NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
Week 4: Assessing And Diagnosing Patients With Anxiety Disorders, PTSD, and OCD
Susaan Ugorji
College of Nursing-PMHNP, Walden University
NRNP 6635C: Psychopathology and Diagnostic Reasoning
PMHNP
September 24, 2023
Assessing And Diagnosing Patient With PTSD
A comprehensive assessment of a client is a necessary step to establishing an appropriate treatment plan and can be completed during the first treatment session (Wheeler, 2014). A comprehensive assessment will determine the client`s needs and the physician’s treatment decisions (Phillips, et al., 2017). The primary objective of this article is to present a comprehensive client assessment, including mental status examination and differential diagnoses for a 27-year-old white male military veteran whose fiancee believes is experiencing post-traumatic stress disorder (PTSD).
Subjective:
CC (chief complaint): My fiancé was worried about how I was acting. At county fairs, fireworks are set off. I took off running and sought to find cover during the fireworks.
HPI: P.F., a 27-year-old white male, presented for psychiatric evaluation for an anxiety disorder, including excessive fear and worry, as well as related behavioral problems. PTSD, agoraphobia, specific phobias, social anxiety disorder, social phobia, and panic disorder are anxiety disorders. According to him, this is the first mental assessment of the patient. He joined the army after graduating from high school and served three long tours in war zones. He retired from the military after 8 years of service in the Marine Corps (MOS Field Artillery). He is engaged and works as a salesman in a furniture store. He said he grew up poor and wouldn’t have done anything else if he hadn’t joined the military. His father is an alcoholic, so the patient denies using drugs and tries not to drink alcohol. His father is still alive and sick; he continued to drink despite diabetes, liver disease, and high blood pressure. The patient’s grandfather was also a veteran who suffered from depression and he never mentioned it to anyone other than the patient; both served in the military. Mother is still alive and takes care of her husband. He has a younger sister and an older sister. Due to an incident at a fireworks display at the fairgrounds, his fiancée requested that he undergo a psychiatric evaluation. He reported that it scared him. When he ran away, two police officers chased him, pulled him to the ground, and handcuffed him. He said he informed the officers that he was a veteran and they backed down because they were also veterans who understood his behavior. They helped him stand up and gave him water to drink.
The patient said he was in severe shock after the incident. He describes the explosion as a fire in a flashback event, and it sends him back in time to the battlefield. His onset was loud noises, like a car backfiring or a circular saw. To him, diesel fuel smells like a “helicopter smell”. His friend burned the hair on his arm at a cookout last week, and the scent reminded him of it so he quickly left the cookout. He said two of his friends were burned when their Humvee exploded. He stopped and decided that his experience was too intense to talk about. He imagined people looking at him when they were stopped or stuck in traffic. “I knew we were going to fall,” he said. He said anyone could roll an IED under their vehicle. At this point, the patient appeared to be breathing heavily and became anxious when discussing the event.
Another example is when his fiancée disagrees with his mother and he cannot handle the situation. Any negative situation makes him want to “go into a hole and hide there,” he believes. He also talked about the difficulty of going to crowded places like baseball fields, restaurants or stores. He often stays in his room because he is afraid to sleep. He said this was the first time he had shared his experience and symptoms with anyone. According to him, his physical symptoms were stomach cramps and nausea. At the end of the interview, the patient said he felt like he was going crazy and there was no end in sight. My mind sometimes falls into itself, as if I could neither see nor hear nor move; It was like a numb feeling everywhere and I lost track of time. The interviewer recommended seeing an individual therapist to help the brain heal. Speaking takes him out of the feeling mode and into the thing mode. Consequently, you don’t always hear the same stories. So in a way, you feel in control.
According to the American Psychiatric Association (APA), the initial psychiatric evaluation should thoroughly examine anxiety related to the patient’s mood, thought content processes, perceptions, and cognitions. The provider should consider the patient’s trauma and psychiatric history, as well as any psychiatric diagnosis and treatment. These guidelines focus on improving the physician-patient relationship, the accuracy of psychiatric diagnoses, and the appropriateness of treatment selection (APA Updated Guidelines for Psychiatric Evaluation in Adults, 2016).
Past Psychiatric History:
· General Statement: No previous psychiatric provider
· Caregivers (if applicable): The client’s fiancée
· Hospitalizations: Denied
· Medication trials: Denied
· Psychotherapy or Previous Psychiatric Diagnosis: Denied
Substance Current Use and History: The patient denies drug use and avoids alcohol.
Family Psychiatric/Substance Use History: His father is recovering recovering alcohol overuse. The grandfather was a veteran. He suffered from undiagnosed depression.
Psychosocial History: The patient was raised by his parents and has two sisters, one younger and one older than him. He lives in the same house with his fiancée but has no children. He said they want to have children and plan to get married within the next two years.
Medical History: None reported
· Current Medications: No current medication
· Allergies: Seasonal allergies
· Reproductive Hx: No reproductive history. He is heterosexual and has a fiancé.
ROS:
· GENERAL: The client is alert and oriented and has no weight problems, fever, or chills.
· HEENT: No issues reported for vision, hearing, or nose
· SKIN: There were no reports of itching or rash
· CARDIOVASCULAR:
· RESPIRATORY: There were no reports of chest pain, chest tightness, or chest discomfort. No palpitations.
· GASTROINTESTINAL: No symptoms of nausea, vomiting, anorexia, or diarrhea were reported. No stomach pain. The client reported occasional stomach cramps and nausea.
· GENITOURINARY: When urinating, there is no burning sensation, no urgency or hesitancy, and no foul smell or unusual color was reported.
· NEUROLOGICAL: No headaches, no loss of consciousness, no dizziness, no fainting, no paralysis, ataxia, numbness or tingling in the limbs was reported.
· MUSCULOSKELETAL: No muscle, back, joint or stiffness reported. All extremities are moveable.
· HEMATOLOGIC: Anemia, bleeding or bruises are not present.
· LYMPHATICS: There are no swollen lymph nodes. There was no previous splenectomy.
· ENDOCRINOLOGIC: There is no sensitivity to sweat, cold or heat. There was no polyuria or polydipsia.
Objective:
Physical exam: T-97.4, P-84, R-18, B/P 130/85. H 5’9″, 170 lbs. Alert and focused. The look is comfortable and weather-appropriate. The atmosphere and appearance adapt to the circumstances.
Diagnostic results: Clinician-administered PTSD scale (CAPS). CAPS includes four criteria corresponding to the DSM-5 diagnosis for PTSD; stressor, intrusion symptoms, avoidance, and negative alterations. The CAPS also includes the twenty-seven elements required to make the diagnosis, 17 items necessary for diagnosis, and must be administered by a trained clinician and lasts 45 to 60 minutes, with brief and accurate follow-up examinations. (Sadock et al., 2015).
To make a diagnosis, there must be evidence of a traumatic event, one symptom of re-experiencing, three symptoms of avoidance, and two symptoms of arousal (Sadock, et al., 2015). The utility of the Short PTSD Rating Interview (SPRINT) and the PTSD Checklist should be evaluated. According to Herta et al., (2013), SPRINT is a clinically based screening method for severely traumatized patients that ensures effective identification and referral of positive cases to appropriate care.
Assessment:
Mental Status Examination: P. F. is alert, focused, and able to express his needs. He appeared both nervous and cooperative during the interview. He was dressed appropriately and appeared well-groomed. There was no evidence of unusual behavior and speech was clear with normal tone and volume. His thought process is very logical and goal-oriented. There was no evidence of abnormal thought processes and his short- and long-term memory remained intact. He can concentrate and his clarity is excellent. No suicidal or homicidal thoughts, and no auditory or visual hallucinations.
Differential Diagnoses:
Post-Traumatic Stress Disorder (PTSD): A trauma and stress-related disorder characterized by persistent difficulties that negatively affect social interactions, ability to work, or other areas of functioning of an individual due to direct or indirect exposure to actual or threatened death, injury, or sexual or emotional violence (Piotrowski & Range, 2020).
According to DSM-5, a person is exposed to PTSD if both of the following are present:
· The person suffered, witnessed, or was exposed to an event that resulted in actual or threatened death.
· The traumatic event is persistently relived.
· Continuous avoidance of relevant stimuli linked to the trauma.
· Persistent symptoms such as increased arousal, difficulty falling asleep or staying asleep, irritability or angry outbursts, difficulty concentrating, increased vigilance
· Duration of symptoms of the disorder is more than one month.
· The disruption causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
According to the client’s report, two of his friends were burned when their Humvee exploded and he smelled them. As a result, he experiences nightmares and other triggers that create flashbacks or anxiety. He also tries to avoid certain events that act as triggers, and these experiences have affected his life and mood in a number of ways. These, along with other reports in his narrative, suggest the presence of at least two of the conditions listed in the DSM-5 diagnostic criteria that suggest the presence of PTSD.
Panic Disorder: Panic disorder is an anxiety disorder in which one frequently has panic attacks or sudden fear. Common symptoms of panic disorder include a racing heartbeat, feeling faint, sweating, nausea, chest pain, shortness of breath, trembling, hot flushes, chills, shaky limbs, a choking sensation, dizziness, and trembling (NHS, 2023).
According to the Anxiety and Depression Association of America, as of 2014, panic attacks are the hallmark symptom of panic disorder. This painful mental condition affects 2.7% of Americans each year, or 6 million people. Panic disorder is part of the anxiety disorder category. (APA, 2013).
The client`s report; “I despise really congested downtown traffic,” “people in front of and behind you in a car stopped at a traffic light”, “That is something I cannot stand”, “I begin to break out in a cold sweat” “I am trembling and cannot seem to catch my breath”, These are pointers to panic attack.
Agoraphobia: Agoraphobia is the fear or anxiety of being trapped in a situation that is difficult to escape from. It is a very distressing phobia that can make it difficult to function at work and in social situations. Most panic disorder researchers in the United States believe that agoraphobia always occurs as a complication in patients with panic disorder. Agoraphobia is caused by the fear of panicking in public places, where escape is difficult. Although agoraphobia and panic disorder are often seen together, agoraphobia is classified as a separate condition in the DSM-5 and may or may not be related to panic disorder. DSM-5 diagnostic criteria for agoraphobia include intense fear or apprehension in at least two of five situations: Using public transportation; Being in open spaces; Being in enclosed spaces (e.g., shops, theaters, cinemas); Standing in line or being in a crowd; Being outside the home alone (S. A. M. H. S. A., (2016). Patients with agoraphobia quickly avoid situations in which it is difficult to receive help (Sadock et al., 2015). Some of the reports of the client, include; “it was an unfortunate incident, like when my fiancée and her mother argued.” “I wanted to crawl into a hole and hide,” “I didn’t want to go anywhere, so I stayed in my room all day,” “I’m afraid of falling asleep.” These suggest that the client’s experiences met the diagnosis conditions.
Reflections: It is helpful to learn about the different anxiety disorders and diagnostic scales. it helps one have a better understanding of PTSD, panic attacks, and agoraphobia. For this 27-year-old white male client, I would request more specific information, while also avoiding mounting pressure on him to talk. I believe the focus should also be on neuropsychological testing and emotional illnesses such as sadness and anxiety. A detailed evaluation is necessary for presentations with a higher index of suspicion for other medical causes of anxiety, such as electroencephalogram, lumbar puncture, head or brain imaging, electrical ECG, tests for cardiac function and infection, arterial blood gas analysis, chest X-ray, and thyroid function. Identify or rule out underlying medical conditions. Selective serotonin reuptake inhibitors (SSRIs) are first-line medications for the long-term treatment of anxiety disorders, with control gradually achieved over the course of 2 to 4 weeks of treatment, depending on necessary dose increases. Ethical principles of voluntary participation and informed consent will be considered while administering this treatment. New approaches, including the integration of patient experience information, are needed to obtain meaningful consent from patients and trial participants, especially regarding the risk of dissociative experiences. (N. A. S. E. M., 2021). Individual psychotherapy would also be another line of action as it can help a client having this experience to recover from trauma.
References
American Psychiatric Association, (2013). Anxiety disorder in Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA Author. Doi: 10.1176/appi.books 9780890425596.dsm05
APA Updates Guidelines on Psychiatric Evaluation in Adults, (2016). American Family Physician, 94(1), 62-64.
Annapureddy, P., Hossain, M. F., Kissane, T., Frydrychowicz, W., Nitu, P., Coelho, J., Johnson, N., Madiraju, P., Franco, Z., Hooyer, K., Jain, N., Flower, M., & Ahamed, S. (2020). Predicting PTSD Severity in Veterans from Self-reports for Early Intervention: A Machine Learning Approach. 2020 IEEE 21st International Conference on Information Reuse and Integration for Data Science (IRI), Information Reuse and Integration for Data Science (IRI), 2020 IEEE 21st International Conference On, 201-208. https://doi-org.ezp.waldenulibrary.org/10.1109/IRI49571.2020.00036
Herța, D.C., Nemeş, B., & Cozman, D. (2013). Screening Methodology for Posttraumatic Stress Disorder through Self-Assessment Scales. Journal of Cognitive & Behavioral Psychotherapies, 13(1), 89-100.
Lurigio, A. J. (2021). Panic attacks. Salem Press Encyclopedia of Health.
National Academies of Sciences, Engineering, and Medicine. (2021). Novel Molecular Targets for Mood Disorders and Psychosis: Proceedings of a Workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/26218.
NHS, (2023). Panic disorder. https://www.nhs.uk/mental-health/conditions/panic-disorder/#:~:text=Panic%20disorder%20is%20an%20anxiety,to%20stressful%20or%20dangerous%20situations.
Phillips A., Frank A., Loftin C., & Shepherd S., (2017). A Detailed Review of Systems: An Educational Feature. https://doi.org/10.1016/j.nurpra.2017.08.012
Piotrowski, N. A., PhD, & Range, L. M., PhD. (2020). Post-traumatic stress disorder. Magill’s Medical Guide (Online Edition).
Sadock, B. J., Sadock, V. A., and Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer
Substance Abuse and Mental Health Services Administration (2016). Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.10, Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t10/
Symptom Media. (Producer). (2016). Training title 21Links to an external site. [Video]. https://go.openathens.net/redirector/waldenu.edu?url=https://video.alexanderstreet.com/watch/training-title-21
Wheeler, K. (2014). The nurse psychotherapist and a framework for practice. In K. Wheeler (Ed.), Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (pp. 3–52). Springer Publishing Company.
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