What is your experience with treatment of insomnia with multiple medications? What diagnostic workups would you consider in treatment of insomnia What considerations would you take

Week 7: SOAP GAD and Insomnia

Student Name: Eden Shumbulo

College of Nursing-PMHNP, Walden University

PRAC 6665: PMHNP Care Across the Lifespan II

Faculty: Deb York

Assignment Due Date: 01/10/2024

Subjective: 

· Chief complaint: “I have been trying to get off the Ambien, which I have been on for more than a year now, I also don’t feel like myself lately”

Miss Y is a 53yo female that presents with symptoms of insomnia, which is okay with her current medications, but she really wants to work on getting off the Ambien, and may be replace it with another medication. Pt reports of not liking the side effects of drowsiness, and she is very concerned of becoming dependent on it. Pt also reports of worrying, feeling anxious, disorganized, it is hard to focus, and finish work, and this has been causing difficulty in maintaining relationships with people in her life, and affects her ability to function at work . Conditions in her relationship post-divorce, her relationship with her daughter, work, and moving to a new place are presented as factors that stresses the patient out. Pt states her insomnia, is reasonably controlled by Trazodone 50mg and Ambien 10mg, but her goal is to get off of Ambien. Previous attempt with trial of Mirtazapine, or Hydroxyzine were not effective for sleep. Pt was started on both Trazodone and Ambien by primary care provider. Pt states that she has taken an SSRI for anxiety previously, which was helpful, which she stopped taking when she felt better, pt does not remember the name.

· Health hx: occurrences of hypotension, Psychiatric hx: Insomnia. No past psychiatric hospitalization, current medications Trazodone 50mg, Ambien 10mg. Currently on psychotherapy twice a month. Family metal health history, Mom: anxiety.

Social Hx; Grow up with mother, has a boyfriend is monogamous, has one daughter whom she lives with . No legal hx.

Substance Use History: Drinks coffee one cup a day in the AM, drinks wine one glass of wie once a week. No substance use.

Current Medications: Trazodone 50mg Qhs, Ambien 10mg Qhs

Reproductive Hx: None. Sexually active, Heterosexual, Contraceptive protective barrier method. LMP 4 years ago

· Allergies: None

GENERAL: No weight loss, fever or chills

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. Has abdominal pain/ sick stomach

GENITOURINARY: No urinary retention, urgency, hesitancy

NEUROLOGICAL: has occasional headache, no dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective: 

Mental health examination: Patient is 52 yo female alert and oriented, who looks her stated age, dressed appropriately, and appears pleasant. Pt is cooperative with examiner. Pt is mildly restless, fidgeting, answers questions with extended amount of explanation. Her speech is clear, coherent, hyperverbal, thought process is linear & goal directed. No looseness of association or flight of ideas. Her mood is good, and affect appropriate to mood. There is no evidence of delusional thinking. Pt has no psychotic symptoms of delusions, hallucinations, or disorganized thoughts. ROS: mild restlessness.

Diagnostic results: Lab works of CBC, CMP, Folate, B12, TSH within normal ranges

Diagnostic Impressions:

Differential Diagnosis #1. Adjustment Disorder with Anxiety (Chronic type) because this has been going on for >6 moths. Pertinent positives: the development of emotional symptoms in response to identifiable stressors occurred within 3 months of the onset of stressors. Pt has marked distress that is out of proportion to the severity of the stressor, and causes impairment in her social, occupational, sleep and her day-to-day activities. Pt has intermittent symptoms of nervousness, worry, jitteriness, and overwhelm nearly every day

#2. Insomnia Disorder, Persistent type: Pertinent positives: Difficulty initiating and maintaining sleep, frequent awakening. The insomnia is not better explained by another sleep disorder, or is not attributable to physiological effect of substance use. The sleep disturbance causes clinically significant distress in social and occupational functioning. The sleep difficulty occurs at least three nights per week and the symptoms are present for more than three months, and the difficulty to sleep occurs despite an opportunity to sleep.

#3 Generalized Anxiety Disorder (GAD): Pertinent positives: Restlessness, feeling keyed up or on edge. Difficulty concentrating or mind going blank. Irritability, Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

Pertinent Negatives: Excessive anxiety and worry (apprehensive expectation), The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms), Being easily fatigued. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, the disturbance is not attributable to the physiological effects of a substance

Primary Diagnosis: Adjustment Disorder with Anxiety, Insomnia Disorder, Persistent type

Case Formulation and Treatment Plan

Though pt was not diagnosed with anxiety by her PCP, and was started on Ambien for sleep, she also has symptoms of an anxiety disorder. So, we now have decided to treat the anxiety symptoms, and reassess sleep condition. Addressing underlying factors of insomnia is important in order to effectively treat the resulting sleep disorders. We have started patient on Lexapro 5mg QD, and follow up and reassess outcomes, with a plan of titrating to 10-15mg, and tapering down the Ambien as well as trazodone. Risks and benefits of medications are discussed including non- treatment, and potential side effects of medications including nausea, headache, dry mouth, diarrhea, fatigue. Informed client not to stop medication abruptly without discussing with providers, and call and report any adverse reactions. Patient education on sleep, anxiety management, and working consistently in their therapy sessions are matters discussed and emphasized in this visit.

Reflection: Sleep disorder is a very common compliant in mental healthcare, since majority of psychiatric symptoms cause lack of sleep. Also, there are various factors for insomnia, some patients have more prominent symptoms than others. In this patient case what appears to be challenging is that pt wants to come off of a medication, that seems to help with their sleep. Previous trial of Mirtazapine, Vestril along with a Mg supplement in effort to replace Ambien is not effective, Lunesta trial of 3 days not effective. Addressing possible causative factors of anxiety and depression through both pharmacologic and none pharmacologic modalities is prioritized, then based on outcomes of these treatments insomnia and medication management can be done. Ethical considerations include confidentiality, also it is important to maintain autonomy in involving patient in her care. Also, beneficence can be maintained by involving the patient in her assessment as well as treatment plan, providing the resources and recommendations in ongoing care. Pt was seen on a follow up visit with tolerance of the new medication, and agreed to increase dose to 10mg QD. Pt is still taking her Ambien and Trazodone. Plan is to start trial tapper of Ambien as pt starts to have improved anxiety symptoms, and consequential possible improvement in sleep. Long term plan as pt is stabilized on Lexapro, is trial of Quivivq (Deodrexant), a medication that has been newly approved by FDA for sleep onset and maintenance disorders. Quivivq is in a drug class of “Orexin antagonists” orexin being a wakeup protein in the bran, and it has very few side effect profile and lesser daytime residual effects compared to Ambien. Some of the considered social and biological determinant that add to the patient’s symptoms of anxiety and depression are female gender, being a divorcee and a single mom (Conroy, 2016).

References