What is your experience with caring for individuals with severe self-harming behaviors. What evidenced-based treatments are available for those who are chronically at risk for suicide a

Week 7: Complex Case Study

Courtney Baker

College of Nursing-PMHNP, Walden University

PRAC 6675: PMHNP Care Across the Lifespan I

Dr. York

January 10, 2024

Subjective:

CC (chief complaint): “I heard you do ketamine here.”

HPI: E.F. is a 17-year-old Caucasian female who presents to Mentally Strong for evaluation and treatment after referred by her primary care provider. She is accompanied by her mother. They are interested in a new psychiatric provider because she will be aging out of her pediatric provider, and they are interested in a ketamine consultation. Pt reports a previous diagnosis of depression, generalized anxiety disorder, PTSD, borderline personality disorder, severe self-harming behavior, unspecified eating disorder, and multiple suicide attempts. She has had multiple medication trials that have been minimally effective. She has had “45-50” suicide attempts and “so many inpatient psychiatric hospitalizations I can’t remember how many” since the age of 13. Most recently, she was discharged from the hospital after stabbing her abdomen which required surgical intervention. She has several scars and multiple stages of healing lacerations to bilateral upper and lower extremities. She reports self-harm with cutting, burning, pulling out eye lashes, stabbing herself, and has taken a toothbrush and pen to reopen her abdominal wound. She also has a history of suicide attempts by overdose. Mother states, “the past 6 years have been rough, but the last 10 months have been even worse.” Mother also reports increased SI and self-harming behaviors after getting disappointed at someone or when she fights with her boyfriend and friends. She has several resources to include therapy once a week, sees mentors daily, and goes with a respite person Tuesdays through Thursdays. Mother reports E.F. idealizing her various therapists in the beginning of sessions and then turns against them which has resulted in her having multiple therapists and respite providers. She also attends several support groups such as a life skills group, art group, and social groups each weekly. She is under constant supervision due to the severity of her self-harming behaviors. She reports added stressors due to being 2 years behind in school because of psychiatric hospitalizations. She denies current suicide or homicidal thoughts. Pt states, “everything that I could hurt myself with is locked up.” Mother states all knives and sharp objects are out of the kitchen, but she still manages to obtain items to hurt herself. The patient and mother want more information about ketamine treatment in the future.

Substance Current Use: Reports a history of “trying cocaine, Xanax, marijuana, and prescription opioids. Denies current use. Vapes daily.

Medical History: Hypothyroidism, GERD, chronic pain

· Current Medications: Fluoxetine 80 mg PO Daily, olanzapine 5 mg ODT daily, Vraylar 4.5 mg PO daily, atomoxetine 60 mg PO daily, Lithium Carbonate ER 300 mg PO BID, Prazosin 6 mg PO QHS, trazodone 150 mg PO QHS. Topamax 50 mg PO BID. Pepcid 20 mg PO daily, Synthroid 25 mcg PO daily, Lyrica 100 mg PO daily.

· Medication Trials: Antidepressants- Prozac, Zoloft, Lexapro, Celexa, Wellbutrin, Remeron, Effexor, Elavil, Cymbalta (all ineffective). Anti-anxiety- Klonopin, Clonidine, Ativan, Buspar, Vistaril (“all ineffective or bad side effects.”). Anti-psychotics- Thorazine, Abilify, Risperdal, Seroquel, Zyprexa, Latuda, Geodon (Seroquel EPS facial tics). Mood stabilizer- Depakote, lithium, Lamictal, Neurontin, Tegretol (all stopped working.) Topamax (effective). ADHD- Strattera, Ritalin, Adderall (ineffective.). Sleep- trazadone, Elavil, Vistaril, Prazosin, Melatonin. Addiction- naltrexone for impulse control (ineffective).

· Previous psychiatric diagnosis: MDD with psychotic features, GAD, Panic disorder, eating disorder, Borderline Personality Disorder, Insomnia.

· Psychiatric Hospitalizations: Reports being admitted over 40 times for crisis stabilization “all over Colorado.” Admitted to residential treatment for 8 weeks. Mother reports the patient is often discharged from the emergency department after a suicide attempt because “all the psychiatric hospitals refuse to take her back stating she does not benefit from inpatient treatment.

· Psychotherapy History: CBT, DBT, PHP, Group therapy, Interpersonal therapy, Psychodynamic therapy, EMDR (“traumatizing”), Family therapy and talk therapy.

· Allergies: Seroquel EPS symptoms, Amoxicillin rash

· Reproductive Hx: Not sexually active. Has Nexplanon implant right arm due for change in March 2024.

· Family psychiatric history: Father side: uncle- suicide, grandma-depression, alcoholic. Mother side: grandpa and aunt-anxiety.

Psychosocial History

E.F was born and raised in Colorado with her mother and father. She has one older stepsister who did not live in the home. Her parents divorced when she was 14 years old, and she would split her time between both parents. She has not attended public school since the 8th grade and has been home schooled since. She endorses the difficulty with bullying while in school. She reports being 2 years behind due to frequent hospitalizations. She has dyslexia which also contributed to her difficulty and insecurities in school. Most recent neuropsychiatric evaluation revealed an IQ of 97. She reports she has a boyfriend that she met while hospitalized. Mother reports E.F. has increased self-harming behaviors when they fight or breakup. Her hobbies include painting, drawing, skateboarding, playing the guitar, and listening to music, however, she has lost interests in those things. She wants to become a tattoo artist. She reports a history of sexual abuse but declined to give details to the evaluator. History of “trying cocaine, marijuana, Xanax, and prescription opioids.” Mother states, “she has never tested positive for cocaine, opioids or any other substances other than marijuana and nicotine. She denies any alcohol use. She does vape daily. Denies any current or previous legal issues.

ROS:

· GENERAL: Denies any fever or chills. No weakness or fatigue. No recent weight gain or loss.

· HEENT: Reports frequent headaches. No vision changes. Denies hearing loss, congestion, rhinorrhea, or sore throat.

· SKIN: Pain at abdominal incision. Itching at large healing laceration on left arm. No rashes

· CARDIOVASCULAR: Reports chest pain during panic attacks. No edema.

· RESPIRATORY: No cough or shortness of breath.

· GASTROINTESTINAL: Reports decreased appetite and constipation

· GENITOURINARY: Denies dysuria, hematuria, or urinary retention.

· NEUROLOGICAL: Frequent headaches and dizziness.

· MUSCULOSKELETAL: Reports lower and upper back pain and knee pain.

· HEMATOLOGIC: No bleeding or bruising.

· LYMPHATICS: No history of splenectomy.

· ENDOCRINOLOGIC: No heat or cold intolerances. No polyuria or polydipsia.

Objective:

Physical Exam: E.F is an over-weight female that is alert to person, place, and time.

Vital Signs: T 98.3 F, P 92, R 18, BP 141/ 87 Wt 315 lb. Ht 5’ 6” BMI 50.8

Skin: Multiple scars to bilateral upper extremities. Large laceration to the abdomen covered with a dressing. No cyanosis or pallor

HEENT: Head normocephalic, atraumatic. Mucous membranes moist.

Gastrointestinal: Abdomen obese and rounded.

Diagnostic results:

Laboratory results reviewed from the most recent emergency department visit. Results included CBC and CMP within normal limits. TSH abnormal at 5.9. Lithium 0.7. Lipid panel within normal limits. Hemoglobin A1c 5.0. Urine pregnancy negative. Urine tox screen positive for marijuana. I would want to obtain B12 and Vit D levels because low levels can contribute to depression. PHQ-9 was 27 severe depression. GAD-7 was 12, moderate anxiety disorder. MDQ was 5, less likely bipolar disorder.

Assessment:

Mental Status Examination: E.F. is an overweight 17-year-old Caucasian female who appears disheveled with poor posture. She is dressed in revealing clothes and has numerous self-inflicted lacerations and burns to her arms. Speech is slow and monotone. Mood is “depressed and sad,” and affect is blunted. Her thought process is clear. Thought content includes guilt, unworthiness, helplessness, and hopelessness. She denies suicidal thoughts currently. She displays no evidence of auditory or visual hallucinations. She is alert and oriented to person, place, and time. Recent and remote memory is intact. Judgment and insight are poor. Her concentration is poor. Fund of knowledge is intact.

Diagnostic Impression:

Persistent Depressive Disorder, early onset, severe F34.1

· Pertinent Positives: Severe depressed mood for the past 2 years. Overeating and poor appetite phases. Insomnia. Low energy and fatigue. Severe low self-esteem. Poor concentration. Feelings of hopelessness and helplessness. Recurrent suicidal thoughts and attempts. No hallucinations or delusions. Failing high school and is 2 years behind. Significant impairment in social and academic functioning. Family history of depression.

· Pertinent Negatives: There has never been a manic or hypomanic episode. No autism. No current substance abuse. No lapse in depressed mood for more than 2 months.

Persistent depressive disorder is a new term in the DSM-5 used to describe the clinical features of what was originally known as dysthymia and chronic major depression (Patel & Rose, 2021). According to the DSM-5-TR, persistent depressive disorder requires the patient to have a depressed mood for at least two years, and for children and adolescents, the depressed mood can be irritability and the time requirements is once year (APA, 2022). The symptoms cannot be absent for more than two months at a time (APA, 2022). Additionally, there must also be two of the following symptoms: poor appetite or overeating, insomnia, low energy or fatigue, low self-esteem, poor concentration, and hopelessness (APA, 2022). Most importantly, as with most DSM diagnosis, the patient’s symptoms must cause significant impairment in important areas of functioning to meet the criterion for diagnosis (Patel & Rose, 2021).

The patient in this case study clearly has significant depression that is impairing her ability to function. She has chronic suicidal ideations and has attempted suicide over 50 times. She has not had a period greater than two months where her symptoms have been resolved. She has tried several classes of antidepressants and adjunct medications without full resolution of her symptoms. I chose persistent depressive disorder as her primary diagnosis due to her chronic nature of depressed mood which has lasted over two years.

Borderline Personality Disorder F60.3

· Pertinent Positives: Unstable interpersonal relationships. Poor self-esteem and poor self-image. Mother reports extremes of idealization and devaluation with therapists and other healthcare providers. Binge eating. Recurrent suicidal behavior. Repeated self-mutilation such as stabbing and burning herself.

According to Chapman and Fleisher (2023), personality disorders involve a rigid and unhealthy pattern of thinking. In the adolescent population, all personality disorders can be diagnosed except antisocial personality disorder, as long as the behavior has been present for a year or more (Chapman & Fleisher, 2023). Borderline personality disorder is characterized by hypersensitivity to rejection, unstable interpersonal relationships, self-image, affects, and impulsivity that presents in early adulthood and adolescence (APA, 2023). There must also be five or more of the following: frantic efforts to avoid real or imagined abandonment, unstable and intense interpersonal relationships, identity disturbances, impulsivity, affective instability, feelings of emptiness, difficulty controlling anger, and paranoid ideations or dissociative symptoms (APA, 2022). E.F. has a documented diagnosis of borderline personality disorder from her previous psychiatric provider. Often, patients with borderline personality disorder are misdiagnosed with depression. This is because many patients with borderline personality disorder also fit the criteria for a major depressive disorder. I chose to use persistent depressive disorder because many treatment options are FDA approved for depression and not personality disorders. However, given the patients continuous self-mutilating behavior, I felt that it should be addressed in the case study and a diagnosis of borderline personality disorder should be included. Additionally, since this is the first encounter with the patient, I would want to see her again before resorting to a personality disorder as her primary disorder and instead as a co-occurring disorder. Historically, borderline personality disorder has been viewed as challenging to treat, but with adequate evidenced-based interventions, people with borderline personality disorder can experience fewer and less severe symptoms (NIMH, 2022)

Major Depressive Disorder, recurrent episode, severe F33.2

· Pertinent Positives: Depressed mood nearly every day for longer than two weeks. Reports of feeling sad and hopeless. Decreased interest in pleasure. Insomnia. Displays psychomotor retardation. Reports of feeling fatigue and without any energy nearly every day. Recurrent thoughts of suicide. Multiple self-harming and suicide attempts. Impairment in functioning at school and is two years behind graduation. Positive for marijuana. TSH elevated with a history of hypothyroidism.

· Pertinent negatives: No subjective or documented reports of mania or hypomania. No autism. No delusions or hallucinations. No alcohol or other substance use other than marijuana.

Adolescent depression is a major risk factor for suicide (Alsaad et al., 2023). According to the DSM-5-TR criteria, major depressive disorder is diagnosed when there is the presence of at least five of the following items in the same 2-week period (APA, 2022). The depressive symptoms include depressed or irritable mood, decrease in pleasurable things, increase, or decrease in weight and appetite, insomnia or hypersomnia, psychomotor retardation, lack of energy, feelings of worthlessness and guilt, difficulty concentrating, and repeated thoughts of death (APA, 2022). The depressive symptoms must also cause significant impairment in important areas of functioning. The patient in this case study has major depression, however, her symptoms are chronic and have lasted much longer than the required two weeks. Therefore, I have chosen persistent depressive disorder as the most likely primary diagnosis.

Case Formulation and Treatment Plan: 

Start Neurofeedback therapy two times weekly here at the office. Neurofeedback therapy is a form of biofeedback based on the learning method called operant conditioning which involves rewards and punishments for behaviors (Melnikov, 2021). It is a technique that relies on the principle that if a person can access information in their brain about bodily functions in real time, they can learn to control them. Neurofeedback can be used for several conditions such as ADHD, anxiety, autism, depression, PTSD, and sleep (Melnikov, 2021).

One health promotion activity and patient education would be regarding eating a healthy diet of fruits and vegetables and engaging in exercise or other physical activities.

Will consider Spravato treatment for MDD when the patient turns 18. Ketamine is a NMDA receptor antagonist and a rapid-acting antidepressant with proven efficacy (Alnefeesi et al., 2022). Ketamine is not FDA approved for depression, however, its use in treatment resistant depression is expanding after multiple studies have shown it is effective. A recent systematic review and meta-analysis found ketamine is significantly effective in treating treatment resistant depression (Alnefeese et al., 2022).

Will continue patients’ current medications during this visit. Fluoxetine 80 mg PO Daily (depression), olanzapine 5 mg ODT daily (irritability), Vraylar 4.5 mg PO daily (Depression adjunct), atomoxetine 60 mg PO daily (attention and focus), Lithium Carbonate ER 300 mg PO BID (suicidality), Prazosin 6 mg PO QHS (nightmares), trazodone 150 mg PO QHS (insomnia). Topamax 50 mg PO BID (eating disorder, PTSD). Since this patient is at a significant risk of completed suicide, lithium has been prescribed. Lithium has been shown to reduce the risk of suicide and mortality in people with unipolar depression (Sarai et al., 2018). E.F. most recent lithium level was within normal range. Will order a repeat lithium level in 3 months as she has been stable at this dose for several months.

Discussed risks and potential side effects of antipsychotics to include risk of irreversible movement disorder (tardive dyskinesia). TD handout provided. Baseline AIMS completed and was negative.

Educated patient on boxed warning of potential for increased suicidality with the use of antidepressants; patient and parent verbalized understanding.

Patient verbally contracts for safety and can verbalize resources to utilize should suicidal ideations or self-harm increase, including utilizing our walk-in hours, the local emergency department, and the 24/7 suicide prevention lifeline.

All medications are locked up in the home to decrease the risk of intentional overdose. Mother monitors and administers patients’ medications. Safey measures are in place and the mother is agreeable to take her home today.

RTC in 2 weeks for medication follow up and neurofeedback.

Social determinate of health impacting this patient’s mental health is regarding access to quality health care. According to the healthy people 2030 objectives regarding adolescence is to increase the proportion of adolescents who get support for their transition to adult health care (OSHA, n.d.). E.F. will be turning 18 and her mother reports she has been encouraged to drop her health insurance. I will provide information on The Resource Exchange (TRE). TRE is a community-based resource that advocates for independence for children and adults with a variety of disabilities, delays, and mental health needs. TRE would offer her multiple resources and support through the Medicaid waiver. The Medicaid waiver that would benefit E.F. when she turns 18 is the Adult Community Mental Health Supports Waiver for ages 18+(TRE, n.d.).

Reflection:

If I could reevaluate this patient, I would want to determine if her current medication regimen and neurofeedback therapy is effective. For this patient, growth and improvement would look like a decrease in self-harming behavior and decreased suicide attempts. I would like to know if she has been in the Emergency Department since our last visit. I would also want to know if she has had an improvement in her interpersonal relationships. The next intervention would be to start Spravato treatment once she turns 18 in a couple of months.

OBJECTIVES:

You will recall the key criteria for diagnosing adolescent depression according to the DSM-5-TR.

Define and explain the key characteristics of borderline personality disorder in adolescents.

Differentiate the symptoms and diagnostic criteria between adolescent depression and borderline personality disorder and recognize the overlapping features and potential comorbidities.

Discussion Prompts:

1. What is your experience with caring for individuals with severe self-harming behaviors. What evidenced-based treatments are available for those who are chronically at risk for suicide and self-harm?

2. What is your opinion of the new wave of treatment for PTSD and treatment resistant depression with NMDA receptor antagonist medications? What is the research showing on the use of Psilocybin as a treatment option for those with mental health issues?

3. What is your opinion on diagnosing children and adolescents with personality disorders? What does the research suggest? Do you think we should treat the psychiatric diagnosis or the symptoms of mental illness?

PRECEPTOR VERFICIATION:

I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.

Preceptor signature: ________________________________________________________

Date: ________________________

References

Alnefeesi, Y., Chen-Li, D., Krane, E., Jawad, M., Rodrigues, N, Ceban, F., Di Vincenzo, J., Meshkat, S., Ho, R., Gill, H., Teopiz, K., Cao, B. Lee, Y. (2022). Real-world effectiveness of ketamine in treatment-resistant depression: A systematic review and meta-analysis. Journal of Psychiatric Research, 151, 693-709. https://doi.org/10.1016/j.psychires.2022.04.037

Alsaad, A., J., Azhar, A. L., & Nasser, Y. (2023). Depression in children. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534797

American Psychiatric Association. (2022). DSM-5-TR (5th ed.).

Chapman, J., Jamil, R. T., & Fleisher, C. (2023). Borderline personality disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430883

Melnikov, M. Y. (2021). The current evidence levels for biofeedback and neurofeedback interventions in treating depression: A narrative review. Neural Plast, 2021. https://www.doi.org/10.1155/2021/8878857

National Institute of Mental Health. (2022). Borderline personality disorder. https://www.nimh.nih.gov/sites/default/files/documents/health/publications/borderline

Office of Disease Prevention and Health Promotion. (n.d.). Increase the proportion of adolescents who get support for their transition to adult health care-AH-R01. https://health.gov/healthypeople/objectives-and-data/browse-objectives/adolescents

Patel, R. K., & Rose, G. M. (2021). Persistent depressive disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541052

Sarai, S. K., Mekala, H. M., & Lippmann, S. (2018). Lithium suicide prevention: A brief review and reminder. Innov Clin Neurosci, 15(11-12), 30-32. https://ncbi.nlm.nih.gov/pmc/articles/PMC6380916

The Resource Exchange. (n.d.). Getting started. https://tre.org/get-services

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