked to a physical  condition or to substance use (Reynolds & Kamphaus,2013).

ADHD:  client consistently complains of feeling tense, irritable, and anxious  (Stahl Online, 2019).  Questions arise once the general anxiety symptoms  are resolved and the client is left feeling hyperactive, inattentive,  and the inability to focus (Stahl Online).

Post-Traumatic  Stress Disorder: The clients diagnosis of anxiety may have been  related to underlying issues related to a traumatic event that he  experienced as a child. The clients father was verbally abusive to him  and was an alcoholic. It is a possibility that the clients issues could  have some relations to previous exposure as a child. Post-Traumatic  Stress Disorder is a serious condition that can occur in clients who  have experienced various incidents including abuse (PTSD, 2018).

Medications

The  case states by year six the client has failed to achieve remission on  an SSRI, a 5-HT1A receptor partial agonist, an antihistamine anxiolytic  and an SGRI (Stahl Online, 2019).

Based on the pharmacological agents, I would select either  Cymbalta 60mg or Effexor XR 150mg.  Cymbalta did illicit a response,  but side effects prevented the escalation of the dosage.  Augmenting  with guanfacine an alpha-adrenergic agonist proved to be the therapy  that elicited remission for this client.

Lessons Learned

I  learned to always consider additional differential diagnosis and  evaluate and re-evaluate every situation separately to be sure of the  correct diagnosis.  Patients  often have comorbid diagnosis and treating both is vital to a  successful outcome for the patient. Symptoms of mental illness change  overtime making continued care necessary for the patient. The provider  must always be approachable and helpful for the client to feel  comfortable in his/her presence. 

 

                                                References

Attention Deficit Disorder Association. (2018). Adult ADHD Test. Retrieved from

Generalized Anxiety Disorder. (2018). Anxiety and Depression Association of America. Retrieved from

Posttraumatic Stress Disorder. (2018). Anxiety and Depression Association of America. Retrieved from

Seay, B., McCarthy, L. F., and Williams, P. (2009). Your complete ADHD/ADD diagnosis guide.

            Retrieved from 

Stahl, S. M. (2013). Stahls essential psychopharmacology: Neuroscientific basis and practical

            Applications (4th ed.). New York, NY: Cambridge University Press.

Stralen, J. W. (2016). Emotional dysregulation in children with attention-deficit/hyperactive disorder.

            Attention Deficit Hyperactivity Disorder. 8(4). p. 175-187. Retrieved from

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110580/

Hoza  B, Mrug S, Gerdes AC, Bukowski WM, Kraemer HC, Wigal T, et al. What  aspects of peer relationships are impaired in children with  attention-deficit/hyperactivity disorder? Journal of Consulting and Clinical Psychology. 2005b;73:411423. 

Reynolds, C. & Kampaus, R. (2013). Generalized Anxiety Disorder. Pearson. Retrieved from:

            Diagnostic-Criteria_GeneralizedAnxietyDisorder.pdf.