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
Main Post
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:
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